DHSM Report

A Report of
District Health System Management
Submitted to
Department of Community Medicine and Public Health

Maharajgunj Medical Campus, Institute of Medicine
Tribhuvan University
Kathmandu
Nepal
Submitted by
MBBS IV Year
Group A3
2014
District Health System Management: Report 2014

DECLARATION AND APPROVAL SHEET
We, the following students of MBBS IV year have produced this report as an outcome of
residential field program from 25 Falgun 2070 to 26 Baisakh 2071 in Bardiya, Surkhet and
Rukum districts. We have invested our sincere efforts and consider this work to be original.
Group A3
Roll. No.
Name
Signature
1221
Bidur Prasad Pandit
1227
Gaurab Tiwari
1238
Prakash Bastola
1265
Santosh Baniya
1267
Subodh Shrestha
1257
Suman Maharjan
1271
Yogesh Subedi
Date:
This report has been accepted and forwarded for final examination.
---------------------------------
---------------------------------
Coordinator, CBL Unit
Head of Department
Date:
Date:
Department of Community Medicine and Public Health

Maharajgunj Medical Campus
Institute of Medicine
Page | ii

ACKNOWLEDGEMENTS
We would like to extend our sincere gratitude to the following people, who have been
of great help to us throughout our field.
From Bardiya district, we would like to thank Mr. Achyut Lamichhane (District
Health Oficer), Dr. Raj Bhakta Maharjan and Dr. Arjun Bhatta (Medical Officers), Mr. Sanat
Sharma (Medical Records Officer), Mr. Mohan Kurmar Sharma (Malaria Focal Person), Mrs.
Sumitra Khadka (Nursing Incharge) of the District Health Office, Bardiya. We would also
like to thank Mr. Khem B.K. of Bardiya District Hospital for providing us fooding
throughout our stay.
From Surkhet district, we express our gratitude to Dr. Bhola Ram Shrestha (Medical
Superintendent) for guiding and assisting us throughout our stay and Mr. Tanka Chapagain
(District Health Officer) from the District Public Health Office. We would like to thank Mr.
Yogendra Shahi, Chief co-ordinator of the voluntarily working committee for Waste
Management on Mid-Western Regional Hospital, Surkhet for his guidance and help on the
critical analysis. We are also thankful to Mr. Khumba Bahadur Khadka of Subham Hotel for
providing us lodging facility and Mr. Ganesh Bista for providing food during our stay in
Surkhet.
From Rukum district, we are thankful to Mr. Dil Bahadur Giri (Hospital
Administrator) and Dr. Keshav Bhattarai (Medical Officer) from HDCS-CHR Hospital, Mr.
Yadu Nath Ghimire (District Public Health Officer). We would especially like to thank Mr.
Prakash Gosain for providing us lodging and food during our stay in Rukum.
Lastly, we would like to thank Prof. Dr. Jeevan Kumar Shrestha- Campus Chief, Prof.
Dr. Sharad Onta- Assistant Dean of Institute of Medicine, Prof. Dr. Rajendra Raj Wagle Head
of Department: Department of Community Medicine and Public Health, Dr. Archana Amatya
(MBBS Coordinator), Mr. Ramesh Sigdel (CBL Unit Coordinator), Prof. Dr. Madhu Dixit
Devkota, Prof. Dr. Ramjee Prasad Pathak, Prof. Dr. Bandana Pradhan, Associate Prof. Shiva
Prasad Sapkota, Associate Prof. Ajay Thakur, Mr. Prem Basel, Assistant Prof. Binjwala
Shrestha, Mr. Bishnu Chaulagain, Mr. Ritu Prasad Gartoulla, Mrs. Saraswoti Singh, Mrs.
Gita Bhandari, Mr. Rajan Poudel, Mr. Durga Parsad Pahari and Mr. Khadga Shrestha. We
extend our heartfelt gratitude to the department for providing us with the wonderful
opportunity to explore the Mid West Nepal and observe the health system and also for
arranging the orientation classes, providing us the logistic supports and for guiding us all the
way from the start. We are grateful to Associate Prof. Shiva Prasad Sapkota, Mr. Ramesh
Shigdel, Mr. Prem Basel for supervising us during our field stay.
We would like to take this opportunity to thank everyone involved, directly or
indirectly, in making this period highly beneficial and productive for all of us.
Page | iii

EXECUTIVE SUMMARY
From nine weeks study on different aspects of district health system management, we
are able to generate this report containing various findings, analysis and conclusions. We
prepared district health profile, a hospital profile and conducted an epidemiological study on
Malaria in Bardiya district based on Bardiya District Hospital; critical analysis on solid waste
management was done in Mid-Western Regional Hospital and a five year plan was prepared
on control of diarrhea in Rukum district.
District Health Profile

Bardiya lies in the Terai belt of our country and is divided into 31 VDCs, 1
Municipality and 4 electoral constituencies. Under DHO, Bardiya consists of 1 district
hospital, 3 PHCCs, 25 HPs and 13 SHPs, 156 PHC-Outreach Clinics, 197 EPI Clinics
supported by 841 FCHVs.
The programs that are being conducted by DHO are EPI, nutrition program, CBIMCI, safe motherhood program, family planning program, TB control program, leprosy
control program, malaria control program, mass drug distribution for filariasis control and
program on HIV AIDS.
1 PHC at Swarahawa VDC and 1 HP at Motipur VDC were visited. The study proved
the importance of peripheral centers in providing health services in community level. The
staffing pattern, management bodys formation and the different services provided by the
basic health facilities in the community level were observed and noted.
Hospital profile
Bardiya District Hospital was established in 1991 B.S. and is a 25 bedded hospital
with 21 staffs. Different services provided are OPD service, In-patient service, Emergency
services, Obstetric services, MCH and family planning services, safe abortion services,
ART/VCT clinic, DOTS and DOTS-plus center, immunization services, laboratory services,
training and health awareness program. Hospital is managed by hospital management
committee and quality control committee.
Epidemiological study on Malaria

Malaria is a disease of tropics and subtropics and is a vector borne disease (VBD)
transmitted by female Anopheles mosquito. Bardiya is amongst the 13 highly endemic
Page | iv

districts where global fund is actively supporting the governments intense malaria control
program as Roll Back Malaria due to high case load.
Epidemiological study was performed on Malaria. The disease was studied based on
time, place and person as variables. The Clinical Malaria Incidence was 10 per 1000
population which was decreasing in the last 3 years. Confirmed malaria cases among total
clinical malaria cases were 69 in 2069/70, which was also decreasing in the past 3 years.
Bhimapur SHP was the area diagnosed with highest number of clinical malaria cases (352 in
2069/70) while Baniyabhar SHP and Neulapur HP had no clinical malaria cases. The age
group <5 years diagnosed with clinical malaria was more than the age group >5 years. There
are no reported deaths due to malaria since last 3 years but there is a large disparity between
clinical malaria cases and slide positive cases.
Critical Analysis
Waste management is a top priority issue in any hospital. In Mid-western regional
hospital there was no authorized body for the waste management and amount of the waste
produced in the hospital was not quantified and there were no skilled trained human resources
for the handling of waste management. Furthermore, earthworm farming system was running
in MWRH. So, critical analysis on solid waste management was performed.
With broad topic of collection, transportation, storage, waste disposal site, waste
disposal process, manpower and budgeting, different aspects were critically analyzed using
SWOT table. The main problems were lack of budget allocation for waste management, nonfunctional incinerator, disposal sites just behind the emergency block and unavailability of
skillful volunteer for handling of waste. The voluntary committee was successful in
establishing and running earthworm farming and is coordinating with hospital to build a
biogas plant, to bring incinerator, and glass and plastic cutter. Recommendations were given
to maintain strength, improve weakness and address the threat.
Five Year Plan

Diarrheal disease is one of the major public health problems of Rukum district and it
surpasses the incidence of the mid-west region. Diarrheal disease ranks first among diseases
in terms of morbidity in HDCS-Chaurjahari hospital and is among the top five diseases in
Rukum district. Incidence of Diarrhea per 1000 Population in year 2069/70 was 518 and it
seems to have a static trend in the previous three years and it continues to be a significant
Page | v

problem. So, five year plan on control of diarrhea was prepared based on the data from
HDCS-Chaurjahari hospital.
Five year plan was made in 3 phases- Committee formation and Planning,
Implementation, Re-assessment and Evaluation. The main target was to reduce incidence of
diarrheal disease per 1000 population from 518 to 259 i.e. by 50%. The estimated total
budget was NRs. 54,00,100, and the sources were government budget and funding from
INGOs and NGOs. Preventive, promotive and curative aspects of Diarrhea were focused.
Page | vi

TABLE OF CONTENTS
Declaration and Approval
ii
Acknowledgements
iii
Executive Summary
iv
List of Tables
viii
List of Figures
List of Abbreviations
xii
Chapter I:
Introduction
Chapter II:
A. District health profile: Bardiya
B. Peripheral Institution Visit/ Health Facility Observation
34
Chapter III:
Hospital profile: Bardiya District Hospital
37
Chapter IV:
An epidemiological study of Malaria in Bardiya district
48
Chapter V:
Critical analysis on solid waste management in Mid-western regional

hospital
Chapter VI:
Chapter VII:
63
Five year plan on diarrheal disease control in HDCS-Chaurjahari

hospital
72
Recommendations and Limitations
91
Chapter VIII: Learning reflections
92
Annex
93
Page | vii

LIST OF TABLES
S.N.
Title
Page
2.1
Demographic indicators
2.2
Number of schools, teachers and students
2.3
Categories of Health Facilities
2.4
Health indicators
2.5
NGOs/INGOs and Private Health Institution
14
2.6
EDP Support
15
2.7
Human resource at DHO, Bardiya
16
2.8
Indicators of malaria
20
2.9
Tuberculosis control programme
21
2.10
Leprosy control programme
21
2.11
Status of rabies in the district
22
2.12
Status of Snake bite in the district
22
2.13
Performance Status FY 2067/68 2069/70, National Immunization
23
Programme
2.14
Status of nutrition programme
25
2.15
Status of service delivery sites in the district
28
2.16
Service status in the district
29
2.17
FCHV Performance Status
30
2.18
PHC-ORC Performance Status
30
2.19
Utilization of laboratory services in Bardiya district
32
2.20
Status of cases registered in the center (from establishment to now)
33
2.21
Age wise distribution of the victims
33
2.22
Human resource of Swarahawa PHCC
35
2.23
Human resource of Motipur HP
36
Page | viii

3.1
Financial Management (in the year 2069/70)
38
3.2
Human resource management in Bardiya district hospital
39
3.3
Obstetrics services provided by Bardiya district hospital
41
3.4
MCH and Family Planning (FP) services
43
3.5
Laboratory Services provided by Bardiya district hospital
45
3.6
Immunization services provided by Bardiya district hospital
45
3.7
Physical facilities available in Bardiya district hospital
46
3.8
Hospital equipments available in Bardiya district hospital
46
3.9
Top 10 diseases in OPD
47
3.10
Top 10 diseases in In-patient department in FY 2069/70
47
5.1
SWOT Analysis
68
6.1
Various types of diarrheal diseases
72
6.2
Phase division
79
6.3
Training activities
82
6.4
Indicators of CDD
83
6.5
Budgeting of five year plan
84
6.6
Log frame matrix
86
Page | ix

LIST OF FIGURES
S.N.
Title
Page
2.1
Map of Bardiya District and its Health Facilities
2.2
Health Care Delivery System in Bardiya District
13
2.3
Planning function of DHO, Bardiya
17
2.4
Health Management Information System (HMIS) flow in Bardiya
18
2.5
Logistic management in Bardiya
18
2.6
Logistic management information system (LMIS) unit
19
2.7
Status of IUCD, implant and satellite clinic service
27
2.8
Status of contraceptive prevalence rate
28
2.9
OPD Services FY 2067/68 2069/70
31
3.1
Morbidity pattern in OPD and Emergency in FY 2066/67 - 2069/70
41
3.2
OPD visits in Bardiya district hospital
42
4.1
Clinical malaria cases with respect to distribution by time
52
4.2
Slide positive cases of P. vivax with respect to distribution by time
53
4.3
Clinical malaria cases with respect to distribution by place
54
4.4
Slide positive cases of P. vivax with respect to distribution by place
55
4.5
Slide positive P. falciparum cases with respect to distribution by place
55
4.6
Distribution of slide positive malaria cases with respect to distribution by

person
56
4.7
Treatment of clinical malaria cases
57
4.8
Trend of clinical malaria incidences over 3 years
57
4.9
Trend of confirmed malaria cases over 3 years
58
4.10
Trend of P. falciparum cases over 3 years
58
4.11
Clinical malaria cases with respect to distribution by time
59
4.12
Clinical malaria cases with respect to distribution by place
60
4.13
Distribution of slide positive malaria cases with respect to distribution by

Page | x

person
61
6.1
Incidence of Diarrhea/1000 Population
73
6.2
Percentage of severe dehydration among total cases
73
6.3
Proportion of CDD cases treated by FCHV
74
6.4
Proportion of CDD cases treated by VHW/MCHW
74
6.5
Proportion of CDD cases treated by HF
74
6.6
Diarrhea cases treated with Zinc and ORS
75
6.7
Number of <2 months children treated in HFs
75
6.8
Problem tree of high morbidity due to diarrheal diseases
78
Page | xi

LIST OF ABBREVIATIONS
ABER
Annual Blood slide Examination Rate
ACT
Artemisinin-based Combination Therapy
AFP
Acute Flaccid Paralysis
AHW
Auxiliary Health Worker
AIDS
Acquired Immuno Deficiency Syndrome
ANC
Antenatal Care
ANM
Auxiliary Nurse Midwife
ARI
Acute Respiratory Infection
ART
Anti Retroviral Therapy
BC
Birthing Center
BCC
Behaviour Change Communication
BCG
Bacillus Calmette Guerin
BEOC
Basic Essential Obstetric Care
CAC
Comprehensive Abortion Care
CB IMCI
Community Based Integrated Management of Childhood Illness
CBS
Central Bureau of Statistics
CDD
Control of Diarrhoeal Diseases
CEOC
Comprehensive Essential Obstetric Care
CFR
Case Fatality Rate
CMI
Clinical Malaria Incidence
CPR
Contraceptive Prevalence Rate
CS
Caesarian Section
DDC
District Development Committee
DHO
District Health Office
DoHS
Department of Health Services
DOTS
Directly Observed Treatment Shortcourse
DPHO
District Public Health Office
DPT
Diphtheria, Pertussis and Tetanus
EDP
External Development Partner
Em
Effective micro-organisms
EP
Ectopic Pregnancy
EPI
Expanded Programme on Immunization

Page | xii

ER
Emergency
FCHV
Female Community Health Volunteer
FY
Fiscal Year
GIZ
Gesellschaft fr Internationale Zusammenarbeit
GMCS
Global Malarial Control Strategy
GoN
Government of Nepal
HA
Health Assistant
HDCS
Human Development Community Service
HF
Health Facility
HIV
Human Immuno deficiency Virus
HMIS
Health Management Information System
HP
Health Post
IEC
Information, Education and Communication
IMCI
Integrated Management of Childhood Illness
INGO
International Non Governmental Organization
IPD
In-patient Department
IUCD
Intra Uterine Contraceptive Device
JE
Japanese Encephalitis
Ka. Sa.
Karyalaya Sahayogi
LFA
Logical Framework Analysis
LMD
Logistics Management Division
LMIS
Logistics Management Information System
MA
Medical Abortion
MCHW
Maternal and Child Health Worker
MO
Medical Officer
MoHP
Ministry of Health and Population
MoV
Means of Verification
MS
Medical Superintendent
MWRA
Married Women of Reproductive Age
MWRH
Mid Western Regional Hospital
Na. Su.
Nayab Subba
NCDDP
National Control of Diarrheal Diseases Programme
NGO
Non Governmental Organization
NIP
National Immunization Program

