Consolidated NHSP-2 IP 092812 QA

Nepal Health Sector Programme-2 IMPLEMENTATION PLAN
2010-2015
Government of Nepal Ministry of Health and Population (MoHP)
PREFACE
EXECUTIVE SUMMARY
The Second Nepal Health Sector Programme (NHSP-2) is a national guiding document for the health sector and contributes directly to meeting the health-related Millennium Development Goals (MDGs) 1 (partly), 4, 5 and 6. It also offers a strong foundation to scale up existing elements of Essential Health Care Services (EHCS) and allows for a few new elements. Within NHSP-2, the EHCS package was expanded to better address Nepals health care needs; some additional programmes were added, including programmes on mental health, oral health, environmental health, community-based newborn care, and a community-based nutrition care and support programme. In addition, a Non-communicable Disease (NCD) control component was included to address changes in demographics and diseases. A few new strategic directions have been included across the programmes, for example Public-private Partnerships (PPPs), governance and accountability, inter-sectoral coordination and collaboration, and sustainability. This NHSP-2 Implementation Plan (IP) has been prepared to ensure that the objectives, strategies, and major activities planned in NHSP-2 are implemented smoothly in the given timeframe. The NHSP-2 IP is divided into three parts. Part one describes the vision, mission, strategies, and implementation, along with the challenges, to ensure that NHSP-2 policies, strategies and programmes are translated into the Annual Work Plan and Budget (AWPB). Part two covers the EHCS components, including the goals, objectives, strategies, monitoring indicators, challenges, and responsible officers for each programme included in NHSP-2. In addition, it incorporates NCDs, environmental health, the Community-based Newborn Care Programme (CB-NCP), and the Community-based Nutrition Programme. Part two of this NHSP-2 IP thus discusses the following: Immunisation Programme: The Immunisation IP 2012-2016 guides the AWPB programme for the next five years to achieve the immunisation-related goals the Government of Nepal (GoN) has expressed in various policy documents, in the MDGs and World Health Assembly (WHA) resolutions, and in different national and international fora. The objectives, strategies, and activities set forth in the plan provide the framework required to meet the goal of reducing infant and child mortality and morbidity associated with Vaccine-preventable Diseases (VPDs). Integrated Management of Childhood Illness (IMCI) and the Newborn Care Programme (NCP ) : The Integrated Management of Childhood Illness, through the progressive implementation and improvement of the Community-based IMCI (CB-IMCI) Programme, contributes to the reduction in deaths due to the major illnesses that cause 70% of child mortality globally. The major illnesses addressed by CB-IMCI are: Acute Respiratory Infections (ARIs), diarrhoeal diseases, malaria, measles, malnutrition, and other common childhood illnesses. The challenge will be to incorporate the community-based elements of the NCP into the CB-IMCI and Safe Motherhood (SM) Programmes. Nutrition Programme: The Nutrition Programme has established the vision of all Nepalese citizens enjoying adequate nutrition, food safety, and food security for adequate physical, mental, and social
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growth, and development and survival. This is designed to improve the overall nutritional status of children, women of childbearing age, pregnant women, and people of all ages. A Community-based Nutrition Programme has been planned; it is to be progressively introduced, starting from the wards with the highest incidence of malnutrition. The IP is therefore designed to implement both NHSP-2 and the Multi-sectoral Nutrition Plan (MSNP). The strategies and activities are embedded under the strategic directions of NHSP-2 and the MSNP. SM Programme: The GoN is committed to continue offering free delivery services at hospitals, Primary Health Care Centres (PHCCs), Health Posts (HPs) and selected Sub-Health Posts (SHPs), and selected non-government facilities. Transport and provider incentives will continue to be paid for women delivering with a Skilled Birth Attendant (SBA) or in a facility. Family Planning (FP) Programme: The unmet need for FP among certain groups of individuals and couples, such as adolescents, residents of rural and hilly areas, the eastern development region, and the western hills, poor communities, and, unexpectedly, among educated groups, is a challenge for the FP programme. To address these gaps, the Ministry of Health and Population/Family Health Division (MoHP/FHD) has recently developed a new FP Strategy 2068 that focuses on increasing access to quality FP services in rural and marginalised communities, and on implementing focused FP programmes to fulfil the needs of special groups like post-partum mothers, post-abortion clients, migrants, and adolescents. Adolescent Sexual and Reproductive Health (ASRH) Programme: The Reproductive Health Strategy and Plan states that ASRH is a major component of reproductive health. GoN developed the National Adolescent Health and Development (NAHD) Strategy in 2000, has included ASRH in the EHCS package, and in 2007 produced the Implementation Guidelines on ASRH for district health managers. The ASRH Programme has at its core the introduction of Adolescent-friendly Services (AFS) and aims for the establishment of 1,000 AFS centres by 2015, as outlined in NHSP-2. The Programme will improve existing clinical services in the areas of safe abortion, FP, maternal and child health care, and HIV and Sexually Transmitted Infection (STI) prevention and treatment with a view of making these services more accessible to adolescents. Female Community Health Volunteer ( FCHV) Programme: The goal of the FCHV programme is to support the national objectives of health through community involvement in public health activities, imparting knowledge and skills for the empowerment of women, increasing awareness on health-related issues, and involving local institutions in promoting health care. This will stimulate the health and healthy behaviour of mothers and community people for the advancement of SM, Child Health, FP, and other community-based health services with the support of health personnel from the SHPs, HPs and PHCCs. Free Health Care Pro gramme: To safeguard every citizens right to basic health care, the MoHP declared free health care in 2007, targeting poor, vulnerable, and marginalised people in order to increase their access to and utilisation of health care services. During NHSP-2, EHCS in district hospitals are planned to be made free to all. Urban Health Care Programme : Only a few government-run urban PHCs, HPs or SHPs are found in urban centres. A few municipalities have established urban health clinics but they cannot meet the growing demand for health care. Lack of coordination and collaboration between the MoHP, Ministry of Local Development (MoLD), and the municipalities is the major hurdle to be overcome. The Three-year
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Interim Plan and NHSP-2 give special emphasis to the Urban Health Programme. Thus, this NHSP-2 IP focuses on improving the health status of urban residents, particularly the poor, the marginalised, and women and children. Malaria Control Programme : The following on-going interventions will continue as the strategies to eliminate the malaria by 2026: vector control with Long-lasting Insecticidal Bed Nets (LLINs) and/or Indoor Residual Spraying (IRS) with synthetic pyrethroid insecticides; parasitological diagnosis with microscopy or Rapid Diagnostic Tests (RDTs); timely treatment of P. falciparum cases with Artemisinine Combination Therapy (ACT) plus primaquine and P. vivax cases with chloroquine (three days) and primaquine (14 days); and early detection and response to malaria outbreaks within a week. Kala-azar Elimination Programme: The Epidemiology and Disease Control Division (EDCD) has revised the diagnosis and treatment of Kala-azar in Nepal, and the rK39 test kit has been introduced and accepted as a diagnostic test along with Miltefosine as the first-line treatment for Kala-azar. Lymphatic Filariasis ( LF) Elimination Programme: EDCD has formulated a National Action Plan (2003-2015) for the elimination of LF in Nepal by establishing a National Task Force under the Chairmanship of the Director-General (DG), Department of Health Services (DoHS), and by adopting the two pillars of LF elimination strategy: transmission control and disability prevention and management. Dengue Control Programme: Dengue Haemorrhagic Fever (DHF), a potentially lethal disease, was first recognised in the 1950s during the dengue epidemic in Philippines and Thailand; today DHF also affects Nepal and is a leading cause of childhood deaths. No specific treatment for dengue has been found, but appropriate medical care frequently saves the lives of patients with the more serious DHF. GoN has thus adopted early case detection, diagnosis, case management, and reporting of DHF. Leprosy Control Programme: The major strategies to control leprosy during this period include: early case detection and prompt treatment of cases, enabling all general Health Facilities (HFs) to diagnose and treat leprosy; ensuring a high Multidrug Therapy (MDT) treatment completion rate; preventing and limiting disability by early diagnosis and correct treatment; reducing stigma through information and education; and advocacy by achieving community empowerment through partnership between media and the community. Public Health Laboratory Services: Public health laboratory services include providing diagnostic services along with public health activities such as surveillance, research, and regulation, etc. as a part of the Nepalese health system. Every decade new and emerging diseases with epidemic and pandemic potential are appearing. Diagnosing these new diseases often requires the latest sophisticated technology in rapid diagnosis and reporting within 24 hours. The programme goal here is to support physicians and patients by offering quality laboratory diagnostic services. HIV/AIDS and STI Control Programme: The overall goal of this Programme is to achieve universal access to HIV prevention, treatment, care and support, and includes halving by 2016 the incidence of HIV, when compared to 2010 (including reduction of new HIV infections in children by 90% compared with a 2010 baseline); and by 2016, reducing AIDS-related deaths by 25% when compared to 2010. National Tuberculosis Programme (NTP): NTP policies are in accord with the National Health Plan, the WHO Stop TB Strategy and the Global Plan to Stop TB (2006-2015). The Stop TB Strategy sets
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out the steps NTP and its partners need to take for TB control in Nepal. The Strategy is based on experience gained over the past decade and on continuing consultations with stakeholders at the global, regional, national and local levels. NCD Control Programme: Tobacco- and alcohol-related illnesses, mental illness, aging-related health problems, and road traffic accidents and injuries are the major areas of NCD and lifestyle-related health issues. NHSP-2 is focused on reducing mortality and disability, and addressing morbidity, by encouraging healthier lifestyles and managing the problems at early stages. Programme on Mental Health and Neurol ogical Disorders: Nepal has made significant progress formulating a Mental Health Policy (1996.) However, implementation has been inadequate and needs to be strengthened. The overall objective of the Programme is increase access to and utilisation of basic mental health services by all, including the excluded and needy. Oral Health Care Pro gramme: The overall objective is focused on increasing the access and utilisation of basic oral health services that will reduce the morbidity and disability caused by oral health problems. Curative Health Servi ces Programme: The exemption provision has increased access to and utilisation of health care services. Regarding catastrophic illnesses, a guideline has been prepared for reimbursing the catastrophic costs to the poor and destitute. The guideline covers catastrophic spending for five diseases: kidney disease, cancer, heart disease, Alzheimers, and Parkinsons. This programme aims to reduce mortality and disability, and will address the morbidity of the general population. Ayurvedic and Alternative Medicine: New Ayurvedic health services are planned, to be established in different parts of the country, in both the Government and non-state sectors. This will increase access to and utilisation of the Ayurvedic system of medicine and will contribute towards improving the health status of Nepalese citizens. Health Education and Communication Programme: Health education and communication is a priority of the GoN and is focused on creating demand and increasing the utilisation of EHCS through the dissemination of messages using appropriate multiple channels of communication. As stated in NHSP-2, health education and communication is a priority for EHCS programmes, such as Maternal and Child Health (MCH), adolescent health, communicable and non-communicable diseases, tobacco control, emergency and disaster preparedness (including pandemic influenza), and Gender Equality and Social Inclusion (GESI). Environmental Health and Hygiene (EHH) Programme : Water-, Sanitation- and Hygiene(WASH-) associated diseases, including skin diseases, ARIs, and diarrhoeal diseases, are the top three preventable diseases among infants and children; ARI and diarrhoeal diseases remain the leading causes of child deaths. In order to promote hygiene and sanitation practices, the EHH Programme aims to improve water quality through water quality surveillance and monitoring. Part three of this document explains health system strengthening, which includes the following: Health Governance : The NHSP-2 IP plans to improve Financial Management and accounting practices through networking and establishing a mechanism to reduce irregularities. Effective fund
management, including fund tracking, is planned in order to develop a responsive and accountable health system. Human Resource (HR) Development: The inequitable distribution of HR remains a problem, with retention of medical doctors and nurses as a major concern. As mentioned in NHSP-2, all remaining SHPs will be gradually upgraded to HPs. Posts for Health Assistants (HAs) and Auxiliary Nurse Midwives (ANMs) will be added in HPs. Thus, ensuring the deputation of staff to additional training and orientation so that Maternal and Child Health Workers (MCHWs) can upgrade to ANM is a major focus for this period. GESI: The GESI strategy has been fully adopted based on the framework of strengthening genderresponsive budgeting. Although the Electronic Annual Work Plan and Budget (e-AWPB) analyses the budget by gender-responsive categories, a need remains to revisit programmes for robust estimation. This will improve health care utilisation and health outcomes, particularly of poor and excluded groups. Health Financing: The expanded prevention effort proposed under NHSP-2 will help slow the growth of the NCD burden, but will not prevent the continued growth of demand for curative services of an increasingly complex and expensive nature. A plan has been made for introducing a social health protection scheme for catastrophic illness that will develop a responsive and fair financing system that moves towards universal coverage to enhance social health protection and equity in health. State and Non -State Partnerships: The non-state sector has contributed to meeting the goals of NHSP-1 in almost all areas, notably TB control, expanding contraceptive use, controlling HIV/AIDS, eye care, and WASH promotion. The overall objective of the NHSP-2 IP approach is to increase the role of the non-state sector in service delivery, using the skills, expertise, and capital of the non-state sector in public service delivery and health system development. Procurement and Supply: Major contributing factors to quality health care delivery include the supply of various commodities (medicines, instruments, equipment, furniture, and other supplies), and physical infrastructure (peripheral facilities, hospital, laboratories, etc.). In the NHSP-2 IP procurement and supply are focused on ensuring an efficient, effective, transparent and accountable, and value for money procurement system in the health sector. Physical Facilities an d Maintenance: Delivering ECHS requires substantial investment in new construction, as well as refurbishing and upgrading existing facilities. At the same time, repair and maintenance of existing facilities will be a regular activity. So, the overall objective is to develop infrastructure for the expansion of service delivery, and to upgrade the HFs for comprehensive care. Monitoring and Evaluation (M&E): The success or failure of any programme largely depends upon the M&E function. Therefore, responding to Output 8 Develop and Implement an Integrated and Comprehensive Health Information System for the Health Sector of NHSP IP-2, MoHP endorsed a Health Sector Information System (HSIS) Strategy. The overall goal of M&E is to improve the health sector M&E system. Sector wide Approach (SWAp) and Health Sector Reform: Increased use of GoN systems is not an end in itself, but is intended to be a route towards improving aid effectiveness, improving coordination, and reducing costs, by gradually replacing the multiplicity of External Development Partner (EDP) systems for planning, budgeting, implementing, reporting, and accounting for aid with a
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single set of procedures that all partners use. Thus, to establish efficient and effective common procedures and to increase harmonisation and alignment, the SWAp will be continued for health sector reform. Finally, the result matrix for NHSP-2 (2010-2015) and the proposed budget (2010/11-2015/16) are presented in the Annexes. Limitations of NHSP -2 IP: The following are the major limitations of this document: 1. This NHSP-2 IP is based within the frame and programmes mentioned in NHSP-2, and 2. Some of the targets have already been achieved before the endorsement of this NHSP-2 IP.
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TABLE OF CONTENTS
Preface.i Executive Summary...ii Table of Contents.viii List of Abbreviations..x PART ONE: INTRODUCTION1 1.1 Introduction..1 1.2 Vision, Mission, Strategies and Implementation.2 1.3 Description of Programmes and Services for the NHSP-2 IP.....5 PART TWO: PROGRAMMES (Essential Health Care Services)..11 2.1 Immunisation Programme11 2.2 Integrated Management of Childhood Illness and Newborn Care Programme.19 2.3 Nutrition Programme..34 2.4 Safe Motherhood Programme..49 2.5 Family Planning Programme..61 2.6 Adolescent Sexual and Reproductive Health Programme.67 2.7 Female Community Health Volunteers Programme..71 2.8 Free Health Care Programme.74 2.9 Urban Health Care Programme 81 2.10 Malaria Control Programme.87 2.11 Kala-Azar Elimination Programme93 2.12 Lymphatic Filariasis Elimination Programme.97 2.13 Dengue Control Programme..101 2.14 Leprosy Control Programme..103 2.15 Health Laboratory Services.109 2.16 HIV and STI Prevention and Control Programme.116 2.17 National Tuberculosis Programme.125 2.18 Non-Communicable Diseases Control Programme132 2.19 Programme on Mental Health and Neurological Disorders.138 2.20 Oral Health Care Programme.141 2.21 Curative Health Services145 2.22 Ayurvedic and Alternative Medicine151 2.23 Health Education and Communication Programme..15 5 2.24 Environmental Health.173
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PART THREE: HEALTH SYSTEM STRENGTHENING..190 3.1 Health Governance..191 3.2 Human Resources for Health196 3.3 Gender Equality and Social Inclusion..203 3.4 Health Financing212 3.5 State and Non-State Partnerships.217 3.6 Procurement and Supply.220 3.7 Physical Facilities and Maintenance.225 3.8 Monitoring and Evaluation.228 3.9 Sector Wide Approach and Health Sector Reform.238 Annex 1: Result Matrix for NHSP-2 (2010-2015).242 Annex 2: Proposed Budget for NHSP-2 (2010/11-2015/16..249
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LIST OF ABBREVIATIONS
AA ACSM ACT AFP AFR AFS AHW AIDS ALB ANC ANM APH ARI ART ASRH AWPB BCC BEOC BPKIHS CEOC BMI BMLT BTS BTSC C4D CABA CAC CB-IMCI CB-NCP CBOs CBS CCF CDC Atlanta CDD CDR CEOC CEONC CFR CHD CHW CMA CMAM CME CMLT CPR CRS Anaesthetic Assistant Advocacy, Communication and Social Mobilisation Artemisinin Combination Therapy Acute Flaccid Paralysis Adolescent Fertility Rate Adolescent Friendly Services Auxiliary Health Worker Acquired Immune Deficiency Syndrome Albendazole Antenatal Clinic Assistant Nurse Midwife Association of Private Hospitals Acute Respiratory Infection Anti-Retroviral Therapy Adolescent Sexual and Reproductive Health Annual Work Plan and Budget Behavior Change Communication Basic Emergency Obstetric Care B.P. Koirala Institute of Health Sciences Comprehensive Emergency Obstetric Care Body Mass Index Bachelor of Medical Laboratory Technology Blood Transfusion Service Blood Transfusion Service Centre Communication for Development Network Children Affected by AIDS Comprehensive Abortion Care Community Based Integrated Management of Childhood Illness Community Based Newborn Care Programme Community Based Organisations Central Bureau of Statistics Country Coordination Forum Centers for Disease Control and Prevention Control of Diarrhoeal Diseases Case Detection Rate Comprehensive Emergency Obstetric Care Comprehensive Emergency Obstetric and Neonatal Care Case Fatality Rate Child Health Division Community Health Worker Community Medicine Auxiliary Community Management of Acute Malnutrition Continuing Medical Education Certificate in Medical Laboratory Technology Contraceptive Prevalence Rate Contraceptive Retail Store Company
CRS CS CTEVT D(P)HO DACCs DALY DDA DDC DEOs DF DG DG II DGO DH DHF DHO DIN DoA DoHS DoT DOTS DSS DUDBC DWSHCC DWSS EAP e-AWPB EBF ECD EDCD EDP EHCS EHH EHHS ELF ENT EOC EPI EQAS EWARS FCHV FCTC FHD FIDU FM FMIS FP FP/MCH
Congenital Rubella Syndrome Caesarean Section Council for Technical Education and Vocational Training District (Public) Health Office District AIDS Coordination Committee Disability Adjusted Life Year Department of Drug Administration District Development Committee District Education Offices Dengue Fever Director General Grade II Disability Diploma in Gynaecology and Obstetrics District Hospital Dengue Haemorrhagic Fever District Health Office Drug Information Network Department of Ayurveda Department of Health Services Department of Transport Directly Observed Treatment Short Course Dengue Shock Syndrome Department of Urban Development and Building Construction District Water Sanitation and Hygiene Coordination Committee Department of Water Supply and Sewerage Equity and Access Programme electronic Annual Work Plan and Budget Exclusive Breast Feeding Early Childhood Development Epidemiology and Disease Control Division External Development Partner Essential Health Care Service Environmental Health and Hygiene Environmental Health Hygiene and Sanitation Elimination of Lymphatic Filariasis Ear Nose and Throat Emergency Obstetric Care Expanded Programme of Immunisation External Quality Assessment Scheme Early Warning and Reporting System Female Community Health Volunteer Framework Convention on Tobacco Control Family Health Division Female Injecting Drug Users Financial Management Financial Management Information System Family Planning Family Planning/Maternal and Child Health
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FPAN FSW FY GAAP GBV GDP GESI GFATM GIS GIVS GIZ GM GMP GO GoN HA HCWM HDI HEFU HF HFMS HFOMC HHS HIIS HIV HKI HMIS HP HR HRH HRDC HSIS HSR HSRU HTC HuRIS HW IBBS ICD IDA IDD IEC IFA IFPSC IHP IHR IMCI IMR
Family Planning Association of Nepal Female Sex Worker Fiscal Year Governance and Accountability Action Plan Gender-based Violence Gross Domestic Product Gender Equality and Social Inclusion Global Fund to Fight AIDS, Tuberculosis and Malaria Geographical Information System Global Immunisation Vision and Strategy Deutsche Gesellschaft fr Internationale Zusammenarbeit Growth Monitoring Growth Monitoring Promotion Government Organisation Government of Nepal Health Assistant Health Care Waste Management Human Development Index Health Economics and Financing Unit Health Facility Health Facility Mapping Survey Health Facility Operation and Management Committee Household Survey Health Infrastructure Information System Human Immunodeficiency Virus Helen Keller International Health Management Information System Health Post Human Resources Human Resources for Health Hospital and Rehabilitation Centre for Disabled Children Health Sector Information System Health Service Reform Health Sector Reform Unit HIV Testing and Counselling Human Resource Information System Health Worker Integrated Bio-behavioural Survey International Classification of Disease Iron Deficiency Anaemia Iodine Deficiency Disorder Information, Education and Communication Iron Folic Acid Institutionalised Family Planning Service Centres International Health Partnership International Health Regulation Integrated Management of Childhood Illness Infant Mortality Rate
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INF INGO IOM IP Ipas IPC IPR IRS ISTC ITI IUCD IYCF JAR JE JHU JICA KAP KOICA KTM LAKH LCD LF LHGSP LIS LLIN LMD LMIS LMN M&E MA MAM MBBS MCH MCHW MD MDA MDG MDGP MDR TB MDT MGH MI MIP MIS MIYCN MMR MNCH MNH
International Nepal Fellowship International Non-Governmental Organisation Institute of Medicine Implementation Plan International Pregnancy Advisory Services Interpersonal Communication Intellectual Property Rights Indoor Residual Spraying International Standards for Tuberculosis Care International Trachoma Initiative Intrauterine Contraceptive Device Infant and Young Child Feeding Joint Annual Review Japanese Encephalitis Johns Hopkins University, USA Japan International Cooperation Agency Knowledge Attitude Practice Korean International Cooperation and Agency Kathmandu Local Ayurveda Kits for Health Leprosy Control Division Lymphatic Filariasis Local Health Governance Support Programme Laboratory Information System Long Lasting Insecticidal Bed Nets Logistic Management Division Logistic Management Information System Leprosy Mission Nepal Monitoring and Evaluation Medical Abortion Management of Acute Malnutrition Bachelor in Medicine and Bachelor in Surgery Maternal and Child Health Maternal and Child Health Worker Management Division Mass Drug Administration Millennium Development Goal Doctor of Medicine General Practitioner Multi Drug Resistant Tuberculosis Multi Drug Therapy Mothers Group for Health Micronutrient Initiative Micronutrient Initiative Powder Management Information System Maternal, Infant and Young Child Nutrition Maternal Mortality Ratio Maternal, Neonatal and Child Health Maternal and Neonatal Health
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MNP MO MoAD MoD MoE MoEST MoF MoGA MoHA MoHP MoLD MoLJ MoIC MoUD MoWC&SW MPDR MSI MSM MSNP MSW MTEF MTOT MUAC MVA NA Na & K NAHD NAMS NCASC NCD NCDR NCP NDHS NEPAS NEQAS NFE NFCC NFHP NGO NHA NHEICC NHSP-1 NHSP-2 NHSSP NHTC NID NIP NLEC
Maternal and Neonatal Programme Medical Officer Ministry of Agriculture and Development Ministry of Defence Ministry of Education Ministry of Environment, Science and Technology Ministry of Finance Ministry of General Administration Ministry of Home Affairs Ministry of Health and Population Ministry of Local Development Ministry of Law and Justice Ministry of Information and Communication Ministry of Urban Development Ministry of Women, Children and Social Welfare Maternal and Perinatal Death Review Marie Stopes International Men who have Sex with Men Multi-Sectoral Nutritional Plan Male Sex Workers Medium Term Expenditure Framework Master Training of Trainers Mid Upper Arm Circumference Manual Vacuum Aspiration Not Available Sodium and Potassium National Adolescent Health and Development National Academy for Medical Science National Centre for AIDS and STI Control Non-Communicable Disease New Case Detection Rate Newborn Care Programme Nepal Demographic Health Survey Nepal Pediatric Society National External Quality Assessment Scheme Non-Formal Education Nepal Fertility Care Centre Nepal Family Health Programme Non-Governmental Organisation National Health Account National Health Education Information and Communication Centre Nepal Health Sector Programme-1 Nepal Health Sector Programme-2 Nepal Health Sector Support Programme National Health Training Centre National Immunisation Day National Immunisation Programme National Leprosy Elimination Campaign
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NLR NLSS NLT NMSS NNC NNT NPC NPHL NPR/NRs NRCS NRHs NSI NSV NTAG-M NTC NTP NUTEC O&M OBB OCM OCMC ODF OP OPD OPMCM OPV ORC ORS OST OT PAC PAHS PAL PCR PER PHAM&ED PHC PHCC PHCRD PHCW PHN PLHIV PMTCT PPA PPH PPICD PPM PPMO
Netherlands Leprosy Relief Nepal Living Standard Survey Nepal Leprosy Trust National Micronutrient Status Survey National Nutrition Centre Neonatal Tetanus National Planning Commission National Public Health Laboratory Nepalese Rupees Nepal Red Cross Society Nutrition Rehabilitation Homes Nick Simon Institute Non-surgical Vasectomy National Technical Advisory Group for Malaria National Tuberculosis Centre National Tuberculosis Programme Nutrition Technical Committee Organisation and Management Output Based Budgeting One-stop Crisis Management One-stop Crisis Management Centre Open Defecation Free Out Patient Out Patient Department Office of the Prime Minister and the Council of Ministers Oral Polio Vaccine Outreach Clinic Oral Rehydration Salts Oral Substitution Therapy Operating Theatre Post Abortion Care Patan Academy of Health Science Practical Approach to Lung Health Polymerase Chain Reaction Public Expenditure Review Public Health Administration Monitoring and Evaluation Division Primary Health Care Primary Health Care Centre Primary Health Care Revitalisation Division Primary Health Care Worker Public Health Nurse People Living with HIV Prevention of Mother-to-Child Transmission Public Procurement Act Post-partum Haemorrhage Policy Planning and International Cooperation Division Public-Private Mix Public Procurement Monitoring Office
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PPP PR PSA PSI PWID QA QoC RBM RD RDQA RDT RECPHEC RED ReSoMal RF RH RHCCs RHD RI RMS RRT RTI RUTFs SAM SBA SC SCF SDC SEARO SHN SHP SIAs SM SMNH SMNHLTP SN SOP SPN SRH SRP SSU STC STI STS SUN SWAp TA TB
Public-Private Partnership Prevalence Rate Public Service Announcement Population Services International People Who Inject Drugs Quality Assurance Quality of Care Roll Back Malaria Regional Director Routine Data Quality Assessment Rapid Diagnostic Test Resource Centre for Primary Health Care Reach Every District Rehydration Solution for Malnutrition Results Framework Reproductive Health Reproductive Health Coordination Committees Regional Health Directorate Routine Immunisation Regional Medical Store Rapid Response Team Research Triangle Institute Ready-to-Use Therapeutic Foods Severe Acute Malnutrition Skilled Birth Attendant Save the Children Save the Children Fund Swiss Development Cooperation South East Asia Regional Office of WHO School Health Nutrition Sub Health Post Supplementary Immunisation Activities Safe Motherhood Safe Motherhood and Neonatal Health Safe Motherhood and Neonatal Health Long Term Plan Staff Nurse Standard Operating Procedure Sunaulo Pariwar Nepal Sexual and Reproductive Health School Resource Person Social Service Unit Salt Trading Corporation Sexually Transmitted Infection Service Tracking Survey Scaling Up Nutrition Sector Wide Approach Technical Assistance Tuberculosis
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TFR TOR TMIS TT Tufts TWG UK UN UNFPA UNICEF UP USAID USD USG VAD VBD VBDRTC VCT VDC VDPV VHW VPD VSC WASH WHA WHO WHO-GMP XDR-TB ZH
Total Fertility Rate Terms of Reference Training Management Information System Tetanus Toxoid Tufts University, USA Technical Working Group United Kingdom United Nations United Nations Fund for Population Activities United Nations Childrens Fund Uterine Prolapse United States Agency for International Development US Dollars Ultra Sonogram Vitamin A Deficiency Vector-Borne Disease Vector-Borne Diseases Research and Training Centre Voluntary Counselling and Testing Village Development Committee Vaccine-derived Poliovirus Village Health Worker Vaccine-preventable Disease Voluntary Surgical Contraception Water, Sanitation and Hygiene World Health Assembly World Health Organisation World Health Organisation-Growth Monitoring Programme Extreme Drug Resistant Tuberculosis Zonal Hospital
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PART ONE: INTRODUCTION
1.1 Introduction
The Government of Nepal (GoN) is committed to bringing about tangible changes in access to and utilisation of Essential Health Care Services (EHCS), thereby improving the health status of the Nepalese population through the health sector development process. The aim of the health sector reform envisaged in 2003 was to develop an equitable, high quality health care system for Nepal. The Millennium Development Goals (MDGs), the Health Sector Strategy: An Agenda for Reform 2003, and the First Nepal Health Sector Programme Implementation Plan (NHSP-1 IP) (2004-2009) provided the basis for developing the Second Nepal Health Sector Programme (NHSP-2) (2010-2015). The best practices and the lessons learned in the course of practising the Sector-wide Approach (SWAp) were capitalised upon and used in developing NHSP-2. A shared vision, agreed priorities, and a joint financial arrangement advanced partnerships and developed mutual accountability between the Ministry of Health and Population (MoHP) and the External Development Partners (EDPs). NHSP-2 has been built upon the foundation of NHSP-1, the Health Sector Strategy, and the Three-year Interim Plan. During NHSP-2, the EHCS package was expanded to address Nepals health care needs. Some new EHCS programmes were added, such as mental health, oral health, environmental health, community-based newborn care, and community-based nutrition care and support. In addition, a Non-communicable Disease (NCD) control component has been included in EHCS to address demographics and disease transition. A few new strategic directions have been included across the programmes, including, for example, Public-private Partnerships (PPPs), governance and accountability, inter-sectoral coordination and collaboration, and sustainability. Various new activities are required to achieve the programme objectives. Although impressive progress was made during the first one and a half years of NHSP-2 in extending the coverage of essential services, access and utilisation are far from universal. Considerable numbers of people remain uncovered by some of the most cost-effective life-saving interventions, e.g. the Community-based Newborn Care Programme (CB-NCP). Consensus has been reached that the new EHCS elements will not be promoted at the cost of existing programmes. Evaluating the resources available and the costs of the new programmes to be piloted and of the aspects of existing programmes that are planned to be scaled up needs more work. Moreover, certain ambiguity and difficulties occur when translating NHSP-2 into the Annual Work Plan and Budget (AWPB) without an IP. The NHSP-2 IP helps make health institutions and their officials accountable, facilitates prioritising activities, guides programme managers in programme and activity planning for five years, and ultimately contributes to achieving the results defined in NHSP-2. Purpose of the NHSP-2 IP To ensure that the objectives, strategies and major activities stated in NHSP-2 are implemented smoothly in the given timeframe.
Methods The NHSP-2 IP was developed through wide consultation with the respective programme directors, programme managers, and health system related in-charges. A series of interactive meetings and a workshop coordinated by MoHPs Policy, Planning and International Cooperation Division (PPICD) and technically supported by two national consultants were organised to develop the NHSP-2 IP. The NHSP-2 IP represents the operational guideline for achieving the visions, goals, and objectives set out in the NHSP-2. All the strategies and major activities outlined in NHSP-2 were translated to the respective programmes. Quick programmatic and thematic gap analyses were performed to plan additional activities to cover the identified gaps. The strategic and multi-year plans of the respective programme divisions helped to embed the activities under the strategies established by NHSP-2. Considering the high demand for additional activities and the limited resources available in the health sector, the NHSP-2 IP proposes only key activities.
1.2 Vision, Mission, Strategies and Implementation
The NHSP-2 IP includes the vision, value statement, strategic directions, issues, and challenges from the official NHSP-2 document. Health Sector Vision Statement The MoHP vision for the health sector is to improve the health and nutritional status of the Nepalese population and to provide an equal opportunity for all to receive quality health care services affordably or free of charge, thereby contributing to poverty alleviation. Mission Statement The MoHP will promote the health of Nepals people by facilitating access to and utilisation of essential health care and other health services, emphasising services to women, children, the poor and excluded, and changing the dangerous lifestyles and behaviour of the Most-at-risk Populations (MARPs) through Behaviour Change Communication (BCC) interventions. Value Statement The MoHP believes in: Equitable and quality health care services Patient-/client-centred health services A rights-based approach to health planning and programming Culture- and conflict-sensitive health services Gender-sensitive and socially inclusive health services. Strategic Directions To achieve the three objectives of NHSP-2, MoHP will embrace the following key directions: Poverty reduction The agenda to achieve the health MDGs by 2015 Free EHCS to patients/clients and the protection of families against catastrophic health care expenditures Gender Equality and Social Inclusion (GESI) Access to facilities and the removal of barriers to access and use Human Resource (HR) development Modern contraception and safe abortion
Disaster management and disease outbreak control Eradication, elimination, and control of selected Vaccine-preventable Diseases (VPDs) Institutionalising health sector reform SWAp for improved aid effectiveness EDP harmonisation and the International Health Partnership (IHP) Improved Financial Management (FM) Inter-sectoral coordination, especially with the Ministry of Local Development (MoLD) and the Ministry of Education (MoE) Local governance: devolution of authority Health system strengthening, especially through Monitoring and Evaluation (M&E).
To increase access to and use of EHCS and achieve the health MDGs by 2015, MoHP will implement a number of major strategies and activities, and measure progress made towards targets by outcome indicators. These strategies will be implemented to achieve several outcomes as measured by reduced mortality rates (including reduced neonatal, infant and under-five mortality rates), the Maternal Mortality Ratio (MMR) and the Total Fertility Rate (TFR). Data related to intermediate indicators, as well as the outcome indicators, will be disaggregated by gender, caste/ethnicity, wealth and region. Issues and Challenges Political instability, exacerbated by the economic crisis, rising food prices, constant power outages, street demonstrations, and a general lack of law and order, constitutes a major challenge (and a constant recent backdrop) to the health sectors efforts. This situation is likely to continue for the foreseeable future. Major accomplishments have been seen in a short time, but much remains to be done for Nepal to achieve its health sector goals and the MDGs. Without partnering with the Non-governmental Organisation (NGO) community, the GoN alone cannot reach remote rural communities to deliver more basic health services, especially to the poor and excluded. The failure to deploy and retain health care providers, particularly doctors and nurses in remote areas, persists and will continue to damage the quality of care at Primary Health Care Centres (PHCCs) and district hospitals. Posting teams at district hospitals for Comprehensive Emergency Obstetric Care (CEOC) must be pursued if Nepal is to continue reducing maternal mortality. Logistic management, especially procuring quality drugs at bulk pricing and distributing these to facilities based on nationwide consumption, must be improved to reduce stock-outs of essential drugs. Maintaining and procuring equipment for district hospitals is another high priority. New schemes are underway to solve both problems. Access to health care facilities continues to be a problem in rural areas, especially for the most disadvantaged. The facilities are too few in number and often not built at locations easily accessible for those who need care the most. New construction is costly and time-consuming. Building standards need to be established. While some evidence indicates that local management of Health Facilities (HFs) is improving health care, the local bodies have little capacity to govern and manage. Minimum standards must be developed and local committees oriented. Supervision by District Health Offices (DHOs) will become more critical to delivery, as will monitoring of pro-poor programmes. Improved access to health care, improved quality of health care services, and lessened disparities in utilisation of health services will continue to pose challenges. Public funds will be increasingly consumed by the burden of NCDs, injuries, and
violence, as well as by funding for expanding prevention, care, and treatment for the populations most at risk of HIV infection. Implementation Plan The NHSP-2 IP will work towards achieving the following three objectives set out in the NHSP-2 Results Framework (RF): To increase access to and utilisation of quality EHCS To reduce harmful cultural practices and cultural and economic barriers to accessing health care services in partnership with non-state actors To improve the health system to achieve universal coverage of EHCS. Phased Implementation The EHCS package needs to be expanded to address disease and demographic transitions. The first phase of implementation will include planning and implementing the existing components of the EHCS programme by incorporating all resources available (GoN, EDPs, and International Non-governmental Organisations (INGOs)). In addition, the planning and design of new EHCS components will be completed. The second phase will include piloting the new elements of EHCS and their gradual scaling up. Sequencing implementation is complex and requires careful planning to determine which groups of activities must be completed before the next set of activities can begin (dependent activities), and which can be pursued independently. Sequencing begins with design and planning, piloting, evaluation, and rollout or scaling up of activities. Activities related to implementation, monitoring, and strengthening await key activities such as preparing frameworks, mechanisms, schemes, and guidelines. They not only direct other activities but also facilitate their implementation. In planning activities, efforts were made to ensure the right mix of reform and routine activities. Some activities have been transferred directly from NHSP-2 and others are embedded under the set strategies. Some activities are expensive and others are relatively less so. The types of activities in the NHSP-2 IP include: Continuation of existing activities Strengthening or restructuring of existing activities Entirely new actions/activities. Prioritising Programmes and Activities The MoHP, National Planning Commission (NPC) and the Ministry of Finance (MoF) jointly prioritise health care programmes by using certain set criteria. The programmes are classified into P1, P2 and P3 as per the Medium-term Expenditure Framework (MTEF). However, prioritising activities falls under the remit of programme divisions and centres, where virtually no effort is made to prioritise at the activity level. The common tendency is to plan the ongoing strategies and activities as before, adding a few additional activities considering the importance and availability of resources. Each component of the health care programme has a ceiling for the upcoming AWPB and, despite a growing demand to add additional activities, lack of resources does not permit this. Therefore, prioritising activities is necessary to balance high demand for additional activities and the limited resources available. During the NHSP-2 period, the programme divisions and centres will prioritise activities in consultation with technical or thematic (sub-)committees to maximise the outputs. Priority will be given to low-cost- and highoutput-related activities.
Coordination 1. At the central level, EDPs will participate in consultative meeting on AWPB formulation, health sector development partners meetings, and sectoral-level joint planning and joint review meetings. At the sub-sectoral level, joint technical committees or thematic committees (comprised of government officials and EDP representatives) will coordinate the design, planning and implementation of the programmes. 2. At the district level, programme-specific coordination committees have been formed to coordinate the activities of state and non-state sectors, for example Reproductive Health Coordination Committees (RHCCs), District AIDS Coordination Committee (DACCs), District Water, Sanitation and Hygiene Coordination Committees (DWASHCCs) etc. In the case of innovations and pilot programmes, agreements will be made between the MoHP and EDPs and then reflected in the AWPB. 3. Multi-sectoral coordination mechanisms will be implemented in HIV/AIDS, nutrition, WASH, infrastructure development, curative services, academic and training institutions etc., at both the central and the district levels to avoid duplication and to maximize synergies.
1.3 Description of Programmes and Services for the NHSP-2 IP
Essential Health Care Services The three objectives set out in the RF are: To increase access to and utilisation of quality EHCS To reduce harmful cultural practices and cultural and economic barriers to accessing health care services in partnership with non-state actors To improve the health system to achieve universal coverage of EHCS. The GoN assumes responsibility for ensuring that these three objectives are met for the defined EHCS package since universal coverage will not be achieved if left to the market. EHCS include services that the market will not provide sufficiently because the costs cannot be recovered by charging for them (such as public health campaigns), or because benefits are broader than to the individual directly receiving the service (such as immunisation). It also includes some services that are only profitable for the private sector to provide at prices many people cannot afford. The services included in the package are those that are the most cost-effective those that have the biggest potential impact in reducing mortality per rupee spent. The focus of the three objectives is on extending and sustaining EHCS coverage. Although impressive progress was made in extending the coverage of essential services during the NHSP-1 IP, access and utilisation are far from universal, and a significant though shrinking share of the population is still not covered by some of the most effective life-saving interventions. The task of NHSP-2 is therefore to continue to increase the proportion of the population benefiting from the existing EHCS package of services, with a particular focus on all women receiving reproductive health services, and the poor and excluded gaining access to essential services and utilising the same services as do wealthier and more advantaged households. Supply-side constraints to the delivery of quality EHCS must be overcome, especially by planning how best to reach those populations that have previously not had good access to services.
Services need to be brought closer to more remote communities and rendered more resultsfocused and accountable to the population; necessary drugs and supplies and sufficiently trained and motivated staff must be available, and services rendered more results-focused and accountable to the population. Demand-side constraints to the utilisation of available services should be reduced. This partly involves reducing the cost barrier to accessing services through extending free EHCS, and through support to help meet transport and other costs for accessing services. It also involves action against other factors that prevent people from using services, including improving knowledge, and helping empower women and socially excluded groups to demand the services which the interim constitution assures them the right to receive. Pressures to expand the range of services offered within the EHCS package are inevitable. Given the limited availability of financial and human resources, however, additions to the EHCS package come at significant opportunity cost, with the addition of a new service implying that fewer resources are available to extend coverage of the existing package of interventions of proven worth. At this stage, the resources available and the precise costs of some aspects of the programmes that are planned to be scaled up or added remain to be estimated. The approach taken will continue to be an incremental one, based on available resources, evidence from international experience, and careful piloting within Nepal. Although the main priority is to continue to extend the coverage of services defined in the existing EHCS package, reconsidering and amending the package of services in light of the changing burden of disease and of the GoNs policy priorities is also necessary. This is a continuous process, and the EHCS package in 2009 was already significantly different from that defined in the NHSP-1 IP. During NHSP-2, the MoHP will add to the existing EHCS package several services that are needed to further address reproductive and child health problems, and communicable and noncommunicable diseases, and to improve the health status of Nepals citizens, especially the poor and excluded. Medical safe abortion, and prevention and treatment of uterine prolapse will be added to reproductive health services. Community-based newborn care and significantly expanded nutrition care will be added to the Child Health Programme. Community-based mental health services and health education and behaviour change services will be added to address the growing burden of NCDs. Promotive and preventive eye and oral health education will be provided in schools and, together with other ministries, hygiene and sanitation will be promoted. All essential services are provided free of charge to reduce financial barriers to access and utilisation, especially for the poor and excluded.
Essential Health Care Services Package for NHSP-2 (New programmes and services in italics) Programme Service 1. Reproductive 1.1 Family planning Health
Status Scaling up
1.2 Safe Motherhood (SM), including newborn care (free institutional deliveries nationwide for all) 1.3 Medical safe abortion
Scaling up
Implementation Modality Partnerships with the Family Planning Association of Nepal (FPAN), Marie Stopes International (MSI), Contraceptive Retail Store company (CRS), Population Services International (PSI), Nepal Fertility Care Centre (NFCC) and others Expanding to medical colleges and private hospitals
Piloting and scaling up Piloting and scaling up Scaling up Maintaining
2. Child Health
1.4 Prevention and repair of uterine prolapse 2.1 Expanded programme on immunisation 2.2 Community-based Integrated Management of Childhood Illness (CB-IMCI) 2.3 Nutrition 2.3.1 Growth monitoring and counselling 2.3.2 Iron supplementation 2.3.3 Vitamin A supplementation 2.3.4 Iodine supplementation 2.3.5 De-worming 2.4 Community-based newborn care (emerging as a separate component) 2.5 Expanded nutritional care and support (added to communitybased nutrition care, community nutrition rehabilitation with institutional care, and School Nutrition Programme)
Partnerships with I/NGOs (MSI, FPAN and others) and private clinics and hospitals Partnerships with medical colleges and private hospitals Government
Scaling up Scaling up Maintaining Maintaining Maintaining Maintaining Piloting and scaling up Piloting and scaling up Partnerships with local governments and intersectoral coordination (schools)
Programme 3. Communicable Disease Control
4. NCD Control
5. Oral Health 6. Eye Care
Service 3.1 Malaria control 3.2 Kala-azar control 3.4 Japanese Encephalitis (JE) control 3.5 Prevention and treatment of snakebites and rabies control 3.6 Tuberculosis control 3.7 Leprosy control 3.8 HIV/AIDS/STI control 4.1 Community-based Mental Health Programme* 4.2 Health promotion for NCD control 5.1 Promotive and preventive oral health care 6.1 Promotive and preventive 6.2 Examination, correction and surgery 6.2 Trachoma (SAFE Programme)
Status Scaling up Elimination Maintaining Maintaining
Implementation Modality Government Partnerships with International Nepal Fellowship (INF) and other INGOs Maintaining Partnerships with INGOs Elimination Scaling up Piloting and scaling up Partnerships with local governments and Communitybased Organisations (CBOs) Partnerships with schools and private clinics and hospitals Partnerships with Nepal Netra Jyoti Sangh (NNJS) and Tilganga Eye Hospital Partnerships with NNJS, Department of Water Supply and Sewerage (DWSS) and International Trachoma Initiative (ITI) Partnerships with Hospital and Rehabilitation Centre for Disabled Children (HRDC and Khagendrad Nawa Jeevan Kendra Inter-sectoral partnerships
Piloting and scaling up Scaling up
Scaling up
7. Rehabilitation of the Disabled
7.1 Promotive and preventive 7.2 Rehabilitation, surgery and therapy
Piloting and scaling up
8. Environmental Health 9. Curative Care
8.1 Promotive and preventive (water, air quality, sanitation, hygiene, waste disposal, etc.) 9. 1 Outpatient care at district facilities
Piloting and scaling up Increasing access and use
Partnerships with local governments, NGOs and medical colleges
* Including Gender-based Violence (GBV) Services Source: NHSP-2, MoHP, 2010.
Strategies to Achieve the Objectives This section details actions and activities under NHSP-2. Implementation of these activities will collectively result in achieving the NHSP-2 objectives. The programme activities fall into three types: 1. Entirely new actions/activities 2. Strengthening or restructuring existing activities 3. Continuing existing activities.
Objective 1: To increase access to and utilisation of quality EHCS. The following EHCS components will be implemented to achieve the above objectives. The detailed IP includes the following programmes: Reproductive Health (FP, SM, including newborn care and medical safe abortion, prevention and repair of uterine prolapse) Child Health (expanded programme on immunisation and CB-IMCI including communitybased newborn care and nutrition) Communicable Disease Control (Malaria, Kala-azar, JE, TB, Leprosy, HIV/AIDS/STIs) NCD Control (Community-based Mental Health Programme, health promotion) Oral Health Eye Care (partnerships providing grants) Rehabilitation of the Disabled (partnerships providing grants) Environmental Health (partnerships providing grants). Objective 2: To reduce harmful cultural practices and cultural and economic barriers to accessing health care services in partnership with non-state actors. The following programmes explicitly, and all other programmes indirectly, contribute to achieving the above objectives: Information Education and Communication Programme National Free Health Care Programme GESI Mainstreaming Programme Health Financing. Objective 3: To improve the health system to achieve universal coverage of EHCS. The following health-system-related components will be implemented to achieve the objectives: State and non-state partnerships Promoting the SWAp Addressing the transition to federalism Strengthening local health governance and FM Human Resources for Health (HRH) Health financing Procurement and distribution Mainstreaming GESI Physical facilities, investment and maintenance Research and M&E. The EHCS package developed in NHSP-2 will be delivered through the static and mobile clinics of health institutions located at district and lower levels. In the case of the SM component, services will be delivered irrespective of level. IPs for the following programmes and services have been prepared to achieve the objective of increasing access to and utilisation of quality EHCS. NHSP-2 includes the following nine programmes under the EHCS package:
1. 2. 3. 4. 5. 6. 7. 8. 9.
Reproductive Health Child Health Communicable Disease Control NCD Control Oral Health Eye Care Rehabilitation of the Disabled Environmental Health Curative Care
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PART TWO: PROGRAMMES (ESSENTIAL HEALTH CARE SERVICES)
2.1 Immunisation Programme
1. Introduction The Immunisation Programme is a priority programme of the GoN. It has helped reduce the mortality and morbidity of children and mothers from VPDs and thus contributes to achieving MDGs 4 and 5. Through its policy documents the GoN has emphasised reaching poor and marginalised populations with equitable immunisation services. Vaccines have been available in the market for decades, and the GoN intends to provide all available means to reduce morbidity and mortality. The Immunisation IP 2012-2016 guides the AWPB for the next five years to achieve the immunisation-related goals the GoN has expressed in various policy documents, in the MDGs and World Health Assembly (WHA) resolutions, and in different national and international fora. The plan also takes into consideration the Global Immunisation Vision and Strategy (GIVS) 2005 and the Global Vaccine Action Plan 2012. The objectives, strategies and activities set forth in the IP provide the framework required to meet the goal of reducing infant and child mortality and morbidity associated with vaccinepreventable diseases. Furthermore, this plan addresses new challenges and expands the previous plan by providing guidelines for the introduction of new vaccines, for the eradication, elimination and control of targeted Vaccine Preventable Diseases (VPDs), and for the strengthening of routine immunisation. 2. Goal and Objectives Goal To reduce the child mortality, morbidity, and disability associated with VPDs. Objectives 1) Achieve and maintain at least 90% vaccination coverage for all antigens both at national and district levels by 2016 2) Enhance the HR capacity for immunisation management 3) Ensure access to vaccines of assured quality and with appropriate waste disposal 4) Achieve and maintain polio-free status 5) Maintain maternal and neonatal tetanus elimination status 6) Achieve measles elimination status by 2016 7) Accelerate control of VPDs through the introduction of new and underutilised vaccines 8) Expand Vaccine Preventable Disease (VPD) surveillance 9) Continue to expand immunisation beyond infancy. 3. Major Strategies Increase access to vaccination services Strengthen the HR for immunisation Strengthen communication and social mobilisation
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Strengthen immunisation services in the municipalities Strengthen monitoring and facilitative supervision Strengthen the vaccine management system Strengthen the cold chain systems at all levels Achieve and maintain immunity levels to stop the transmission of polio Respond adequately and timely to outbreaks of polio with the appropriate vaccine Achieve and maintain certification standard Acute Flaccid Paralysis (AFP) surveillance at the district level Develop post eradication strategic guidelines Introduce new and under-used vaccines (rubella, pneumococcal, typhoid, cholera, rota) based on the disease burden and financial sustainability Continue to expand immunisation beyond infancy.
4. Indicators and Targets Health Outcome 2010/11 Infant Mortality 46 Rate (IMR) (per 1,000 live births) Under-five 54 Mortality Rate (per 1,000 live births) DPT3 >80% in 30 dist. All antigens >80% in 20 dist.
2011/12 43.2
2012/13 40.4
2013/14 37.6
2014/15 34.8
2015/16 32
50.8
47.6
44.4
41.2
38
90 % in 30 districts 90% in 20 districts
5. Major Challenges and Issues Achieving 90% coverage for all antigens and maintaining their quality Ensuring the availability of vaccines Maintaining the cold chain Filling vacant posts of vaccinators (Village Health Workers (VHWs)) Reducing the dropout rate (BCG vs. measles 9.85% in 2010/11) Reducing vaccine wastage rate (BCG: 78%, DPT/Heb and Hib: 8.6%, measles: 64%, JE: 29%, and TT: 32% in 2010/11) Improving the immunisation structure in municipalities (8 + 40 municipalities) Strengthening surveillance and monitoring Expanding immunisation beyond infancy.