Page | xiii

OCMC
One stop Crisis Management Centre
OPD
Out-patient Department
ORS
Oral Rehydration Solutions
ORT
Oral Rehydration Therapy
OT
Operation Theatre
OVI
Objectively Verifiable Indicators
PAC
Post Abortion Care
PF
Plasmodium falciparum
PHC ORC
Primary Health Care Out Reach Clinic
PHCC
Primary Health Care Centre
RAP
Risk Awareness Programme
RBM
Roll Back Malaria
RHD
Regional Health Directorate
RTAG-M
Regional Technical Advisory Group on Malaria
SBA
Skilled Birth Attendant
SHP
Sub Health Post
SPHA
Senior Public Health Administrator
SPR
Slide Positivity Rate
API
Annual Parasite Incidence
SWOT
Strength Weakness Opportunity Threat
TT
Tetanus Toxoid
UNICEF
United Nations Childrens Fund
USAID
United States Agency for International Development
VBD
Vector Borne Disease
VCT
Voluntary Counselling and Testing
VDC
Village Development Committee
VHW
Village Health Worker
WHO
World Health Organization
Page | xiv

Chapter I
INTRODUCTION
1.1 Background
A system can be defined as a set of elements which are arranged in such a way that all of
its components fit together or work together in order to perform a particular function. A health
system can be referred to as the complex of interrelated elements that contribute to health in
homes, educational institutions, workplaces, public places and communities as well as in the
physical and psychosocial environment and the health and related sectors.
A district, being the meeting-point of bottom-up planning (need based) & top-down
planning (for support), is considered to be the focal point for decentralization. District Health
System is an appropriate means of improving the health status of communities where 90 % of
health problems can be addressed at district level. It facilitates interaction and co-ordination
among different governmental departments and NGOs working locally.
District Health System is a self contained segment of the national health system. It
comprises of a well-defined population, living within a clear administrative & geographical area
and includes all institutions (government, non-government, international) providing health care
in the district. In addition it also includes all the traditional and private health care workers and
facilities.
Management, principally, is the task of planning, coordinating, motivating and
controlling; performed to determine and accomplish the objectives by the use of people and
resources. Health Management is a process with which both interpersonal and technical health
services organization are specified and accomplished by utilizing human and physical resources
and technology.
District health system could be regarded as a big container containing many other smaller
and inter-linked groups of containers with interwoven structures, interfaces and channels of
communication. The contents of these containers are the people and the programs and services to
them, whereas the structures are community structures and other sector health structures. The
ways and means whereby the containers and contents are arranged so as to be effective and
efficient is the health management which involves management of appropriate hierarchical
arrangement of health facilities for providing easy access to health services to the communities.
Page 15

The pillars of health system management include organization, planning and
management, community financing and resources allocation, inter-sectored collaboration,
community involvement, development of human resources and health system research.
1.2 Objectives
1.2.1 General Objective
To acquire knowledge and skills required for the management and development of health
care delivery system.
1.2.2 Specific Objectives
To understand the existing health care delivery system in the district in terms of
infrastructure, human resources, financial status, management, accessibility and
availability.
To understand the managerial aspect and activities of various health institutions in the
district; including Regional/Zonal/ District/ Private Hospitals, DPHOs, PHCCs, HPs and
SHPs by observation and participation in the activities in and outside these institutions.
To understand the roles / activities of other Government Organizations (GOs) / Non

Government Organizations (NGOs) and alternative health care providers in the health
care delivery of the district and the co-ordination between them.
To develop skills necessary for conducting epidemiological study on a major health

problem of the district.
To develop skills necessary for performing critical analysis on a particular aspect of

health-related facility / activity of the hospital / DHO / DPHO.
To develop planning skills necessary for the maintenance and development of the health
care delivery system and formulate a five year plan on a pertinent health issue in the
district.
Page 16

1.3 Process and preparation
1.3.1 Study Areas
Bardiya
: District Hospital, Gulariya
Surkhet
: Mid-Western Regional Hospital, Birendranagar
Rukum
: HDCS-Chaurjahari Hospital, Chaurjahari
1.3.2 Study duration

Nine weeks (25 Falgun 26 Baisakh, 2070)
1.3.3 Literature review
1.3.4 Study Tools
a. Observation checklist (for hospital equipment and infrastructures).
b. Interview guidelines for Senior Public Health Administrator, Medical Superintendent
(MS) and other key informants.
c. Note taking during interviews, clinical rounds and observations.
d. SWOT matrix.
e. Logical framework matrix.
f. Photography.
g. Focused Group Discussion (FGD) guidelines.
1.3.5 Study techniques
The major techniques of the study are as enlisted below:
a. Observation:
i. Resources/facilities (adequacy, utilization, etc).
ii. Management (effectiveness, weaknesses, constraints, etc).
iii. Human interaction (e.g. among staffs or between staffs and patients).
b. Participation:
i. Health service delivery activities.
ii. Other activities like meetings, discussions, teaching-learning activities and mobile
health programs.
c. Visits and interactions:
i. Authorities of health institutions (MS/MO).
ii. District Public Health Office authorities
Page 17

iii. Others: District Development Committee, I/NGOs, municipality office.
iv. Staff: Hospitals and others.
v. Patients and patient parties
d. Document review:
Hospital records, reports, annual reports (national, district, DHO/DPHO)
e. Data collection:
The type of data obtained were both qualitative and quantitative and they were
obtained from annual reports, patient record book, store records and hospital records, data
from account section, administrative documents and records.
f. Data processing:
The information collected from multiple sources and methods were triangulated
and integrated. The data were analysed to obtain the indicators and describe the situation.
1.3.6 Ethical considerations
The objectives of the study were explained to the concerned authorities. Informed
consent was taken from the health personnel, patient and the patient parties and other
personnel involved before interview and confidentiality was maintained in all aspects.
1.4
Logistics management
Accommodation was recommended by the campus and a daily allowance was
also provided. In addition transportation cost and stationery were also provided by the
campus.
Page 18

Chapter II
A. DISTRICT HEALTH PROFILE: BARDIYA
2.1 District Profile
Figure 2.1: Map of Bardiya District and its Health Facilities

2.1.1 Introduction
Bardiya district of Bheri zone occupies an area of 2025 square kilometer and has a
population of 434,300 and population density of 211 (persons/sq. km.). Gulariya is the district
headquarter. 37 percentage of its total area is occupied by the Bardiya National Park.
2.1.2 Political and Administrative Division

1. Development region:
Mid Western Development Region
Page 19

2. Zone:
Bheri Zone
3. Ecological region:
Terai
4. District Headquarter:
Gulariya
5. Number of electoral constituencies: 4

6. No. of Municipalities:
7. Number of VDCs:
31
2.1.3 Population
1. Demographic Indicators
Table 2.1: Demographic indicators
Indicators
Number
Number of VDCs
31
Number of Municipality
Total Population
434,300
Under 1 Population
10,700
Under 5 Population
50,047
Female
married
women
15-49
86,297
years
Expected pregnancy
12,488
Under 3 years Population
30,353
Adolescent 10-19 years Population

Annual Population Growth Rate
Sex Ratio (males per 100 Females)
1,01,285
1.10%
92.6
Number of Household
83,176
Average household size
5.13
Population
Density
211
(persons/sq.Km.)
Total Absent (abroad) Population
25,044
Male Absent (abroad) Population
21,719
Page 20

Female
Absent
(abroad)
3,325
Population
(Source: CBS, Census 2011)
Page 21

2.1.4 Development resources
1. Education
Table 2.2: Number of schools, teachers and students
Particulars
Primary
Secondary
206
Lower
Second
ary
75
44
Higher
Secon
dary
27
Total
schools
652
Total
students
18,494
Total
teachers
-
79,100
38,010
16,280
5,679
1352
344
240
30
(Source: DDC, Bardiya)
2. Health
Table 2.3: Categories of Health Facilities
Category
District Hospital
Ayurved Aushadhalaya
PHCCs
HPs
SHPs
PHC-Outreach Clinics
EPI Clinics
FCHVs
Number
1
1
3
25
13
156
197
841
(Source: District Population Profile, DHO, Bardiya)
2.1.5 Development indicators
1. Education
Total literacy: 76.64%
Male literacy rate: 84.33%
Female literacy rate: 68.72%
Page 22
2. Health
Table 2.4: Health indicators
Reporting Status
2067/68
2068/69
2069/70
District Hospital
100%
100%
100%
PHCCs
100%
100%
100%
Health Posts
100%
100%
100%
Sub Health Posts
100%
100%
100%
PHC/ORC Clinics
91.77%
87.38%
90.92%
EPI Clinics
94.96%
94.17%
99.24%
NGOs
42.19%
34.90%
54.49%
BCG Coverage
67.71%
66.05%
75.00%
DPT1 Coverage
60.92%
70.03%
76.52%
DPT2 Coverage
71.43%
68.78%
76.64%
DPT-Hep b-Hib 3 coverage
76.86%
69.15 %
76.17 %
Measles coverage
68.33%
65.73%
75.70 %
JE Coverage
75.03%
71.06%
80.58%
25.16
25.35%
32.84 %
Dropout rate DPT-1 Vs DPT-3
-0.08%
1.25%
0.46 %
Dropout rate BCG Vs Measles
-0.01%
0.18%
-0.93%
3765
(32.29%)
28 VDCs
4002
(34.15%)
29 VDC
2600
(24.30%)
30 VDCs
8
65
0
6
12
0
14
2
0
Expanded Programme on Immunization
% of TT2+ (Pregnant women) coverage
Number and % of unimmunized children

Number of VDCs with <than 90% DPT3
Coverage
No. of AFP Cases
No. of Measles cases
No. of Neonatal tetanus Cases
Nutrition Programme
Page 23

New growth monitoring visits as % of
<5 years children
Proportion of malnourished children as
54.28%
59.03%
74.41%
3.22%
2.66%
3.29%
76.39%
68.25%
71.60%
40.75%
41.20%
47.28%
69.25%
66.42%
67.14%
56.00%
55%
54.11%
46289
(92.17%)
43,667
(89%)
41908
(93.59%)
44518
(88.64%)
42,671
(87%)
39333
(87.84%)
41692
(94.10%)
38051
(88.28%)
37692
(95.79%)
40220
(90.78%)
38463
(89.24%)
34761
(88.34%)
24.49%
24.17%
21.62%
0.39 %
0.40%
0.25%
65.77
65.25
64.55
% of new growth monitoring (< 5

years)
%
of
expected
pregnant
mothers
supplemented with Iron tablets

% of pregnant mothers who received
180 iron tablets
% of pregnant
supplemented by
Antihelmenthic tablet
% of Postpartum mothers receiving
Vitamin A
Vitamin
"A" Distribution Coverage
(number and %) 1st (Kartik) round

(6 month to < 5 years children)
Vitamin
"A"
distribution
coverage
(number and %) 2nd (Baishakha)

round (6 month to <5 years children)
Antihelmenthic
coverage
tablet
(number
distribution
and
%)
1st
(Kartik) round (1- <5 years children)

Antihelmenthic
tablet
distribution
coverage (number and %) 2nd

(Baishakha) round (6 month to <5
years children)
Acute Respiratory Infection (ARI)
% of pneumonia among new ARI cases
% of severe pneumonia or very severe

disease among total cases
Proportion of ARI cases treated by
Page 24

FCHV
8.09
7.67
6.85
26.14
27.08
28.60
0.06 %
3.39 %
0.06 %
70.01
70.04
71.80
9.55
8.84
7.77
20.44
21.12
20.42
Proportion of diarrhea cases treated with

zinc and ORS
Safe Motherhood Programme
91.30 %
93.78 %
98.23 %
Antenatal First visits as % of expected
68.44%
66.72%
68.22%
4 ANC visits as % of 1st ANC visit
65.07%
66.43%
68.19%
Delivery conducted by SBA at HF as %
39.90 %
41.20%
43.64%
1.09%
0.32%
0.08%
39.99
41.08
43.54
49.04
44.91
45.08
580
242
200
159
153
162
100%
100 %
100%
Proportion of ARI cases treated by

AHW/ANM
Proportion of ARI cases treated by HF
Control of Diarrheal Diseases (CDD)
% of severe dehydration among total
cases
Proportion of Diarrheal cases treated by
FCHVs
AHW/ANM
HF
pregnancies
of expected pregnancy
Delivery conducted by health worker as
% of Expected Pregnancy
%
of institutional delivery among

expected live births
PNC First visit as % of expected live
birth
Number of CAC & Medical Abortion
(MA)
Number of PAC
%
of
women
receiving
maternity
incentives among total institutional

Page 25

deliveries
33
41
63.57
0.1%
9.03%
10.74%
0.11
0.03
0.00
98
79
45
Contraceptive Prevalence Rate (CPR)
52.5
53.29
59.66
% of FP new acceptor method mix
12.84
14.22
16.52
102.88
105.55
NA
VSC cases target versus achievement
79.44
77.07
116.67
FP (spacing) new acceptor as % of
12.82
13.07
15.30
2.76
N/A
N/A
120
124
62
1.72
1.26
1.67
5.61( 6
cases
out of
107)
9.68 (12
cases
out of
124)
9.68(6
out
of 62
Case
of
women
receiving
ANC
incentives among total institutional

deliveries
Met need of emergency obstetric care
(need of EOC is 15% of expected
live birth)
Caesarian Section (CS) rate ( 5% of total
expected birth is the usual CS rate)
Number of Maternal Death, Ratio to
Total delivery
Number of Neonatal Death, Ratio to
Total delivery
Family Planning Programme
FP
current
users
target
versus
achievement
MWRA
% of services provided by NGOs to total
new acceptors of FP
Malaria Control Programme
No of confirmed malaria cases among
total malaria cases
Annual Blood Slide Examination Rate
(ABER) per 100
% of PF among total positive cases
Page 26

s)
10
18
13
157.54
108.55
119.45
94.39(101
cases
out of
107)
90.32(112
out of
124)
90.32(56
out
of 62
cases
)
78.80
73.04
0
86.34
72.8
0
89.52
73.89
9 (under
treat
ment
in
INF,
Bank
e)
New
case
Detection
Rate(NCDR)/10,000
Registered Prevalence Rate (PR)/10,000
Disability Rate Grade 2 Among New
Cases
HIV/AIDS Programme
1.90
2.35
2.12
1.45
4.49
1.81
1.79
1.77
5.43
Number of HIV +ve cases

Number of people counseling
Number of persons receiving ART
Number of ART sites
Number of Counseling centres
Curative Services
36
6069
24
1
3
12
10762
27
1
2
8
11614
34
1
3
Total OPD New Visits as % of Total

89.71
86.46
Population
Total new female OPD visits as % of
56.87
57.97
total OPD visits
% of communicable disease among total
21.28
17.36
OPD new visit
Average Number of People Served by Health Facilities Per Month
Government Hospital
3,209
2,381
93.79
Clinical
malaria
incidences
(CMI)
/1,000 risk population

Target versus achievement of blood
slide collection
Reported death due to malaria
percentage of indigenous cases among
total positive cases
Tuberculosis Control Programme

Treatment Success Rate on DOTS
Case Finding Rate
No of MDR Cases
Leprosy Control Programme
57.67
19.33
2415
Page 27

NGO/Private Hospitals and other health
institutions
PHCCs
Health Posts
Sub Health Posts
EPI Clinics
PHC/ORC Clinics
3,348
2,396
2524
4,359
11,562
21,605
5,657
5,664
4,395
11,666
22,372
5,315
5,374
4422
15627
18459
5882
5437
(Source: District Population Profile, DHO, Bardiya)
2.2 District Health System

District heath system comprises of different health care agencies which either act under
the government or independently, to provide preventive, promotive and rehabilitative services to
a defined population living in a district. These agencies act in a coordinated way to improve the
overall health status of the people of the district.
2.2.1 Health Care Delivery System
Page 28
FCHVs: 841
PHC/ORC: 156
Fig. 2.2: Health Care Delivery System in Bardiya District