12
Accountable Officer: Director, Child Health Division (CHD), Department of Health Services (DoHS) Major Major Activities Responsibility Supporting 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Strategies Agencies Increase access to vaccination Revise micro-planning guidelines Expanded Programme of Immunisation (EPI) section EPI section EPI section World Health Organization (WHO), United Nations Childrens Fund (UNICEF) WHO, UNICEF WHO, UNICEF X EPI section WHO, UNICEF X EPI section EPI section CHD EPI section X EPI section EPI section EPI section WHO, UNICEF WHO, UNICEF WHO, UNICEF X 20 20 X X X 20 30 20 35 20 30 X X UNICEF, WHO X X X X X X X X X X X X X X X X X
Review micro-planning (district) Develop a strategy for integration of immunisation with other child health programmes Prepare and implement the periodic intensification of the Routine Immunisation (RI) plan Conduct two rounds of National Immunisation Day (NID) Conduct micro-planning in municipalities Conduct an integrated child health review meeting Develop and implement an action plan to reach unreached groups Revise training material Conduct Mid-level Managers training (persons) Conduct refresher training for vaccinators (districts)
30 districts
60 districts
75 districts
75 districts
75 districts
Reach unreached groups Enhance HR capacity
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Major Strategies
Major Activities
Responsibility Supporting Agencies EPI section WHO, UNICEF
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Train basic-level staff to operate, repair, implement, and maintain the cold chain Strengthen Develop innovative district-specific communication social mobilisation plans and social Revise the strategy and policy for mobilisation conducting NID
100 EPI section EPI section WHO, UNICEF, National Health Education Information and Communication Centre (NHIECC) X X
100 X
50 X X X
Strengthen immunisation services in the municipalities Strengthen supportive supervision and monitoring
Review, finalise and implement RI BCC strategy Initiate a continuous mass media communications campaign Implement an immunisation policy and guidelines for the municipalities
X EPI section X X X X X X
X EPI section Primary Health Care Revitalisation Division (PHCRD), UNICEF, WHO
Conduct a minimum of two joint (government and partners) supervisory visits from the central office to low-performing districts, three from the region to HFs, and at least one joint visit from district headquarters to all Village Development Committees (VDCs) and sessions in a year using the tools
14
Major Strategies Strengthen the vaccine management system
Major Activities
Responsibility Supporting Agencies Logistics Management Division (LMD) LMD CHD, WHO, UNICEF
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Assess the forecasting, procurement, storage and distribution of vaccines and the related logistics Introduce/adopt and implement strategic guidelines on the cold chain and vaccine management system Monitor implementation Standard Operating Procedures (SOPs) on vaccine management at all levels Provide tool kits for maintenance to staff Dispose of medical waste according to the guidelines Procure cold chain equipment and spare parts, and replace old equipment as per the replacement plan Procure generators, solar freezers, and hybrid systems for districts with poor electricity supply Introduce Oral Polio Vaccine (OPV) birth dose in CB-NCP districts
CHD, UNICEF WHO CHD, UNICEF WHO CHD, UNICEF WHO UNICEF, WHO CHD, UNICEF WHO
LMD
X X X
X X X
LMD EPI section LMD
Strengthen the cold chain system at all levels
LMD
CHD, UNICEF WHO UNICEF, WHO
Achieve and maintain immunity levels to stop transmission Respond adequately and promptly to
EPI section
Conduct mop-up campaigns with Vaccine-derived Polio Virus (VDPV) in the appropriate type of vaccine
EPI section
UNICEF, WHO X X X X X
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Major Strategies outbreaks of polio
Major Activities
Responsibility Supporting Agencies EPI section Epidemiology and Disease Control Division (EDCD), UNICEF, WHO UNICEF, WHO
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Conduct cross border activities during Supplementary Immunisation Activities (SIAs)
Achieve and maintain certificate standard surveillance
Intensify AFP surveillance activities in each district to meet certification standards Implement a laboratory containment plan with review
EPI section
X National Public Health Laboratory (NPHL) EPI section WHO
X UNICEF, WHO
Develop and implement posteradication strategies Achieve and maintain 80% coverage of TT2+
Develop and implement posteradication strategies for polio
Integrate and implement tetanus toxoid (TT or Td) in the BCG immunisation strategy against Tuberculosis Develop and implement policy on TT five doses Conduct two rounds of TT campaign (districts in numbers) Develop guidelines for measles elimination Provide a second opportunity for measles vaccine
EPI section
UNICEF, WHO X X X X X
EPI section
EPI section EPI section EPI section
Family Health Division (FHD), UNICEF, WHO UNICEF, WHO UNICEF, WHO, FHD MoHP, UNICEF, WHO
X 10 X
X 10
X 10
X 10
Achieve and sustain the immunity level for measles
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Major Strategies
Major Activities
Responsibility Supporting Agencies EPI section UNICEF, WHO
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Investigate all suspected measles outbreaks Introduction of new and under-used vaccines in National Immunisation Programme (NIP) Expand VPD surveillance
Conduct a follow up Measles and Rubella campaign targeting children from nine months to under five years of age Introduce a second dose of measles vaccine in RI Investigate all suspected measles outbreaks and follow up with appropriate response Introduce the rubella vaccine (as MR) in routine immunisation Introduce pneumococcal vaccine in RI
X EPI section EPI section UNICEF, WHO EDCD, UNICEF, WHO
EPI section EPI section
UNICEF, WHO UNICEF, WHO
Conduct integrated surveillance of AFP, measles, Neonatal Tetanus (NNT) and JE Initiate surveillance for Congenital Rubella Syndrome (CRS)/Rubella Conduct sentinel surveillance for typhoid and cholera Continue sentinel surveillance sites for pneumo and rota surveillance Continue to provide support for NPHL ( test kits, reagents, additional staff and other support)
EPI section
UNICEF, WHO X X X X X X X X X X X X X X X X X X X X X X X X
EPI section EPI section EPI section EPI section
UNICEF, WHO UNICEF, WHO UNICEF, WHO NPHL
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Major Strategies Control of JE, CRS/Rubella and other VPDs Expand schoolbased immunisation
Major Activities
Responsibility Supporting Agencies EPI section UNICEF, WHO
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Continue to conduct JE campaigns in high risk districts (districts in number) Expand school-based TT immunisation among 1-8 grade students (districts)
5 EPI section UNICEF, WHO 2
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2.2 Integrated Management of Childhood Illness and Newborn Care Programme
1. Introduction IMCI, through the progressive implementation and improvement of the CB-IMCI Programme, will contribute to the reduction in deaths due to the major illnesses that cause 70% of child mortality globally. The major illnesses addressed by CB-IMCI are acute respiratory infections, diarrhoeal diseases, malaria, measles, malnutrition, and other common childhood illnesses. At the community level, CB-IMCI is more focused on diarrhoea and pneumonia management and treatment by Community Health Workers (CHWs). The Programme expects that the poor and excluded groups will benefit from interventions as they have higher rates of illnesses and less access to care at facilities. CB-IMCI is also expected to improve community-based and facility-based management of pneumonia, diarrhoea, malnutrition, malaria, measles and neonatal care. Early research showed that IMCI case management training does improve quality of care (as evidenced by more thorough assessment and more accurate treatment, with carers more likely to receive key messages). However, training alone was insufficient to achieve gains in child survival without health system strengthening measures. Based on 20 years of experience with Female Community Health Volunteers (FCHVs), Nepal leads the world in early identification and case-based management of childhood disease at the community level. This has resulted in significant gains in child survival in both diarrhoea and Acute Respiratory Infection (ARI); results from the evaluation of the CB-NCP on the equivalent impact on newborns are eagerly awaited. The challenge will be to incorporate the community-based elements of the NCP in the CB-IMCI and SM Programmes. From the present level covering neonates it will be difficult to reduce under-five mortality to the desired level by 2015. The CB-NCP started in 15 districts in 2008; it expanded to 10 further districts in 2010 and to an additional 15 districts in 2011. The Nepal Demographic Health Survey (NDHS) 2011 shows a slowing of progress of health child services in the last five years. The under-five mortality rate has decreased from 61 per 1,000 live births in 2006 to 54 in 2011. The neonatal mortality rate has remained stagnant (33 per 1,000 live births) over the last five years. Deaths amongst newborns account for 33 of every 54 childhood deaths. The CB-NCP is being scaled up and an evaluation is expected in 2012. Given the need to make rapid progress in newborn survival, the expansion of CB-NCP to achieve coverage in all 75 districts should remain a top priority. Therefore, NHSP-2 has focused on the following: Maintaining programme quality by training new entrants (health workers and FCHVs), conducting refresher training, providing intensive supervision, monitoring, and periodic programme reviews Developing PPPs for implementing the CB-IMCI programme Incorporating CB-IMCI protocols into the pre-service curriculum of health workers Integrating tested CB-NCP interventions with CB-IMCI and SM after evaluation of CB-NCP programmes in piloted districts Revitalising the programme in low-performing districts. 2. Goal and Objectives Goal To reduce death, illness, and disability, and to promote improved growth and development in newborns and children under five years of age. Objectives 1. To complete the expansion phase of the CB-NCP
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2. 3. 4. 5.
To reach the unreached (poor and excluded, newborns) To improve the quality of CB-IMCI To increase the coverage of CB-IMCI To broaden the components of CB-IMCI.
3. Major Strategies Improving Health Workers Skills Ensure that all facility-based staff provide high-quality management of childhood illness Integrate the post-natal case management skills training of the CB-NCP into CB-IMCI training Ensure that all CHWs, including FCHVs, commence treatment and refer sick children where appropriate Ensure the inclusion of CB-IMCI in the curriculum of pre-service medical and paramedical schools. Improving the Health System Build capacity for CB-IMCI programme management at all levels, especially district and regional levels Strengthen logistic management of IMCI/NCP commodities Strengthen CB-IMCI/NCP in urban areas Strengthen the referral system for CB-IMCI/NCP Engage the private health sector in CB-IMCI/NCP Improve the monitoring and supportive supervision system Undertake operational research for CB-IMCI/NCP Ensure inter-sectoral and divisional collaboration for efficient programme management and delivery. Improving Family and Community Practices Reach disadvantaged and hard-to-reach communities through participatory community groups Encourage changes in key family and community practices through community mobilisation and communication strategies Engage in local resource mobilisation to strengthen CB-IMCI/NCP at the local level. 4. Indicators and Targets Health Outcome Under-five Mortality Rate (per 1,000 live births) IMR (per 1,000 live births) Neonatal Mortality Rate (per 1,000 live births) % of children with symptoms of ARI treated with antibiotics % of diarrhoea cases among children under five treated with zinc
2010/11 46
2011/12 43.2
2012/13 40.4
2013/14 37.6
2014/15 34.8
2015/16 32
54 33
50.8 30
47.6 27
44.4 24
41.2 20
38 16
30
35
40
44
47
50
15
25
30
35
40
20
(and Oral Rehydration Salts (ORS)) 5. Major Challenges and Issues Continuum of care to achieve MDG 4 Integrating tested CB-NCP interventions with CB-IMCI and SM Scaling up CB-NCP to the remaining districts Quality maintenance Reaching the unreached Increasing resources for CB-IMCI.
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Accountable Officer: Director, CHD, DoHS Major Major Activities Strategies Ensure all Provision of IMCI training facility-based to newly recruited staff provide Medical Officers high-quality (MOs)/health workers management of (five/district/year) with childhood VDCs to hire health illness workers (c.20/district/year) Regional five-year contracting process to supply one IMCI training/district including clinical skills component Revision of IMCI training
Responsibility IMCI section
Supporting Agencies Nepal Health Sector Support Programme (NHSSP), training providers, Nepal Pediatric Society (NEPAS) NHSSP, training providers, NEPAS
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
IMCI section
IMCI section
Revised CB-IMCI (2) protocol to be phased in to replace CB-IMCI (1) to districts (once CB-NCP is fully established in that district) Referral-level management of sick newborn/child training for district hospital doctors and nursing staff (districts)
IMCI section
National Health Training Centre (NHTC) NEPAS CB-IMCI (2) for CB-NCP districts
IMCI section
Curative Division Adapt Training Package
10
20
25
22
Major Strategies
Major Activities
Introduce peer review of case management through CME (Continuing Medical Education) programme at HF level with district support Integrate the Rationalise FCHV training post-natal case organisation management Prepare Revised Training skills training of for CHWs (FCHVs, the CB-NCP Maternal and Child programme into Health Workers CB-IMCI training (MCHWs), VHWs) with Revised CB-IMCI protocol*and field testing Develop indicators of newborn care Ensure that all Training to newly CHWs, including recruited FCHVs in CBFCHVs, IMCI (c. 60/district/year commence allowing for turnover) treatment and three batches/district refer sick Replace new recruit children where training with revised appropriate format to include case management for 0-2 month olds in all districts where CB-NCP is fully established
Supporting Agencies Health Management Information System (HMIS)
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Piloting
IMCI section IMCI section
NHTC NHTC
IMCI section IMCI section
HMIS NHTC/EDPs
IMCI section
NHTC
23
Major Strategies
Major Activities Refresher training for FCHVs to include new components as revisions are agreed (piggy back onto CB-NCP expansion) Review of pre-service curricula of paramedical school (co-opt representative of Council for Technical Education and Vocational Training (CTEVT) into IMCI technical working group) Provide CB-IMCI training to faculty/junior doctors/clinical staff of medical colleges and institutes Provide CB-IMCI training to faculty and clinical staff of paramedical colleges and institutes Broaden the mandate of the CB-NCP secretariat to CB-IMCI and CB-NCP secretariat for logistics, information, training management, and monitoring and supervision
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Inclusion of CBIMCI in the curriculum of pre-service medical and paramedical schools
IMCI section
CHD, WHO, UNICEF
IMCI section
CHD, WHO, UNICEF X X
IMCI section
CTEVT X X X
Capacity building for CBIMCI/NCP programme management at all levels, especially at district and regional levels
IMCI section
24
Major Strategies
Major Activities Strengthen the CBIMCI/NCP secretariat in terms of technical capacity at the centre Establish the CBIMCI/NCP secretariat support team at regional and district levels Micro-planning for strengthening CBIMCI/NCP at regional, district, municipality and below district levels Capacity building for CBIMCI/NCP focal persons (district and region: c. 100) Develop a system of procurement of commodities for community, HF and referral centres as per the multi-year procurement plan Strengthen the supply chain system for CBIMCI/NCP commodities at regional, district, HF and community levels
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X IMCI section X IMCI section X
IMCI section X IMCI section LMD, Regional Medical Store (RMS) X X X X X X X X
Strengthen logistic management of CB-IMCI/NCP commodities
IMCI section
LMD, RMS
25
Major Strategies
Major Activities Strengthen the supply chain system for CBIMCI/NCP commodities in the municipalities Logistics management orientation to DHO chiefs, store in-charges, and finance and HF in-charges Liaise with metro and sub-metro municipalities to establish the training needs for staff working in Maternal and Child Health (MCH) Clinics Liaise with the PHCRD regarding joint plan for revitalisation of urban CBIMCI/NCP Provide CB-IMCI/NCP training for appropriate MCH staff, including urban FCHVs Build partnerships with urban NGOs working in child-related fields Map a district-level referral system for each facility to include travel time, and the availability of transport (e.g. district ambulance)
Supporting Agencies CHD, LMD, RMS, PHCRD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
IMCI section X IMCI section PHCRD/ municipalities X X X X X
Strengthen CBIMCI/NCP in urban areas
IMCI section
PHCRD/ municipalities
IMCI section
IMCI section
PHCRD/ municipalities HMIS X
Strengthen referral system for CBIMCI/NCP
IMCI section
26
Major Strategies
Major Activities Prepare and conduct district and zonal level advanced clinical training for the management of serious childhood illness (referral IMCI) and newborns Develop a monitoring and information management system for referral case management of underfive-year-old children and newborns, both outpatients and inpatients, for piloting and expansion Conduct a mapping of pharmacies, chemists, and private sector providers in districts, municipalities and VDCs Screen pharmacies, private sector providers in districts, municipalities and VDCs for eligibility for training Provide training and orientation on CB-IMCI and CB-NCP
Supporting Agencies Curative Division
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Strengthen referral system for CBIMCI/NCP
IMCI section
HMIS
Engagement of private health sector in CBIMCI/NCP
IMCI section
UNICEF/PSI X
IMCI section
UNICEF/PSI X X
IMCI section
UNICEF/PSI X X X
27
Major Strategies
Major Activities Certify private sector providers to provide child and newborn services Develop an orientation and continuous medical education package for pharmacies and private sector providers Develop a system of distribution of CB-IMCI and newborn commodities through retailers Review the monitoring tool for CB-IMCI/NCP using HMIS data at district levels (based on assessment) Identify the gaps in the CB-NCP monitoring system and tools Develop a set of integrated monitoring tools for CB-IMCI and CBNCP Use monitoring tools to determine district performance Support IMCI focal persons to apply monitoring tools to
Supporting Agencies UNICEF/PSI
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X IMCI section UNICEF/WHO/ NHSSP X X
IMCI section
PSI X X
Improved monitoring and supportive supervision system
IMCI section
HMIS X
IMCI section
HMIS X
IMCI section
HMIS X
IMCI section
HMIS X X X X
IMCI section
HMIS X X X X
28
Major Strategies
Major Activities district data to better understand local performance Review the performance change in CB-IMCI/NCP of HFs at both the VDC and municipality levels during regular quarterly meetings Strengthen the district supervision system using a checklist approach for routine district supervisor visits, to include IMCI monitoring at HF level Conduct annual performance review monitoring meetings with focal persons at regional, district, municipality and below district levels focusing on low-coverage interventions Develop the system of private sector reporting to local HF and DHO Undertake monitoring and supervision of the private sector on the quality of care for children and newborns
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
IMCI section
HMIS X X X X
IMCI section
HMIS X X X X
IMCI section
HMIS
Improved monitoring and supportive supervision system
IMCI section
HMIS X X X X X
IMCI section
HMIS X X X
29
Major Strategies Operational research for CBIMCI/NCP
Major Activities Collaborate with the Clinical and NGO research sectors, including Kanti Childrens Hospital, the Maternity Hospital and NPHL in setting a Child Health Research Agenda Commission an infectious disease research team to determine the continuing efficacy of co-trimoxazole treatment for community-acquired pneumonia in zero to five-year-old children Conduct operational research on programme management of lowcoverage or underutilised interventions Determine the perception of users regarding IMCI services Undertake a Knowledge, Attitude and Practice (KAP) study on private providers Broaden the existing performance-based incentive scheme of CBNCP for FCHVs to add on
Supporting Agencies Curative Division/Nepal Health Research Council (NHRC)
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
IMCI section
EDCD/NHRC
IMCI section
NHRC/ research firms X X X
IMCI section
NHRC/ research firms
IMCI section
Inter-sectoral and divisional collaboration
IMCI section
FHD/EDCD/ PHCRD /partners
30
Major Strategies
Major Activities the activities of EDCD, FHD and PHCRD Hold regular joint meetings among FHD, ECDC, PHCRD and CHD for efficient programme management and delivery through FCHVs Training of FCHVs/CHWs to identify hard-to-reach communities, and in actions for reaching them (tools and a training package must be developed and included in the revised CB-IMCI package) Map FCHVs ethnicity by VDC, and have the district focal persons analyse and advise on selective recruitment In urban areas, provide capacity building of local organisations working in urban slums and poor communities on IMCI/NCP Focus urban recruitment of FCHVs in hard-to-reach communities
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
IMCI section
FHD/EDCD/ PHCRD/partners X X X X X
Reach the disadvantaged and hard-toreach communities
IMCI section
IMCI section X
IMCI section X X X X
IMCI section
31
Major Strategies Encourage changes in key family and community practices through participatory community groups and
communication
Major Activities Provide Interpersonal Communication (IPC) and group facilitation skills training for community health workers at all levels FCHVs, VHWs and Health Workers (HWs) (develop a module and integrate it in ongoing and basic training) Use proven community mobilisation methods (e.g. pregnant mothers groups) but with a focus on zero to five-year-olds health and development Make IMCI a standing agenda item for the FHD FCHV subcommittee Develop an early child development policy with MoE colleagues Undertake two-way mass communication Integrate the IMCI/NCP message in the nonformal education (NFE) curriculum, School Health Nutrition (SHN) activities, and existing parenting and Early Child
Supporting Agencies NHEICC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
strategies
IMCI section
NHEICC X X X X
IMCI section X IMCI section X IMCI section IMCI section District Development Committee (DDC)/VDCs/ municipalities X X X X
Local resource mobilisation to strengthen IMCI/NCP at the local level
32
Major Strategies
Major Activities Development (ECD) modules Localise IMCI/NCP BCC messages, especially by using local FM radio and other innovative approaches Train district-level stakeholders (DHOs) in micro-planning and implement an IMCI/NCP BCC plan to address district gaps (e.g. religious leaders, health exhibitions, etc.) and link to the Maternal, Neonatal and Child Health (MNCH) communication strategy
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
IMCI section
DDC/VDCs/ municipalities X X X
IMCI section
DDC/VDCs/ municipalities
33
2.3 Nutrition Programme
1. Introduction Nepal has made significant progress in reducing micronutrient deficiency over the past decade, and is one of the very few countries in the world that is on track to meet the micronutrientrelated goals of the 1990 World Fit for Children. This progress can mainly be attributed to sustained and consistent programmes of semi-annual vitamin A supplementation and deworming distribution to pre-schoolers, which cover more than 90% of children. The percentage of households consuming adequately iodised salt has risen to 80%. The prevalence of anaemia among children under five years of age was reduced by more than one-third between 1998 and 2011, while during the same period a reduction by almost half was noted in anaemia among reproductive-aged women. However, not much reduction was found in the prevalence of anaemia in children between 2006 and 2011 (NDHS 2011). Progress in reducing general malnutrition among children and women has remained slow. The prevalence of stunting, underweight and wasting has been reduced to 41% and 29% respectively in 2011 from 47% and 53% in 2001. The status of wasting has remained stagnant. Maternal malnutrition, especially chronic energy deficiency and micronutrient deficiencies, is also still an important challenge in Nepal. NDHS 2011 shows that the prevalence of thinness (Body Mass Index (BMI) <18.5kg/m2) among reproductive age women is 18.2%, and the prevalence of obesity/overweight (BMI>25kg/m2) is 13.5%. To address micro- as well as macronutrient deficiency in women and children, the GoN has highly prioritised improving the nutritional status of the Nepalese people through the involvement of multi-sectoral stakeholders from the government and non-government sectors. Likewise, the MoHP has aligned its ongoing interventions and activities to match the approved and costed Multi-sectoral Nutrition Plan (MSNP) to improve the nutritional status of children aged under five, adolescent girls, and pregnant and breastfeeding women. The Nutrition Section under the CHD has been working to review, revise and develop strategies for different priority programmes that will be scaled up in a phase-wise manner in all districts. During the NHSP-2 IP, MoHP is committed to expanding priority programmes under the leadership and management of the CHD. The focus of the interventions is to break the intergenerational cycle of malnutrition by prioritising the critical 1,000 days from pregnancy to a childs second birthday, considering this as a long-term investment for the future, with generational payoffs. Evaluation of the Community Management of Acute Malnutrition (CMAM) pilot programme in five districts in terms of reducing mortality due to severe acute malnutrition (0.46%) and identifying the highest recovery rate (90%) compared to the Sphere standard (The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response, The Sphere Project) provided a strong basis for further scale-up of the programme. The GoN will be scaling up the CMAM programme in six additional districts in 2012, and progressively to other districts, in order to address severe acute malnutrition using Ready-to-use Therapeutic Foods (RUTFs). In addition, Nutrition Rehabilitation Homes (NRHs) have gradually been established in 11 zonal, sub-regional and regional hospitals. NRHs have also been established in two districtlevel hospitals and will be further extended to five more zonal and sub-regional hospitals. Furthermore, components of Water, Sanitation and Hygiene (WASH), comprehensive child care
34
including ECD, CB-IMCI and Infant and Young Child Feeding (IYCF) will be integrated into CMAM and NRH activities. Orientation training to CHWs, volunteers, and Mothers Groups for Health (MGHs) will be conducted to strengthen the Iron Folic Acid (IFA) supplementation of pregnant and breastfeeding women to improve coverage and compliance. Zinc treatment will also be strengthened. New interventions such as newborn vitamin A dosing, and Maternal and Neonatal Programme (MNP) supplementation linked with IYCF community promotion will be initiated at scale. Additional funding will be leveraged through the SWAp to sustain vitamin A distribution and salt iodisation and to intensify IYCF promotion. Action to address the broader impact of poverty and food insecurity on malnutrition requires interministerial cooperation, and MoHP may not be the lead ministry. Inter-ministerial collaboration will be strengthened to increase awareness of under-nutrition as well as to utilise non-health structures and programmes to promote good nutrition and appropriate care practices. For example, under the framework of the joint MoHP and MoE School Health and Nutrition Strategy, schoolchildren can be mobilised as community advocates promoting good nutrition. At present, various community organisations, such as forest user groups and those carrying out credit and saving activities, exist in most districts and can provide a useful platform to promote nutrition at the community level. The government is reviewing the case for introducing food supplementation for malnourished children and pregnant and lactating mothers on a larger scale. This would be a significantly more expensive intervention. Piloting is needed in order to identify the form of assistance that would have the biggest impact, and how best to deliver it. Options range from developing cash transfer or voucher programmes to directly providing food supplements. Decisions are needed on the extent to which the programme should be targeted, how targeting should be done, and how to effect a durable improvement in household food security without creating long-term dependence on food subsidies. Various options exist regarding the type of conditions that should be attached to the additional assistance to households, and this is an area where MoHP might have a more direct interest. Since malnutrition is linked to poor feeding practices rather than simply a lack of food, there is a good case for linking the programme to the Community-based Nutrition Programme, in order to ensure that food or financial support is linked to improved knowledge on how to protect children from malnutrition. EDPs have indicated that significant additional funding could be available for an expanded nutrition programme. Partners will be involved in developing the programme. There would be merit in piloting several alternative models, and scaling up those that appear to be most promising in addressing the problem. Recently, the health sector has taken the lead in enhancing the countrys capacity for emergency preparedness and providing a nutrition response in the case of humanitarian crisis. District-based capacity for emergency preparedness and response on nutrition will be enhanced and implemented. This IP is prepared to implement NHSP-2 and the MSNP. The strategies and activities are embedded under the strategic directions of NHSP-2 and the MSNP.
35
2. Goal To achieve the nutritional wellbeing of all the people in Nepal so they can maintain a healthy life and contribute to the countrys socioeconomic development, through implementation of an improved nutrition programme in collaboration with the relevant sectors. Nutrition-specific MDGs The following Nutrition-specific Goals are to be achieved by the end of 2015 (MDGs): Reduce sub-clinical Vitamin A Deficiency (VAD) to 7% Reduce anaemia in pregnant women to 43%; reduce anaemia in all women to 42% Reduce anaemia in children to 43% Increase consumption of adequately iodised salt ( 15 PPM) at household level to 88% Reduce prevalence of night blindness in pregnant women to 1% Reduce prevalence of underweight in <5 years children to 27% Reduce prevalence of stunting in <5 years children to 28% Reduce prevalence of wasting in <5 years children to 5% Increase exclusive breastfeeding in <6 months children to 88% Reduce prevalence of thinness (BMI 18.5 below 25) in women to 15% Reduce worm infestation rate in children (pre-school) to less than 10%. 3. General Objective To enhance child and maternal mortality through nutritional interventions. Specific Objectives Reduce general under-nutrition among children and women, i.e. stunting, underweight, wasting, low BMI Reduce Iron Deficiency Anaemia (IDA) among children under five with a focus on under-twoyear-old children, and pregnant and lactating women Maintain and sustain Iodine Deficiency Disorder (IDD) and VAD control activities Improve maternal nutrition Align with multi-sectoral nutrition initiatives Improve nutrition-related BCC Improve M&E for nutrition-related programmes/activities. 4. Major Strategies Protect, promote and support optimal feeding practices of children Promotion of growth monitoring and counselling Prevention and control of IDA among children, adolescent girls, and pregnant and breastfeeding women Maintaining and sustaining achievements made in programmes for prevention and control of micronutrient deficiency disorders, e.g. IDD, VAD disorders Control of intestinal parasitic infections Gradual expansion of the School Health and Nutrition activities Communication for changing dietary practices to improve maternal and child nutrition practices and care Management of acute malnutrition though facility- and community-based approaches Improvement of adolescent and maternal nutrition
36
Alignment of the heath sector nutrition plans, policies and activities with multi-sectoral and global nutrition initiatives Institutional strengthening and capacity building for an effective nutrition programme Strengthen community participation to reach the unreached populations Strengthen preparedness and response capacity to address nutrition in humanitarian crises Establishment of an effective Nutrition Surveillance System, M&E, and research.
5. Indicators and Targets Impact Indicators Under-five Mortality Rate (per 1,000 live births) IMR (per 1,000 live births) Neonatal Mortality Rate (per 1,000 live births) % prevalence of stunting among under-five-year-old children % of low birth weight babies Outcome Indicators % of women with chronic energy deficiency (measured as mean BMI) % prevalence of underweight among under-five-year-old children % prevalence of wasting among under-five-year-old children Output Indicators % of women who took deworming medicine during pregnancy % of women who took iron tablets or syrup during the pregnancy of their last birth Vitamin A distribution as % of children 6-59 months old Postpartum vitamin A coverage % of severe acute malnourished children with access to therapeutic feeding services % of 6-23-month-old children with access to the multiple Micronutrient Powder (MIP) supplementation
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 46 43.2 40.4 37.6 34.8 32 54 33 41 50.8 30 38.6 47.6 27 36.2 44.4 24 33.8 41.2 20 31.4 38 16 29
32 21.4
30.6 20.1
29.2 18.8
27.8 16.6
26.4 16.3
25 15
29
27.2
25.4
23.6
21.8
20
11
9.8
8.6
7.4
6.2
55.1
60
65
70
75
80
79.5
81.6
83.7
85.8
87.9
90
90.4
91 40 90
92
93
94
95
90
90
90
90
60
70
75
80
80
37
6. Major Challenges and Issues Slow scale-up and low coverage of evidence-based and cost-effective interventions, e.g. IYCF, CMAM, and multiple MIP supplementation Institutional strengthening for nutrition and capacity building of HWs at all levels including management capacity at the central level Reducing inequities in nutritional outcomes Weak monitoring and supervision at all levels with poor use of available data Maintaining and sustaining progress attained in micronutrient deficiency disorders Changing the behaviour of the people to promote consumption of local indigenous food, diet diversity, and nutrition-rich food, for improved nutrition outcomes for women and children Sustained and predictable financing for scaling up priority programmes Sluggish procurement process for commodities and services Identification of the impact/outcome of interventions such as targeted food supplementation and cash grants
38
Accountable Officer: Director, CHD, DoHS Major Major Activities Strategies Protect, Develop IYCF strategy promote and support optimal feeding practices of children
Responsibilities Nutrition Section, CHD
Promotion of Growth Monitoring (GM) and counselling
Develop IYCF training manuals, guidelines and Information, Education and Communication (IEC) materials Provide training on IYCF counselling to HWs, community volunteers and Mothers Groups for Health (MGHs) Procure consultancy services to provide training Print and distribute training manuals, guidelines and IEC materials Celebrate breastfeeding week (1-7 August) Revise GM guideline as per the new WHO GM standard Develop community-based Growth Monitoring Promotion (GMP) guidelines
Nutrition Section, CHD
Supporting Agencies UNICEF, United States Agency for International Development (USAID), United Nations World Food Programme (WFP), Save the Children (SC) UNICEF, USAID, WFP, SC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Nutrition Section, CHD LMD Nutrition Section, CHD Nutrition Section, CHD Nutrition Section, CHD Nutrition Section, CHD
UNICEF, USAID, WFP, SC Nutrition Section, CHD UNICEF, USAID, WFP, SC UNICEF, USAID, SC UNICEF, SC UNICEF, SC
X X X X X X
X X
X X
X X
X X
39
Major Strategies
Major Activities Conduct operational feasibility research of new GM charts in four districts up to the community level Undertake national scale-up of a new GM chart based on the findings of the operational feasibility study Print and distribute training manuals, guidelines and IEC materials Provide orientation on the new GM chart and guidelines to CHWs and volunteers Procure and distribute the Salter Scale, Mid Upper Arm Circumference (MUAC) and equipment for measuring height/length IFA supplementation to pregnant and breastfeeding women Pilot weekly IFA supplementation to adolescent girls Procurement and distribution of IFA tablets and MIPs Scaling-up of MIP supplementation to children aged 6-23 months, linked with IYCF community promotion
Responsibilities Nutrition Section, CHD Nutrition Section, CHD
Supporting Agencies UNICEF, SC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X UNICEF, SC
X UNICEF, SC, USAID UNICEF, SC, USAID UNICEF X
LMD; Nutrition Section, CHD Nutrition Section, CHD Nutrition Section, CHD
Prevention and control of anaemia among children, adolescent girls, pregnant and breastfeeding women
Nutrition Section, CHD Nutrition Section, CHD LMD; Nutrition Section, CHD Nutrition Section, CHD
UNICEF, USAID, Micronutrient Initiative, SC UNICEF, SC UNICEF, WFP, MI, USAID UNICEF
X X
40
Major Strategies
Major Activities Refresher orientation of IFA intensification programme to CHWs, volunteers and MGHs Promotion of household consumption of adequately iodised salt through targeted awareness campaigns such as social marketing of two children logo packet salt Celebration of February as Iodine Month nationwide for increased household consumption of adequately iodised salt Ensure the availability and accessibility of iodised salt through close collaboration with the Salt Trading Corporation (STC) Semi-annual supplementation (Baisakh and Kartik) of vitamin A to children aged 6-59 months Postpartum vitamin A supplementation, treatment in cases of prolonged diarrhoea, measles, xerophthalmia and Severe Acute Malnutrition (SAM) Procurement and distribution of vitamin A capsules Semi-annual distribution of a single dose of deworming tablet (e.g. Albendazole) to children 12-59
Supporting Agencies MI
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X UNICEF, USAID, MI X X
Maintaining and sustaining achievements made in prevention and control of micronutrient deficiency disorders, e.g. IDD and VAD
UNICEF, MI X UNICEF, STC X UNICEF, USAID X UNICEF, USAID X X X X X X X X X X X X X X X X X
Nutrition Section, CHD Nutrition Section, CHD
Control of Intestinal Parasitic
LMD; Nutrition Section, CHD Nutrition Section, CHD
UNICEF, USAID, MI UNICEF, USAID
X X
X X
X X
X X
X X
41
Major Strategies Infections
Major Activities months old, along with mass vitamin A supplementation Bi-annual distribution of a single dose of deworming tablet (e.g. Albendazole) to school children (grade 1-10) Distribution of a single dose of deworming tablet (e.g. Albendazole) to pregnant women after completion of first trimester Procurement and distribution of deworming tablet (e.g. Albendazole) Phase-wise scaling up of SHN activities in districts
Responsibilities
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
UNICEF, USAID, Department of Education (DoE) UNICEF, USAID
X Nutrition Section, CHD UNICEF, DoE, SC, Centro Cooperazione Sviluppo Onlus (CCS Italia) UNICEF, DoE, SC, CCS Italia
LMD
Gradual expansion of SHN activities
Orientation training on SHN to HWs, School Resource Persons (SRPs), school supervisors and schoolteachers to improve use of SHN services (first aid kit box, deworming, IFA and physical checkups) and health and nutrition behaviour Procurement and distribution of first aid kit box to schools
LMD
Nutrition Section, CHD, MoE
42
Major Strategies Improve adolescent and maternal nutrition
Major Activities Develop Health Sector Strategy for Addressing Maternal Undernutrition Develop and pilot a package for improving adolescent and maternal nutrition based on the strategy Evaluate the piloted package in terms of its cost-effectiveness and scalability Develop a detailed communication framework for maternal infant and young child nutrition based on the strategies for IYCF, Maternal Nutrition and existing MNCH communication Develop, pre-test, and finalise harmonised communication materials and tools Print IEC materials related to the nutrition programme Develop and disseminate messages about the consumption of an adequate diversified diet through the promotion of locally available food rich in iron and vitamin A with improved care and practices for Maternal, Infant and Young Child Nutrition (MIYCN)
Nutrition Section, CHD Nutrition Section, CHD Nutrition Section, CHD
Supporting Agencies UNICEF, USAID, Helen Keller International (HKI), WFP UNICEF, USAID, HKI, WFP UNICEF, USAID, HKI, WFP UNICEF, USAID, SC, HKI, WFP
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Communication for changing dietary practices for improved maternal and child nutrition practices and care
UNICEF, USAID, SC, HKI, WFP UNICEF, USAID, SC, HKI, WFP UNICEF, USAID, SC, HKI, WFP
X X X
43
Major Strategies Management of acute malnutrition through facility- and communitybased approaches
Major Activities Phase-wise scaling up of CMAM and training to district, CHWs, volunteers and MGHs Establish and strengthen hospitalbased rehabilitation and NRHs for SAM cases Integrate NRH, WASH, ECD and IYCF activities into CMAM programme components Formulate national Management of Acute Malnutrition (MAM) guidelines and integrate with CMAM to develop an integrated training package Procurement and distribution of RUTFs, formula milk (F-75), Rehydration Solution for Malnutrition (ReSoMal) and essential drugs and commodities Active participation in global Scaling Up Nutrition (SUN) Movement, Reach Every District (RED) and multi-sectoral nutrition initiatives Align health sector nutrition activities with the NPCs MSNP Review and revise the Nutrition Policy and Strategy 2004
Responsibilities Nutrition Section, CHD Nutrition Section, CHD Nutrition Section, CHD Nutrition Section, CHD
Supporting Agencies UNICEF, WFP, SC, Partners UNICEF, Partners
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X UNICEF, WFP, ACF, SC, NYF WFP, UNICEF, Patan Academy of Health Sciences (PAHS), ACF, NYF UNICEF, ACF, SC
LMD; Nutrition Section, CHD
Align health sector nutrition plan, policies and activities with multi-sectoral and global nutrition initiatives
NPC; CHD
UNICEF X X X X
NPC
CHD, UNICEF, WFP, USAID, SC, WHO UNICEF, WFP, USAID, SC, WHO
44
Major Strategies
Major Activities Formulate a multi-year costed health sector nutrition plan in accordance with the revised Nutrition Policy and Strategy Build capacity and strengthen the district- and village-level MultiSectoral Nutrition and Food Security Steering Committee Finalise and disseminate national food-based dietary guidelines
Supporting Agencies UNICEF, WFP, USAID, SC, WHO
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
NPC
CHD, UNICEF, WFP, USAID, SC, WHO Department of Food Technology and Quality Control (DFTQC), UNICEF, WHO NHSSP
Institutional strengthening and capacity building for effective nutrition programme
Design and conduct an Organisation and Management (O&M) assessment for establishing a National Nutrition Centre (NNC) Review and revise health sector institutional arrangements at all levels in line with existing health policy and the NNC Approve and establish the organisational structure of the NNC Fill the allotted positions according to the NNCs approved organisational structure Formulate a capacity development plan based on the O&M assessment and the NNC organisational
X NHSSP X NHSSP NHSSP X NHSSP X X X
45
Major Strategies
Major Activities structure Review and revise various existing nutrition training materials and curricula (pre-service and inservice) Based on findings of the curriculum review of health cadres and a capacity needs assessment, integrate essential nutrition components (IYCF, CMAM, adolescent girls and pregnant and breastfeeding women) in pre- and in-service training curricula Network and link with key international/national vocational and academic institutions for improved nutrition programme advocacy, technical support, and knowledge and experience sharing Review the existing job descriptions of health personnel in line with the revised Nutrition Policy and Strategy and MSNP Procure essential office equipment for the nutrition programme Strengthen the Nutrition Technical Committee (NUTEC)
Responsibilities
Supporting Agencies UNICEF, WHO, WFP, SC, USAID
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
UNICEF, WHO, WFP, SC, USAID X
UNICEF, WHO, WFP, SC, USAID, Tufts, Johns Hopkins University (JHU) NHSSP
X UNICEF, WFP, USAID, SC UNICEF, WFP, USAID, SC
LMD; Nutrition Section, CHD Nutrition Section, CHD
46
Major Strategies
Major Activities Procure consultancy services to recruit for the national-level programme coordinators i.e. SHN, MCHC and Nutrition; transport of nutrition-programme-related commodities to programme districts Map the district to identify the underserved, unreached, and disadvantaged populations Develop and implement a plan based on the mapping Revitalise and mobilise MGHs and Primary Health Care (PHC)/Outreach Clinic (ORC) for improved nutrition, dietary intake, care and practices Finalise and disseminate the Nutrition Cluster Contingency Plan for earthquake and flood scenarios
Responsibilities LMD; Nutrition Section, CHD
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Strengthen community participation to reach the unreached populations
NPC, UNICEF, WFP NPC, UNICEF, WFP NPC, UNICEF, WFP
X X
Strengthen preparedness and response capacity to address nutrition in humanitarian crises
Build capacity of HWs and stakeholders at all levels as per the contingency plan
Procure and preposition essential UNICEF, WHO drugs and commodities in identified places
UNICEF, Nepal Red Cross Society (NRCS), WFP, WHO, USAID, SC, HKI, partners UNICEF, NRCS, WFP, WHO, USAID, SC, NYF, ACF CHD, NRCS, WFP, USAID, SC, partners
47
Major Strategies
Major Activities Develop and implement a guideline for IYCF in emergencies Follow up and monitor: IYCF, GMP, MIP, IFA supplementation, IDD and VAD prevention and control programme, CMAM and NRH programmes Conduct the second National Micro-nutrient Status Survey (NMSS)
Establish effective Nutrition Surveillance System, M&E, and research
Supporting Agencies UNICEF, WHO, WFP, USAID UNICEF, USAID, WFP, WHO, SC, HKI, partners
2010/11
2011/12
2012/13 X
2013/14
2014/15
2015/16
Establish a Nutrition Surveillance System in selected areas/regions Strengthen and build capacity training on nutrition surveillance and nutritional information systems for different levels of HWs Develop and integrate the M&E framework to ensure effective programme implementation
Nutrition Section, CHD Nutrition Section, CHD
UNICEF, USAID, Centers for Disease Control and Prevention (CDC Atlanta), WFP UNICEF, WHO, Tufts, JHU, WFP, HKI UNICEF, WHO, Tufts, JHU, WFP, HKI UNICEF, WFP, WHO, USAID, SC, HKI, partners
48
2.4 Safe Motherhood Programme
1. Introduction Global evidence shows that all pregnancies involve risk, and complications during pregnancy, delivery, and the postnatal period are difficult to predict. Experience also shows that three key delays are of critical importance to the outcomes of an obstetric emergency: (1) delay in seeking care, (2) delay in reaching care, and (3) delay in receiving care. To reduce the risks associated with pregnancy and childbirth, the SM Programme has made significant progress in terms of developing policies and protocols as well as expanding the role of service providers such as staff nurses and Auxiliary Nurse Midwives (ANMs) in life-saving skills. The Policy on Skilled Birth Attendants (SBAs), endorsed in 2006 by MoHP, specifically identifies the importance of skilled birth attendance at every birth and embodies GoNs commitment to training and deploying doctors and nurses/ANMs with the required skills across the country. The revised SM and Neonatal Health Long-term Plan (SMNHLTP) 2006-2017 includes the following: recognition of the importance of addressing neonatal health as an integral part of SM programming; the policy for SBAs; health sector reform initiatives; legalisation of abortion and the integration of safe abortion services under the SM umbrella; addressing the increasing problem of mother-to-child transmission of HIV/AIDS; and recognition of the importance of equity and access efforts to ensure that the neediest women can access the services they need. The current low level of care at childbirth, including care for women with complications, must improve in order for the MMR to decline further. GoN will continue to offer free delivery services at hospitals, PHCCs, Health Posts (HPs) and selected Sub-Health Posts (SHPs), and selected non-government facilities. Transport and provider incentives will continue to be paid for women delivering with an SBA or in a facility. The incentive to SBAs for home delivery has been reduced to ensure that there is no disincentive to institutional delivery. The IP has been prepared by embedding the activities under the following strategies and measures included in NHSP-2: Further strengthening the community-based support organised through FCHVs, including mothers groups and birth planning. Particular stress will be placed on identifying danger signs, strengthening the referral links, and reducing the immediate financial constraints that inhibit women from travelling to a facility by encouraging mothers to save funds for transport in preparation for the birth, and establishing or expanding the emergency funds that FCHVs manage on behalf of the community. These funds are quite distinct from the FCHV revolving fund, although one possible use for expanded FCHV revolving funds could be for loans to meet the up-front costs of reaching a facility, given the delays that have been experienced in payment of the transport allowance extended to women delivering in a HF. Training of SBAs will be expanded in line with the National In-Service Training Strategy for SBAs, which estimated that achieving MDG 5 would require 60% of births to be attended by an SBA. To achieve this target, 4,573 SBAs will be needed by 2012, and 7,000 by 2012, allowing for attrition. The MoHP will provide some kind of SBA training and/or orientation to approximately 5,000 nurses and doctors by that date, and will ensure their proper placement in relation to need. The precise form of training will depend on an assessment of current skills against the competencies defined in the training strategy. To encourage increased institutional delivery, investment in Basic Emergency Obstetric Care (BEOC) and Comprehensive Emergency Obstetric Care (CEOC) will continue towards national coverage. This investment will be planned alongside training and deployment of the necessary staff teams to ensure that facilities can be brought into operation. When NGO or private facilities with the capacity to provide CEOC are available in locations where there are currently
49
no public facilities able to do so, consideration will be given to negotiating a PPP to secure the required CEOC coverage through a contract with the non-government facility. An additional 1,000 SHPs will be upgraded to HPs with the addition of birthing units. In areas with poor physical access to facilities, community-based administration of misoprostol will be implemented as a supplement to reduce the risk of Post-partum Haemorrhage (PPH). Based on the Blood Policy, 1991 (Revised in 2006) and the Strategic Plan (2009-2013), coordination among existing blood centres will be strengthened and expanded, HR skills will be strengthened, and quality will be ensured through an accreditation process by NPHL/NRCS, in addition to other interventions.
2. Goal To improve maternal and neonatal health and survival, especially of the poor and excluded. 3. Objective Increased healthy practices and utilisation of quality maternal and neonatal health services, especially by the poor and excluded. 4. Major Strategies 1. Strengthening and expansion of maternal and newborn health care services to improve coverage and quality of services Strengthening and expansion of Comprehensive Emergency Obstetric and Neonatal Care (CEONC) services Strengthening and expansion of birthing centres at PHCC, HP and SHP levels Expansion of safe surgical and Medical Abortion (MA) services Expansion of Adolescent Sexual and Reproductive Health (ASRH) Programme (1,000 HFs) Screening for uterine prolapse through Reproductive Health (RH) camps Management of uterine prolapse in static (hospitals) and mobile settings Revise/develop (as required) and implement RH and SM-related guidelines and protocols Develop a mechanism for quality monitoring Strengthening the referral system, including Emergency Obstetric Care (EOC) referral funds for remote districts Other RH services (fistula, cancer screening). 2. Enhancing the capacity of service providers and managers at different levels (Advanced Skilled Birth Attendants (ASBAs), SBAs, Public Health Nurses (PHNs) to provide various services, such as Intrauterine Contraceptive Devices (IUCDs), implants, Ultrasonogram (USG), medical/surgical abortion, etc. Local recruitment of HR to provide CEONC and birthing centre services Advocate and implement development of service providers for CEONC (Doctor of Medicine General Practitioner (MDGP), Diploma in Gynaecology and Obstetrics (DGO), Anaesthetic Assistant (AA)) Strengthen and expand the community Maternal and Neonatal Health (MNH) Programme including community mobilisation and the FCHV Programme Prevention of PPH through misoprostol especially in remote areas Equity and Access Programme (EAP) through PHCRD Promoting BCC Coping with excess demand for institutional delivery Fostering PPPs Strengthening the Aama Programme and integration with the incentive for four Antenatal Clinic (ANC) visits Fostering coordination and collaboration
50
Research and M&E to improve quality and service delivery Strategies to improve governance and accountability and to mainstream GESI.
5. Indicators and Targets Health Outcome and Coverage MMR (maternal deaths per 100,000 live births) Neonatal Mortality Rate (neonatal deaths per 1,000 live births) Obstetric case fatality rate (%) % of HPs providing delivery service % of PHCCs providing BEOC service, including Comprehensive Abortion Care (CAC) % of districts with at least one facility providing all CEONC services % of women with knowledge about the abortion sites % of women having had an abortion who experienced complications % of safe abortion (surgical and medical) sites with longacting FP service % of deliveries assisted by SBAs % of births which are institutional deliveries % of pregnant women completing at least four ANC visits during pregnancy
2010/11 170 (UN estimate) 33 (NDHS 2011) <1 79 (Annual Report 2010/11) 53.6 (Annual Report 2010/11) 57.3 (Annual report 2010/11) 19 (NDHS 2006)
2011/12 229 30 <1 85 (current)
2012/13 229 28 <1 >80
2013/14 192 23 <1 >80
2014/15 160 19 <1 >80
2015/16 134 16 <1 >80
>50
>50
>50
60
70
60 58.8 (NDHS 2011) 12
64
68
72
76
25
35
40
50
14 (2009)
11
10
>80 18.7 (NDHS 2006) 18 (NDHS 2006) 35.2 (2008 Health Management Information System (HMIS)) 31 (2008/9 HMIS) 3.6 (2008/9 HMIS) 36 (NDHS 2011) 35 (NDHS 2011) 57 (NDHS 2011) 34 4.6 (NDHS 2011)
>85
>90
>90
>90
38
40
54
60
36
37
38
40
60
65
72
80
% EOC need met % of births delivered by Caesarean Section (CS)
35 4.0
43 4.3
47 4.4
49 4.5
6. Major Challenges and Issues Shortage of service providers at both hospitals (especially CS providers) and peripheral levels Single- (fiscal-) year contracts for HR and services
51
Problems in continuity of service delivery owing to frequent transfer of staff Low level of awareness of mothers regarding transport incentives (70% in 2010) Insufficient number of ASBAs and SBAs (4,543 SBAs needed by 2012, 7,000 by 2015) Weak monitoring of the Aama programme (institutional delivery) including the private sector Ensuring quality services Expanding Aama programme and quality monitoring in private hospitals Coping with excess demand for institutional delivery at tertiary level Low utilisation of lower-level health facilities for childbirth Institutionalising the management of uterine prolapse
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Accountable Officer: Director, FHD, DOHS Major Strategies Major Activities Responsibility Strengthen and expand maternal and newborn health care services to improve coverage and quality of care Strengthening and expansion of CEONC services Strengthening and expansion of birthing centres at HP and SHP levels Expansion of surgical and medical safe abortion services a) Surgical and medical services (integrated in hospitals and PHCCs) b) Expansion of MA only in phase-wise manner in HPs with SBAs SM Section
Supporting Agencies Partners
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X SM Section Partners X SM Section International Pregnancy Advisory Services (Ipas) and partners
Surgical scaled up in 75 districts
Monitoring
Monitoring
Monitoring
Monitoring
Monitoring
MA piloted in 6 districts
Integrated MA in 75 districts
10 districts Expansion of the ASRH Programme (1,000 HFs) Revise/develop (as required) and implement RH-/SMrelated guidelines and protocols Family Planning (FP) Section FP/SM Section GIZ and partners Partners
6 districts
5 districts
4 districts
53
Major Strategies
Major Activities Develop mechanisms for quality monitoring Strengthening the referral system including the EOC referral fund for remote districts Screening for uterine prolapse through RH camps
Responsibility FP/SM Section
2010/11
2011/12 X
2012/13 X
2013/14 X
2014/15 X
2015/16 X
Uterine Prolapse (UP) Section
Management of uterine prolapse in static (hospitals) and mobile settings Initiate other RH services (fistula, cancer screening)
UP Section
United Nations Population Fund (UNFPA), WHO UNFPA, WHO
FHD
Partners X X X X
Enhance the capacity of service providers and managers at different levels
ASBA training (target for two per site including attrition) SBA training IUCD training (in PHCCs and HPs, including upgraded SHPs)
SM Section; NHTC SM Section; NHTC FP/SM Section; NHTC
Partners 30 Partners Partners 1,000 304 (status) 40 1,000 402 40 1,000 402 40 1,000 402 40 1,000 402 40 1,000
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Major Strategies
Major Activities Implant training (in PHCCs and HPs, including upgraded SHPs) USG training PHN capacity building Operating Theatre (OT) management training (target for three per site) Medical/surgical abortion training
Responsibility FP/SM Section; NHTC SM Section; NHTC SM Section SM Section; NHTC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
168 (status) Partners Partners Partners
431
431
431
431
X X
X X
X X
X X
X X
X Ipas/ Partners: Medical (HP and PHCC); Surgical (Manual Vacuum Aspiration (MVA) Ipas/ partners X 116
SM Section; NHTC
145
X 93
X 89
X X
X X
300
300
300
300
300
300
Develop capacity of region- and districtlevel on SM, FP and ASRH including GESI mainstreaming
SM Section
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Major Strategies Local recruitment of HR for CEONC and birthing centre services
Major Activities CEONC fund for districts ANM Staff Nurse (SN) Recruitment of supervisors for monitoring of SM Programme (six persons) MDGP
Responsibility SM Section
2010/11 24
2011/12 26 900 50
2012/13 28 1,200 60
2013/14 30 1,400 70
2014/15 30 1,500 70
2015/16 30 1,500 70
Demography Section
Finance Section 6 6 6 6 6
Advocate and implement the development of CEONC service providers
FHD
Nick Simon Institute (NSI) National Academy for Medical Science (NAMS) NAMS
DGO training
FHD
10
12
15
15
15
AA Training
FHD/NHTC
15 Strengthen and expand the communitybased MNH Programme including FCHV community mobilisation Prevention of PPH through misoprostol, especially in remote areas of districts Birth Preparedness Plan implementation Implement EAP through PHCRD in districts FHD Partners 23 25
15
15
15
28
30
30
FHD
Partners
X 20
X 20
X 25
X 30
X 35
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Major Strategies
Major Activities RH referral by FCHVs in districts Develop messages on SM and newborn care Air messages on SM, newborn care services, and the transport incentive to mothers Implement information/ awareness/advocacy campaigns for youth and adolescents BCC focusing on husbands, mothers-inlaw, and decision makers Air messages on management of uterus prolapse Develop a coping strategy for excess demand for institutional delivery Establish large birthing centres at referral hospitals Promote local-level planning for excess demand for institutional delivery
Responsibility
Supporting Agencies Ipas NHEICC/ NGOs NHEICC/ NGOs Ipas NHEICC, UNFPA, WHO, UNICEF, INGOs, Ipas NHEICC/ partners
2010/11 10 X
2011/12 6 X
2012/13 5
2013/14 4
2014/15 X
2015/16 X
Promote BCC
SM Section SM Section
10
FP Section
10
SM Section
UP section
NHEICC X X X X X X
Cope with excess demand for institutional delivery
SM Section
NHSSP and partners
SM Section
NHSSP and partners NHSSP and partners
SM Section
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Major Strategies
Major Activities Build a referral system to discourage bypassing
Responsibility SM Section
Promote PPPs
Strengthen the Aama programme and integrate with the incentive for four ANC visits Foster coordination and collaboration at central and district levels
Implement PPP for CEONC services, Aama, uterine prolapse, safe abortion services Integrate 4 ANC visits with the Aama programme
All Sections
Supporting Agencies NHSSP, UNICEF and partners SM partners, Ipas NHSSP/ WHO/ UNFPA
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
10
Director
RHCC and subcommittee meetings (districts) RH planning and review meetings Regular monitoring
Director
Director Demography Section
All partners, Ipas All partners UNFPA, WHO, UNICEF, INGOs, Ipas SM partners SM partners
10 X
6 X
5 X
4 X
X X
X X
Research and M&E to improve quality and service delivery
Integration of EOC and Aama monitoring in HMIS Rapid assessment of Aama Surakchha Programme by NGOs/private organisations
Demography Section Demography Section
58
Major Strategies
Major Activities Recruitment of supervisors for monitoring SM programme (six persons) Study on GBV, trends, level, protection against, and the impact on FP and SM Monitoring and supervision of the RH Programme Data analysis and report writing of maternal mortality sentinel districts Internet service, web hosting and updating Evaluation of ASRH and UP programmes Conduct a feasibility study on the appropriateness of misoprostol for treatment of incomplete abortion in the Nepal context Evaluation of nurses as CAC service providers
Responsibility Demography Section
Supporting Agencies Finance Section
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Demography Section
Population Division
Demography Section
Ipas/ partners
Demography Section
Partners X Partners X X X X X
Demography Section Demography Section
X X UP
X X ASRH
Ipas
Ipas X X
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Major Strategies
Major Activities Evaluation of SBAtrained ANMs as MA service providers Post Abortion Care (PAC) monitoring RH planning and review meetings
Responsibility
Supporting Agencies Ipas
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X Ipas FHD Ipas/ All partners X X X X X X X X X
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2.5 Family Planning Programme
1. Introduction The main aim of the FP Programme is to improve the health status of mothers and children and to improve the overall quality of family life by fulfilling the FP needs of individuals and couples throughout Nepal. To address the aim of the FP Programme, MoHP has committed to provide quality FP services to all individuals and couples through the health service network, including hospitals, PHCCs, HPs, SHPs, PHC/ORCs and mobile Voluntary Surgical Contraception (VSC) services. In addition, FP services are available through NGOs, private clinics, and social marketing initiatives; FCHVs also provide information, distribute condoms, and re-supply oral pills. Various BCC approaches are being implemented at different levels to make individuals and couples aware of the importance of FP, healthy timing and spacing for pregnancy, the concept of a well-planned family, and contraceptive methods. FP has been proven to reduce maternal mortality by reducing the number of pregnancies, the number of abortions, and the proportion of high-risk births. It also helps reduce child mortality, slow the spread of HIV/AIDS, promote gender equality, reduce poverty, accelerate socioeconomic development and protect the environment. International studies have repeatedly confirmed that FP is one of the most cost-effective of all health services. Investing in FP can result in large savings to the health and education sector and help countries to achieve development goals. Thus, attention to FP has recently been increasing worldwide. Nepal has achieved significant progress in reducing the TFR, and the adolescent fertility rate, increasing knowledge about FP methods and birth intervals. The Contraceptive Prevalence Rate (CPR) and method mix have improved. However, the CPR has stalled within the last five years (2006-2011). Progress on fertility and FP is uneven. A high unmet need for FP remains among certain groups such as adolescents, residents of rural and hilly areas, the eastern development region, and the western hills, poor communities, and, unexpectedly, among educated groups. The last decade has seen a high rate of out-migration, especially among men of reproductive age. To address these gaps, MoHP/FHD has recently developed the new FP Strategy 2068. The current strategy focuses on increasing access of quality FP services in rural and marginalised communities. It implements a focused FP programme to fulfil the needs of special groups like post-partum mothers, post-abortion clients, migrants, and adolescents. In addition, the strategy works to integrate FP into other health services like MCH and HIV/AIDS. 2. Goal To improve the health status of mothers and children and improve the overall quality of life of the entire family through increasing the accessibility, availability and utilisation of quality FP services for individuals and couples. 3. Objectives To increase access and use of quality FP services that are safe, effective and acceptable to individuals and couples. Special focus will be given to increase access to those regions where rural, poor, Dalit, other marginalised people and groups with high unmet needs live.