Page 29
EPI Clinics: 197
Motipur HP
Belawa HP
Tatatal SHP
Baniyabh SHP
Kalika HP
Mainapo. HP
Jamuni HP
Deudakala HP=2
Sanoshree HP=2
Patabhar HP=2
Neulapur HP=2
Nayagaun HP=2
Khairichandanpur
HP=1
Khairapur HP=2
Bagnaha HP=2
Sorahawa PHC
MagragadhiPHC
Rajapur,PHC=2
Public Health Section
Gola SHP
Pasupati HP
Thakurdw ara SHP
Shivpur HP
Badalpur SHP
Daulatpur HP
Padnaha SHP
Dhadawar SHP
Manau SHP
Mohamad SHP
Mathura SHP
Suryapatu SHP
Manpurt HP
Bhimapur SHP
Dhodari SHP

District Health Office, Bardiya
Hospital Section

2.2.2 Health Care Providers in Bardiya District
Government Supported
o Bardiya District Hospital
o PHC : 3
o HP : 25
o SHP : 13
o PHC-ORC : 156
o EPI Clinics : 197
List of NGO/INGO & Private Health Institution

Table 2.5: NGOs/INGOs and Private Health Institution
Name
Institute of
Community
Health
Blue
Diamond
Society
NSAARC
Family
Planning
Association
of Nepal
Geruwa
Community
Health Center
SOS
Banshgadhi
KP Poly
Clinic
Bardiya Poly
Clinic
Sanoshree
Area of Geographic And Technical Support
Reporting
Status Y/N
Working on HIV/AIDS control in Bardiya in FSW and

their clients.
Working on HIV/AIDS control in Bardiya district in

MSM/TG.
Working on HIV/AIDS control in Bardiya district
Working on Maternal and Child Health
Not regular
Working on curative services in Pashupati Nagar VDC

of Bardiya
Working on Family Health, HIV/AIDS, Malaria, T.B.

and other curative services in Motipur, bardiya.
Working on family planning and curative services
Not regular
Working on family planning and other curative services
Not regular
Page 30
EDP Support
Table 2.6: EDP Support
Name of EDP
GIZ
Technical
Technical
Types of Support
Logistics
Financial
Financial
Save the children
Technical
Logistic
Health for Life (H4L)
Technical
support on
system
strengthening and
capacity building
UNICEF
Max Pro
Financial
Financial
Technical
2.2.3 District Health Office (DHO)

The health care delivery system has been decentralized by the Ministry of Health and
Population. Therefore the health care system is administered on a district level by the District
Public Health Office (DPHO) or the District Health Office (DHO).
The governing body
responsible for the preventive, promotive and curative aspect of health care in Bardiya is DHO.
The Senior Public Health Administrator (SPHA) supervises and monitors all components of the
district health system. Mr. Achyut Lamichhane currently holds this post.
Page 31

2.2.3.1 Human resource
Table 2.7: Human resource at DHO, Bardiya
Government
S.N.
Posts
Sanctioned
post
(in number)
Technical Staffs
1.
Sr. Public Health
Administrator
2.
HA/Sr.AHW
3.
Statistics Supervisor
4.
Family Planning
Supervisor
5.
EPI
Supervisor
6.
Health Education
Technician
7.
TB Leprosy
Supervisor
8.
Public
Health Nurse
9.
Vector Control
AssistantInspector
10. Malaria
11. Lab Technician
12. Computer Operator
13. Cold Chain Assistant
14. ANM
15. Lab Assistant
16. Typist
17. Driver
Administrative Staffs
1.
Na. Su.
2.
Accountant
3.
Kharidar
4.
Sub Accountant
5.
Ka .Sa.
Fulfilled
(in
number)
Currently Available
Among
government
sanction (in
number)
Local and
other
resources (in
number)
1
2
1
1
1
1
1
1
1
2
1
1
1
2
2
1
1
1
2
1
1
1
1
1
1
1
2
0
1
1
2
2
1
1
1
2
1
1
1
1
1
1
1
2
0
1
1
2
2
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
4
0
0
0
0
4
0
0
0
0
4
0
0
0
0
0
(Source: DHO, Bardiya)
Page 32

2.3 Management Functions of DHO
2.3.1 Planning
District Performance Review meeting at DHO (in Kartik)
Program Review meeting at DDC (in Falgun)
Regional level of Performance meeting
National Level Performance meeting
National Planning Commission
Ministry of Finance
Budget Allocation
meeting
Ministry of Health
Programs and targets fixed for DHO / PHCC / HP / SHP
Figure 2.3: Planning function of DHO, Bardiya
Planning begins from the district level and progresses upwards. The MoHP formulates
programs and sets targets each year. Resources are allocated accordingly based on meetings held
at various levels of the health system management structure.
2.3.2 Supervision and Monitoring
There is a regular system of integrated supervision and monitoring (S & M) of all
existing health related activities. For S & M, a tentative schedule of the whole year is prepared
and followed accordingly. There is supervision in each Primary Health Care Center (PHCC),
Health Post (HP), and Sub Health Post (SHP) at least once a month by the DHO.
Page 33

2.3.3 Recording and Reporting System
Regional Health Directorate / Department of Health Service / HMIS Section
th
12 day of every month
DHO
th
HP / PHCC
rd
SHP
st
FCHVs
Figure 2.4: Health Management Information System (HMIS) flow in Bardiya
The reporting status from SHP, HP, PHCC and District Hospital is 100% in the last 3
years.
2.3.4 Logistic management
Logistic Management Division
Donor Agencies
Regional Medical Store
District Store
SHP
HP
Local Purchase as per need
PHCC
Figure 2.5: Logistic management in Bardiya
Page 34
SHP, HP, PHCC

3 monthly report
Logistic management system, DHO

3 monthly report
DOHS, LMD
LMIS Unit
Figure 2.6: Logistic management information system (LMIS) unit: Logistic planning for
need based procurement, storage and distribution of all health care logistics.
2.3.5 Financial management (FY 2069/70)

As per the data obtained from DHO, Bardiya,
The total budget allocated was NRs. 69,27,000 for the FY 2069/70.
The total budget released was NRs. 55,71,830.
The total income for the FY 2069/70 was NRs. 34,81,621 and expenditure was NRs.
37,40,838.
2.3.6 Evaluation
Performance of staff is evaluated using a Performance Evaluation Form. The use of the
performance evaluation form is done on yearly basis.
Programs were evaluated through review meetings held once a month in each illaka.
Quarterly, half yearly and annual reviews are also held for each program. The evaluation of the
other NGOs working in the health was not in practice.
2.4 Health programs of DHO
2.4.1 Disease control program
a. Malaria
Annual blood slide examination rate in 2069/70 is 1.67 percent among total malarious
population which is more than previous year 2068/69. Number of confirmed malaria case has
decreased to 61 in 2069/70 from 124 in 2068/69. Total number of PF case has also decreased.
Page 35

Due to expansion of Lab service and TOT of Malaria for health institution in-charge, clinical
malaria has decreased to 10/1000 population.
Table 2.8: Indicators of malaria
Indicators
No of confirmed malaria cases among total
2067/68
2068/69
2069/70
120
124
62
1.72
1.26
1.67
5.61( 6 cases
out of 107)
9.68 (12 cases

out of 124)
18
13
9.68(6
out of
62
Cases)
10
157.54
108.55
119.45
94.39(101
cases out of
107)
90.32(112 out
of 124)
90.32(56
out of
62
cases)
malaria cases
Annual Blood Slide Examination Rate (ABER)
per 100
% of PF among total positive cases
Clinical malaria incidences (CMI) /1,000 risk

population
Target versus achievement of blood slide
collection
Reported death due to malaria
Percentage of indigenous cases among total
positive cases
b. Lymphatic Filariasis
The coverage was very low in fiscal year 2068/69 which was only 51.01 percent. Rumors
of people dying from taking prophylaxis against lymphatic filariasis originated from Banke
district spread very quickly and thousands of effort and strategies failed to stop that storm and
people did not accept drugs distributed in mass campaign but in fiscal year 2069/70, it was
radically increased than previous year (75.41%) due to mass communication, awareness, hard
work of health workers and public understanding of advantage of program.
Page 36

c. Tuberculosis (TB)
Tuberculosis is a major public health problem in Nepal. T.B. patients are being treated
with Directly Observed Treatment Short Course. The case finding in 2069/70 is 73.89 percent in
Bardiya district which is a little bit more than the year 2068/69. Treatment success rate has also
been increased to 89.52 percent in 2069/70 from 86.34 percent in 2068/69. All these indicators
meet the WHO standards.
Table 2.9: Tuberculosis control programme
Tuberculosis Control Programme
2067/68
2068/69
2069/70
Treatment Success Rate on DOTS
78.80
86.34
89.52
Case Finding Rate
73.04
72.8
73.89
No of MDR Cases
9 (under
treatment
in INF,
Banke)
d. Leprosy
The new case detection rate has declined very slowly. In 2069/70, it was 2.12 per 10,000
populations whereas in 2068/69 it was 2.35. Although the prevalence has decreased, it is more
than 1 per 10,000 population. In 2069/70 it is 1.77 per ten thousands population which exceeded
the elimination level and disability grade 2 is 5.43 which indicates the late detection of new
cases.
Table 2.10: Leprosy control programme
Leprosy Control Programme
2067/68
2068/69
2069/70
New case Detection Rate(NCDR)/10,000
1.90
2.35
2.12
Registered Prevalence Rate (PR)/10,000
1.45
1.81
1.77
Disability Rate Grade 2 Among New Cases
4.49
1.79
5.43
Page 37

e. Rabies
Rabies is a significant problem in Bardiya district. The number of animal bites in the year
2069/70 was 707 out of which 674 people were treated for post-exposure prophylaxis of rabies.
However, there was no death due to rabies.
Table 2.11: Status of rabies in the district
Indicators
2069/70
Total number of animal bites (species wise)
707
Number of persons treated for post-exposure prophylaxis of rabies
674
Vaccine (vial) expenditure
2601 vial
Number of deaths due to rabies (hydrophobia)
f. Snake bite
Snake bite is a problem in Bardiya district in summer and rainy season. The total number
of snake bites in the year 2069/70 was 46 out of which only 6 required anti-snake venom serum.
Only 1 person died of snake bite in the year 2069/70.
Table 2.12: Status of Snake bite in the district
Indicators
2069/70
Total number of snake bite
46
Number of persons treated for poisonous snakebite
Anti snake venom serum expenditure
38 vial
Number of deaths due to snake bite
2.4.2 Child Health

The Child Health and Nutrition Section of the DHO is responsible for conducting the
following programs: Expanded Program on Immunization (EPI), School Health and Nutrition
Program, Integrated Management of Childhood Illness (IMCI) program, Control of Diarrheal
Diseases (CDD) and Acute Respiratory Illness (ARI), Community Responsive Antenatal,
Delivery and Life Support project for mothers and newborn.
Page 38

a. Immunization
The National Immunization Program (NIP) is a high priority program (P1) of
Government of Nepal and is provided free of cost. Immunization is considered as one of the
most cost-effective health interventions. It has significantly contributed to reduce the burden of
vaccine preventable diseases and child mortality. The Regional Health Directorate (RHD) acts as
a facilitator between the Central and the District levels. It is the responsibility of the DHO to
ensure that a successful immunization program is implemented at the district and below level.
Primary Health Care Centers (PHCs), Health Posts (HPs), and Sub-Health Posts (SHPs)
implement immunization programs in their respective municipalities and Village Development
Committees (VDCs) by extending the EPI clinics.
In Bardiya district immunization services has been providing from all the health facilities
including 197 EPI clinics. There are 4 to 7 EPI clinics in each VDC as the national references it
is estimated 3 to 5 EPI clinics in each VDC.
Table 2.13: Performance Status FY 2067/68 2069/70,
National Immunization Programme
S.N.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Indicators
BCG Coverage
DPT-Hep B-Hib 3 coverage
Measles coverage
% of TT2+ (Pregnant
women)
coverage
Dropout rate DPT-1 Vs
DPT-3
Dropout rate BCG Vs
Measles
Number and % of
unimmunized
children
Wastage rate by antigen
BCG
DPT Hep B
Polio
Measles
J.E.
TT
No. of VDC with <90%
2067/68
67.71
76.86
68.33
25.16
2068/69
66.05
69.15
65.73
25.35
2069/70
75.00
76.17
75.70
32.84
-0.08
1.25
0.46
-0.01
0.18
-0.93
3692
(32.29%)
4012
(34.15%)
2600
(24.30%)
81
1
17
60
29
24
28 VDCs
81
2
16
60
33
23
29 VDCS(only
80.96
11.35
17.18
62.06
36.42
17.14
30 VDCs (Only
Page 39

DPT3
10.
11.
12.
coverage
No. of AFP Cases

No. of Measles cases
No. of Neonatal tetanus
Cases
(Belawa,
Jamuni and
Kalika Have
more than 90)
8
65
0
Belwa and
jamuni have
>90%
Coverage)
6
12
0
Belwa VDC has >

90 % coverage)
9
2
0
(Source: Annual Health Report, DHO, Bardiya 2069/70)
b. Nutrition Program
Malnutrition remains a serious obstacle to child survival, growth and development in
Nepal. National nutrition program aims to improve the overall nutritional status of children,
pregnant women, women of child bearing age. This is implemented through the control of
general malnutrition and prevention and control of micronutrient deficiency disorder.
In Bardiya district the overall nutritional status of children and pregnant women, women of child
bearing age, the following programs are under intervention:
Community based Management of Acute Malnutrition (CMAM)
Infants and Young Child Feeding (IYCF) program
Growth monitoring under 5 children
National Vitamin A program and Anti-helmenthic tablet distribution to under 5 years

children (Kartik to Baisakh)
Iron distribution to pregnant mothers
Anti-helmenthic tablet distribution for pregnant mothers
Vitamin A distribution for post partum mothers
Celebration of world breast feeding week (first week of August)
Celebration of Iodine month (February)
Celebration School health and nutrition week (Jesth 1 to7)
De-worming program for government school children
Baal-vita program for 6 months to 23 months children
Page 40

Table 2.14: Status of nutrition programme
S.N. Nutrition Programme
2067/68
2068/69
2069/70
1.
New growth monitoring visits as % of <5 years

children
54.28%
59.03%
74.41%
2.
Proportion of malnourished children as % of new
3.22%
2.66%
3.29%
68.25%
71.60%
growth monitoring (< 5 years)

3.
% of expected pregnant mothers supplemented with 76.39%

Iron tablets
4.
% of pregnant mothers who received 180 iron

tablets
40.75%
41.20%
47.28%
5.
% of pregnant supplemented by Anti-helmenthic
69.25%
66.42%
67.14%
tablet
6.
% of Postpartum mothers receiving Vitamin A
56.00%
55%
54.11%
7.
Vitamin "A" Distribution Coverage (number and
46289
43,667
41908
%) 1st (Kartik) round (6 month to < 5 years
(92.17%) (89%)
(93.59%)
Vitamin "A" distribution coverage (number and %)
44518
39333
2nd (Baisakha) round (6 month to <5 years
(88.64%) (87%)
(87.84%)
Anti-helmenthic tablet distribution coverage
41692
37692
(number and %) 1st (Kartik) round (1- <5 years
(94.10%) (88.28%)
(95.79%)
Anti-helmentic tablet distribution coverage
40220
34761
(number and %) 2nd (Baishakha) round (6 month
(90.78%) (89.24%)
children)
8.
42,671
children)
9.
38051
children)
10.
38463
(88.34%)
to <5 years children)

(Source: Annual Health Report, DHO, Bardiya 2069/70)
c. CB-IMCI
Community Based Integrated Management of Childhood Illness (CB-IMCI) Program is
an integrated package of child-survival programs and addresses major 5 killer diseases like
Pneumonia, Diarrhea, Malaria, Measles, and Malnutrition in 2 months to 5 year children and
Page 41

basic new born care in holistic approach. CB-IMCI also includes management of infection,
jaundice, hypothermia and counseling on breastfeeding for young infants less than 2 months of
age. With the implementation of this package children are diagnosed early and treated
appropriately for major childhood diseases at the health facility and community level. At the
community level FCHVs play key role to increase community participation.
The objectives are to
reduce frequency and severity of illness and death related to ARI, Diarrhea, Malnutrition,
Measles and Malaria.
contribute to improved growth and development.
Impacts of the Program

Institutional delivery is found to be increased.
Infectious new born cases are being treated in the community level.
Treatment procedure is similar all over the district.
FCHVs are happy because government is providing incentives for new born care.
Community people are satisfied due to low/no cost for the treatment.
Saving of time of community people because of availability of treatment in community.
It enhanced the level of knowledge, skills of health workers and FCHVs.
It developed precise and easy protocol.
It has decreased neonatal and child morbidity and mortality because early management in
community level.
2.4.3 Maternal and Child Health/Reproductive Health

a. Family Planning Program
The main thrust of the National Family Planning Program is to expand and sustain
adequate quality family planning services to communities through the health service network
such as hospitals, primary health care (PHC) centers, health posts (HP), sub health posts (SHP),
primary health care outreach clinics (PHC/ORC) and mobile voluntary surgical contraception
(VSC) camps. The policy also aims to encourage public private partnership. Female community
health volunteers (FCHVs) are to be mobilized to promote condom distribution and re-supply of
Page 42

oral pills. Awareness on FP is to be increased through various IEC/BCC intervention as well as
active involvement of FCHVs and Mothers Groups as envisaged by the revised National Strategy
for Female Community Health Volunteers program. In this regard, family planning services are
designed to provide a constellation of contraceptive methods/services that reduce fertility,
enhance maternal and neonatal health, child survival, and contribute to bringing about a balance
in population growth and socio-economic development, resulting in an environment that will
help the Nepalese people improve their quality of life.
Status of IUCD, Implant and satellite clinic service sites:
Fig. 2.7: Status of IUCD, implant and satellite clinic service
The graph shows the sites of the long term methods. These numbers of sites cannot cover
the total MWRA. Implant demand is high but sites and trained human resources are not
sufficient. All existed sites cover very small area of the district. The diagram shows that CPR in
the fiscal year 2069/70 is 59.66 percent which is 6 percent more than fiscal year 2068/69 which
is very good and the district is very near to Millennium Development Goal of 67 percent by
2015. Percentage of new acceptor, both method mix and spacing FP method are also in
increasing trend in the last three years. According to the given target the achievement of the VSC
is in increasing trend though the number of client of VSC is going to be decreased every year.
Page 43
Fig. 2.8: Status of contraceptive prevalence rate
b. Safe Motherhood Program

The goal of the National Safe Motherhood Program is to reduce maternal and neonatal
mortalities by addressing factors related to various morbidities, death and disability caused by
complications of pregnancy and childbirth. In Bardiya, safe delivery incentive program provides
NRs. 500 for transportation to a health facility.
Table 2.15: Status of service delivery sites in the district
Indicators
2067/68
2068/69
2069/70
No of functional BEOC sites
No of functional CEOC sites
No of Safe abortion sites
Ratio of BEOC/CEOC sites to Population

(Population/No. of sites)
1:117100
1:118933
1:108575
No of birthing centers and Ratio to EP (No.

EP/No. BC)
17
17
17
Page 44

Table 2.16: Service status in the district
S.N.
Indicators
2067/68
2068/69
2069/70
1.
ANC 1st visit as % of expected pregnancy
68.44%
66.72%
68.22%
2.
ANC 1st visit as % of expected live birth
76.03%
74.27%
75.79%
3.
4.
4 ANC visits as % of 1st ANC visit

Delivery conducted by SBA as % of expected live
births
Delivery conducted by health worker as % of Exp.
live birth
% of institutional delivery among expected live
births
PNC 1st visit as % of expected live birth
No of CAC (Surgical and Medical Abortion, MA)
No of PAC
% of women receiving maternity incentives among
total institutional deliveries
% of women receiving 4 ANC incentives among
total institutional deliveries
Met need of emergency obstetric care (need of
EOC is 15% of expected live birth)
Caesarian Section (CS) rate ( 5% of total expected
birth is the usual CS rate)
Number of Maternal Death
Number of Neonatal Death
65.07%
39.90
66.43%
41.20
68.19%
43.64
1.09
0.32
0.08
39.99
41.08
43.54
49.04
580
159
100
44.91
242
153
100
45.08
200
162
100
33
41
63.57
0.1%
9.03%
10.74%
0.11
0.03
0.00
8
98
7
79
5
45
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
2.4.4 Female Community Health Volunteers (FCHV) Program

Recognizing the importance of women's participation in promoting health of the people,
GoN initiated the Female Community Health Volunteer (FCHV) Program in FY 2045/46
(1988/1989) in 27 districts and expanded to all 75 districts of the country in a phased manner.
The major role of the FCHV is to promote health and healthy behavior of mothers and the
community. Besides the motivation and education, the FCHVs re-supply pills and distribute
condoms, ORS packets and vitamin A capsules; and in IMCI program districts, they also treat
pneumonia cases and refer more complicated cases to health institution. Similarly, they also
distribute iron tablets to pregnant women.
Page 45

Table 2.17: FCHV Performance Status
Indicators
2067/68
2068/69
2069/70
Proportion of Pills cycles distribution by

FCHVs among total distribution
Proportion of Condoms distribution by
FCHVs among total distribution
Proportion of ORS distribution by FCHVs
among total distribution
Number of maternal death reported by FCHV
Number of newborn death reported by FCHV
% of Mother's Group Meeting held
Total Loan Mobilized from FCHV Fund (Rs.)
51.23
43.58
46.56
51.03
47.88
48.73
64.14
NA
NA
0
0
73.34
11,408,256
0
0
75.48
10,558,439
0
0
77.18
10,13,244
2.4.5 Primary Health Care-Outreach Clinic (PHC-ORC) Program

PHC/ORC program was launched in 1994 by the Government of Nepal with an aim to
improve access to some basic health services including Family Planning and Safe motherhood
services for rural households. PHC-ORC clinics are an extension of HP & SHP at the community
level. VHW & MCHW or ANM provide basic PHC services (FP & ANC services/HE/minor
treatment) to communities (2-5 catchment areas per VDC) at a pre-arranged place on a
predetermined date once a month.
Table 2.18: PHC-ORC Performance Status
Indicators
2067/68
2068/69
2069/70
Number and % of PHC/ORC conducted with

respect to targeted
1718
(91.77)
1635
(87.34)
1700
(90.81)
Number of People Treated by First Aid
15558
14658
10829
No. of women who received ANC Services
10301
9933
8098
% of growth monitoring through ORC (to total

growth monitoring)
51.53
51.16
52.80
Page 46

2.4.6 Free Health Services
The interim constitution of Nepal 2063 has emphasized that every citizen shall have the
right to basic health services free of cost as provided by the law. As a result, the free health
service is provided in all sub-health posts and health posts. This service has also been extended
to PHC and government hospitals with capacity of 25 beds in 35 districts. Essential drugs (33 in
PHCC, 24 in SHP/HP, 41 in District Hospital) including basic lab investigations are also
provided free to the patients. Family Planning, Immunization, Nutrition, Malaria, Filaria, TB,
Leprosy treatment and interventions are provided free.
The percentage of targeted groups receiving free indoor service among total discharge
patients was 2.54 in 2068/69 and 3.62 in 2069/70 (Source: Annual Health Report 2069/70, DHO,
Bardiya).
2.4.7 OPD-IPD CARE

The OPD, IPD and ER are essential components of the health service. Essential health
care services (emergency and inpatient) are provided free of cost to the poor, disabled, senior
citizens and FCHVs in 25 bedded district hospitals; and PHCCs and emergency service to all
citizens at SHP/HP level. Curative services aim to reduce morbidity, mortality and to provide
quality health services by means of early diagnosis; adequate as well as prompt treatment and
appropriate referral if necessary.
Fig. 2.9: OPD Services FY 2067/68 2069/70

Page 47

The above diagrams shows that peoples visit in HFs are increasing in fiscal year 2069/70
compared to previous year 2068/69. The percentage of female patients is similar in the last three
years and percentage of communicable disease has increased slightly (2 %) in the year 2069/70
than previous year 2068/69.
2.4.8 Health Education, Information and Communication Program
IEC is the most important and valuable program of health system which helps and promotes
to have a healthy life and promotes positive behavior change in community people. It enhances
the accessibility of people to utilize health services. The DHO is actively involved conducting
various programs that produce and distribute IEC materials such as posters and pamphlets. In
this program, major activities are conducted like- FM broadcasting, interaction with community
people, printing and distribution IEC material, health promotion campaign, different health day
celebration.
2.4.9 Laboratory Services

Table 2.19: Utilization of laboratory services in Bardiya district
FY
Parasitology/
Bacteriology
Virology
Hematology
Histopathology
Biochemistry
Immunology/
Serology
Other
Tests
2067/
68
6740
8890
1451
2768
13
2068/
69
4888/8165
16202
4162
6129
1111
5160
8731/
2069/
70
5353/12040
2979
20767
537
Above table shows that laboratory services are in increasing trend. It is due to expansion
of lab service in health facilities in Bardiya.
2.4.10 OCMC : One stop Crisis Management Centre

OCMC is a center to provide all the care needed in one place, including treatment of
injuries, shelter, psychological counseling, rehabilitation, negotiation with the family, legal
Page 48

advice and protection. Basically, it is a patient centered management place because officers from
all relevant agencies will come to provide assistance once they are called.
Hospital based OCMC was established at District Health Office Bardiya in 2068/8/16
before inauguration of the centre. District co-ordination committee was formed in the
chairmanship of Chief District Administrator and also case management committee was formed
on guidelines developed by Ministry of Health and Population.
Table 2.20: Status of cases registered in the center (from establishment to now)
S.N.
1.
2.
3.
Type of Crime
Rape
Physical Assaults
Burns by others
Total
Numbers
29
27
5
61
Out of the total 61 cases, three were cases of F/Y 2070/71. The data shows that rape case
in Bardiya is high as compared to others.
Table 2.21: Age wise distribution of the victims

Age interval
0-5
6-10
11-20
21-30
31-50
51 +
Total
2068/69
0
2
7
6
0
0
15
Fiscal Year
2069/70
0
2
7
17
13
4
43
Number
0
4
14
23
13
4
58
Table shows that age group 11-50 is mostly affected.

About 7% victims are below 10 years age. In the fiscal year 2068/69, only 15 victims
were registered in the center because the center started the work late in the fiscal year. In fiscal
year 2069/70, 43 cases were registered and managed in the centre.
Page 49

B. PERIPHERAL INSTITUTION VISIT/ HEALTH FACILITY OBSERVATION
2.5 Visits to Different Health Facilities
2.5.1 Swarahawa PHCC
a. Introduction
It is located in Swarahawa VDC. This PHCC can be reached by a motorable road in
about thirty minutes from Gulariya District Hospital and kachhi road link with Highway. It was
established in 2032 B.S. in the form of HP and it was upgraded to PHCC in 2052 B.S. The
catchment areas of the PHCC include 7 VDCs which are:
Swarahawa
Jamuni
Mainapokhari
Motipur
Belawa
Kalika
Deudakala
b. Resources
Physical resources
The PHCC has 2 buildings:
Administrative building
Service providing building.
The administrative building has store room, administrative room and two computer
rooms along with separate office.
The service providing building has registration room, emergency room, TB/Leprosy
(DOTS clinic), Laboratory, Dressing room, VCT counseling room and MCH (Family Planning,
ANC).
The PHCC has capacity of three beds: one for labor and two for emergency. The PHCC
also provides the comprehensive abortion care service by trained nursing staffs upto 8 weeks.
Within the PHCC premises is also the quarter capable of accommodating three families.
Page 50

Human resource
Table 2.22: Human resource of Swarahawa PHCC
S.N.
Post
Sanctioned
Medical officer
H.A.
Sr. AHW
Staff Nurse
AHW
ANM
Lab. Assistant
VHW
Peon
12
11
Total
Fulfilled
2.5.2 Motipur HP
a. Introduction
Motipur HP was established in Asar, 2050 BS as a SHP and was promoted to HP in Asar
7, 2070 BS. It is located in Bansgadi, Bardiya. Its catchment areas include ward no. 6 of Belawa
VDC, ward no. 3, 5 and 9 of Deudakala VDC.
b. Resources
Physical Resources
It has got 2 buildings; one storied each, one with 3 rooms and the other with 2. The
buildings have:
1 Office which also works as OPD
1 Dressing room
1 Store room
1 Labor room / Birthing centre
1 Employees room
The health post has 2 beds for examination.

Page 51
Human resource
All posts sanctioned for SHP were fulfilled.
Table 2.23: Human resource of Motipur HP
S.N.
Post
Sanctioned
Fulfilled
1.
HA
2.
AHW
2+1
3.
ANM
1+1
4.
Peon
5+2
Total
Page 52

Chapter III
HOSPITAL PROFILE: BARDIYA DISTRICT HOSPITAL, BARDIYA
3.1 Introduction
Bardiya District Hospital was established in 1991 B.S. Total area of this hospital is above
6 bighas. Though the hospitals catchment area is whole district, because of its geographical
location it has been able to provide service to municipality and only few VDCs.
11 VDCs of Bardiya district are located on the other side of Geruwa river. So during
rainy seasons, accessibility to the hospital is difficult and people go to nearby hospitals. Because
of the close proximity to Nepalgunj and India, majority of the people seek health services in
Nepalgunj and Lucknow.
3.3 Capacity of the Hospital

The hospital was initially 15 bedded. During fiscal year 2061/62, hospital support
committee (sahayog samitee) was changed to hospital development committee and additional 10
beds were approved making the hospital 25 bedded.
3.4 Infrastructure
The hospital premises houses the following buildings:
a. Main hospital building (2 Block, New and Old)
The main hospital building houses Emergency department, OPD, Dressing rooms,
DOTS centre, ART clinic, In-patient department, Labour room, Radiology room
and Operation Theatre
b. MCH building
c. Nepal Red Cross building
d. Store building
e. Laboratory building
f. Post mortem building
g. Staff buildings- 3 (2 Doctor quarters and 1 Nursing quarter)
Page 53

3.5 Management and Other Facilities
3.5.1 Bardiya District Hospital Development Committee, Bardiya
A. Hospital Management Committee
President Khem Prasad Poudel
Members Officer of DAO (G PRa ka)
NRCS President
LDC Officer
Chief of Municipality
President of Chamber of Commerce
DEO officer
Nursing in-charge
Female Representative from ward or nominated by president
B. Quality Control Committee
President District Health Officer
Members Medical Superintendent / Representative of Hospital
Nursing Incharge
Lab Technician (DHO)
HA, Public health nurse (DHO)
Statistical Assistant (DHO)
Consumers forum
NGOs of District / Nursing Home members
District Health Officer/Supervisor (DHO)
3.5.2 Financial Management (in FY 2069/70)

Table 3.1: Financial Management (in the year 2069/70)
Programme/ Activities
Development
Committee
Sadharan Anudan
Budget
Allocated
2069/70
-
Budget Released
2069/70
34,81,621
Budget
Expenditure
2069/70
37,40,838
13,17,000
14,01,967
14,01,967
Page 54

3.5.3 Human Resource Management
Human resource and its management is the integral part of health care delivery system.
Local resource utilization is an important aspect in health care delivery system especially in the
peripheral areas where the manpower is usually lacking. Below is the list of human resources
working in Bardiya District Hospital.
Table 3.2: Human resource management in Bardiya district hospital
S.N.
POSTS
GOVERNMENT
CURRENTLY AVAILABLE
Sanctioned
post
(in
number)
Among
government
sanction (in
number)
Local and other

resources
1
1
1
4
1
1
1
2
1
2
1
0
1
1
4
1
1
0
2
1
2
0
0
0
1
4
1
1
0
2
1
2
0
0
4
0
0
0
0
0
0
0
0
0
1
1
9
0
1
4
0
1
4
0
0
0
(in
number)
Technical Staffs
1.
2.
Medical Officer
3.
HA/Sr. AHW
4.
Staff Nurse
5.
Medical Recorder
6.
Lab Technician
7.
Radiographer
8.
AHW
9.
Lab assistant
10.
ANM
11.
Dark Room Assistant
.
Administrative (Non-Technical)
1.
Na.Su.
2.
Kharidar
3.
Ka. Sa.
Fulfilled
(in number)
Page 55