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To create an enabling environment for increasing access to quality FP services for men and women. To increase the demand for FP services by conducting various BCC activities.
4. Major Strategies Emphasise the provision of quality FP services, including the ability of men and women residing anywhere in Nepal to make an informed choice based on facts and comprehensive information FP services will be made available through government, private, NGO and social marketing initiatives. The role of the private sector in providing FP services will be encouraged Establish FP as a reproductive right of men and women Increase access to and availability of FP services Enhance the effective integration of FP with other health services Implement various activities to develop the capacity of service providers and managers Establish an effective logistic management system to ensure the regular availability of FP services Initiate various innovative approaches to engage men in FP services Implement various BCC activities to enhance the general publics decision-making capacity to accept FP methods based on facts and knowledge Implement focused programmes to fulfil the FP needs of special groups and communities living in areas of high unmet need Promote BCC by using multiple channels Train care providers Continue micro-planning in low CPR districts Increase the availability of five methods (condoms, Pills, Depo-provera, IUCD, implants) in all service centres Integrate FP services with health care and non-health services Reduce the barriers to clients in accessing services Promote PPPs Target FP to educated and better-off groups Fostering coordination and collaboration. 5. Indicators and Targets Indicators and Outputs TFR CPR (%) % unmet need for contraception (15-19) VSC IUCD Implant No. of districts providing regular VSC services No. of PHC/HPs providing
2010/11 3 48 27 63,000 23,000 28,000 21 422
2011/12 2.9 50 25 70,000 44,800 60,000 30 600
2012/13 2.8 52 20 70,000 58,000 63,000 45 900
2013/14 2.7 54 20 70,000 64,000 66,000 55 1,200
2014/15 2.6 56 19 70,000 70,500 73,000 70 1,200
2015/16 2.5 67 18 70,000 77,000 80,000 70 1,500
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IUCD services No. of PHC/HPs providing implant services 318 500 900 1,200 1,200 1,500
6. Major Challenges and Issues Stagnant CPR over the last five years Unequal use of FP between urban and rural, rich and poor, tarai and mountain regions, and among various ethnic groups Need to fulfil the FP needs of special groups: adolescents, the poor, rural and mountainous communities, post-partum and post-abortion women, spouses of migrants Integration of FP services with other health services such as immunisation, MCH, HIV/AIDS and general health services High percentage of women with husbands away from home.
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Accountable Officer: Director, FHD, DOHS Major Major Activities Strategies Promote BCC through multiple channels Airing messages on delayed marriage, birth spacing, and a well-planned family norm Developing and implementing a BCC framework targeting educated and better-off people Strengthening counselling, infection prevention, and management of side effects and complications Providing training on QoC Recanalisation after vasectomy Complication management Forecasting of requirements for contraceptives and logistic supplies Procurement and supply of contraceptives Conducting regular year-round mobile VSC outreach services
Responsibility
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
FP Section: FHD FP Section
X NHEICC
X FP Section Partners X FP Section FP Section FP Section FP Section FP Section FP Section Partners Partners Partners LMD, partners LMD, partners FPAN, MSI/ Sunaulo Pariwar Nepal (SPN) Curative Division Partners Partners HMIS X X
Improve the Quality of Care (QoC)
X X X X X X
X X X X X X
X X X X X X X X X
Increase the availability of five FP methods in all service centres
Providing recanalisation services in selected hospitals Continuing the post-partum FP service Continue micro-planning in low-CPR Expanding IUCD/implantation services to PHCs and HPs Promoting wider use of Health
FP Section FP Section FP Section FP Section
X X X X
X X X X
X X X X
X X X X
X X
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Major Strategies districts; Target FP to educated and better-off people
Major Activities
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Integrate FPand populationrelated services
Management Information Systems (HMISs) in low-CPR districts Conducting micro-planning in low-CPR districts Developing and implementing a special programme of FP for educated groups Distribution of better-quality contraceptives through campuses, shopping malls, department stores Integrating FP services with safe abortion care, post-partum care, Ayurvedic care and EPI clinics Strengthening Institutionalised FP Service Centres (IFPSCs) Introducing VSC services in district hospitals and PHCCs (year-round) Implementing population-related activities Integrating population- and FP-related activities Developing and implementing a population management plan Enhancing multi-sectoral coordination of population-related programmes Training service providers on IUCD, implant, Non-surgical Vasectomy (NSV) and minilaparotomy
FP Section FP Section FP Section
CHD Partners
X X X X
X X X
X X X
X X X X X
FP Section
MoHP X X X X
FP Section FP Section Population Division Population Division Population Division Population Division FP Section
Hospitals
X X X X
X X X X X X X X X X
X X X X X
X X NHTC X
X X X
X X X
Train care providers
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Major Strategies
Major Activities
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Reduce the barriers to clients Foster coordination
Institutionalising policy/operational guidelines and clinical protocols Introducing FP in the school curriculum Supporting the development of 1,000 "youth-friendly centres" Coordinating the FP programme and activities through RHCC networks, including the Family Planning SubCommittee meetings Developing a state and non-state partnership framework for FP service delivery (focusing on I/NGOs) Developing a PPP modality to run the Family Welfare Centre (Chetrapati) Conducting periodic policy reviews through national RH Steering Committee meetings Conducting district, regional and national reviews of the FP Programme (RH review) Providing intensive monitoring and facilitative supervision in low-CPR districts
FP Section FP Section FP Section FP Section RHCC X FP Section RHCC CDC Atlanta, MoE
X X 200
X X 200
X X
200
200
200
Promote PPP
X FP Section FP Section RHCC HMIS X FP Section HMIS X FP Section X X X
X X X X X X
Monitor FP services
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2.6 Adolescent Sexual and Reproductive Health Programme
1. Introduction Improving the Sexual and Reproductive Health (SRH) of adolescents through the health sector has been of strategic importance for more than a decade; most recently this has received programmatic attention from the FHD. The NDHS surveys show a positive trend over the past two decades regarding marriage patterns and maternity during adolescence. The mean age at marriage of girls has increased from 16.4 years in 1996 to 17.8 years in 2001, and the percentage of adolescent girls aged 15-19 who are already married has declined from 44% in 2006 to 29% in 2011. This has resulted in a decline of the percentage of adolescents who have begun childbearing, from 24% in 1996 to 17% in 2011. Nevertheless, reducing the age of marriage and motherhood during adolescence remains a crucial issue, requiring a sustained and multi-sectoral approach. The extremely low CPR among currently-married adolescent girls (only 14.4% in 2011) and the equally high (40%) unmet need for contraception in this age group also reflect this. MoHP in 1998 issued the RH Strategy and Plan, which clearly states that ASRH is a major component of RH. Subsequently, in order to meet this strategic objective, FHD developed the National Adolescent Health and Development (NAHD) Strategy in 2000, included ASRH in the EHCS package, and in 2007 produced the Implementation Guidelines on ASRH for district health managers. In 2010, FHD finalised the National ASRH Programme as a health sector response to addressing adolescents RH needs. This programme has at its core the introduction of Adolescent-friendly Services (AFS) and aims for the establishment of 1,000 AFS centres by 2015 as outlined in NHSP-2. The programme will improve existing clinical services in the fields of safe abortion, FP, maternal and child health care, and HIV and STI prevention and treatment, with a view of making them more accessible to adolescents. The programme will be scaled up by FHD with the support of EDPs throughout the country. The ASRH Programme essentially consists of: Upgrading 13 PHC facilities (SHPs, HPs, PHCCs and district hospitals) per district to offer AFS, and creating demand for the services in the communities Equipping HFs with basic equipment to provide private and confidential services to adolescents Providing HWs with a job aid on ASRH, a counselling flipchart on ASRH, and IEC materials (eight booklets) developed by NHEICC Involving adolescents in the decision making of respective HFs Health Facility Operation and Management Committees (HFOMCs) for adolescent issues Providing appropriate SRH services to adolescents (FP, HIV and STI services, abortion) and recording service utilisation.
The ASRH programme includes orientations outlining the respective responsibilities and tasks in terms of management, service provision, and demand creation for the following key implementing stakeholders: District health managers District key actors (RHCC) HFOMCs Health care providers. ASRH has so far been a sub-component of the Health Communication Strategy for Family Planning, Maternal and Child Health (2005-2009), but will be given more specific strategic attention in the ASRH Communication Strategy to be developed by NHEICC. This will emphasise the new programmatic focus that FHD has given to this health issue and will provide more specific guidance for communication to address the knowledge gaps of adolescents, to increase service demand, and to sensitise parents,
67
households, and communities in order to provide a supportive environment for adolescents to lead a healthy life. At the end of 2015, evidence on the effectiveness of the ASRH Programme in terms of the utilisation of health services by adolescents, their satisfaction with these services, and their knowledge, attitudes and practice regarding SRH will be available from an impact evaluation conducted by FHD with approval from NHRC. 2. Goal To promote the SRH of adolescents. 3. Objectives To increase the availability of and access to information about adolescent health and to provide opportunities to build the skills of adolescents, service providers and educators. To increase the accessibility and utilisation of health and counselling services for adolescents. 4. Major Strategies Scaling up the national ASRH Programme to introduce AFS in the remaining districts Promoting BCC, targeting adolescents and their social environments Capacity building Increase cooperation with MoE to improve comprehensive sexuality education. 5. Indicators and Targets Health Outcome and Coverage Adolescent Fertility Rate (AFR) (per 1,000) % unmet need for contraception (15-19) Number of health facilities offering AFS
2010/11 98 (NDHS 2006) 34.7 (NDHS 2006) -
2011/12 2012/13 2013/14 2014/15 2015/16 90 30 100 85 27 200 82 25 200 80 22 200 70 20 300
6. Major Challenges and Issues Changing cultural and social reasons for early marriage and childbearing Reducing cultural and social barriers for unmarried adolescent girls to access contraception and safe abortion services Ensuring access to AFS for marginalised adolescent girls and boys.
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Accountable Officer: Director, FHD, DOHS Major Strategies Major Activities Scaling up the ASRH Programme Implement the ASRH Programme in 1,000 HFs in 75 districts Link the ASRH Programme with the ASRH component of the local population management programme (peer education) Supervision of existing AFS
Responsibility ASRH Section
ASRH Section
Supporting Agencies GIZ, UNICEF, UNFPA, WHO Population Division
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
ASRH Section
Demand creation for AFS Promoting BCC Develop an ASRH Communication Strategy and IP
ASRH Section ASRH Section
Develop a mass media campaign with key messages on ASRH, targeting adolescents and their social environment Implement an ASRH mass media campaign
ASRH Section
ASRH Section
Assess and design interventions based on using modern technologies for reaching adolescents
ASRH Section
GIZ, UNFPA, UNICEF, WHO, INGOs GIZ, UNICEF, UNFPA NHEICC/ GIZ, UNFPA, UNICEF, WHO, INGOs NHEICC/ GIZ, UNFPA, UNICEF, WHO, INGOs NHEICC/ GIZ, UNFPA, UNICEF, WHO, INGOs NHEICC
X X
X X
X X
X X
X X
X X
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Major Strategies Capacity building
Major Activities Orientation on the ASRH Programme for district managers Orientation on the ASRH Programme for district stakeholders Orientation on the ASRH Programme for HFOMCs Orientation on the ASRH Programme for service providers Regular monitoring of district reports
Responsibility ASRH Section
ASRH Section
Supporting Agencies GIZ, UNFPA, UNICEF, WHO, INGOs DHOs
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X ASRH Section ASRH Section ASRH Section DHOs DHOs UNFPA, WHO, UNICEF, INGO GIZ X X
X X X
X X X
X X X
Research and M&E
Conduct impact evaluation of the ASRH programme
ASRH Section
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2.7 Female Community Health Volunteers Programme
1. Introduction Recognising the importance of women's participation in promoting health, GoN initiated the FCHV Programme in Fiscal Year (FY) 2045/46 (1988/1989) in 27 districts, and in a phased manner has expanded to all of Nepals 75 districts. Initially, the approach was to select one FCHV per ward regardless of the population size. In 1993 a population-based approach was introduced in 28 selected districts. At present there are 48,489 FCHVs actively working in VDCs all over the country. The FCHVs major role is to improve the health and healthy behaviour of mothers and community members by promoting SM, child health, FP, and other community-based health services with the support of health personnel from the SHPs, HPs, and PHCCs. As well as motivating and educating, the FCHVs re-supply pills and distribute condoms, ORS packets and vitamin A capsules. They treat pneumonia cases and refer more complicated cases to health institutions. They also distribute iron tablets to pregnant women in districts with Iron Intensification Programmes. Various policies, strategies, and guidelines have been developed to strengthen the programme. FCHVs provide their services voluntarily, thus their performance depends on the support they receive. MGHs are responsible for the selection and removal of FCHVs, and also for supporting FCHVs in their work. Interested women from marginalised, oppressed, and backward communities will be promoted to become MGH members. Generally, every VDC ward will have at least one FCHV, and when selecting new FCHVs priority will be given to women from Dalit, Janajati and marginalised communities. The success of the FCHV Programme has resulted in more responsibilities being given to FCHVs. This trend raises the issue of how to continue to motivate what remains a cadre of volunteers. Arguably, the commitment to voluntary community service is what makes the FCHVs so effective, and the same level of results would not be achieved if delivered by an equivalent force of poorly paid public employees. Training and recognition of the importance of their work are strong motivating forces for many. A balance should be struck between compensating the women for the real financial and time costs they incur in carrying out their duties, and not losing the spirit of voluntary service. FCHVs do receive a flat per diem rate for their participation in vitamin A distribution, and are paid for their attendance at biannual two-day review meetings and for participation in training/orientation. The CB-NCP proposes to pay a lump sum to FCHVs based on their individual performance in delivering newborn care services. A further incentive introduced in 2007/08 is the establishment of a fund in each VDC which the FCHVs can use in order to support income generation activities. Each VDC is provided with 50,000 Nepalese Rupees (NRs) as seed money to establish the FCHV fund. In addition, every year NRs 10,000 will be added to this amount. Moreover, local government and partners can add any amount of money to this fund. A survey of the funds use will also be conducted to find the most effective uses. 2. Goal To support the goal of health through community involvement in public health activities, including imparting knowledge and skills for womens empowerment, increasing awareness on health-related issues and involving local institutions in promoting health care. 3. Objectives To inspire women to tackle common health problems by imparting relevant knowledge and skills
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To prepare a pool of self-motivated volunteers as focal persons for bridging health programmes and the community To prepare a pool of volunteers to provide service for community-based health programmes To increase the participation of communities in health improvement To develop FCHVs as health motivators To increase the utilisation of health care services through demand creation.
4. Major Strategies Creating demand Providing training Offering primary care Strengthening the FCHV Programme. 5. Indicators Coverage Number of FCHVs who will have been recruited and deployed in mountain regions and remote districts
2010/11 -
2011/12 100
2012/13 200
2013/14 300
2014/15 400
2015/16 200
6. Major Challenges and Issues Increased expectation of FCHVs Trade unionism Overloaded FCHVs Coordination Effective utilisation of the FCHV fund Supportive supervision and monitoring Lack of replacements for ageing population of FCHVs.
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Accountable Officer: Director, FHD, DOHS Major Major Activities Strategies Advocacy FCHV Day Celebration (all VDCs)
Responsibility FCHV Section
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X Training Provide guidelines to MGHs to select FCHVs from poor and excluded groups and to provide them training Conduct two-day training for the VDClevel FCHV fund management committee Organise the FCHV Biannual Review Meeting (all VDCs) Organise Biannual Review Meeting of Sub Health Post In-charges at district and Ilaka levels Reward for voluntary retirement Add FCHV fund (NRs 10,000) Revitalisation Orient to MGHs Revitalise FCHVs and MGHs Assess the performance of FCHVs after revitalisation National FCHV survey (quantitative) Service-seeking behaviour of people and their perceptions of FCHVs (in remote area of Nepal) FCHV fund utilisation MGHs, HFOMC FCHV Section Partners
X Partners X X X X X X X X
X X X X X X X
X X X X X X X
X X X X X X X
X X X X X X X
Review and monitoring
FCHV Section FCHV Section
Partners Partners
X X
Contribution to FCHV fund
FCHV Section FCHV Section FCHV Section FCHV Section
Partners Partners Partners Partners
X X X X
Research/ study
FCHV Section FCHV Section
Partners Partners
X X
X X X
X X X
FCHV Section
Partners
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2.8 Free Health Care Programme
1. Introduction The Interim Constitution of Nepal (2007) specifies free basic health care as a fundamental right of every citizen (article 16.2). To safeguard every citizens right to basic health care, the MoHP declared free health care in 2007. The free health care policy of the GoN targets poor, vulnerable, and marginalised people to increase their access to and utilisation of health care services. The policy also declared free essential health care to all at HPs, SHPs and PHCCs across the country. In order to materialise the constitutional commitment (Interim Constitution, 2007) of the fundamental right of basic free health care, the MoHP introduced a policy of providing Free Health Care Services to the population in a phased manner to enhance access to EHCS for every citizen on an equal footing, with special consideration being given to providing a safety net for the poor, ultra-poor, destitute, disabled, senior citizens, and FCHVs. During NHSP-1, free EHCS were initially designed for the poor and excluded, but later EHCS became free of charge for all at district facilities, except for district hospitals, where free EHCS continued to be targeted, although 40 essential drugs were free to all. The evolution of free health care is as follows: On December 15, 2006 (2063-8-29), the GoN made emergency and inpatient services free of charge to ultra-poor, poor, destitute, and elderly people, people living with disabilities, and FCHVs, at district hospitals and PHCCs. Outpatient (OP) services were also made free to the targeted groups in low- Human Development Index (HDI) districts from FY 2064/65 (2007) onward. On October 7, 2007 (2064-6-21) the GoN declared EHCS free of charge to everyone at all HPs and SHPs. The policy was implemented in mid-January 2008. On November 16, 2008 (2065-10-1), the GoN declared EHCS free of charge to all at PHCCs. On January 15, 2009 (2065-10-1), the GoN declared OP services, inpatient services and emergency services free of charge to the targeted groups in hospitals of 25 or fewer beds, as well as listing all medicines as free. For non-targeted groups, 20 listed drugs were made available free of charge. In addition, as a safety net, under the MoHP free care is provided to poor patients in central, regional and zonal hospitals. The MoHP has prepared guidelines providing some relief to the poor and destitute by reimbursing them for a certain amount of costs for catastrophic illness. The guidelines cover catastrophic spending for five diseases: kidney disease, cancer, heart disease, Alzheimers and Parkinsons. Each patient receives the equivalent of NRs 50,000.00 annually. Patients identified as poor by district committees have direct access to the accredited treatment centres, with their costs being reimbursed by the MoHP. Free care is provided to the poor and destitute, and free dialysis is provided for citizens above 75 years of age. Patients below 14 or above 75 years of age will receive free operations for heart disease in the Shahid Gangalal National Heart Centre. During NHSP-2, EHCS in district hospitals is planned to be made free to all. As was the case with the earlier extension of free services, this should result in a substantial increase in utilisation of district hospital services, but this will happen only if quality is maintained and, if possible, improved. At present, district hospitals rely on user fees for a quarter of their revenues. Moreover, user fees finance expenditures that government revenues at present do not. They pay for contract staff where an established public servant is not available, they pay for some performance incentives to staff, and they finance maintenance and additional drugs and supplies. They also help to cover problems caused by delayed or interrupted disbursement of government funds. Some revenues will continue to be collected for services outside the definition of EHCS, but they will be significantly reduced. Maintaining the quality of services offered at district hospitals, and increasing their volume in response to increased demand caused by abolition of fees, will thus require that lost fee revenue is replaced with increased government
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funding. The increased government funds will need to be both timely and flexible as to how they can be used. These policies contribute to mitigating the financial barriers to seeking care, provide relief to poor families, promote the utilisation of EHCS, and, ultimately, contribute to improving the health of the population. 2. Goals To reduce out-of-pocket spending on health care, particularly of the poor, marginalised and vulnerable groups To reduce the disability rate, and address morbidity, especially of poor, marginalised and vulnerable people, by securing the right of citizens to basic health services. 3. Objectives To ensure the citizens constitutional right to basic health care services To increase access to and utilisation of EHCS, especially by poor and marginalised groups. 4. Major Strategies Increasing awareness of free care through effective and localised health communication Strengthening free care Increasing allocative efficiency Improving the quality of care Institutional development Promoting the role of local government in free care. 5. Indicators and Targets Health Outcome and Coverage Under-five Mortality Rate (per 1,000 live births) % of people with disability % of total cost paid by patient for obtaining health services % of households aware of free care % of households that received free care at the district level and below % of district facilities that will have no stock-outs of tracer drugs/commodities for more than one month per year by 2015
2010/11 54 3.6 53 60 29
2011/12 50.8 3.5 52 66 45
2012/13 47.6 3.4 51.5 72 60
2013/14 44.4 3.3 51 78 70
2014/15 41.2 3.2 50 84 80
2015/16 38 3 49 90 90
70
75
80
85
90
90
6. Major Challenges and Issues Increasing awareness of free care (60% of the population is aware of free care) Ensuring the retention of care providers at service centres Maintaining the quality of care Reducing stock-outs of essential drugs at the facility level Expanding the list of free essential drugs Monitoring free care Classifying poor and non-poor patients in district hospitals Moving from case-based to population-based budget allocations for free care.
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Accountable Officer: Director, PHCRD, DoHS Major Strategies Major Activities Increasing awareness of free care With NHEICC, develop a communication framework on free care Develop and spread additional messages on free care through print media, especially to women, the poor and excluded Develop IEC materials (electronic) on free care Airing free-care-related messages through FM radio and television Localise free-care-related messages in local languages with local contexts Integrate free-care-related messages in non-health interventions such as forest users groups, womens empowerment, formal education and local-development-related programmes Promote free care through FCHVs, schoolteachers, students, and local stakeholders Study the strategic and financial implications of free care Assess the marginal and total costs for expanding free care
Responsibility NHEICC
Supporting Agencies PHCRD/ EDPs PHCRD/ EDPs
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
NHEICC
NHEICC NHEICC NHEICC
PHCRD/ EDPs PHCRD/ EDPs PHCRD/ EDPs PHCRD/ EDPs
X X
X X X X X
NHEICC
PHCRD
NHEICC X X X X X X
Expanding universal free care in district hospitals
PHCRD PHCRD
PPICD, NHSSP PPICD, NHSSP
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Major Strategies
Major Activities Develop a framework to replenish the loss of user fees Generate evidence to inform policy makers Replenish the registration fees of DHOs, PHCCs, HPs and SHPs (grants) Provide institutional grants on the basis of OP/inpatient and emergency visits/morbidity/ population Develop procurement plan with forecasting of the drug Ensure timely procurement and supply of listed essential drugs for free care Provide additional care providers on a contract basis Orient care providers on free care Train focal persons on the operation of software and websites Train the storekeeper on medicine store management Maintain coordination and collaboration through stakeholder meetings
Responsibility PHCRD PHCRD PHCRD
Strengthening free care
Supporting Agencies PPICD, NHSSP PPICD, NHSSP Finance Section Finance Section
2010/11
2011/12
2012/13 X X
2013/14
2014/15
2015/16
PHCRD
PHCRD PHCRD
LMD LMD; Finance Section Personnel Section; DoHS NHTC HMIS
X X X X X X
PHCRD
X X X
X X X X
X X
X X
PHCRD PHCRD
PHCRD PHCRD
LMD Department of Drug Administration (DDA)
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Major Strategies Increasing allocative efficiency
Major Activities
Responsibility
Revise resource allocation criteria PHCRD for free care
Use allocation criteria for funding Improving the quality of care Periodically expand the list of essential drugs for free care Introduce a QoC package as a performance evaluation of HFs (provide a standardised system of infection prevention) Ensure the regular presence of service providers in all HFs throughout the year. Provide at least basic physical and infrastructure facilities, including equipment and instruments in each HF Expand and strengthen the role of the monitoring committee Ensure year-round drug availability in public health facilities as per free care drug list Strengthen and make functional monitoring mechanisms within PHCRD
PHCRD PHCRD
Supporting Agencies Health Economics and Financing Unit (HEFU), GIZ HEFU DDA
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X X
X X
X X
X X
PHCRD
PHCRD
Management Division (MD)/EDPs DoHS/MoHP
DoHS/MoHP
MD/PHCRD/ EDPs
Institutional development
PHCRD PHCRD
MD LMD
X X X X X
PHCRD
MD X X X
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Major Strategies
Major Activities Strengthen the free care management support units and cells at PHCRD, Regional Health Directorate (RHD), and DHOs Orient the members of local government bodies and stakeholders on free care and their supporting roles Develop a framework for the joint funding and monitoring of free care Prepare and agree to the joint funding modalities (centre, provincial, and district governments) for free care Revise and update the free care monitoring framework Develop software and websites on free health care Promote web-based monitoring of free care Conduct an intensive review workshop on free care (quarterly, half-yearly and yearly) at least up to the district level. Conduct social audits of free care together with other health programmes Undertake periodic monitoring of free care, through visits and longdistance communication
Responsibility PHCRD
Supporting Agencies EDPs
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X PHCRD MoLD/DDC VDC Federation MoLD/DDC VDC Federation MoLD/DDC VDC Federation HMIS HMIS HMIS HMIS X PHCRD HMIS/Civil society/ NGOs HMIS
Promote the role of local government in the provision of free care
PHCRD
PHCRD
Monitoring of free care
PHCRD PHCRD PHCRD PHCRD
X X X X X X X
PHCRD
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Major Strategies
Major Activities
Conduct internal assessments of free care through mobilising independent consultants Undertake periodic evaluation of free care; connect with Household Survey (HHS) and other surveys as appropriate Social mobilisation Review and refine existing equity and and access implementation empowerment for modalities and programmes increased service Roll out EAP in additional districts utilisation by unreached Identify and address the sociocommunities cultural barriers of specific target groups through EAP Undertake capacity building of health managers and health service providers on GESI Strengthen the GESI technical group based at DoHS
Supporting Agencies HMIS
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X PHCRD
Independent
firms
PHCRD
EDPs and MoHP EDPs and MoHP MoHP/EDPs X
X X X
X X X
X X X X X X X
PHCRD MoHP/PHCRD
PHCRD and the Population Division PHCRD and the Population Division
All divisions X All divisions X X X X X X X X X
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2.9 Urban Health Care Programme
1. Introduction Nepals population reached 26,620,809 in the year 2011, with the population growth rate decreasing from 2.25% in 2001 to 1.4% per annum in 2011. The urban population constituted about 17% of Nepals total population in 2011, compared to 14% in 2001, revealing a massive urban increase. The sex ratio in urban areas (92) is lower than in rural areas (104). Among the urban areas, the Kathmandu Metropolitan City has the largest population (1,006,656), followed by Pokhara, Lalitpur and Biratnagar Municipalities. Dhulikhel Municipality has the lowest urban population (16,406) followed by Dasharathchand, Bhadrapur and Ilam Municipalities (CBS, 2011). Migration is very high in Nepal, with almost half of the migrants moving within the country. Most migrants move from rural to urban areas in search of jobs and in pursuit of education. They are at greater risk of contracting HIV/AIDS and STIs and increase pressure on public services and utilities. Migration brings significant demographic shifts to a society and carries socioeconomic implications in urban areas. Poor people may not be able to afford housing, drinking water, and a power supply, and so may stay in temporary shelters on riverbanks. These unplanned settlements, and the mobility of the urban poor, have caused the health care delivery system difficulties in addressing this populations needs. The urban poor are prone to illness owing to poor housing, unsafe drinking water, and unhealthy life styles. They are more exposed to risk factors, including a polluted environment. Urban residents are more likely to have improper food habits and unhealthy life styles, with higher prevalence of smoking, alcoholism, and the consumption of junk food. Very few government run HPs or SHPs, and no FCHVs are functional in urban areas. A few municipalities have established urban health clinics but they have been unable to cater to the growing demand for health care. Coordination and collaboration between the MoHP, MoLD, and municipalities is lacking. The health of the urban poor has drawn the attention of the policy makers. The Three-year Interim Plan and NHSP-2 give special emphasis to the Urban Health Care Programme. 2. Goal To improve the health status of the urban population, particularly the poor, marginalised, women, and children. 3. Objectives To increase the access to and utilisation of quality basic health care services in urban areas, particularly by the poor, marginalised, women, and children. 4. Major Strategies Increasing access to basic health services, especially by poor and excluded (urban slum dwellers) Integrating urban health into local development plans and programmes Multi-sectoral coordination and collaboration, including partnerships Developing the capacity of the municipalities and urban health sections of PHCRD Improving QoC Scaling up urban health care services, especially in locations where urban slum dwellers live Conducting operational research and studies M&E.