3.6 Services Provided by the Hospital
The hospital provides following services:
a. OPD service
The OPD service is provided by the hospital 6 days a week from 10:00 am 2: 00 pm.
The tickets for the OPD are available from 9:00 am 12:00 pm. The price of ticket is NRs. 5.
The OPD is functioning in 3 different rooms and there is separate OPD service to the HIV/AIDS
patients through ART/VCT clinic. There are 2 separate dressing rooms.
b. Indoor service
There are 25 beds in the hospital out of which 6 beds are separated for malnutrition, 6 for
post-partum mothers and 2 for delivery. Remaining 11 beds are used as per the flow of patient in
the hospital.
The admission charge is NRs 30, and patients are not charged for further stay in the
hospital.
c. Emergency service
The hospital provides 24 hour emergency service run by 6 staffs:
Emergency Room In-charge : Senior AHW
Senior AHW
:2
AHW
:3
HA
:1
There is a provision for 24 hour on call service by the medical officer who is the first
duty on call and there is no separate emergency lab but the lab assistant also works on call. There
are 8 beds altogether. The charge for the emergency admission is NRs 10.
d. Obstetrics services
This service is provided by the hospital for 24 hour throughout the week. The hospital
provides the service of normal vaginal delivery, vacuum delivery, forceps delivery and
Caesarean Section. There is an adequate supply of equipment and drugs for different procedures.
There are 2 beds for delivery and 6 for post-partum mothers.
Page 56

Table 3.3: Obstetrics services provided by Bardiya district hospital
Particulars
2066/67
2067/68
2068/69
2069/70
Total
no.
of
delivery
conducted
No. of normal delivery
669
916
857
718
421
557
503
416
No. of Caesarian Section
248
359
354
302
Total live births
660
905
851
712
Total maternal deaths
(Source: MCH records, Bardiya District Hospital)
Service Delivery
a. Morbidity pattern in OPD and Emergency
35000
30344
30000
25757
No. of patients
25000
22028
19369
20000
OPD
15000
ER
10000
5000
3122
4529
4089
4050
0
2066/67
2067/68
2068/69
2069/70
Fiscal Year
Fig. 3.1: Morbidity pattern in OPD and Emergency in FY 2066/67 - 2069/70

(Source: Annual report 2069/70, Bardiya District Hospital)
Number of patients in Emergency is in increasing trend in first three fiscal years and
slightly decreased in the last one. This is due to a number of reasons like increasing awareness
about health related problems in people, private hospitals reluctant to admit critical cases,
increasing Road traffic accidents, increased population, increasing popularity of essential health
Page 57

care services, etc. The number of patients coming to OPD is decreasing primarily due to better
facilities available in nearby areas like Banke district and Lucknow, India.
2067/68
100
90
89.71
2068/69
2069/70
93.79
86.46
80
70
56.87 57.97 57.67
60
50
40
30
21.28
20
17.36 19.33
10
0
Total new OPD visits as % of Total new female OPD visits as
total OPD visits
% of total OPD visit
% of communicable disease
among total OPD new visit
Fig. 3.2: OPD visits in Bardiya district hospital

(Source: Annual Report 2069/70, Bardiya)
Most of the OPD cases are new one among which most are females. Fraction of
communicable disease is about one-fifth of total OPD new visit.
b. Mortality pattern among In-patients
Total Hospital Deaths
2067/68
2068/69
2069/70
10
Trend
( - or + )
-
The cause of death of patient in 2069/70 was COPD.
Page 58

3.6.3 Institutional Services
a. MCH and Family Planning (FP) services:
There is a separate building for MCH/FP service in the hospital, which provides services
in the working days. The services provided on different days are as follows:
Table 3.4: MCH and Family Planning (FP) services
Days
Sunday
Monday
Services
and
Child immunization, HE, Nutrition and Counseling
Tuesday
Wednesday
Friday
ANC, TT, Counseling.
to
FP (Temporary), HE and Counseling
b. ART/VCT Clinic:
ART clinic was established in B.S. 2067, Mangsir. There are 3 staffs ART counselor,
DAC co-ordinator and focal person (staff nurse), in ART clinic. The clinic runs for 10 am to 5
pm and is closed on Saturdays and public holidays. The services of the clinic are ART, VCT, STI
and PMTCT. The clinic has provided ART therapy to 48 HIV positives (till March 2014) out of
which 36 are currently under medication, 5 males died, 2 females died, 2 females were
transferred out and 1 male and 2 females discontinued therapy for unknown reasons.
When patient is found ELISA positive he/she is referred to Nepalgunj for CD4+ count. If
CD4 count is low, medication is started and the patient is kept under observation for 15 days in
Nepalgunj. Then the patient is referred back to the ART clinic for the continuation of
medication.
c. DOTS and DOTS plus center:
There are two staffs in DOTS center DOTS center incharge and focal person (AHW).
This center runs every day from 10 am to 5 pm. Both of these clinics are within the hospital
premises. Patients can receive TB treatment free of cost as instructed by the Ministry of Health.
National Tuberculosis Program started DOTS plus project for the treatment of MDR cases since
B.S. 2070, Magh. The DOTS plus center also provides service to the Leprosy patients.
There are 35 TB patients and 2 Leprosy patients. 3 out of 35 TB patients are MDR TB.
Page 59

d. Safe abortion services:
Number of CAC Services Provided
2066/67
2067/68
2068/69
2069/70
63
102
81
3.6.4 Radiology and Diagnostics

X-ray and USG services are available in the hospital. There is 1 X-ray machine operated
by dark room assistant and 1 USG machine used by the General Practioner.
3.6.5 Laboratory
The laboratory service is provided by the hospital in a separate building. Most of the
essential investigations are available. The service is provided throughout the week and sample is
collected from 10:00 am to 3:00 pm. Emergency investigation service is provided 24 hours a day
on call. The investigations available in BDH are as follows:
a. Biochemical Investigations
Na+, K+, Blood Sugar, Urea, Creatinine, Uric Acid, Total Bilirubin and Direct Bilirubin
b. Serological and Immunological Investigations:
Widal slide agglutination test, Blood HBs Ag test, VDRL test, TPHA test, RA factor test
and CRP test.
c. Hematological Investigations:
Total Count, Differential Count, Hemoglobin, Erythrocyte Sedimentation Rate, Platelets,
Blood grouping and Malarial Parasite test (free)
d. Other Investigations:
Routine and microscopic examination of urine and stool, Urine Pregnancy Test and
Sputum test (free)
Laboratory Equipments:
a.
b.
c.
d.
e.
f.
g.
h.
Microscope 3
Water Bath 1
Hot Air Oven 1
Incubator 1
Colorimeter 2
Balance 1
Centrifuge 2
Shaker 1
Page 60
S.N.
1.
2.
3.
4.
5.
6.
7.
8.
Table 3.5: Laboratory Services provided by Bardiya district hospital

Health Laboratory Services on Type (in 2066/67
2067/68 2068/69
2069/70
Total Number)
Parasitology/Bacteriology
1842
3751
3847
2448
Virology
46
563
1686
Hematology
5918
6119
5846
4581
Microbiology
861
Histopathology
Biochemistry
955
737
1537
638
Immunology/Serology
1625
842
919
944
Other Tests
7
66
5
(Source: Annual Health Report 2069/70, DHO, Bardiya)
3.6.6 Preventive and Promotive Facilities

a. Immunization:
It is provided according to the national policy on immunization.
Table 3.6: Immunization services provided by Bardiya district hospital
S.N.
Particulars
1.
No.
Recommended Age
BCG
of
Doses
1
2.
DPT, HEP B, Hib
6, 10, and 14 weeks of age
3.
Polio
6, 10, and 14 weeks of age
4.
Measles
9 months of age
5.
TT
6.
JE
All Pregnant women

Note 5 doses of TT vaccine
during
a
womans
reproductive life
12 to 23 months
At birth or first contact
b. FP
c. Safe motherhood
d. TB DOTS and Leprosy centre
e. ART/VCT Centre
3.6.7 Post-mortem Services and Medico-legal Services

BDH provides post mortem examination of medico legal cases as recommended by the
district police office. The post mortem is performed by a MO on duty. The toxicological samples
Page 61

are sent to the forensic lab in National Academy of Science and Technology, Kathmandu for
further examination.
3.7 Physical Facilities
Table 3.7: Physical facilities available in Bardiya district hospital

25
No. of sanctioned beds
No. of available beds
25
Functioning ambulance
Electric supply
Water supply
Inadequate because of
loadshedding
(generator
available)
Adequate
Other essential facilities
No ICU, CCU, NICU
General services
Yes
Orthopedic services
No
Medical services
Yes
Surgical services
Yes
Gynae/Obs services
Yes
Pediatric services
Yes
Dental services
No
Pathology services
No
Operation theatre
Yes (1 minor and 1

major)
3.8 Hospital Equipment

Table 3.8: Hospital equipments available in Bardiya district hospital
Equipment
X-ray
Number
1
Equipment
Refrigerator
Number
3
Microscope
Oxygen concentrator
Oxygen cylinder
ECG machine
USG machine
3
2
8
2
1
OT table
OT lights
Incubator
Suction machine
2
2
1
2
Page 62
3.9 Top 10 diseases in OPD (in terms of morbidity, FY 2069/70)
S.N.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Table 3.9: Top 10 diseases in OPD

Disease
Percentage
Upper Respiratory Tract Infection
6.97%
Impetigo/Boils/Furunculous
6.16%
ARI/Lower Respiratory Tract Infection 4.82%
Gastritis (APD)
4.81%
Headache
4.36%
PUO
3.94%
Typhoid (Enteric Fever)
3.78%
Intestinal Worm
3.39%
Amoebic Dysentery
3.38%
Fungal Infection
3.17%
(Source: Annual report 2069/70, Bardiya)
3.10 Top 10 diseases in In-patient department (in terms of morbidity)

Table 3.10: Top 10 diseases in In-patient department in FY 2069/70
S.N.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Cases
Incomplete abortion
Acute Gastroenteritis
COPD
PUO
Pneumonia
Enteric Fever
Severe Malnutrition
Burn
Chest Infection
Abdominal Pain/APD
No.
81
80
56
39
35
28
17
10
7
5
(Source: Annual report 2069/70, Bardiya)
Page 63

Chapter IV
AN EPIDEMIOLOGICAL STUDY OF MALARIA IN BARDIYA DISTRICT
4.1 Introduction
Malaria is a disease of tropics and subtropics all over the world. It is a vector borne
disease (VBD) transmitted by female Anopheles mosquito. Only 10 districts of Nepal are malaria
free so far and hence is still an endemic disease of Terai of Nepal. Bardiya is amongst the 13
highly endemic districts where global fund is actively supporting the governments intense
malaria control program as Roll Back Malaria due to high case load.
It is caused by 4 different species of plasmodium, viz P. vivax, P. falciparum, P.
malariae and P. ovale. P. vivax is the predominant malarial parasite (approximately 10 times
more common than P. falciparum) found in Nepal over the past few years (national malarial
treatment protocol, November 2004, Epidemiology and Disease Control Division). However the
exact proportion of this parasite species varies from place to place and air to air. P. malariae is
not so common in Nepal. P. ovale is found mainly in Africa.
P. falciparum causes a potentially fatal disease (cerebral malaria). Clinical condition of
the patient suffering from P. falciparum malaria suddenly deteriorates within 24 hours of
presentation of febrile illness. However, so is not the case with P.vivax which runs a relatively
benign course of the disease.
Resistance of P. falciparum against currently available anti malarial drugs is an
increasing problem worldwide. Malaria control program in Nepal was initiated in 1954 through
the Insect Borne Disease Control Program, supported by USAID. In 1958 Malaria Control
Program, the first national public health program in the country was launched with the objective
of eradicating malaria from the country. Later it was reverted back to Malaria Control Program
in1978.
After intense reviews, the strategies were revised in accordance with the WHO Global
Malarial Control Strategy (GMCS) in 1983. Following the call of WHO to revamp the Malarial
Control Program in 1998, RBM initiative was launched to address perennial problem of malaria
in hard core forested, foothills, and inner Terai and valley areas of the hills, where more than 70
percent of total malarial cases in the country prevail. RBM was operational in 12 priority districts
and currently malaria control activities are carried out in 65 districts at risk of malaria. The
Page 64

global fund is actively supporting Malaria Control Program in the high endemic 12 districts since
2004.
4.2 Case Definition
1. Clinical Malaria: a person from malaria endemic area who presents with fever or history
of fever during last 3 days after the exclusion of other causes of fever.
2. Imported Case: a person with malaria who has a travel history to India in the past 6
months.
3. Indigenous case: a person with malaria who has not travelled to India in the past 6
months.
4. Relapse: a person with laboratory proved malaria showing symptoms of malaria after
completion of full course of treatment.
4.3 Indicators
Page 65
4.4 National Treatment Protocol 2010/11

Antimalarial drugs will be provided free of charge from all public sector health facilities.
Antimalarial drugs will be provided free of charge through the Female Community
Health Volunteer (FCHV) network in high risk area (stratum 1 VDCs) and moderate risk area
(stratum 2 VDCs) according to national treatment guidelines.
Artemisinin-based combination therapy (ACT) will be provided for confirmed falciparum

malaria cases throughout the country (according to national treatment guidelines).
Chloroquine will be provided for confirmed vivax cases and suspected malaria cases
(according to national treatment guidelines).
Primaquine will be provided for the radical cure of confirmed vivax cases (according to
national treatment guidelines).
National malaria treatment guidelines will be reviewed regularly and revised as

appropriate based on the findings of drug resistance surveillance.
National malaria treatment guidelines (and any revisions to them) will be implemented at
all public sector health facilities throughout the country within one year of ratification by the
Regional Technical Advisory Group on Malaria (RTAG-M). Recommended antimalarials,
including ACT, will be incorporated into the essential drug list.
National malaria treatment guidelines (and any revisions to them) will be communicated
to private sector health care providers throughout the country within one year of ratification by
RTAG-M (through drug regulatory authority).
4.5 Rationale of the study

1. Malaria is one of the major public health problems in 65 districts of Nepal.
Page 66

2. Bardiya is one of the 13 high endemic districts of malaria where global fund is assisting
RBM program.
3. Malaria Control Program is a national priority program.
4. Ecological determinants like hot and humid climate, low altitude, forest areas, frequent
flooding and stagnant water favoring breeding of the vectors of Malaria.
5. Being one of the border districts with India, there is high chance of cross border
importing cases.
6. An effective intervention carried out in the district has resulted in drastic decrease of case
load, morbidity and mortality.
4.6 Objectives of the study

4.6.1 General Objectives
a) To describe the epidemiological trend of malaria in Bardiya district.
a) To find out the magnitude of the disease in the district.
b) To describe disease in terms of time, place and person.
c) To describe the trend of the disease in the past 3 years.
d) To describe the clinical malaria cases in terms of time, place and person of 2070/71.
4.7 Methodology
1. Study area: DHO, Bardiya district
2. Study design: Retrospective study
3. Study duration: 3 weeks
4. Study technique:
a) Secondary data review
b) Entry register review
c) Interactions with the Vector Control Officer and Malaria Inspector in
DHO Bardiya
d) Interaction with medical officers in BDH
5. Study tools: observation check list, guidelines for interviews and discussions, format for
secondary data analysis
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6. Data collection: source
a) Reports on malaria control, Vector Control Office, DHO, Bardiya
b) Discharge register review BDH
7. Data processing: manual processing, analysis and interpretation
8. Validity and reliability:
a) Consultation with
Mr. Bishnu Vaisya (Vector Control Officer, DHO,

Bardiya)
Mr. Balkrishna Sharma (Malaria Inspector, DHO,
Bardiya)
9. Study area:
a) Total population in district 434,300
4.8 Findings and Analysis