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5. Major Challenges and Issues Fostering coordination and collaboration Low coverage of immunisation in urban areas Low use of contraceptives among the educated population High levels of pollution Ensuring basic health care as a fundamental right of the urban poor and excluded.
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Accountable Officer: Director, PHCRD, DoHS Major Major Activities Strategies Provision of Develop Urban Health Policy Urban Health framework Policy and Develop and implement Urban structural Health Strategy framework Rapid assessment of existing urban health activities with activities modified accordingly Increasing Data collection on urban health access to basic health Estimate target population, services including mobile population, by programme Conduct needs assessment of urban poor Conduct stakeholder analysis Design and disseminate messages related to urban health clinics and available services through multimedia Strengthen referral mechanism to specialised hospitals from urban health clinics Develop and implement special social mobilisation initiatives for urban slums Support equipping FCHVs
Responsibility MoHP/MoLD PHCRD with MoLD PHCRD with MoLD PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD with Municipalities
Supporting Agencies EDPs EDPs EDPs
2010/11
2011/12 X
2012/13 X X
2013/14
2014/15
2015/16
X HMIS/MD/ Municipalities HMIS/MD X X X HMIS/MD HMIS/MD NHEICC X MoHP/MoLD X MoHP/MoLD X LMD X X X X X X X X X X X X X X X X X X X X X
PHCRD with Municipalities PHCRD with Municipalities PHCRD/ Municipalities
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Major Strategies Developing the capacity of municipalities
Major Activities Support preparing Urban Health Plans for municipalities, including setting priorities Support municipalities to establish and strengthen urban health units Provide urban health care service grants Develop and print a training manual for care providers on urban health care Develop and print a training manual for FCHVs on urban health care Conduct basic and refresher training to urban FCHVs Develop and introduce mechanisms to engage FCHVs with urban poor and excluded communities, especially with urban slum dwellers Hire HR for urban health clinics Train and orient health care providers on urban health care Establish and promote FCHV funds
Responsibility PHCRD/ Municipalities PHCRD/ Municipalities PHCRD PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities
Supporting Agencies MoLD/ Municipal Federation LMD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X MoLD LMD X NHTC X NHTC Other divisions of DOHS X X X X X
X X X
X X X
X X X
X X
X X
X X
PHCRD/ Municipalities PHCRD PHCRD/ Municipalities
MoHP/MoLD MoHP/MoLD
X X
X X X
X X X
X X X
X X X
MoHP/MoLD
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Major Strategies Developing the capacity of municipalities
Major Activities Observe FCHV Day Develop/revise/expand urban health care package to include ayurvedic, and other alternative medicine Provide basic physical facilities and medical instruments to urban health clinics Support municipalities to organise (mobile) free care services in urban slums Support municipalities to deliver Reproductive Health Services from service centres Support municipalities to deliver HIV/AIDS-related services from service centres Support municipalities to organise specialised care clinics Develop Memorandum of Understanding (MoU) with care provider hospitals to offer free care to poor and excluded groups Prepare a framework for exemption of user fees to urban poor, including a reimbursement mechanism
Responsibility PHCRD/ Municipalities PHCRD/ Municipalities
Supporting Agencies MoHP/MoLD MoHP/MoLD
2010/11
2011/12 X
2012/13 X
2013/14 X
2014/15 X
2015/16 X
X LMD X MoHP/MoLD X MoHP/MoLD X MoHP/MoLD X MoHP/MoLD MoHP/MoLD X X X X X X X X X X X X X
Improving QoC
PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities
X X
X X
PHCRD/ Municipalities
MoHP/MoLD X X X X
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Major Strategies
Major Activities Scale up Urban Health Programme to other (new) municipalities
Responsibility PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities
Supporting Agencies Finance Section MoHP/EDPs MoHP/MLD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X X
Expansion and extension of Urban Health Programme
Promoting research and studies
Review the function of existing urban health clinics Expand the number of health clinics and promotional initiatives to other parts of existing municipalities, focusing on urban slums Conduct assessment of air, water and noise pollution Conduct assessment on QoC provided by private institutions Conduct a situation analysis/stocktaking report on NCDs Provide support to develop and implement integrated municipality plans
PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities PHCRD/ Municipalities Interministerial Committee PHCRD PHCRD/MoLD
MoHP/EDPs MoHP/EDPs
X X
X X
X X
X X
MoHP X MoHP/EDPs X PHCRD X MoLD MoLD X X X X X X X X X X
Integrating urban health into local development Inter-sectoral coordination and
Conduct an Inter-ministerial Committee meeting
Conduct a Management Committee meeting Develop funding modalities for
X X
X X
X X
X X
X X
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Major Strategies collaboration and partnership
Major Activities the Urban Health Programme Develop a MoU between the MoHP and MoLD on urban health Establish and promote FCHV funds Coordinate with WASH, accident prevention, and infrastructure development programmes Prepare a monitoring framework for the Urban Health Programme Monitor air, water, and noise pollution
Responsibility
Supporting Agencies MoLD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
PHCRD
X PHCRD MoLD MoLD PHCRD/ MoLD MoLD X MoLD X MoLD MoLD MoLD X MoLD MoLD X X X X X
X X X
X X X
X X X
X X X
PHCRD
M&E
Interministerial Committee Monitor QoC PHCRD/ Municipalities Undertake national, regional, PHCRD and district reviews Undertake regular monitoring of PHCRD quality of instant and prepared foods Review FCHV programme PHCRD Undertake external evaluation of Urban Health Programme (process in 2013 and Impact in 2015) PHCRD
X X X X X
X X X X X X
X X X X X
X X X X X X
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2.10 Malaria Control Programme
1. Introduction In 1958, the malaria eradication programme, the first national public health programme in Nepal, was launched with the objective of eradicating malaria from Nepal within a limited time period. For various reasons, the eradication concept became a control programme in 1978. Following the call of WHO to revamp the malaria control programmes in 1998, the Roll Back Malaria (RBM) initiative was launched to address the perennial problem of malaria in heavily forested, foot hills, the inner tarai and valley areas of the hills, where more than 70% of the total malaria cases of the country occur. Since 2004, interventions have been carried out in high-risk areas, covering a population of 5.98 million with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). From 2011/12 to 2015/16, similar interventions are being extended to moderate-risk areas, affecting a population of 8.24 million, again supported by the GFATM. In addition, Nepal has low-risk areas with a population of 6.12 million, and malaria-free areas with a population of 2.13 million, where malarial control activities will be carried out with funding from the regular government budget and without EDP support. This is based on the provisional stratification of malaria endemic areas of the country in 2010. Currently, malaria control activities are carried out in 65 districts at risk of malaria. The GFATM supports malaria control programmes in 31 high endemic districts and 18 moderate districts. The strategy has shifted from control to pre-elimination. The programme is divided into two implementation phases: the time between 2011 (July) and 2013 (July) will be pre-elimination phase I (preparatory phase), and August 2013 to July 2017 will be pre-elimination phase 2. Preparatory phase activities include: update of stratification of Nepals malaria endemic areas, i.e. micro-stratification; preparation of national guidelines for the elimination of malaria; assessment of HR and their capacity; recruitment of additional staff; and training and reorientation of the programme to implement elimination activities. During this phase, special attention will be given to developing and enhancing the entomological capacity at the central and regional levels. The ongoing interventions include: vector control with Long-lasting Insecticidal Bed Nets (LLIN) and/or Indoor Residual Spraying (IRS) with synthetic pyrethroid insecticides; parasitological diagnosis with microscopy or Rapid Diagnostic Test (RDT); timely treatment of P. falciparum cases with Artemisinine Combination Therapy (ACT) plus primaquine, and of P. vivax cases with chloroquine (three days) and primaquine (14 days); and early detection and response to malaria outbreaks within a week. 2. Goal To eliminate malaria by the year 2026. 3. Objective To completely interrupt the malaria transmission and reduce the incidence of locally contracted malaria in Nepal to zero by 2026. 4. Major Strategies Vector control and personal protection Early diagnosis and appropriate treatment Malaria surveillance and epidemic preparedness
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BCC Programme management Pre-elimination intensification.
5. Indicators and Targets Health Outcome and Coverage Malaria annual parasite incidence (per 1,000) At least 90% of households with at least one LLIN per two residents in all high-risk districts and areas by 2015 At least 80% of children under five years old who slept under a LLIN the previous night
2010/11 0.15 -
2011/12 0.15 90%
2012/13 0.14 90%
2013/14 0.14 90%
2014/15 0.13 90%
2015/16 0.12 90%
70%
80%
80%
80%
80%
80%
6. Major Challenges and Issues Low coverage of blood slide collection and examination Inadequate training and orientation to staff on the Malaria Programme Less effective spraying activities Reaching the pre-elimination stage of malaria Lack of coordination and collaboration.
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Accountable Officer: Director, EDCD, DoHS Major Strategies Major Activities Vector control and personal protection Early diagnosis and appropriate treatment Conduct two rounds of routine IRS LLINs will be provided free of charge to all people living in highrisk areas Provide diagnostic services for malaria (slide collection and examination) Perform RDTs Support to develop a referral laboratory network Provide ACT Malaria surveillance and epidemic preparedness Establish and maintain a malaria outbreak early warning system in selected public health facilities Establish and maintain an integrated surveillance system Provide technical and operational linkages between EDCD and epidemic-prone districts Conduct focal IRS in the wards Conduct RDT-based active case detection in the outbreak ward(s) and in all adjacent wards Perform RDT-based active case detection in the outbreak ward(s)
Responsibility Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section
Supporting Agencies LMD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X GFATM/PSI X LMD X X NPHL WHO Partners X Partners Partners X X
X X X X X X
X X X X X X
X X X X X X
X X X X X X X
X X X X X X X X X X
Partners Partners
X X
X X X
X X X
X X X
X X X
Partners
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Major Strategies BCC
Major Activities Develop and produce BCC materials Air/print messages on malaria control during special events (malaria day) and establish highlevel advocacy Promote interpersonal communication on malaria Provide technical and management training through central- and district-level staff Hold Technical Working Group (TWG) meetings Prepare/revise technical guidelines: guidelines on case management, vector control, epidemic preparedness and control, monitoring drug and insecticide resistance Hold National Technical Advisory Group for Malaria (NTAG-M) meetings Promote community participation and partnership Draft/adapt and implement International Health Regulations (IHR) Prepare structure, tools and mechanisms for the implementation of IHR
Responsibility Disease Control Section Disease Control Section
Supporting Agencies Partners Partners
2010/11 X
2011/12
2012/13 X
2013/14
2014/15 X
2015/16
X Partners Partners X Partners Partners X X
Programme management
Disease Control Section Disease Control Section Disease Control Section Disease Control Section
X X X
X X X
X X X
X X X
X X X
Disease Control Section Disease Control Section Legal Section
Partners X Partners WHO X X X X X X X X X X X X
Pre-elimination intensification
EDCD
WHO X
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Major Strategies
Major Activities Conduct micro-stratification Conduct weekly reporting including zero reporting and epidemiological/entomological investigation of cases/foci Prepare and implement national guidelines for elimination of malaria Assess HR and their capacity Recruit additional staff to implement elimination activities Train and reorient staff on elimination of malaria Enhance entomological capacity Establish and maintain integrated surveillance system (policy, guidelines, and tools)
Responsibility Disease Control Section Disease Control Section
Supporting Agencies Partners Partners
2010/11
2011/12 X
2012/13
2013/14
2014/15
2015/16
X Partners X WHO/ partners WHO/ partners partners WHO/ partners WHO/ partners X X X X X X X X
Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section Disease Control Section
X X
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2.11 Kala-azar Elimination Programme
1. Introduction Kala-azar is a vector-borne disease caused by the parasite Leishmania donovani, which is transmitted by the sand fly, Phlebotomus argentipes. The disease is characterised by fever for more than two weeks with splenomegaly, anaemia, progressive weight loss and sometimes darkening of the skin. In the endemic areas, children and young adults are its principal victims. The disease is fatal if not treated promptly. Kala-azar has emerged as a health problem in recent years, but over the last decade, some significant advances have been made both in its diagnosis and treatment. A rapid and easy applicable serological test, the rK39 dipstick test, has been demonstrated to have high sensitivity and specificity in validity studies conducted on the Indian subcontinent. For the first time, an oral drug Miltefosine has proven to be efficacious in drug trials and has been registered for use in treating Kala-azar. GoN has accepted the regional strategy of eliminating Kala-azar, and with India and Bangladesh is a signatory to the MoU that was formalised during the May 2005 WHA on Kala-azar elimination, with the target of eliminating the disease by 2015. In 2005, the EDCD of DoHS formulated a three-phase National Plan for the Elimination of Kala-azar: Preparatory Phase: 2005-2008, Attack Phase: 2008-2015, and Consolidation Phase: 2015 onwards. There are six expected outputs of the plan. One of the outputs is to develop a functional network that provides diagnosis and case management with special outreach to the poorest of the poor. EDCD has revised the diagnosis and treatment of Kala-azar in Nepal. The rK39 test kit has been accepted and introduced as a diagnostic test and Miltefosine as a first-line treatment. This strategy was tested in Saptari district in 2007 as a pilot programme, and Saptari has served as a demonstration district for all the other endemic areas. 2. Goal To contribute to improving the health status of vulnerable groups and at-risk populations living in Kalaazar endemic areas of Nepal through the elimination of Kala-azar by 2015, so that it is no longer a public health problem. 3. Objective To reduce the annual incidence of Kala-azar to less than 1 per 10,000 people in every district by 2015 (elimination target). 4. Major Strategies Improve programme management Early diagnosis and complete treatment (introducing new technology) Integrated vector management Expand the elimination activities Effective disease surveillance and vector surveillance Social mobilisation and partnerships Clinical implementation and operational research. 5. Indicators and Targets Outcome Case fatality rate (%) Incidence of Kala-azar (per 10,000 population)
2010/11 0.50 0.95
2011/12 0.40 0.90
2012/13 0.30 0.85
2013/14 0.25 0.80
2014/15 0.20 0.75
2015/16 0.1 0.70
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6. Major Challenges and Issues Shortage of staff for outbreak investigation and control Delayed response due to unavailability of staff Incomplete reporting Staff overwhelmed by control activities Delayed or non-existent care seeking.
94
Accountable Officer: Director, EDCD , DoHS Major Strategies Major Activities Early diagnosis and complete treatment Develop a functional network that provides diagnosis and case management Continue treatment (Miltefosine) Provide training to health workers and laboratory personnel on rK-39 dipstick diagnosis of Kala-azar
Responsibility Disease Control Disease Control Disease Control
Supporting Agencies Hospitals
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X Hospitals Vectorborne Diseases Research and Training Centre (VBDRTC) VBDRTC X
X X
X X
X X
X X
X X
Training
Expanding elimination activities Integrated vector management Effective disease surveillance and vector surveillance Social mobilisation and partnerships Clinical implementation
Provide training to DHOs, MOs, Public Health Officers and other health personnel on Kala-azar and other Vector-borne Diseases (VBDs) Expand the elimination activities
Disease Control
Disease Control Disease Control Disease Control
VBDRTC/ partners Districts Partners X Partners VBDRTC B.P. Koirala X
X X
X X
X X
X X X
Conduct two rounds of selective IRS (included in malaria control) Conduct integrated disease surveillance and vector surveillance (as included in malaria control) Promote social mobilisation and partnerships Undertake implementation and operational research
Disease Control Disease Control
X X
X X
X X
X X
X X
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Major Strategies and operational research
Major Activities
Responsibility
Assessment
Conduct internal and external assessment of Kala-azar elimination
Disease Control
Supporting Agencies Institute of Health Sciences (BPKIHS) HMIS/ partners
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
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2.12 Lymphatic Filariasis Elimination Programme
1. Introduction Nepal is endemic for three of the target neglected tropical diseases for which chemotherapy is available: lymphatic filariasis (LF), soil-transmitted helminthiasis, and trachoma. Recent mapping exercises indicate that there are a number of districts, particularly in the tarai region, where these diseases are coendemic. LF is a public health problem in Nepal. The disease is a major cause of morbidity, primarily hydrocele and lymphoedema of legs, and impedes socioeconomic development in many areas of Nepal where it is endemic. The disease is prevalent in rural and slum areas, predominantly affecting the poorer sections of the community. LF mapping completed in 2005 by using the Immunochromatography Card Test (ICT) revealed that 60 of Nepals districts are endemic for LF. The disease has been detected in different topographical areas ranging in altitude from 300 feet above sea level in the tarai plains ecological zone to 5,800 feet above sea level in high hill areas. More LF cases are seen in the tarai than in the hills. Elimination of LF (ELF) means that LF would cease to be a public health problem, defined as when the number of microfilaria carriers is less than 1% and the children born after initiation of ELF are free from circulating antigenaemia. Absence of antigenaemia among children is considered as evidence for the absence of transmission and new infection. Nepal is a signatory to the WHA resolution to eliminate LF by 2020. The GoN is fully committed to eliminate the disease within the stipulated time, with support from EDPs (NHSP-2 IP (2010-15)). The EDCD under the DoHS has formulated a Plan of Action (2003-2015) for the elimination of LF in Nepal by establishing a Task Force under the Chairmanship of the DirectorGeneral (DG), DoHS. 2. Goal To eliminate LF from Nepal by the year 2020 and reduce the disease to such a level that transmission within Nepal will be stopped. 3. Objectives To interrupt the transmission of LF To reduce and prevent morbidity To provide deworming by giving Albendazole (ALB) to endemic communities, especially to children To reduce mosquito vectors through application of suitable and available vector control measures (integrated vector control management). 4. Major Strategies The national target has been to eliminate LF as a public health problem in Nepal by the year 2015 by reducing the level of the disease in the population to a point where transmission no longer occurs. The objectives are to reduce and eliminate transmission of LF by Mass Drug Administration (MDA), and to reduce and prevent morbidity in affected persons. The twin pillars of the ELF strategy are: 1. Transmission control: The strategy of interruption of disease transmission is based on MDA to prevent the occurrence of new infection and disease by administration of annual single dose of Diethylcarbamazine (DEC) + ALB once a year for four to six years. 2. Disability prevention and management: For those individuals who already have the disease, provide home-based management and limb hygiene for lymphoedema and surgical correction for hydrocele.
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5. Major Challenges and Issues Increasing coverage (in 19 additional districts) Mobilising resources (budget and logistic support) Addressing morbidity meticulously MDA Social mobilisation and mass campaigns. Increasing public awareness about the disease Increasing the coverage of MDA in urban communities.
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Accountable Officer: Director, EDCD, DoHS Major Major Activities Strategies Transmission control Mapping and disease burden estimation
Responsibility EDCD
Rapid assessment through questionnaire Direct physical examination Detection of microfilariae in the blood ICT card tests Endemicity mapping of LF Staging and phasing of the programme MDA Surgical management of hydrocele due to lymphatic filariasis
EDCD EDCD EDCD EDCD EDCD EDCD EDCD EDCD
Supporting Agencies World Health Organisation / Research Triangle Institute (WHO/RTI) WHO/RTI WHO/RTI WHO/RTI WHO/RTI WHO/RTI WHO/RTI WHO/RTI WHO/RTI
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X X X X X X X X
X X X X X X X X
X X X X X X X X
X X X X X X X X
X X X X X X X X
X X X X X X X X
Disability prevention and management Social mobilisation Monitoring and surveillance
Social mobilisation and campaign M&E Microfilaria baseline survey and sentinel surveillance Staff training Transmission assessment surveys
EDCD EDCD EDCD EDCD EDCD
WHO/RTI WHO/RTI WHO/RTI WHO/RTI WHO/RTI
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
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Major Strategies
Major Activities Post-MDA surveillance (WHO draft recommendations 2010)
Responsibility EDCD
Supporting Agencies WHO/RTI
2010/11 X
2011/12 X
2012/13 X
2013/14 X
2014/15 X
2015/16 X
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2.13 Dengue Control Programme
1. Introduction Dengue Fever (DF) is a very important mosquito-borne viral disease and a major international public health concern. Aedes (Stegomyia) Aegypti (Ae. Aegypti) and Aedes (Stegomyia) Albopictus (Ae. Albopictus) are the two major vectors of dengue. DF is a usually self-limiting disease found in tropical and sub-tropical regions around the world, predominantly in urban and semi-urban areas. Dengue Haemorrhagic Fever (DHF), a potentially lethal form of disease, was first recognised in the 1950s during a dengue epidemic in the Philippines and Thailand, but today DHF affects most Asian countries and is a leading cause of childhood deaths. There is no specific treatment for dengue, but appropriate medical care frequently saves the lives of patients with the more serious DHF. The most effective way to prevent dengue virus transmission is to combat the disease-carrying mosquitoes. Nepals first case of DF was reported in 2004 in Chitwan district. During September-October 2006, following a dengue epidemic in India, hospitals in the central and western tarai and also a hospital in Kathmandu reported 32 laboratory-confirmed dengue cases. Most of these cases were indigenous. Sporadic clinical cases were reported between 2007 and 2009. However, in 2010, a dengue epidemic occurred in several locations in lowland districts as well as in some hilly areas. According to EDCD, 4,529 suspected cases, 917 serologically-confirmed cases, and five deaths were reported by the end of December. This was the highest recorded morbidity caused by the dengue virus in Nepal to date. The 2010 dengue epidemic highlights the first expansion of DF/DHF to Nepals hilly regions, whereas only classic DF caused by multiple serotypes had been reported previously. 2. Goal To reduce the morbidity and mortality owing to DF/DHF to a level where dengue will no longer present a public health problem. 3. Objectives To develop an integrated vector control approach for prevention and control To develop capacity on diagnosis and case management of DF, DHF, Dengue Shock Syndrome (DSS) and chickengunya To intensify health education/IEC activities To strengthen the surveillance system for prediction, early case detection, preparedness and early response to dengue outbreaks. 4. Major Strategies Early case detection, diagnosis, case management and reporting of DF, DHF, DSS and chickengunya Regular case-based surveillance of DF, DHF, DSS and chickengunya through the Early Warning and Reporting System (EWARS) Mosquito vector surveillance in concerned municipalities An integrated vector control approach that combines several approaches directed towards container management and source reduction BCC Operational research Integrated vector management. 5. Major Challenges and Issues Outbreak control Increasing capacity on diagnosis and case management Diagnosis, case management.
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Accountable Officer: Director, EDCD, DoHS Major Major Activities Strategies Early case detection, diagnosis, case management Provide training on early case detection, diagnosis, case management Strengthen laboratory facilities/diagnostic support Develop and maintain vector control management guidelines Undertake integrated vector management (cross reference with malaria control) Provide rapid response during outbreaks and conduct an Ae. Aegypti larva survey and control the Ae. Aegypti larva (search and destroy) Dengue case and vector surveillance Provide health education through electronic, print and interpersonal communication Conduct operational research
Responsibility Disease Control Disease Control Disease Control Disease Control Disease Control
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X Partners X Partners Partners X Partners X X
X X X
X X X
X X X
X X X
X X X
Integrated vector management
Outbreak control
Surveillance BCC
Disease Control Disease Control Disease Control
Partners Partners
X X
X X X
X X X
X X X
X X X
X X X
Operational research
Partners
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2.14 Leprosy Control Programme
1. Introduction Nepal eliminated leprosy as a public health problem, defined as a Prevalence Rate (PR) of <1 case per 10,000 population, in December 2009. The DoHS acknowledged this achievement as one of the health sectors major success stories of the past decades. Since then Nepal has consistently sustained the elimination status with a PR of <1 case per 10,000 population, and efforts are underway to further reduce the disease burden and achieve universal elimination. Although significant progress has been made in reducing the national-level disease burden, sustaining the achievement and further reducing the disease burden through delivering quality leprosy services still remain as major challenges. After meeting the elimination target, the national strategy was formulated to "Sustain Quality Leprosy Services and Further Reduce the Disease Burden due to Leprosy in Nepal: 2011-2015 (2068/69-2072/73)" based on the "Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy: 2011-2015" and the updated Operational Guideline laid down by WHO. The main principles of leprosy control are based on early detection of new cases and their timely and complete treatment with Multidrug Therapy (MDT) through integrated health services. The emphasis is on sustaining the provisions for quality patient care that are equitably distributed, affordable and easily accessible. Milestones Following are the notable milestones of Nepals leprosy control programme: 1960 - Leprosy survey performed in collaboration with WHO 1966 - Pilot Project established to control leprosy with dapsone monotherapy 1982 - Introduced MDT in the leprosy control programme 1987 - Integrated leprosy control within the general basic health services 1996 - MDT coverage reached all 75 districts 1999 - National Leprosy Elimination Campaign (NLEC) carried out in 27 districts 2001 - NLEC carried out in 17 districts 2009 - Leprosy elimination declared on 2066/10/5 (December 2009) 2010 onwards - Sustained elimination at the national level with a PR <1 case/10,000 population 2011 - National strategy formulated to "Sustain Quality Leprosy Services and Further Reduce the Disease Burden due to Leprosy in Nepal: 2068/69 - 2072/73" More than 80% of the leprosy burden is found in tarai districts. 2. Goal for 2015 To further reduce the disease burden due to leprosy in comparison to the 2010 level. 3. Objectives To further reduce the disease burden due to leprosy To improve and sustain the quality of leprosy services in an integrated manner To rehabilitate people affected by leprosy To increase awareness and reduce the stigma related to leprosy. 4. Major Strategies The new national strategy has envisioned delivering leprosy services through the following ten strategic methods: 1. Early new case detection and their timely and complete management
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2. Provide quality leprosy services in an integrated manner by qualified health workers 3. Prevent leprosy associated impairment and disability 4. Rehabilitate people affected by leprosy, including medical and community-based rehabilitation 5. Reduce stigma and discrimination through advocacy, social mobilisation, and IEC activities, while addressing GESI issues 6. Strengthen referral centres for management of complications 7. Promote meaningful involvement of people affected by leprosy in leprosy services, while addressing human rights issues 8. Promote and conduct operational research/studies 9. Conduct monitoring and supportive supervision, including onsite coaching, surveillance, and evaluation to ensure and strengthen quality leprosy services 10. Strengthen partnership, co-operation and coordination with local government, EDPs, civil society, and community-based organisations. 5. Targets The programme has set the following national-level targets (in comparison to the 2010 level): To reduce the New Case Detection Rate (NCDR) by 25% by the end of 2015 To reduce the PR by 35% by the end of 2015 To reduce Grade II Disability (DG II) amongst newly detected cases by 35% by 2015.