The findings of secondary data analysis of Bardiya district are presented below.
4.8.1 Distribution by time
Clinical Malaria Cases in 2069/70
Number
1252
738
729
262
208
115
197
75
93
171
198
257
Fig. 4.1: Clinical malaria cases with respect to distribution by time
The above figure shows that the clinical malaria cases are high during rainy season.
Page 68
Slide Positive Cases of P. vivax in 2069/70

9
8
Number
6
5
1
0
Fig. 4.2: Slide positive cases of P. vivax with respect to distribution by time
Malaria parasite slide positivity is also seen more during rainy season.
Page 69
4.8.2 Distribution by place

Clinical Malaria Cases in 2069/70
Bhimapur SHP
Mainapokhar SHP
Mahamadpur SHP
Badalpur SHP
Kalika SHP
Dhodhari SHP
Patabhar HP
Sanoshree HP
Suryapatawa SHP
Deudakala HP
Manpur Tapara SHP
Mathura Haridawar SHP
Khairapur HP
Baganaha HP
Manau SHP
Nayagaun HP
Pasupatinagar SHP
Magaragadi PHC
Belawa HP
Motipur SHP
Thakudwara SHP
Gola SHP
Sivapur HP
Khairi Chandanpur HP
Jamuni HP
Dhadhawar SHP
Taratal SHP
Daulatpur HP
Padanaha SHP
Sorhawa PHC
Rajapur PHC
352
300
276
275
264
261
238
171
166
142
139
137
135
133
131
127
121
121
115
92
90
74
69
69
68
61
46
42
33
27
20
Fig. 4.3: Clinical malaria cases with respect to distribution by place
The highest number of clinical malaria cases was detected in Bhimapur SHP, whereas in
Baniyabhar SHP and Neulapur HP the case detection was zero.
Page 70
Slide Positive P. vivax cases in 2069/70

Neulapur HP
11
Baganaha HP
11
Patabhar HP
Sanoshree HP
Rajapur PHC
Jamuni HP
SoS Medical Center
Magaragadi PHC
Deudakala HP
Nayagaun HP
Belawa HP
Fig. 4.4: Slide positive cases of P. vivax with respect to distribution by place
Slide positive P. vivax cases in health centers other than those in fig 4.4 were nil.
Slide Positive P. falciparum Cases in 2069/70
Number
Magaragadi PHC
Sorhawa PHC
Neulapur HP
Bardiya Hospital
Rajapur PHC
Fig. 4.5: Slide positive P. falciparum cases with respect to distribution by place
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There is disparity of clinical cases and slide positive cases between VDCs. Though high
number of clinical cases were found in Bhimapur SHP, slide positive cases were maximum in
Neulapur, Baganaha and Patabhar HPs.
Only a small proportion of the slide positive cases (6 out of 69) were caused by P.
falciparum. A 4 year old boy and 25 year old male were imported P. falciparum cases detected in
Ashwin and Mangsir respectively.
4.8.3 Distribution by person
Age and Sex wise Distribution of Slide positive Malaria

(2069/70)
14
13
12
12
Number
10
8
6
Male
6
5
Female
4
2
2
2
0
2
1
0
0 - 10
1 0 - 20 20 - 30
30 - 40
40 - 50
50 - 60
60 - 70
70 - 80
Fig. 4.6: Distribution of slide positive malaria cases with respect to distribution by person
There is a huge burden in the age group 10-20 years and 20-30 years followed by 30-40.
The slide positive cases are higher in male population.
Page 72
Clinical Malaria Cases and Total Treatment in 2069/70

1200
1000
800
600
1133
<5 years
1120 1063
979
400
889 883
882 936
Total Treatment
Male
Total Treatment
Female
>5 years
200
0
Clinical Malaria
Male
Clinical Malaria
Female
Fig. 4.7: Treatment of clinical malaria cases
The total clinical malaria cases are diagnosed and treated more in females compared to
males but confirmed malaria cases are more in male population.
4.8.4 Trend Analysis
a) CMI trend over 3 years
Number
Clinical Malaria Incidences (CMI) per 1000 Risk

Population
20
18
16
14
12
10
8
6
4
2
0
18
13
10
67/68
68/69
69/70
Fig. 4.8: Trend of clinical malaria incidences over 3 years
The incidence of clinical malaria is declining every year.

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b) Trend of confirmed malaria cases over 3 years
Confirmed Malaria Cases Among Total Malaria Cases
140
124
120
120
Number
100
69
80
60
40
20
0
67/68
68/69
69/70
Fig. 4.9: Trend of confirmed malaria cases over 3 years
The confirmed malaria cases have significantly declined over past 2 years.
c) Trend of P. falciparum cases over 3 years
P. falciparum Among Total Slide Positive Cases
124
Number
120
69
P. falciparum cases
Total cases
12
6
67/68
68/69
6
69/70
Fig. 4.10: Trend of P. falciparum cases over 3 years
Only a small proportion of total slide positive cases were caused by P. falciparum.
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4.9 Analysis of malaria cases in Bardiya district from Shrawan 2070 to Falgun 2070
A total of 913 clinical malaria cases in Bardiya district from Shrawan 2070 to Falgun 2070 were
taken from the district health office. The information gathered was then analyzed on the basis of time,
place and person.
a) Distribution by Time
Clinical malaria cases in 2070
Number
401
211
123
69
56
33
Shrawan
Bhadra
Ashwin
Kartik
Mangsir
12
Poush
Magh
Falgun
Fig. 4.11: Clinical malaria cases with respect to distribution by time
Alike previous years, the clinical malaria cases are higher during rainy season (Shrawan,
Bhadra and Ashwin).
Page 75

b) Distribution by Place
Clinical Malaria Cases in 2070 Shrawan - Falgun
113
Bhimapur SHP
Mahamadpur SHP
Badalpur SHP
Kalika SHP
Dhodhari SHP
Surayapatawa SHP
Manpur Tapara SHP
Mathura Haridwar SHP
Khairapur HP
Beganaha HP
Manau SHP
Nayagaun HP
Pasupatinagar SHP
Belawa HP
Thakurdwara SHP
Motipur SHP
Gola SHP
Sivapur HP
Khairi Chandanpur HP
Padanaha SHP
79
87
35
142
44
40
61
22
57
14
4
39
22
5
5
83
15
43
3
0
20
40
60
80
100
120
140
160
Fig. 4.12: Clinical malaria cases with respect to distribution by place
This year more clinical malaria cases are identified in Dhodhari SHP followed by
Bhimapur SHP. Like previous years, clinical malaria cases are found to be high in Bhimapur
SHP.
Page 76
c) Distribution by Person
Age and Sex wise distribution of Slide positive Malaria cases (2070
Shrawan - Falgun)
12
11
10
Number
7
Male
Female
4
2
2
1
0
0
0 - 10
1 0 - 20
20 - 30
30 - 40
40 - 50
0
50 - 60
60 - 70
Fig. 4.13: Distribution of slide positive malaria cases with respect to distribution by person
This year there is high burden of confirmed malaria cases in age group 30-40 years and
20-30 years. Still confirmed malaria cases are higher in male population.
4.10 Conclusion
The annual slide collection is increasing (6801 in 068/69 to 7167 in 069/70).
Clinical Malaria Incidence is 10 per 1000 population which is decreasing in the last 3
years.
Confirmed malaria cases among total clinical malaria cases is 69 in 2069/70, which is
also decreasing in the past 3 years.
Bhimapur SHP is the area diagnosed with highest number of clinical malaria cases (352
in 2069/70) while Baniyabhar SHP and Neulapur HP have no clinical malaria cases.
There is a predominance of slide positive malaria in male population over female

population both with P. vivax and P. falciparum.
Page 77
The age group <5 years diagnosed with clinical malaria is more than the age group >5
years.
The percentage of P. falciparum among total slide positive cases is 10.90% which is
almost same as that of previous years.
The percentage of indigenous cases among total slide positive cases is 90.32% which is
also same as that of previous years.
There are no reported deaths due to malaria since last 3 years.
There is a large disparity between clinical malaria cases and slide positive cases.
4.11 Limitations
Data were not well-managed which caused a major problem for the study.
Page 78

Chapter V
CRITICAL ANALYSIS ON SOLID WASTE MANAGEMENT IN MID-WESTERN
REGIONAL HOSPITAL
5.1 Introduction
Solid waste management is the generation, prevention, characterization, monitoring,
treatment, handling, reuse and residual disposition of solid wastes. Medical waste is one of the
most problematic types of wastes for a solid waste authority. When such wastes enter the
municipal solid waste stream, pathogens in the wastes pose a great hazard to the environment
and to those who come in contact with the wastes.
Ideally, these types of waste should be separated. However, separation is possible only
when there is significant management commitment, in-depth and continuous training of
personnel, and permanent supervision to ensure that the prescribed practices are being followed.
Otherwise, there is always a risk that infectious and hazardous materials will enter the common
waste stream.
5.2 Rationale
Amount of the waste produced in the hospital is not quantified and there are no skilled
and trained human resources for the handling of waste management.
There is no authorized body for the waste management in such a regional hospital.
Unmanaged waste inside the hospital premises is itself a source of diseases.
Waste management is a top priority issue in any hospital.
There is no incinerator in Mid-Western Regional Hospital for management of hazardous

solid waste.
Though there isnt any authorized body, a voluntary committee is working for the waste
management and hospital cleanliness.
Since 2068/69 the voluntary committee is successful in establishing and running

earthworm farming in MWRH.
The hospital is putting special efforts in bringing glass cutter, plastic cutter and
incinerator in near future.
Page 79
The committee in co-ordination with hospital is building biogas plant in the new hospital
building for the management of waste produced within the hospital.
5.3 Objectives
5.3.1 General Objectives
To study the various aspects of solid waste management system in MWRH and critically
analyze the findings.
To identify the existing infrastructure and human resources for the solid waste
management at MWRH.
To identify various problems present and look for possible causes.
To obtain information regarding the training and expertise acquired by the working
personnel.
To analyze the impacts of waste management within the hospital premises.
To provide the recommendation to MWRH based on our critical analysis.
5.4 Methodology
Study Area: Mid-Western Regional Hospital, Birendranagar, Surkhet
Study Design: Descriptive
Study Duration: 3 weeks
Study Techniques:
a. Identification of Problem
Techniques
Observation
Photography
Verify and Establish as a Critical Problem
1. Further observation of waste disposal site
2. Interview with the waste management incharge and medical superintendent
Tools
Note Keeping
Camera
1) Observation Checklist
2) Interview
Guidelines/
structured Questionnaire
SemiPage 80
b. Identification of the Underlying Cause

Techniques
Tools
Observation
Observation Checklist/ Photography
Interview with MS/Involved Manpower
Semi-structured Questionnaire
c. Identification of Solution
Techniques
Observation
Interview
Discussion with hospital staff
Tools
Note Keeping
Interview Guidelines
Discussion Guidelines
5.5 Sources of Information

1. In-charge of waste management committee and other members
2. Medical Superintendent
3. Sweepers and helpers of the hospital
4. In-charge of Emergency, In-patient, Out-patient, OT, Laboratory, Labor room and
Canteen
5. Other staffs
5.6 Findings
In this hospital, the categorization of solid waste is done as follows:
1. Combustible waste
2. Bio-degradable waste
3. Non-combustible and non bio-degradable waste
5.6.1 Sources of waste
Waste collected in the hospital comes from the following sources:
1. Wards, OPDs, Emergency, OT and laboratory.
- Sharps, glasses, dressings and bandages.
2. Operation theater and labour room
-Pathological wastes such as human tissues, placenta, body parts, dressings and band
Page 81

3.
Hospital canteen, patient parties

- Daily general waste (remains of food, paper, plastics, etc.)
5.6.2 Collection of waste

All the solid waste generated within the hospital premises is collected in dust bins with
specific color coding system implemented by hospital for the last 3 years. These dust bins are
kept in each and every ward, OPDs, emergency, laboratory, pharmacy, OT, and around the
hospital premises.
Color coding of the dust bins:

Color
RED
GREEN
BLUE
Type of Waste
Hazardous waste other than sharps and syringes
Biodegradable
Combustible
The hospital uses SAFETY BOX for the collection of the sharps and syringes which is
provided by the government of Nepal. If safety box is not available then the hospital uses the
Yellow color bins for the collection of these wastes.
5.6.3 Transportation of waste
The wastes collected were taken to the disposal site manually, by the sweepers and peons
of the hospital once daily at the end of the day or as soon as the dust bins get full.
5.6.4 Storage of waste
Since wastes were taken at the end of each shift and disposed off, no such provision for
storage was in place.
5.6.5 Disposal of waste

The wastes produced by the hospital are disposed off according to the type of the waste.
1. Combustible waste
There is an open pit of size 10x10x10 cubic feet where all the combustible wastes are
dumped and burned up.
Page 82
2. Bio-degradable waste
The disposal of bio-degradable wastes goes through specially designed earthworm
farming. This system is in use since 2 years. Approximately 2000 earthworms were
bought at the beginning which has now increased to more than 20,000 in number.
There are 8 containers for the collection of bio-degradable wastes and each is filled daily.
The lid is closed in the filled container and is soaked in an Em (effective microorganisms) fluid for 1 week. Then the container is opened and dumped in an especially
designed pit with compartments where underneath lie the earthworms. The manure
produced is used in agricultural purposes (viz. gardening) within the hospital premises.
3. Non combustible and Non bio-degradable waste

These kinds of wastes are filled in a big pit which is dug within the hospital premise. The
wastes are disposed off and as the pit fills up, it is closed with mud.
4. Placenta pit
There is a separate placenta pit for the disposal of the placenta. This pit is also used for
the disposal of other body tissues produced from surgery.
5.6.6 Management
To put any sets of tasks into proper perspective, there needs to be a co-ordinated
approach to the action. Though MWRH runs a waste collection and management committee,
which is a voluntary committee, waste management isnt a prioritized issue here.
a) Staffing
Sweepers and Peons
All the staffs of the hospital work together voluntarily every Friday for hospital
cleanliness and awareness
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b) Facilities
Colour coded buckets in each and every ward, Operation Theater, labour room,
OPDs, emergency, corridors, etc.
c) Budgeting
No budgeting on separate head on waste management

5.7 Strength Weakness Opportunity and Threat (SWOT) Analysis
Table 5.1: SWOT Analysis
Issues
Collection
waste
Strength
of Different color
coded dustbins
available in all
departments and
around
the
hospital premises
Transportation
of waste
Storage
waste
Transported on
daily basis or
when the bins are
filled
Weakness
Patients
and
general people
are unaware of
the color coding
system
Opportunities
Information
board should be
placed at various
places within the
hospital
Safe
handling
during
transportation
not done
Gloves
and
masks for safe
handling should
be
made
available
Not all dustbins Replacement of
are closed;
older bins with
Some of them new ones and use
leak;
of
closed
Foul-smell
dustbins
around the leaky
and
open
dustbins
of Stored
in
respective
dustbins
until
transported;
Dustbins
are
placed
in
appropriate
locations and are
accessible
Waste Disposal
Disposal site
Accessible
Disposal
sites Disposal pits can
within
the just behind the be
relocated
hospital premises Emergency block away from the
hospital
block
within
the
hospital premises
Pits
Separate
pits Pits are open Pits have to be
available
for except
for sealed or closed;
different types of placenta pits;
Large sized pits
waste;
New pits are to can be made;
Threat
Haphazard
collection
of
waste;
more
human
resources
required
to
separate
the
waste again
Increased risk
of injuries and
infection
to
handlers
Increased risk
of spread of
infection
in
Emergency
visiting patients
Becomes
the
source
of
infection;
Wastes could be
Page 84
Incinerator
Separate
be dug once it is
earthworm house filled;
for
Pits are fenceless
biodegradable
waste
Separate placenta
pit for placenta
and human tissue
waste;
Separate pit for
combustible
waste
Separate pit for
non-combustible
and
nonbiodegradable
waste
Broken/Not
functional
Disposal process
Biodegradable Waste
goes
waste
through
earthworm
farming system
Earthworm pits
are open;
Time consuming;
Size of drums are
small
Plastics are also
burned in the
same pit
Combustible
waste
Burned everyday
Noncombustible
and
nonbiodegradable
waste
Separately
disposed in pit;
Plastic
bottles
and saline bottles
are sold
Pits
are
not
closed properly
when filled;
All the hazardous
waste
are
disposed in the
same pit
Manpower
A
waste
management
committee
is
present which is
working
voluntarily;
All the staffs of
the hospital work
together
Paid staffs are

not allocated by
the hospital;
Lack of skillful
volunteer
for
handling
of
waste
Fence/Walls
washed away by
around the pits rain;
can be made
People/children
may fall down
Broken one can Air pollution

be repaired
Compost manure
can be sold or
used
for
plantation
and
gardening
Hospital
is
planning to buy
plastic cutter in
the near future
Hospital
is
planning to buy
needle and glass
cutter in the near
future;
Pits
can
be
properly dumped
and sealed
Separate
paid
staffs can be
allocated by the
hospital;
Training to the
staffs
for
handling
of
waste;
Increased use of
Air pollution
Land is wasted;
Increased risk
of
environmental
pollution
Voluntary
committee
is
temporary;
Increased risk
of injuries and
infection
to
unskillful
handlers
Page 85

voluntarily every
Friday
for
hospital
cleanliness and
awareness
Budgeting
gloves and mask

during handling
of waste
Not allocated
Should
allocated
be Waste
management
committee will
not
be
sustainable in
the absence of
budget
5.8 Conclusion
The hospital does not have adequate infrastructure required for waste management.
There is inadequate number of skilled and trained human resources.
There is no authorized committee working for waste management of hospital and no

budget is allocated for the voluntarily working committee.
The openly disposing system within the hospital premises is posing a serious threat to the
health and environment around the hospital.
Lack of information about the color coding system inside the hospital is causing mess
during collection and disposal of waste.
The works done by the voluntary committee regarding waste management is exemplary
and is praised and appreciated by everyone.
The earthworm farming running in the hospital is very productive and environment
friendly.
5.9 Recommendations
As the hospital is being expanded and shifted in a new building, it is mandatory to have a
proper waste management system.
The infrastructure and trained human resources need to be increased.
Separate budget needs to be allocated for waste management.
The basic equipments and facilities for waste management should be fulfilled
accordingly.
Page 86
The information regarding color coding system should be provided to everyone.
A sustainable waste management committee needs to be formed.
The hospital needs to help and motivate the voluntary committee working for waste
management.
Hospital can set an example to others by making earthworm farming more sustainable.
Page 87
Chapter VI
FIVE YEAR PLAN ON DIARRHOEAL DISEASE CONTROL IN HDCSCHAURJAHARI HOSPITAL, RUKUM
6.1 Introduction
World Health Organization (WHO) has defined diarrhea as having three or more loose or
liquid stools per day, or as having more stools than is normal for that person. Diarrhoea is caused
by a variety of micro-organisms including viruses, bacteria and protozoas. Diarrhoea causes a
person to lose both water and electrolytes, which leads to dehydration and, in some cases, to
death.
Table 6.1: Various types of diarrheal diseases
Type of Agent
Toxin in food
Organisms
Bacillus cereus, Clostridium spp., Staph. Aureus
Bacterial
Vibrio cholerae , Enterotoxigenic , E. coli, Shiga toxin-producing E. coli,

EIEC, Campylobacter jejuni, Clostridium difficile
Viral
Rotavirus, Norovirus
Protozoal
Giardiasis, Amoebic dysentery, Cryptosporidiosis
Diarrheal disease is still a leading cause of morbidity and mortality in country like Nepal.
Diarrheal diseases control program is functioning since 1983 with the aim to controlling the
morbidity and mortality due to diarrheal diseases within the country. Moreover, recognizing
diarrheal diseases as one of the major public health problems among children under five in
Nepal, the National Control of Diarrheal Diseases Programme (NCDDP) has been accorded high
priority status by GoN and is an integral part of Primary Health Care.
Standard diarrhoea case management with Oral Rehydration therapy, continued feeding
and zinc tablet is provided in the health institutions by establishing Oral Rehydration Therapy
(ORT) corners in all Hospitals, Primary Health Care Centres, Health Posts and Sub Health Posts
throughout the country. All health facilities and community health volunteers serve as the
primary health providers in the treatment of Diarrhoea with low osmolar Oral Rehydration
Solutions (ORS) with Zinc supplementation.
Page 88

6.2 Recent indicators of diarrheal diseases in Rukum district
6.2.1
Incidence of Diarrhea /1000 Population

Incidence of Diarrhoea / 1000 Population
522
518
2067/68
2068/69
2069/70
Fig. 6.1: Incidence of Diarrhea/1000 Population
6.2.2
Percentage of severe dehydration among total cases

Percentage of severe dehydration among total
cases
0.9%
1%
0.68%
2067/68
2068/69
2069/70
Fig. 6.2 Percentage of severe dehydration among total cases
Page 89

6.2.3

40%
39%
33.67%
2067/68
2068/69
2069/70
Fig. 6.3: Proportion of CDD cases treated by FCHV

6.2.4

25%
21.37%
18.52%
2067/68
2068/69
2069/70
Fig. 6.4: Proportion of CDD cases treated by VHW/MCHW

6.2.5

47.79%
35%
2067/68
2068/69
39.58%
2069/70
Fig. 6.5: Proportion of CDD cases treated by HF

Page 90

6.2.6
Diarrhea cases treated with Zinc and ORS

Diarrhoea Cases Treated with Zinc and ORS
100%
100%
100%
2067/68
2068/69
2069/70
Fig 6.6: Diarrhea cases treated with Zinc and ORS

6.2.7

794
793
783
2067/68
2068/69
2069/70
Fig. 6.7: Number of <2 months children treated in HFs
6.3 Rationale
1. Diarrheal disease is one of the major public health problems of Rukum district.
2. Diarrheal disease ranks first among diseases in terms of morbidity in HDCSCHAURJAHARI hospital and is among the top five diseases in Rukum district.
3. The incidence of the disease seems to have a static trend in the previous three years and it
continues to be a significant problem.
Page 91

4. Diarrheal disease incidence in the district continues to surpass the incidence of the nation
and the mid-west region.
5. Diarrheal diseases can be prevented by using available resources in the community.
6. Diarrheal diseases can be managed (diagnosis, treatment and referral) at the community
level by FCHVs, VHWs and MCHWs.
7. Diarrheal diseases have been given priority at national as well as regional levels and
decreasing the morbidity and mortality due to it can bring about special benefits in terms
of health status and economy.
8. Diarrheal disease is a significant cause of morbidity and mortality in children under five
years of age and controlling it can help in achieving the millennium development goal.
9. CB-IMCI addresses diarrhoea as one of the five major killer diseases in children.
6.4 Methodology
The selection of topic for developing five year plan was done by review of Annual report
of DoHS and interview with Chief Administrator, medical doctor and focal persons of HDCSChaurjahari hospital.
Situational analysis on status of CDD in the district was done by taking secondary data
from record review of annual report of DPHO. With the goal of improving the health of all
children in Rukum district and ensuring that no child dies of diarrheal diseases, objectives,
targets, strategies and activities were set. Based on the information collected, Logical framework
matrix was designed.
6.5 Goal
Assuring no morbidity, mortality and no disability due to Diarrheal diseases in Rukum
district through promotive, preventive and curative services and help develop a healthy
population.
6.6 Objectives
6.7.1 General
To reduce morbidity and mortality due to diarrheal disease and dehydration in Rukum
district.
Page 92
6.7.2 Specific
To reduce the Diarrheal disease related morbidity and mortality by increasing awareness
in the community.
To reduce the Diarrheal disease related morbidity and mortality through proper diagnosis
and treatment.
6.7 Target
To reduce incidence of diarrheal disease/1000 population from 518 to 259 i.e. by 50%.
To reduce the percentage of severe dehydration among total cases from 0.68% to zero.
To maintain the diarrhea cases treated with zinc and ORS at 100%.
To double the proportion of CDD cases treated in health facilities from 39.5% to 79%.
To double the proportion of CDD cases treated by FCHVs from 39% to 78%.
Page 93

6.8 Problem Tree
High Morbidity Due To Diarrhoeal Diseases
Consumption of
contaminated water and
food
Contaminate
d water and
food
- Lack of
proper
waste
manageme
nt
- Open
defecation
Poor
access to
safe water
- Remote
drinking water
resources
- Lack of
provision of tap
water for
drinking
purpose
Lack of proper health

care facilities
Poor sanitation and

hygiene
- Lack of trained
manpower
- Poor hygiene
practices
- Inadequate
sanitation
facilities
- Lack of
proper
drainage
- Inaccessible health
facilities
- Lack of good referral
system
- Inadequate drugs for
treatment of disease
- Faith healers
- Poor water
treatment plants
Poor
planning
Low
Illiteracy
Inadequate
economy
and
health
unawarenes
facilities
Fig. 6.8: Problems tree of high morbidity due to diarrheal diseases
Cultural
beliefs
6.9 Strategies
6.9.1 Promotive
Spreading awareness through public health campaigns in the community.
Spread awareness through health awareness programs in schools and colleges.
Advocacy and lobbying for promotion of diarrhea related activities in Rukum district.
Promotion of environmental sanitation programs.
Training to the health care providers.

Page 94
Orient community leaders including DDC and VDC members and faith healers.
Develop IEC materials as and when necessary.
Supervise/Monitor at all levels and provide feedback accordingly.
Development of the proper drinking water facility in the district.
Spreading awareness on the use toilet and hand washing.
6.9.2 Preventive
Encourage public for safe drinking water.
Use of healthy food consumption.
Self Protection Strategies (Personal Hygiene)
6.9.3 Curative
Management of Diarrheal diseases cases according to WHO guidelines
Supply adequate drugs for treatment of Diarrheal diseases in all health institutions
and FCHVs.
Provision of ORT and Zinc supplementation in the management of the diarrheal

disease.
Provision of grading of dehydration and appropriate treatment.
Provision of good referral system.
Capacity building of the HDCS-Chaurjahari Hospital to manage large number of

cases.
6.10
Activities
6.10.1 Phase division

Table 6.2: Phase division
Phase I
Phase II
Phase III
Committee formation and Planning

Implementation
Re-assessment and Evaluation
One year
Three years
One year
Page 95

6.10.2 Formation of Diarrheal control program central committee
a. Members
District Health Officer - Chairperson
Medical Superintendant (District Hospital)
Hospital Director (HDCS-CHR Hospital)
Local Development Officer
District Development Officer
District Education Officer
Representatives from NGOs, INGOs
Representatives from HPs, SHPs, PHCCs
Representatives from FCHVs
Representatives from Mothers Groups
Advisory Board
o Medical Officers
o Public Health Officials
b. Functions of the committee

1. Formation of policies
2. Formation of different units and coordinating their activities
3. Identification of target groups
a. Children
b. Mothers group
c. Health workers at all levels
d. Faith healers
e. Community leaders
f. Schools
4. Assessment of resources
a.
Human Resources
i. Human Development and Community Service (HDCS) Chaurjahari
hospital, Rukum and its staff
ii. Rukum DPHO and its staff
Page 96

iii. Rukum district hospital and its staff
iv. 2 PHCCs and its staff
v. 25 HPs and its staff
vi. 27 SHPs and its staff
vii. 387 FCHVs
viii. Mothers group, faith healers, members of youth clubs
ix. VDC chairmen, members of VDC and VDC staff, staff of locally operating
NGOs/INGOs/international aid agencies
b. Financial resources
i. DPHO
ii. HDCS Chaurjahari hospital
iii. NGOs/INGOs
iv. Municipalities and VDCs
c. Logistics
i. IEC materials
ii. Stationeries and transportation
iii. Training venues
iv. Drugs
5. Monitoring
6. Establishment of diarrheal disease ward in the district hospital
6.10.3 Formation of Units
A. Information Education Communication and Training unit
This unit will be responsible for developing manuals and curriculum related to various
aspects of Diarrheal diseases for health education and training. Training of health workers
will be conducted at all levels. In the first one and half years of second phase, training of all
the target groups will be conducted and during the next two years guidelines will be
implemented. During this period regular supervision and monitoring of the activities will be
done and additional training sessions will be conducted as required.
Risk Awareness Program (RAP) will be conducted to spread awareness about the
importance of nutrition, hand washing, healthy food habits, oral rehydration solution, zinc
Page 97

supplementation, safe drinking water, Vitamin A supplementation, breast feeding,
Immunization,
The unit will specify a date to be celebrated as Diarrheal Disease Control Day annually
in the district. On this day, health education programs will be conducted regarding risk
factors, prevention and management of Diarrheal diseases. Also, free drug distribution and
rally including school children, mothers group, community leaders and health workers will
be held. Essay and quiz competition, street drama and role play among school children will
also be held on the same day.
The unit will also organize door to door awareness program regarding Diarrheal
diseases with the help of FCHVs, VHWs, MCHWs, youth clubs and school children.
Interaction programs between the unit and different groups of people will be held.
Table 6.3: Training activities
Training for
1.
2.
3.
4.
5.
6.
7.
Training objectives
Trainer
Sett
Freque
i
ncy
n
g
DPHO
Yearly
Doctors from district

Management
of
diarrheal
Experts
hospital,
HDCS- diseases and
severe
CHR hospital and dehydration
PHCC
Medical
staff
of
Management
of
Diarrheal
Doctors from district hospital,
PHCC
Half yearly
PHCC(excluding
diseases cases based on HDCS CHR hospital and
doctors), HPs and WHO guidelines
PHCC
SHPs
VHWs and MCHWs Diagnosis,
treatment
and
Medical
staffs
of
PHCC
Half yearly
referral of diarrhea cases
PHCC(excluding doctors),
health posts and sub health
posts
FCHVs
Diagnosis,
treatment
and
Medical
staffs
of
PHCC
Half yearly
referral of diarrhea cases
PHCC(excluding doctors),
posts
Mothers group
Education
regarding
risk
FCHVs
Local set upHalf yearly
factors, signs, symptoms,
danger signs and proper
management of Diarrhea
cases
Faith healers
Education regarding diagnosis
Medical
staffs
of
PHCC, HP,
Yearly
and timely referral of PHCC(excluding doctors), SHP
diarrhea cases
posts
School teachers
Education
regarding
risk
Medical
staffs
of
PHCC,
Yearly
Page 98
8.
factors, prevention and PHCC(excluding doctors), HP,SHP

timely management of health posts and sub health
diarrhea cases
posts
Youth groups(clubs), Education
regarding
risk
Medical
staffs
of
Schools Half yearly
Students of secondary factors, prevention and PHCC(excluding doctors),
and
higher timely management of health posts and sub health
secondary levels
Diarrhea cases
posts
B. Administrative and Logistics Unit

This unit will be responsible for conducting the following activities:
a. Keeping records of financial transactions.
b. Record keeping of logistics.
c. Provision of human resources (trainers and trainees)
d. Provision of logistics
i. Drugs
ii. ORS and zinc supplementation
iii. Stationeries and transport facilities
C. Monitoring and Supervision unit

This unit will monitor and supervise activities. It will observe and record the
activities, identify deviations and take corrective actions.
Monitoring of the following activities will be done:
I.
Attendance percentage
II.
Total numbers of trainings conducted
III.
Total number of drugs distributed
IV.
Total number of ORS distributed
V.
Assessment of the knowledge of trainees after the training by using

questionnaires
6.10.4 Evaluation of the program

Evaluation of the program will be done based on following indicators:
Table 6.4: Indicators of CDD
Main Indicators
Numerator and Denominator

Page 99

Incidence
of
Total diarrheal cases in one year
diarrhea/1000
Total population in the same year
population
Percentage
of
Total number of severe dehydration
severe
Total diarrheal cases in the same period
dehydration
among
total
cases
Proportion of CDD
Total number of diarrhea cases treated by FCHVs
treated
by
FCHVs
Proportion of CDD Total number of diarrhea cases treated by VHWs/MCHWs
treated
by
VHWs/MCHW
s
Total number of diarrhea cases treated in HF
Proportion of CDD
cases treated by
HF
Diarrhea
Cases
Treated
with
Zinc and ORS
Total number of diarrhea cases treated with Zinc and ORS

X 1000
X 100
X 100
X 100
X 100
X 100
6.11 Budgeting of five year plan of Control of Diarrheal Disease Program

(Based on interviews with the concerned authorities and the annual budget allocated
for the district by the Government of Nepal.)
Table 6.5: Budgeting of five year plan
1. Committee Formation and Planning
Rs. 50,000
2. Administrative and Logistic Unit

Purchasing furniture
Stationeries and Transport
Drugs
Rs. 50,000
Rs. 1,80,000
Rs. 25,00,000
3. Training
Activities
Target
manpower
Training
program
a. Trainer
(expert)
b. Doctors
a. Trainer
(Doctors)
Training
program
Number
Daily
Number
of
allowances of days
manpower
1
3000
1
Number of
Total (in
activities (in NRs.)
Phase II)
1x3=3
9,000
8
1
3
2x3=6
500
700
1
2
12,000
8,400
Page 100

b. H.A.
15
c. AHW
47
d. Nursing
19
staff
Training
a. Trainer
5
program
(Medical
staff of
PHCC, HP,
SHP
excluding
doctors)
43
b. VHWs
34
c. MCHWs
387
d. FCHVs
e. Mothers
group
Training
a. Trainer
5
program
(Medical
staff of
PHCC, HP,
SHP
excluding
doctors)
b. School
teachers
c. Students
and youth
groups
Refreshment for orientation and training
program
Travel Allowance
4. IEC Unit
500
500
500
2
2
2
3
3
3
45,000
1,41,000
57,000
500
2x3=6
45,000
200
200
200
3
3
3
3
3
3
77,400
61,200
6,96,600
20,000
500
1x3=3
7,500
Publication of IEC materials (Posters,

Pamphlets, Leaflets, Flip charts, Hoarding
boards, etc.)
Distribution of IEC materials (allowances and
refreshment for volunteers)
Media advertisement (TV, Radio, Newspaper)
School Health Program (Quiz competition,
Essay competition, etc.)
Training Manuals
Seminars and workshops
CDD Day
Door to door awareness program
Rally
4,20,000 (4086 x 100; + misc.)