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6. Indicators Year Indicators and Targets Population by HMIS Patients being treated PR (%) New cases NCDR (%) DG II among new cases DG II proportion (%) * Baseline data 7. Major Challenges and Issues Limited resources Trained HR and their retention Rehabilitation of people affected by leprosy Mainstreaming leprosy-related charity approach services Increase in numbers of endemic districts as compared to the base year Declining attention to leprosy programmes especially at highly endemic districts. Validation of reported new cases Sustaining quality services Sustaining effective surveillance, monitoring and supervision Community-based and medical rehabilitation including local participation Further reducing stigma and discrimination with a focus on marginalised and unreached populations Sustain elimination at the national level Achieve elimination at the district level (universal achievement). 2009/10* 27,495,585 2,104 0.77 3,157 1.15 86 2.72 2010/11 27,999,405 2,210 0.79 3,142 1.12 2011/12 28,480,814 2012/13 27,248,474 2013/14 27,629,953 2014/15 2015/16 28,016,772 28,409,007 1,367 0.45 2,368 0.79 56 2.36
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Accountable Officer: Director, Leprosy Control Division (LCD), DoHS Major Major activities Responsibility Supporting Strategies Agencies Early case detection and timely and complete management Case detection, free treatment with MDT, and management of complications LCD/ Regional Health Directorate
Netherlands
2010/11
2011/12 2012/13
2013/14
2014/15
2015/16
Capacity building for quality integrated service delivery in the health system
Provide comprehensive LCD/RHD leprosy training for HWs Provide refresher LCD/RHD training to HWs and managers' training Training of MOs Orientation to volunteers and CBOs Formation of selfcare/self-help groups Provide supportive materials and devices LCD/RHD LCD/RHD LCD/RHD LCD/RHD
Leprosy Relief (NLR)/ Leprosy Mission Nepal (LMN)/ Nepal Leprosy Trust (NLT)/ INF NLR/LMN/ NLT/INF/ BIKASH1 NLR/LMN/ NLT/INF/ BIKASH LMN/INF/ NLR Partners Partners Partners
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
Prevention of disability due to leprosy
BIKASH: an NGO Building in Knowledge, Attitude and Skills for Health
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Major Strategies Prevention of disability due to leprosy Medical, physical and social rehabilitation of people affected by leprosy
Major activities Early detection and management of complications at HF level Surgical correction of physical disabilities Income generation programmes
Responsibility LCD/RHD
2010/11
2011/12 2012/13
2013/14
2014/15
2015/16
X LCD/RHD LCD/RHD LCD/RHD LCD/RHD LCD/NHIECC NLM/NLT/ INF Partners Partners Partners Partners X LCD/NHIECC LCD/RHD/ districts MoHP/LCD/ DoHS/RHD/ districts MOHP/DoHS/ LCD/RHD Partners Partners NLR/ Partners Partners X
X X X
X X X
X X X X
X X X X
X X X X
X X X X
Provide social rehabilitation Provide vocational training IEC and social Produce and distribute mobilisation posters, leaflets, activities to brochures, bulletins raise and annual reports awareness and Use electronic and nonreduce stigma electronic media Celebrate World Leprosy Day Conduct school health education programmes Strengthen leprosy referral centres for complication management Involvement of people affected Expand speciality services in central and regional hospitals
X X X
X X X
X X X
X X X
X X X
X X X
Increase meaningful involvement of people
LCD/RHD/ Districts
Partners/ network
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Major Strategies by leprosy in leprosy services
Major activities affected by leprosy in programme planning and services, motivation, and vocational training Conduct operational research and studies Organise review meetings/monitoring workshops Conduct technical supervision Conduct on-site coaching
Responsibility
Supporting Agencies
2010/11
2011/12 2012/13
2013/14
2014/15
2015/16
Research and studies Programme monitoring
LCD/RHD LCD/RHD
Partners/ WHO Partners
X LCD/RHD LCD/RHD Partners Partners/ WHO Partners/ WHO Partners Partners/ NGOs/ INGOs/ MoLD/ local bodies X
X X
X X X X
X X X X
X X X X
Conduct case validation LCD/RHD and data verification Conduct surveillance Partnership LCD/RHD/ HF/districts
X X
Strengthen partnership, MoHP/LCD/ collaboration, and RHD coordination among various organisations including local governments
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2.15 Health Laboratory Services
1. Introduction The National Public Health Laboratory (NPHL) has a mandate to serve as the national reference laboratory for public health activities. Routine and specialised diagnosis services and laboratory-based surveillance of diseases of public health importance are performed with quality assurance under the network of health laboratories. Nepal's health care system includes laboratories involved in diagnostic services and laboratories involved in public health activities (surveillance, research, regulatory). At present almost half of these laboratories are functioning under the MoHPs direct government health care management system at central, regional, zonal, district, and local HP levels, while the remainder are functioning under private management at hospital, poly clinic, and diagnostic centre levels. The health laboratory service has been expanded to the periphery, with eight central hospital-based, three regional-based, two sub-regionalbased, 11 zonal-hospital-based, 66 district-hospital-based and 204 PHCC-based laboratories operating directly under the MoHP, a few under the Ministry of Home Affairs (MoHA), Ministry of Defence (MoD) and Ministry of Education (MoE), and more than 1,000 private laboratories. IHR 2005 has identified health laboratory service as one of the eight core capacities; Nepal as a signatory country needs to develop the core capacities to the required level as directed by the guidelines. Nepal has no specific legislation for registration, renewal, quality monitoring, and accreditation procedures for health laboratories. MoHP has nominated the NPHL as the national nodal/coordinating laboratory for health care laboratories in Nepal. Every decade new and emerging diseases appear, with epidemic and pandemic potential. New disease diagnosis often requires the latest sophisticated technology in rapid diagnosis and reporting within 24 hours. This is part of governments commitment towards IHR 2005. Every few years huge outbreaks of established but dangerous pathogens occur in different and difficult parts of Nepal, taking the lives of underprivileged groups. 2. Goal To support physicians and patients by offering quality laboratory diagnostic services. 3. General Objective To strengthen the capacity of public health laboratories at all levels. Specific Objectives 1. To prepare policy, guidelines, and an overall framework for capacity building 2. To develop NPHL as a nodal institute and national influenza centre 3. To strengthen laboratory procedures and communications between different levels and also to strengthen the laboratory system. 4. Major Strategies Laboratory Service Expand basic health laboratory services down to the HP level Develop health laboratory legislation Develop and implement a Laboratory Information System (LIS)
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Develop HR for laboratory services through scholarship programmes (priority will be given to women, Dalits, Janajatis, Madheshis and other socially excluded groups) Assure laboratory quality Improve monitoring and supervision Upgrade laboratory physical facilities and the level of services Strengthen service centres (National Influenza Centre, Virological Lab, Biosafety Level (BSL) 3 Lab) Strengthen infection control.
Blood Transfusion Services (BTS) Establish a National Blood Centre Strengthen BTS with the provision of component facilities down to the zonal level Advocate for awareness raising and motivation for blood donations Establish new Blood Transfusion Service Centres (BTSCs), giving priority to remote and diseaseburdened areas. 5. Indicators and Targets Coverage and Output 2010/11 No. of laboratory services established at HP level (priority will be given to remote HPs with birthing centres, and low-HF areas) No. of regional laboratories established No. of zonal hospitals with the facility for bacteriological, culturing, and sensitivity services No. of electrolyte (Na & K) services in zonal hospital laboratories No. of district hospitals with the facility for bacteriological, culturing and sensitivity services No. of district hospitals with semi-automatic analysers No. of labs participating in the National External
2011/12
2012/13 10
2013/14 50
2014/15 50
2015/16 50
15
20
20
13
20
20
20
300
Continuous
Continuous
Continuous
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Coverage and Output Quality Assessment Scheme (NEQAS) programme No. of lab personnel receiving qualification upgrades No. of districts with BTSC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
17
Continuous
Continuous
Continuous
Continuous
Continuous
Laboratories established at HP level Laboratories established at regional level Bacteriological, culturing, and sensitivity services expanded in zonal hospital laboratories Expansion of electrolyte (Na & K) services in zonal hospital laboratories Expansion of bacteriological service Expansion of semiautomatic analyser service National laboratories operation and management guidelines will be developed Laboratory policy will be developed Highly advanced biosafety lab will be established for diagnosis of highly infectious diseases NIC will be upgraded with facilities for other respiratory viruses
10 1
50 1
50 1
Each district will have at least one BTSC 50 2
All zonal hospitals
All zonal hospitals
All zonal hospitals
All zonal hospitals
15 districts 20 districts
X At NPHL Continuous Continuous Continuous
At NPHL
Continuous
Continuous
Continuous
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Coverage and Output (Real Time Polymerase Chain Reaction (PCR) and viral culture) Registration and licensing of health laboratories All districts will have a BTSC Registration and licensing of BTSC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Continuous
Continuous
Continuous
5 districts
15 districts Continuous
6. Major Challenges and Issues Establishing BSL 2-plus lab, molecular biology and viral isolation facility Upgrading NPHL Ensuring logistics and supplies Establishing LIS Communicating laboratory requirements and test results Providing evidence for physicians and patients for decision making Finding focal persons for training at district level Needs assessment and curriculum development for training for new components of EHCS
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Accountable Officer: Director, NPHL, DoHS Major Strategies Major Activities Expansion of laboratory services Establish basic health laboratory at HPs
Responsibility NPHL
Developing health laboratory legislation Developing and integrating LIS
Establish/strengthen regional-level health laboratories Expand bacteriological laboratory services in zonal hospital Expand electrolyte (Na & K) services in all zonal hospitals Expand bacteriological services at district hospitals Prepare framework for health laboratory legislation Develop laboratory operation and management framework Develop and implement LIS (software) Provide training on LIS Provide scholarships for Doctor of Medicine in Pathology, Masters in Medical Laboratory Technology, Masters in
NPHL
Supporting Agencies NHSSP/WHO/ Nepal Family Health Programme (NFHP) NHSSP/WHO/ NFHP NHSSP/WHO/ NFHP NHSSP/WHO/ NFHP NHSSP/WHO/ NFHP NHSSP/WHO/ NFHP NHSSP/WHO/ NFHP HMIS/NHSSP/ WHO/NFHP HMIS/NHSSP/ WHO/NFHP NHSSP/WHO/ HR Section, MoHP
2010/11
2011/12
2012/13
2013/14
2014/15 2015/16
NPHL
X X X X X X X X X X
NPHL NPHL NPHL NPHL NPHL NPHL NPHL
Developing HR for laboratory services
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Major Strategies
Major Activities Medical Laboratory, and Certificate in Medical Laboratory Programmes NEQAS, External Quality Assessment Scheme (EQAS), Proficiency Testing Panel preparation and dispatch to public and private labs Facilitative supervision and monitoring Renovate/upgrade physical facilities at all levels Upgrade NPHL as national reference lab for blood transfusion services Functioning of BSL 2-plus lab Maintain national Influenza centre Developing guidelines on infection control Train laboratory staff on infection control Train in proper disposal of waste (waste management) Support awareness and blood donations to achieve 100% non-remunerated blood (especially focusing on
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15 2015/16
Assuring quality
NPHL
Hospitals X X X X
Improving monitoring and supervision Upgrading physical facilities and level of services
NPHL X NPHL NPHL MD MOHP X NPHL NPHL NPHL NPHL NPHL NPHL WHO MOHP/WHO WHO WHO WHO MOHP/NRCS/ Blood Donors Association X X X X X X X X X X X X X X X X X X X X X X X
Strengthening service centres Infection control programme
Support blood donation
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Major Strategies
Major Activities women, marginalised people and those from remote areas who are not interested in donating)
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15 2015/16
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2.16 HIV and STI Prevention and Control Programme
1. Introduction Since the first HIV case was reported in 1988, Nepals HIV epidemic has matured from a lowlevel to a concentrated epidemic among key higher-risk populations, such as People Who Inject Drugs (PWID), Men who have Sex with Men (MSM), and Female Sex Workers (FSWs). HIV prevalence is consistently more than 5% among PWID and less than 1% among pregnant women in urban areas: Nepals HIV epidemic is characterised as concentrated rather than generalised. More than 80% of infected people acquired the infection through sexual transmission. In 2011, it was estimated that Nepal had nearly 50,200 People Living With HIV (PLHIV)2, about 0.3% of the adult population between 15 and 49 years of age. Most HIV cases have been among male labour migrants (29.5%) who travel to areas in India with high HIV prevalence. Clients of sex workers in Nepal and male labour migrants (particularly to areas in India with high HIV prevalence where they often visit sex workers) act as a bridging population transmitting the HIV infection to low-risk populations. Surveillance data in Nepal during the last five years indicate a decreasing HIV prevalence among adults (15-49 years) and key populations (mainly PWID, FSWs and clients of FSWs). This achievement is mainly attributed to targeted preventive interventions conducted for the key population groups. However, sustaining the prevention interventions with quality, coverage, and effectiveness is the key challenge. The current National HIV/AIDS Strategy, 2011-20163 has prioritised a national response that aims to (i) reduce new HIV infections by 50%, with the goal to reduce new HIV infections among children by 90%, and (ii) reduce HIV-related deaths by 25% by 2016, compared with the 2010 base line. These strategic goals are built upon the goal of reaching universal access to HIV prevention both among key higher-risk populations and among the general population, and providing treatment, care, and support to HIV-infected and affected populations according to the following strategic directions: Optimising HIV prevention Providing treatment, care, and support Implementing cross-cutting strategies such as strengthening health and community systems, strengthening strategic information for evidence-based planning and programming, and providing legal support, human rights, and social protection. The previous strategy of 2006-20114 had aimed to contribute directly to MDG 6: To halt and begin to reverse the spread of HIV by 2015; it was designed to be in line with the universal access target (of 80% in most of the interventions) of prevention of HIV among key higher-risk populations. Review of the previous strategy has identified considerable gaps in the following areas: reaching migrant workers in India and their spouses with prevention interventions; rates of utilisation of HIV Counselling and Testing (HCT) and Prevention of Mother-to-child Transmission (PMTCT)
2
National Centre for AIDS and STI Control (NCASC) (2012) National Estimates of HIV Infections, 2011, March, 2012. 3 NCASC (2011) National HIV/AIDS Strategy, 2011-2016, Kathmandu Nepal, December, 2011. 4 NCASC (2007) National HIV/AIDS Strategy, 2006-2011, Kathmandu Nepal.
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services; policy in the initiation of Antiretroviral Treatment (ART); HIV mainstreaming in other sectoral development plans; coordination for effective planning and programming in the field; civil society capacities; combatting discrimination against PLHIV, sex workers and transgender persons; and sustainable and independent funding for the HIV response. Therefore, the NHSP-2 IP has undertaken to address the major challenges, issues, and concerns through the following: Increasing the effectiveness of HIV and STI prevention and control interventions at the local level (district and below) Fostering coordination and cooperation between government, donors, NGOs, and communities, including PLHIV Sustaining the quality and effectiveness of targeted prevention interventions, and improving coverage Expanding comprehensive PMTCT services to reach more children, girls, women, and men Scaling up of care and support services for PLHIV and affected populations Managing QoC of interventions for improved programme outcomes Improving the predictability of funds and exploring the resources Correcting the uneven distribution of care and support programmes between districts and regions Strengthening M&E systems. 2. Vision Nepal will become a place where new HIV infections are rare and when they do occur, every infected person will have access to high-quality, life-extending care without any discrimination. 3. Goals To achieve universal access to HIV prevention, treatment, care and support. Specific goals are: 1) Halve the incidence of HIV by 2016 compared to 2010 (including reduction of new HIV infections in children by 90% compared with a 2010 baseline) 2) Reduce HIV-related deaths by 25% by 2016, compared with a 2010 baseline. 4. Objectives To meet Goal 1, the following objectives are set: 1) Reduce sexual transmission of HIV 2) Reduce HIV transmission through the injecting of drugs 3) Reduce vertical (mother-to-child) transmission of HIV 4) Maintain low levels of blood-borne transmission of HIV 5) Create an enabling environment for HIV prevention. To meet Goal 2, the following objectives are set: 1) Provide prophylaxis for opportunistic infections among PLHIV 2) Provide ART for eligible adults and children living with HIV 3) Provide treatment for co-infection among adults and children living with HIV 4) Provide care and support services to PLHIV according to their needs 5) Reduce the HIV-related impacts among PLHIV.
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5. Major Strategies Optimising HIV prevention Provision of HIV treatment care and support Cross-cutting strategies. 6. Indicators Impact Indicators 1. HIV prevalence in the population aged 15-24 years 2. Percentage of adults and children with HIV known to be on treatment 12, 24 and 36 months after initiation of ART
Baseline (2010) 0.12% (2010) (NCASC, 2011) 89% - 12 months (2010) 84% - 24 months (2010) 70% - 36 months (2010)
Target by 2016 0.06% At least 93% - 12 months At least 90% - 24 months At least 85% - 36 months
The key outcome-level indicators and targets are: Outcome 1.1 Reduce sexual transmission of HIV Outcome Indicators (a, b) 1.1.1 % of Most-at-risk Populations (MARPs) (sex workers female and male and male labour migrants aged 15-49 years) who are HIV-infected 1.1.2 % of MARPs who both correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission % of men reporting the use of a condom the last time they had anal sex with a male partner % of FSWs and Male Sex Workers (MSWs) reporting the use of a condom with their most recent client % of migrants aged 15-49 reporting the use of a condom the last time they had sex with a non-regular sexual partner % of MARPs who had received an HIV test in the last 12 months and know their results
1.1.3
Baseline (2010) FSWs = 1.7 (2011) MSWs = 5.2 (2009) MSM = 3.8 (2009) Labour migrants (1549) = 4.5 FSWs = 30 (2011) MSM = 64 (2009) Labour migrants (1549) = 18.1 75 (2009)
Target by 2016 FSWs = 1.0 MSWs = 2.5 MSM = 2.0 Labour migrants (15-49) = 0.5 FSWs = 60 MSM = 80 Labour migrants (15-49) = 50 >80
1.1.4
FSWs: 83 (2011) MSWs: 87 (2009) 53
>85
1.1.5
>80
Notes:
FSWs = 54.7 (2011) FSWs = 80 MSWs = 65.2 (2009) MSWs = 80 MSM = 42 (2009) MSM = 80 Labour migrants (15 Labour migrants 49) = 13.8 (2010) (15-49) = 80 a: The baseline and targets referred to Kathmandu valley cluster of Integrated Bio-behavioural Survey (IBBS), used as proxy b: The baseline and targets referred to mid-and far-western cluster of IBBS, used as proxy
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Outcome 1.2: Reduction of HIV infection through the injecting of drugs 1.2.1 1.2.2 Outcome Indicators * Baseline (2010) Target by 2016 % of PWID who are HIV-infected 6.3 (2011) 3 % of PWID who both correctly identify ways of 64 (2011) 80 preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission % of PWID reporting the use of sterile injecting 95 (2011) >95 equipment the last time they injected % of PWID who received an HIV test in the last 12 21.4 (2011) 80 months and who know their results % of PWID currently on Oral Substitution Therapy (OST) NA 80 who have been on OST continuously for the past 12 months Note: * The baseline and targets referred to Kathmandu valley cluster of IBBS, used as proxy Outcome 1.3: Reduction of vertical (mother-to-child) transmission of HIV Impact/Outcome Indicators Baseline (2010) Eliminate new HIV infections in children: reduce new HIV NA infections in children by 90% (compared with a 2010 baseline) % of infants born to-HIV infected mothers who are HIVNA infected % of HIV-positive pregnant women who received ART to 8.3 reduce the risk of mother-to-child transmission of HIV % of infants born to HIV-infected women receiving a 1.7 virological test for HIV within two months of birth
1.2.3 1.2.4 1.2.5
1.3.1
Target by 2016 90%
1.3.2 1.3.3 1.3.4
12 80 100
1.4.1 1.4.2
Outcome 1.4: Maintenance of low level of blood-borne transmission of HIV Outcome Indicators Baseline (2010) Target by 2016 % of HFs providing HIV services with post-exposure NA 100 prophylaxis available % of donated blood units screened for HIV in a quality 38 (2009) 100 assured manner* *Quality assured manner is defined as the blood units screened for HIV included in EQAS Outcome 1.5: Creation of enabling environment in HIV Prevention Outcome Indicators Baseline (2010) % of HWs aged 15-49 years, both women and men, NA expressing an accepting attitude towards PLHIV
1.5.1
Target by 2016 >90%
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Outcome 2.1: PLHIV received prophylaxis for opportunistic infection, treatment, and other common co-infections treatment according to national guidelines Outcome Indicators Baseline (2010) Target by 2016 2.1.1 % of people enrolled in HIV care and treatment NA 80% who received cotrimoxazole prophylaxis in the last 12 months 2.1.2 % of PLHIV (both adults and children) currently NA 80% enrolled in HIV care receiving prophylaxis against opportunistic infection Outcome 2.2: Adults and children living with HIV and eligible for ART who are receiving it. Outcome Indicators Baseline (2010) Target by 2016 2.2.1 % of eligible adults and children currently receiving 27% (2010) 80% ART 2.2.2 % of people starting ART who picked up all the NA 80% prescribed antiretroviral drugs on time Outcome 2.3: Adults and children with HIV-associated co-infections who received treatment for co-infection management Outcome Indicators Baseline (2010) Target by 2016 2.3.1 Number (and %) of adults and children enrolled in NA 22,500 (80%) HIV care who had their TB status assessed and recorded during their last visit (among all adults and children enrolled in HIV care in the reporting period) 2.3.2 % of estimated HIV-positive incident TB cases who NA 80% received treatment for both TB and HIV 2.3.3 % of adults and children newly enrolled in HIV NA 80% care who will start treatment for latent TB infection (isoniazid preventive therapy) among the total number of adults and children newly enrolled in HIV care over a given time period
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Accountable Officer: Director, NCASC Major Strategies Optimising HIV prevention Major Activities Reduce sexual transmission of HIV: condom programming, BCC, IEC, peer education Provide comprehensive prevention interventions among key populations such as PWID, MSM, FSWs, labour migrants, and their spouses Provide HCT Responsibility NCASC Supporting Agencies GFATM, multi-bilateral partners, USAID GFATM, multi-bilateral partners, USAID 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NCASC
NCASC
Protect against HIV infection among PWID through safe syringe and needle exchanges with a special emphasis on creating an enabling environment for female injecting drug users Provide diagnosis and management of STIs Prevent mother-to-child transmission of HIV, with a special emphasis on attracting the poorest and excluded women to PMTCT services by providing them with incentives such as nutritional packages
NCASC
GFATM, multi-bilateral partners, USAID GFATM, multi-bilateral partners
NCASC NCASC
GFATM, USAID, WHO GFATM, UNICEF, WHO, UNFPA
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Major Strategies Optimising HIV prevention
Major Activities Prevent HIV transmission in health care settings Ensure blood safety
Responsibility NCASC NCASC, NRCS, NPHL NCASC
Supporting Agencies GFATM GFATM, WHO GFATM
2010/11 X X X
2011/12 X X X X X
2012/13 X X X X X
2013/14 X X X X X
2014/15 X X X X X
2015/16 X X X X X
Prevent HIV transmission in close settings such as prisons and work places Prevent HIV among youth and adolescents at risk Provision of Optimise HIV treatment and HIV care of adult and children treatment, scale up ART services care, and Manage HIV-associated cosupport infections (TB treatment for PLHIV) Provide community- and home-based care for PLHIV Support CABA
NCASC NCASC
GFATM, UNICEF, UNFPA GFATM, WHO
X X
NCASC, National Tuberculosis Centre (NTC) NCASC NCASC, Ministry of Women, Children and Social Welfare (MoWC&SW) NCASC
GFATM, WHO X GFATM, USAID, partners GFATM, UNICEF X X X X X
Establish social protection, addressing the poorest and excluded girls and women, infected and affected spouses, and children of migrant workers
GFATM X X X X X X
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Major Strategies
Major Activities Promote health system strengthening service delivery, health information, HR development, procurement and supply chain management, financing of HIV response, and leadership and governance Health system strengthening - provision of integrated service delivery including logistics and reporting systems, improving the quality of services including quality logistics of drugs and commodities, and capacity building of the health workforce Community system strengthening strengthening networks, human rights, social entitlement, M&E HIV surveillance case reporting, Integrated Biobehavioural Survey , size estimation, epidemic analysis and modelling, including HIV drug resistance surveillance
Responsibility NCASC, LMD
Supporting Agencies GFATM, USAID, NHSSP
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Crosscutting strategies
NCASC, LMD
GFATM, USAID
NCASC
GFATM, multi-bilateral partners
NCASC
GFATM, multi-bilateral partners, NGOs X X X X X X
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Major Strategies
Major Activities Undertake operational research to improve quality, coverage and effectiveness of interventions Undertake M&E of interventions and programmes Reduce stigma and discrimination among key populations and PLHIV Provide legal support, legal reforms and human rights
Responsibility NCASC
Supporting Agencies GFATM, WHO
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X NCASC GFATM X NCASC GFATM, hospitals, NGOs GFATM, multi-bilateral partners, I/NGOs GFATM, multi-bilateral partners, I/NGOs
NCASC
Address sexual and genderbased violence
NCASC
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2.17 National Tuberculosis Programme
1. Introduction The National Tuberculosis Programme (NTP) is an approach within the national health system for control of Tuberculosis (TB). NTP has specific policies, plans and activities to achieve its goals, objectives and targets. NTP is countrywide, continuous and permanent, and fully integrated within the general health services. NTP policies are in accordance with the national health plan, the WHO Stop TB Strategy and the Global Plan to Stop TB (2006-2015). The Stop TB Strategy sets out the steps NTP and its partners need to take for TB control in Nepal. The strategy is based on experience gained over the past decade and on continuing consultations with stakeholders at the global, regional, national and local levels. 2. Vision Nepal free of TB. 3. Goal To reduce the mortality, morbidity and transmission of TB until it is no longer a public health problem in Nepal. 4. Objectives Achieve universal access to high-quality diagnosis and patient-centred treatment Reduce the human suffering and socioeconomic burden associated with TB Protect poor and vulnerable populations from TB, TB/HIV and Multidrug-resistant TB (MDRTB) Support development of new tools and enable their timely and effective use. 5. Targets MDG6, Target 8: halt by 2015 and begin to reverse the incidence... Target linked to the MDGs and endorsed by the Stop TB Partnership: By 2005: detect at least 70% of new sputum-smear-positive TB cases and cure at least 85% of these cases By 2015: reduce the prevalence of and deaths due to TB by 50% relative to 1990 By 2050: eliminate TB as public health problem (<1 case per million population). Components of the Stop TB strategy 1. Pursue high-quality Directly Observed Treatment Short Course (DOTS) expansion and enhancement Political commitment with increased and sustained financing Case detection through quality assured bacteriology Standardised treatment with supervision and patient support An effective drug supply and management system M&E system and impact measurement. 2. Address TB/HIV, MDR-TB and other challenges Implement collaborative TB/HIV activities Prevent and control MDR-TB Address prisoners, refugees and other high-risk groups and special situations. 3. Contribute to health system strengthening Actively participate in efforts to improve system-wide policy, HR, financing, management, service delivery and information system.