75,000
70,000
45,000
1,50,000
15,000
40,000
50,000
25,000
25,000
10,000
Page 101

5. Supervision, monitoring and evaluation
Field visits
Review meetings
Provision of record forms and
reports
Provision of feedback
questionnaires
Evaluation meeting at district
level
6. Preparation of Field Report
Rs. 1,00,000
7. Establishment of Diarrheal Diseases ward
Rs. 2,00,000
8. Miscellaneous expenses
Rs. 1,00,000
35,000
30,000
25,000
15,000
10,000
Total budget of five year for control of diarrheal diseases 2014-2018 is Rs. 54,00,100
6.12 Logical Framework Analysis
The Logical Framework Approach (LFA) is a tool or rather an open set of tools for
project design and management. Its purpose is to provide a clear, rational framework for
planning the envisioned activities and determining how to measure a projects success, while
taking external factors into account.
Table 6.6: Log frame matrix
Narrative Summary
Objectively Verifiable
Indicators
( OVIs)
Goal
Incidence
To decrease the
Prevalence
morbidity of diarrheal Percentage of severe
diseases and assuring no dehydration
mortality.
KAP Assessment
Purpose
Annual Incidence
1. To reduce number of Percentage of diarrhoea
new diarrheal cases
among IMCI cases
Number of Public
Awareness Campaigns
Means Of
Verification (MoV)
Annual District
Health Report
Final Report of 5
year plan
Assumptions
Political Stability
Financial
Adequacy
Annual Report of
DPHO
Annual Health
Report
Reporting from
Awareness Program
Conductors
Surveillance
Concerned
authorities support/
involvement
Proper Reporting
and Recording
Support of donor
agencies for
training programs
Page 102

Authorities Records Financial adequacy
Reporting from
to provide
laboratory
incentives and
facilities to staffs
2. To reduce diarrhoea
related dehydration
Proportion/percentage
of diarrhoea with
dehydration
3. To prevent diarrhoea No. of deaths due to

related mortality
diarrhea and severe
dehydration
CFR
4. To establish proper
diagnosis and
management protocol
Output
Annual Report of
DPHO
Hospital Records
Prompt treatment
facilities.
Adequate trained
manpower,
infrastructure/
resources
Annual Health
Report of DPHO
Hospital Records
Good recording
and timely
reporting system
Adequate facility,
infrastructure,
manpower to
provide prompt
treatment to
prevent deaths
Preparedness to
manage epidemics
Competency of the
medical personnel
at all levels
Availability of
good quality
services at health
facilities
Adequate
manpower and
financial strength
to train health
workers
support from
hospital
administration and
government
Trained manpower
Number of trained health Annual Reports of

workers
DPHO
Number of training
Hospital records
sessions to health
Minute Books of
workers
Training sessions
Number of treated cases
Number of referrals
Mortality Rate
CFR
Annual Incidence Rate
Annual Health
Page 103

1. Reduction in number Percentage of
of new diarrheal cases
DIARRHOEA among
by 50%.
IMCI cases
Report of DPHO
2. Reduction in
Case detection Rate
Annual Health
percentage of severe
Report of DPHO
Percentage of
dehydration among new DIARRHOEA among Surveillance
cases from 0.68% to
IMCI cases
Reports
zero.
Lab reports
Finance
Safe drinking
water
Environmental
sanitation
Proper Reporting
and Recording
System
Lab technician
Reliable
Surveillance
Strategy
3. Maintain the
percentage of cases
treated with ORS at
100%
Written protocol of
diagnosis
Written protocol of
management
Protocol for referral
Annual Health
Report
Record Books
4.
Immunization
coverage rate
Drop-out rate
Number of trainees
% of IEC materials
utilized
Number of occasions
and places of
distribution
Population receiving
IEC materials
Number of awareness
Annual Record
Book
Enough IEC
materials
Standardized IEC
materials
Minute books
Adequate resources
Activities
15 day training program
for peripheral level
health workers
IEC material
Distribution
Public awareness on
Annual Health
Report
DPHO report
Minute book of
training period
Assessment of
knowledge of
trainees at end of
training period
Coordination with
Health facilities
Motivated and
trained health care
providers
Qualified trainers
Motivated trainees
Page 104

environmental sanitation programs
Annual record books Finance
Number of VDCs where
programme was
conducted
Number of participants
Number of health
education programs
Safe drinking
Number of households Chlorine distribution Adequate finance
water/Chlorination
supplied of chlorine
register
Aware people
Amount
consumed/record
Lab test of water
Number of samples sent Lab reports
Adequate finance
for test
Trained manpower
Number of positive
samples
Healthy food
Number of participants Minute books
Trained manpower
consumption/preparation Number of training
training
sessions
School/ College Health Number of sessions
Minutes
Adequate
Program
motivation to
Number of participants Reports from
school or college
school/college
where the session Adequately
was organized
motivated students
Public Awareness
Number of awareness Minute books
Adequate
program
resources
Annual Record
Numbers of VDCs
Book
where program was
conducted
Number of participant
Number of educators
Number of trainees
Refresher trainings to
Minute book of
Adequate resources
Number of sessions
training
care providers
Capacity building of
HDCS-CHR Hospital
Number of beds for

Hospital records
diarrhea and
Annual Health
severe/dehydration
Report
patients
Number of doctors for
diarrhea and
Support from
government
Donor's support
Page 105
Strengthening of EPI
(measles vaccine)
program
dehydration cases
Number of cases
treated each year
% of increase in
coverage
% of decrease in
drop-out rate
Annual Health
Report
DPHO report
Smooth supply
of vaccines and
logistics
Proper recording
and reporting
system
6.13 Conclusion
Reducing the burden of Diarrheal diseases in the district requires combined efforts from
higher level officials to health workers at community level (FCHVs, VHWs, MCHWs).
Awareness regarding Diarrheal diseases in the community (especially among mothers

and child caretakers) plays a key role in prevention and prompt treatment of the disease.
Early diagnosis and appropriate treatment can help reduce diarrhea and dehydrationrelated mortality in the community.
Adequate supply of drugs and other materials should be maintained to treat the cases in
time and avoid complications.
Adequate supply and proper use of ORS and Zinc supplementation should be maintained
to treat diarrhea and dehydration.
The development of hospital and strengthening its facilities, which is chiefly concerned
from the financial point of view for staffing and providing logistics, has to be supported
by lobbying at various levels.
Regular supervision and monitoring is mandatory for fulfillment of objectives in

accordance with the five year plan.
6.14 Problems / Constraints

The following problems / constraints can be faced during the implementation of the program:
1. Difficulty in acquiring sufficient budget.
2. Timely conduction of activities.
3. Mobilization of human resources and logistics.
Page 106

4. Timely supervision and monitoring.
Page 107

Chapter VII
RECOMMENDATIONS
To the Department:
To increase monitoring and direct supervision of students activities in field to at least

once in each district.
To focus more on practical aspects of the work to be done in the field.
To manage inter-district transport facilities for students.
To DHO and Bardiya District Hospital, Bardiya:
To work in collaboration with the DDC to empower and uplift the education and health
status of Bardiya district.
To continue the health programs being run by DHO and emphasize on LLIN distribution.
To add pathological services in laboratory so as to diagnose and treat more diseases in the
hospital without having to refer elsewhere.
To Mid-Western Regional Hospital, Surkhet:
To form a sustainable waste management committee and allocate separate budget for it.
To sustain and expand earthworm farming which is biological and environment friendly
method of waste management.
To repair the broken incinerator so that hazardous waste can be well managed.
To HDCS-Charujahari Hospital, Rukum:
To work in collaboration with all the health-care providers in the district for successfully
reducing the burden of Diarrhoeal diseases in the district with the feasible long term plan.
Page 108

Chapter VIII
LEARNING REFLECTIONS
The District Health System Management field was a great experience for us to-be
doctors to learn about the health care delivery system in different districts of Nepal in terms of
accessibility, service delivery, effectiveness and limitations. We had the opportunity to know
about the different health programs run by the DPHO/DHOs as well as about their organograms,
manpower and administration of different health institutions under them. We also learned about
the reporting and logistics management systems of health facilities in the district and the
importance of the efficiency of such systems. This exercise also provided us with the opportunity
to observe the coordination among different health related organizations working in the districts
and also differences in infrastructure, manpower and service delivery of different hospitals
(zonal, district and private/community hospitals).
Apart from these observations, we also gained experience in communicating with
different people in and out of health related organizations and collecting primary as well as
secondary data. We have acquired skills in performing epidemiological analyses so as to assess
the burden of the disease; critically analyzing a part of a health institution and recommending
ways to improve them; and also formulating a five year plan on a pertinent health issue of a
district so that it ceases to exist as a health problem in the days to come.
This field experience was a chance for us to know the differences between working in
health facilities in the center and periphery of this country. It provided us with the opportunity to
discover the geography, language, tradition and culture of the Mid-Western Development
Region, a region mostly neglected by the rest of the country. This undertaking at this stage of our
medical career will definitely prove to be a milestone in the path of making us adept in the roles
that are to be played by a doctor in a health setup; care provider, decision maker, communicator,
community leader and manager - The Five Star Doctor.
Page 109

ANNEX
List of Activities for District Health System Management Field (MBBS, Maharajgunj
Medical Campus, Institute of Medicine, Kathmandu)
2070/071 (Bardiya, Surkhet and Rukum)
Month
S.N. Activities
Falgun
25-Chaitra
15
Weeks/ 1 2 3
Days
Chaitra
16 Baishak 5
1 2 3
Baishak 6
Baishak
25
1 2 3
First Placement (Bardiya)

1
Reach the destination
Accommodation, logistic management,

Rapport building with senior public health
officer and other staffs at DHO- Bardiya
Formulation of tools with group discussion
Prepare district health profile of Bardiya

District
11
Visit to District Development Committee

(DDC) and meeting with Medical Officer of
District hospital Bardiya.
Visit to peripheral health institutes and
other NGOs/INGOs
Prepare hospital profile of Bardiya District
Hospital and supervision by Mr. Prem Basel
and Mr. Shiva Prasad Sapkota.
Group discussion for topic of
epidemiological study
Preparation of tools for epidemiological
study
Meeting with the Malaria Inspector and
collection of data for epidemiological study
Conduct epidemiological study
12
Preparation for presentation
13
Presentation of our findings and feedback
6
7
8
9
10
1
3
1
1
1
3
Page 110

14
Departure from Bardiya to Surkhet
Second Placement (Surkhet)

1
Arrival at Surkhet
Arrangement of accommodation and

logistics and rapport building with hotel
owner.
Meeting and rapport building with Medical
Superintendent of Mid-Western Regional
Hospital, Surkhet.
Visit to the different departments of the
hospital and observation of hospital.
Group discussion and selection of topic for
critical analysis
Preparation of tools for critical analysis
Data collection, interview with focal

persons and observation of waste collection
mechanism in OPDs, In-patient, Emergency,
OT and laboratory
Critical analysis of different aspects of waste
management
Visit to Earthworm farming site and waste
disposal site
Preparation for presentation and report
writing
Presentation of our findings and feedback
from Medical Superintendent and focal
persons
Departure from Surkhet to Rukum
4
5
6
7
8
9
10
11
12
1
1
2
3
1
3
1
Third Placement (Rukum)

1
Arrival at Rukum
Accommodation, lodging management
1
Page 111

3
rapport building
Group discussion, selection for topic for

critical analysis, formulation of tools
Collection of data
Interview with MS, DPHO/DHO,

stakeholders
Survey with patients and health workers
Review of national plan and policies
10
Data analysis
11
Preparation for presentation
12
Presentation and feedback
13
Finalization of report
14
Preparation for returning/ analysis of DHSM 1

field program
5
6
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A Report of

District Health System Management

Department of Community Medicine and Public Health

District Health System Management: Report 2014

Bidur Prasad Pandit

Coordinator, CBL Unit

Department of Community Medicine and Public Health

District Health System Management: Report 2014

District Health System Management: Report 2014

District Health Profile

Epidemiological study on Malaria

District Health System Management: Report 2014

Five Year Plan

District Health System Management: Report 2014

District Health System Management: Report 2014

A. District health profile: Bardiya

B. Peripheral Institution Visit/ Health Facility Observation

Hospital profile: Bardiya District Hospital

An epidemiological study of Malaria in Bardiya district

Critical analysis on solid waste management in Mid-western regional

Five year plan on diarrheal disease control in HDCS-Chaurjahari

Recommendations and Limitations

Chapter VIII: Learning reflections

District Health System Management: Report 2014

Number of schools, teachers and students

Categories of Health Facilities

NGOs/INGOs and Private Health Institution

Human resource at DHO, Bardiya

Tuberculosis control programme

Leprosy control programme

Status of rabies in the district

Status of Snake bite in the district

Performance Status FY 2067/68 2069/70, National Immunization

Status of nutrition programme

Status of service delivery sites in the district

Service status in the district

FCHV Performance Status

PHC-ORC Performance Status

Utilization of laboratory services in Bardiya district

Status of cases registered in the center (from establishment to now)

Age wise distribution of the victims

Human resource of Swarahawa PHCC

Human resource of Motipur HP

District Health System Management: Report 2014

Financial Management (in the year 2069/70)

Human resource management in Bardiya district hospital

Obstetrics services provided by Bardiya district hospital

MCH and Family Planning (FP) services

Laboratory Services provided by Bardiya district hospital

Immunization services provided by Bardiya district hospital

Physical facilities available in Bardiya district hospital

Hospital equipments available in Bardiya district hospital

Top 10 diseases in OPD

Top 10 diseases in In-patient department in FY 2069/70

Various types of diarrheal diseases

Budgeting of five year plan

Log frame matrix

District Health System Management: Report 2014

Map of Bardiya District and its Health Facilities

Health Care Delivery System in Bardiya District

Planning function of DHO, Bardiya

Health Management Information System (HMIS) flow in Bardiya

Logistic management in Bardiya