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4. Engage all care providers Public-Public, and Public-Private Mix (PPM) approaches International Standards for Tuberculosis Care (ISTC). 5. Empower people and communities with TB Advocacy, communication and social mobilisation Community participation in TB care Adoption of Patient's Charter for Tuberculosis Care. 6. Enable and promote research Programme-based operational research. The NTP Stop TB Strategy is in line with the Global Plan to Stop TB (20062015) developed by the Stop TB Partnership. With this strategy NTP aims to achieve the MDG and Stop TB Partnership targets for TB control and eliminate this disease. Therefore, the IP 2012-2016 provides a plan for the next five years to achieve the immunisation-related goals the Government of Nepal (GoN) has expressed in various policy documents, in the MDGs and World Health Assembly (WHA) resolutions, and in different national and international fora. Millennium Development Goals and Stop TB Strategy The MDGs require halving the 1990 TB prevalence and mortality rates by 2015. In 1990, the TB incidence rate was 243/100,000, prevalence rate 621/100,000, and mortality rate 51/100,000.5 Hence by 2015, the targets should be: an incidence rate of 121.5/100,000, prevalence rate of 310.5/100,000 and mortality rate of 25.5/100,000. 6. Major Strategies Pursue high-quality DOTS expansion and enhancement Address TB/HIV, MDR-TB and other challenges Contribute to health system strengthening Engage all care providers Empower people and communities with TB Enable and promote research. 7. Indicators and Targets The number of deaths in this period will be reduced by 75% to 24,770, saving about 70,222 lives according to the National Strategic Plan Stop TB Strategy of 2010 - 2015. Health Outcome and Coverage Case Detection Rate (CDR) (new smear positive) (%) Treatment success rate (%) 2010/11 78 90 2011/12 80 90 2012/13 81 90 2013/14 82 90 2014/15 82 90 2015/16 82 90
8. Major Challenges and Issues 1. Inability to increase the national CDR beyond 70% 2. Access to and utilisation of health services in rugged areas 3. Lack of a sustainable national reference laboratory within NTP, and decentralised culture facilities for MDR-TB detection
5
Source: Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report, 2007.
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4. Health system weak owing to the following: Inadequate diagnosis and treatment of respiratory illnesses Lack of required infection control measures with special focus on the MDR-TB management sites No specialised respiratory service in Kathmandu 5. HIV/AIDS epidemics influence on TB control 6. MDR-TB default rates due to patients needing to be away from families and jobs for 24 months 7. Inadequate IEC materials to meet specific target groups 8. Lack of coordination of TB diagnosis and treatment by the private sector, resulting in low CDR and the possible development of MDR TB 9. Insufficient research to determine the causes of gender inequity in TB registrations, the effectiveness of community-based DOTS in Nepal, etc. 10. Lack of electronic data management for DOTS, MDR-TB management programmes, and logistics management, and follow-up on internal and cross-border migration 11. Programme sustainability at risk due to limited programme financing through GoN resources and insufficient HR to implement the expanded scope of work after adopting the Stop TB Strategy, particularly for specialised programmes such as MDR-TB treatment, TB/HIV collaboration, Practical Approach to Lung Health (PAL), Advocacy, Communication and Social Mobilisation (ACSM) and PPM.
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Accountable Officer: Director, NTC Major Activities Free treatment for TB patients Expand reach of diagnostic facilities Case detection (%) No. of Sputum Positive Cases (increasing CFR) No. of total new TB cases (pulmonary and extrapulmonary) No. of Cat 2 @ 15% of new Sputum Positive Cases Total estimated first-line TB cases Estimated MDR-TB cases Total detected TB cases Intensified case finding among specific groups Chest camps Revision of NTP policy and guidelines Treatment services (DOTS) expansion Drug procurement and supply HR development (training and retention)
Responsibility NTC NTC NTC NTC NTC NTC NTC NTC NTC NTC NTC NTC NTC NTC NTC
Supporting Agencies WHO, Partners GFATM, Partners
2010/11 32,731 21 78 16,365 32,731 2,455
2011/12 33,809 21 80 16,904 33,809 2,536 36,344 300 36,644 X
2012/13 34,468 27 81 17,234 34,468 2,585 37,053 300 37,353 X
2013/14 35,128 28 82 17,564 35,128 2,635 37,763 300 38,0633 X
2014/15 35,357 28 82 17,679 35,357 2,652 38,009 300 38,309 X
2015/16 35,500 28 82
GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners
35,186 300 35,486 X 15
300
20 X
25
30
35
21 X X X X
21 X X
27 X X
28 X X
28 X X
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Major Activities Expand partnerships with (I/NGOs) and private organisations Improve the quality and coverage of TB microscopy programme Build and expand national laboratory capacity at the regional level for cultures and DST (number) Provide monitoring and supervision of TB laboratories Provide support to I/NGOs operating QC Laboratories Adapt a comprehensive and systematic approach to managing patients with respiratory symptoms Expand PAL (in districts) Develop a National Infection Control Strategy and guidelines Develop MDR Infection control and staff safety mechanism Establish a 100-bedded respiratory hospital Expand TB/HIV collaboration Revise operational guidelines, training manuals, and IEC materials Conduct surveillance and operational research on HIV prevalence in TB patients, carry out a sentinel sites survey
Responsibility NTC NTC NTC
Supporting Agencies GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners GFATM, Partners
2010/11 X X
2011/12 X X
2012/13 X X 2
2013/14 X X 1
2014/15 X X
2015/16 X X
NTC NTC NTC
X X X 5 5
X X
X X
X X
X X
X X
NTC NTC NTC NTC NTC NTC NTC
4 X X
GFATM, Partners WHO, GFATM, Partners GFATM, Partners WHO, GFATM, 5 Partners GFATM, Partners WHO, GFATM, Partners
X 5 X 5 5
X 5
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Major Activities Establish Voluntary Counselling and Testing (VCT)/ART sites in DOTS centres Establish DOTS sites in VCT/ART centres Provide care and support to TB/HIV coinfected cases in VCT/ART sites in DOTS Build and implement a two-way referral system between TB and HIV Provide joint supervision and M&E of TB/HIV activities Expand MDR-TB management Centre Sub-centre Manage MDR-TB Extreme Drug-resistant TB (XDR-TB) management plan and targets (10 cases) PPM in urban areas ACSM Operational Research
Responsibility NTC
Supporting 2010/11 Agencies WHO, GFATM, Partners
2011/12 3
2012/13 3
2013/14 3
2014/15 3
2015/16 3
10 NTC GFATM, Partners X X
10 X
10 X
10 X
10 X
X NTC NTC WHO, GFATM, Partners WHO, GFATM, 11 EDPs 39
X 13 44
X 15 48
X 17 52
X 19 56
X 20 60
300 NTC WHO, GFATM, 10 Partners GFATM, Partners GFATM, Partners Nuffield Centre for International Health and 10 10
300 10
300 10
300 10
300 10
NTC NTC NTC
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Major Activities
Responsibility
Supporting Agencies Development (University of Leeds, UK), GFATM, Partners
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
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2.18 Non-Communicable Diseases Control Programme
1. Introduction WHO estimates that NCDs account for 39% of Disability-adjusted Life Years (DALYs) lost, and for 44% of deaths. About half of the deaths are from cardio-vascular diseases, 18% relate to cancers, 10% to respiratory diseases, and 7.5% to digestive diseases. Neuro-psychiatric conditions account for 28% of DALYs lost to NCDs, cardio-vascular diseases for 20%, sense organ diseases for 13%, and respiratory and digestive diseases about 7.5% each. Injuries account for a further 11% of deaths and 12% of DALYs, with around half of the injuries caused by violence or war; road traffic accidents are the other major cause. NCDs were not part of the EHCS package during NHSP-1. They are relatively expensive to treat, and it remains unaffordable to offer comprehensive free services during NHSP-2. However, in response to the rising importance of NCDs and injuries in the burden of disease, NHSP-2 will expand prevention activities aimed at reducing the burden of NCDs by encouraging healthier lifestyles. Measures will include: BCC via multiple channels, aimed at encouraging a better diet, more exercise, reduced smoking and alcohol consumption, and safer driving, including the wearing of seatbelts and helmets Advocacy for implementation and enforcement of tobacco and alcohol controls and legal requirements to wear seatbelts and helmets Strengthening the capacity of health facilities located close to highways and to the sites of frequent traffic accidents to handle injuries from road traffic accidents. Mental health problems are clearly widespread, and may be associated with the legacy of conflict and with the very high rates of violence and suicide. What can be achieved with the available resources is less clear. Before committing to a major expansion of mental health services, one or more scalable pilots will be implemented. The initial approach will focus on giving basic mental health training to HWs in pilot districts, beginning to cover mental health issues in health education programmes, and on integrating mental health within PHC, following guidance issued by WHO. The elderly benefit from free services, and appear to make use of health services in proportion to their share in the population, though less than their higher incidence of health problems would predict. The first step to addressing this potential inequality will be a study of the issue, to identify the extent to which the health service meets the needs of this group, as preparation for considering what further measures might be appropriate and feasible. 2. Goal To reduce mortality and disability, and to address morbidity by encouraging healthier lifestyles and managing NCDs at early stages 3. Objectives To reduce the prevalence of tobacco use To prevent and control accidents and injuries To reduce the prevalence of mental disorders To prevent and manage the health care problems of the elderly. 4. Major Strategies New programme development Piloting new programmes
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BCC Expansion of care and support activities for NCDs Partnerships Collaboration and coordination.
5. Indicators and Targets Indicators and Targets Prevalence of tobacco use among men (%) Prevalence of tobacco use among women (%) % reduction of prevalence of mental disorders % reduction of premature death from cardio-vascular diseases, cancer, diabetes, and chronic respiratory diseases % reduction in prevalence of diabetes % reduction in fat intake Halt in prevalence of obesity
2010/11 29.8 15.4
2011/12 27 14 1 1
2012/13 24 13 1 1
2013/14 22.5 12 1 1
2014/15 21.5 11 1 1
2015/16 20 10 1 1
0.5 0.5 Rural 0.25 Urban 0.5 0.5 1 1 2 2 1 0.25 4
0.5 0.5 Rural 0.25 Urban 0.5 0.5 1 1 2 2 1 0.25 4
0.5 0.5 Rural 0.25 Urban 0.5 0.5 1 1 2 2 1 0.25 4
0.5 0.5 Rural 0.25 Urban 0.5 0.5 1 1 2 2 1 0.25 4
1 1 Rural 0.5 Urban 1 0.5 1 1 2 2 1 0.25 4
% reduction in physical inactivity % reduction in prevalence of high cholesterol level % reduction in raised blood pressure % reduction in salt intake % reduction in tobacco smoking % distribution of drug therapy to prevent heart attack % availability of essential NCD medicines % of women 30-49 years screened for cervical cancer
6. Major Challenges and Issues Programme development Piloting Training Establishing new services.
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Accountable Officer: Chair, Non-Communicable Disease Control Committee, MoHP Major Strategies Major Activities Responsibility Supporting Agencies Reducing the Implement Tobacco prevalence of Control Act tobacco use Law enforcement NHEICC Partners Formulate a Tobacco Control (regulatory) Act BCC Enhance capacity of NHEICC and law enforcement agencies Ban advertising, promotion, and sponsorship of tobacco products and companies Expand the coverage of non-smoking areas BCC, considering the practices of different social groups Increase tax on tobacco products Packaging and labelling of tobacco products Tobacco use cessation Develop a supply reduction strategy Define the roles and implement activities for prevention and management of accidents and injuries NHEICC Partners
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X NHEICC Partners
X NHEICC NHEICC Partners Partners X NHEICC NHEICC NHEICC NHEICC Curative Division Partners Partners Partners Partners MoHA, Traffic Police, NHEICC, media X X X X X X X X
X X X X X X
X X X X X X X X X
Prevention and control of accidents and injuries
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Major Strategies
Major Activities Develop and implement a joint plan of action to prevent accidents and injuries Organise a coordination meeting on the prevention and handling of accidents and injuries
Responsibility Curative Division
Curative Division
Training
Monitoring
Provide training to health and non-health workers to handle injury and accident cases in a responsive manner Support traffic police to monitor the incidence of accidents, deaths, and severe injuries due to driving under the influence of alcohol
Curative Division
Curative Division
Supporting Agencies MoHA, Traffic Police, Department of Transport (DoT), media MoHA, Traffic Police, National Trauma Centre, Association of Private Hospitals (APH), DoT MoHA, National Trauma Centre, NHTC, DoT, APH MoHA, National Trauma Centre, NPHL, I/NGOs MD, Institute of Medicine, psychiatric hospitals, I/NGOs
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Mental health Reduce the incidence and prevalence of mental disorders Conduct needs assessment on mental health in a disaggregated manner
Curative Division
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Major Strategies Programme development
Major Activities Develop/adapt a mental health programme with relevant components Prepare a mechanism including indicators, the frequency of monitoring, and tools
Responsibility Curative Division
Curative Division
Service provision
Expansion of services
Develop and implement a full pilot plan with cost estimates based on needs assessment Expansion of mental health service with backup and follow up Include operational research to test the models Process and impact evaluation of pilot programmes among different social groups Develop a modality of partnerships with I/NGOs, hospitals, and medical colleges
MD
Curative Division
Research and M&E
MD
MD
Partnerships
Curative Division
Supporting Agencies PPICD, IOM, psychiatric hospitals, I/NGOs PPICD, MD, IOM, psychiatric hospitals, I/NGOs IOM, psychiatric hospitals, I/NGOs MD, IOM, psychiatric hospitals, I/NGOs IOM, psychiatric hospitals, I/NGOs IOM, psychiatric hospitals, I/NGOs MD, M&E Division, IOM, psychiatric hospitals, I/NGOs,
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
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Major Strategies
Major Activities
Responsibility
Elderly care Study and research Programme development
Study on the inequality in health care utilisation by the elderly by sex, location, and social group Identify the health care needs of elderly by sex and social group Develop and implement a programme for the elderly as required for different income and social groups Develop a monitoring mechanism and GESIresponsive guidelines Develop a partnership modality for an elderly care programme
Curative Division/ PHCRD Curative Division/ PHCRD Curative Division/ PHCRD
Supporting Agencies media MoWC&SW, Elderly Homes, I/NGOs MoWC&SW, Elderly Homes, I/NGOs MoWC&SW, Elderly Homes, NHEICC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Monitoring
X Curative Division MoWC&SW, Elderly Homes, NHEICC, I/NGOs, media
Partnerships
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2.19 Programme on Mental Health and Neurological Disorders
1. Introduction Mental health conditions constitute five out of the total top ten conditions that cause lost DALYs in developing countries. It is estimated that depression will top the list in 2020. Between 25 and 30% of patients coming to seek help at any health delivery point come because of underlying mental health problems. Suicide is reported as the second most common cause of maternal mortality in Nepal, and can be easily attributed to undiagnosed and untreated depression. Although Nepal has made significant progress formulating a Mental Health Policy (1996), implementation has been inadequate and needs to be strengthened. Ongoing programmes that require strengthening include the following: Mental health services will be strengthened as more districts are chosen for the implementation and introduction of HP-level mental health services Health Assistants (HAs) and Auxiliary Health Workers (AHWs) (paramedics) at HPs and counsellors at hospitals will be trained in mental health care. FCHVs will be trained in case detection and referral Psychiatrists will be posted at least to the level of zonal hospitals to ensure the availability of specialist care and a referral point for community-level workers The availability of basic psychotropic and anti-epileptic medication will be ensured at the HP level. 2. Goal To reduce the morbidity and disability caused by mental health problems. 3. Objective To increase the access to and utilisation of basic mental health services to all, including the poor and excluded. 4. Major Strategies Programme development Institutional development Training Partnership with Government Organisations (GOs), INGOs/CBOs and academia Expansion of services, especially to areas where mental health problems are reported. 5. Major Challenges and Issues Limited information regarding mental health problems Programme refinement for mental health care Developing indicators and a monitoring framework Financing a mental health programme PPPs Institutional development Lack of skilled HR.
138
Accountable Officer: Director, MD Major Major Activities Strategies Policy Creation of a Mental decision Health Unit Programme Develop and revise the development training manual of paramedics (HAs, Senior AHWs/Community Medicine Auxiliaries (CMAs)) Develop and revise the training package for doctors with a Bachelor in Medicine and Bachelor in Surgery (MBBS) degree Develop a training package for FCHVs Develop a training manual for counsellors
Responsibility MD
MD
Supporting Agencies NCD Committee/ MoHP Curative Division
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
MD
Curative Division X X
MD
Curative Division MD
NHTC
X Curative Division Partners Partners X X X X X
Training
Provide training to MD paramedics of new districts Provide training to FCHVs MD of new districts Provide post-training MD follow-up for doctors and paramedics
X X
X X
X X
X X
X X
139
Major Strategies
Major Activities Training of counsellors
Responsibility MD MD
Supporting Agencies NHTC Private hospitals
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 X X X
Partnership
M&E
Develop and implement a collaborative programme with medical colleges, GOs, I/NGOs, CBOs and academia Develop a monitoring mechanism Survey/study Design and implement a programme based on the survey findings
MD
HMIS X X X X X X X
Service expansion
MD MD
PHCRD PHCRD
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2.20 Oral Health Care Programme
1. Introduction Oral health conditions are estimated by WHO to account for 0.6% of DALYs lost in Nepal, and account for 3% of Outpatient Department (OPD) visits recorded in DoHSs 2007-08 Annual Report. More than 57% of Nepalese children at six years of age and 69% of adults above the age of 50 suffer from untreated dental caries affecting more than three teeth. Untreated dental caries is the most prevalent childhood disease in Nepal more prevalent than malnutrition (53%) and vitamin deficiency (58%). Nepal ranks among the top 15 countries in the world where periodontal disease in the age group of 35-44 years is prevalent. However, GoN has made significant progress formulating an Oral Health Policy (2004) and has an Oral Health Strategic Plan. It also has advocated for fluoridation of toothpastes that are produced in Nepal. Ongoing programmes that need to be strengthened include the following: Dental surgeons or dental assistants will be recruited and posted at selected district hospitals to train staff at HPs and PHCCs in basic dental/oral check-ups. Mobile dental camps will work in communities in collaboration with medical and dental colleges Primary Health Care Workers (PHCWs) will be trained on basic oral health care, including extraction and simple fillings Dental surgeons will be posted at district hospitals where facilities are available throughout the country helping ensure the availability of oral health services Teachers, schoolchildren, FCHVs and HWs will be trained on oral-health-related subjects to promote good oral health. Brushing programme will be promoted at schools. 2. Goal To reduce the morbidity and disability caused by oral health problems. 3. Objective To increase access to and utilisation of basic oral health services. 4. Major Strategies Programme development Institutional development Training Partnership Piloting Expansion of services Strengthening M&E. 5. Indicators and Targets Outcome 2010/11 Prevalence of dental caries at age six years (%) 57
2011/12 54
2012/13 50
2013/14 46
2014/15 42
2015/16 40
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Prevalence of dental caries (caries in three or more teeth) at age 50 (%)
69
66
62
58
54
50
6. Major Challenges and Issues Programme development for basic oral care Developing indicators and monitoring framework Financing oral health programme PPPs Institutional development.
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Accountable Officer: Director, MD Major Major Activities Strategies Programme Assess oral health development needs Prioritise oral health care services Develop or adapt an oral care package for District Hospital, PHCC, HP/SHP levels Training Plan service provision for oral health Offer oral health care Train HWs on oral health Institutional Orient teachers, development schoolchildren, FCHVs, and HWs on oral health Conduct an O&M survey for adding dental surgeons at selected DHs and dental assistants in PHCCs Create posts and recruit dental surgeons at selected DHs
Responsibility MD MD MD
Supporting Agencies Curative Division Curative Division Curative Division
2010/11 X
2011/12 X X
2012/13
2013/14
2014/15
2015/16
MD
Curative Division X
MD MD MD
Partners Partners Partners
X X
X X
X X
X MD Administrative Division, MoGA
Curative Division
MoGA X
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Major Strategies Partnership
Major Activities Develop and implement a collaborative programme with medical and dental colleges Develop a pilot plan of oral health (DH, PHCCs and HPs) Offer oral health services Organise oral health camps in communities Organise a brushing campaign for a year Develop a monitoring mechanism Carry out process and impact evaluation
Responsibility MD
Supporting Agencies Private hospitals
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Piloting
MD
Partners X
Expansion of services
MD MD
Partners Private hospitals
X X
X X X X
X X X X
X X X X
MD
Private hospitals
X X
M&E
MD
HMIS X X
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2.21 Curative Health Services
1. Introduction GoN facilities provided curative services to 60% of the population in 2007-8, 45% if only new contacts are included. Over 85% of patient contacts were through HPs, SHPs and outreach clinics, about 10% through PHCCs, and the remaining 5% or so via hospitals. A 35% increase in new outpatient contacts was seen in 2007-8 following the introduction of free services at HPs and SHPs, and targeted free services at PHCCs and district hospitals for some population groups in low-HDI districts. The main reasons for low and delayed utilisation of health services are distance and cost, with qualitative factors such as the non-availability of drugs and staff playing a role through raising the risk of incurring significant costs for uncertain benefits. The strategy is therefore to bring services closer to the population, especially to the poor and excluded, to make them more affordable, and to ensure that they meet minimum standards of quality and availability. Roughly half of all outpatient visits for acute illness among both children and adults are to private providers (NDHS 2006 and Nepal Living Standard Survey (NLSS) 2004). Private providers include private pharmacies (some of which are owned by GoN health staff) that provide diagnostic services as well as drugs. Nearly two-thirds of households taking a sick child to a pharmacy report that the child was examined (NDHS 2006). In some areas a two-tier system of access to public-sector health staff is found. Those willing to pay to see staff in their private pharmacies will be given a more thorough examination and access to diagnostics not available from the government. Guidelines on exemption have been developed as a safety net in the referral hospital to increase access to and utilisation of health care services. This provision has also been made for poor and excluded group in tertiary care hospitals. Regarding catastrophic illness, a guideline has been prepared for reimbursing the catastrophic costs to the poor and destitute. The guideline covers catastrophic spending for five diseases: kidney disease, cancer, heart disease, Alzheimers and Parkinsons. Patients whom district committees determine to be poor have direct access to the identified treatment centres and their cost is reimbursed by the MoHP. Patients below 14 or above 75 years of age will receive selected services in few centres. 2. Goal To reduce mortality and disability, and to address the morbidity of the general population. 3. Objective To increase access to and utilisation of curative health services, including by women, the poor and excluded. 4. Major Strategies Increase physical access to health facilities Upgrade all SHPs to HPs and add birthing units, giving priority to locations with easy access for poor and excluded women Declare district hospitals free to all Strengthen district hospitals Establish an accreditation system Expand universal free outpatient, inpatient and emergency care to district hospitals Expand specialised services to selected district hospitals (obstetric care, paediatric care, basic surgical care with anaesthesia, eye care, oral health and mental health care) Provide more allocations to district hospitals Develop a referral policy
145
Contract out ancillary services.
5. Major Challenges and Issues Expansion of universal free care to district hospitals High demand for the reimbursement of treatment cost Ensuring the availability of HWs and drugs De-motivated care providers Identifying the poor to receive free services.
146
Accountable Officers: Chief, Curative Division, MoHP; Director, MD; Director, PHCRD Major Major Activities Responsibility Supporting Strategies Agencies Increase Increase and provide new MD physical access investment in HPs and SHPs to health Develop an incentive policy Curative MD, PPICD facilities and package for care providers Division in remote areas Develop the infrastructure to MD Department of ensure the privacy of women Urban patients Development and Building Construct-ion (DUDBC) Upgrade all Upgrade SHPs to HPs and add MD PPICD SHPs to HPs and birthing units, giving priority to add birthing locations with easy access for units poor and excluded women Develop criteria for upgrading HPs to PHCCs and PHCCs to rural hospitals, ensuring GESIrelated criteria Develop a guideline for upgrading HPs to PHCCs and PHCCs to community/rural hospitals, ensuring GESIrelated criteria Upgrade HPs to PHCCs and establish one PHCC per 50,000 population (c. 40 based on new municipalities) MD PPICD
2010/11 X
2011/12 X
2012/13 X X
2013/14 X
2014/15 X
2015/16 X
500
500
500
500
500
X MD PPICD
MD
PPICD
10
10
10
10
147
Major Strategies
Major Activities Upgrade PHCCs to rural/community hospitals (10 based on demand) considering unreached groups and areas Expand specialised care in selected district hospitals
Responsibility MD
Supporting Agencies PPICD
2010/11
2011/12 2
2012/13 2
2013/14 2
2014/15 2
2015/16 2
Expand specialised care at district hospitals Provide exemption for the poor and excluded Strengthen district hospitals
Curative Division
Finance Section, PPICD
Prepare exemption criteria and process for the poor and excluded at referral and central-level hospitals Implement a plan for strengthening district hospital management Conduct an O&M survey to add specialised care at DH Create positions for MDGPs, paediatricians, obstetricians, anaesthetists/Anaesthetic Assistants (AAs), dental surgeons/dental assistants, physiotherapists/ physiotherapy assistants, optometrist or ophthalmic assistants Strengthen the capacity of district hospitals to manage One-stop Crisis Management Centres (OCMCs) where applicable
Curative Division
Finance Section, Hospitals PPICD
Curative Division MD Personnel Administration MoHP
X HR, FM Curative Division X
Population Division
Curative Division, LMD, NHTC
148
Major Strategies Expand universal free care at DHs Provide greater discretion to DH
Major Activities Prepare for making EHCS at district hospitals free to all Provide block grants to district hospitals Provide clearer targets with disaggregation and performance indicators to district hospitals Upgrade selected PHCCs to community/rural hospitals (as per need) Upgrade numbers of hospitals beds (from 15-20) to 25-50 beds Revise the guidelines for reimbursement of treatment costs for the poor and excluded Organise health camps with specialised care (surgical, medical, Obstetrics and Gynaecology, ENT etc.) Develop a mechanism for hospital accreditation (policy/legal, structure, paralegal, tools) Plan and implement for waste management
Supporting Agencies PPICD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X PHCRD PHCRD Finance Section PPICD X MD X MD X Curative Division Finance Section X X X X X X X X X X X X X X
Upgrade health facilities
Treatment support to the poor Increase access to specialised care in remote areas Enhancing QoC
PHCRD/ Curative Division Curative Division
Hospitals X PPICD, EDPs and partners X X X X X
Curative Division
Hospitals (private and public), partners
149
Major Strategies
Major Activities Provide training to nurses on QoC and leadership development including GESI
Responsibility MD
Develop nursing standards for hospital care Monitor the quality of private and public hospitals
Contracting out
Sectoral and cross-sectoral coordination
Prepare and implement a framework for contracting out ancillary services such as cleaning and laundry Establish a multi-sectoral coordination committee
Curative Division Curative Division/Public Health Administration M&E Division (PHAM&ED)/ MoHP Personnel Administration
Supporting Agencies Nursing Council, Medical Council, National Health Traders Council Partners Hospitals
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Curative Division, Hospitals PPICD
Curative Division
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2.22 Ayurvedic and Alternative Medicine
1. Introduction Ayurveda is Nepals indigenous treatment system. According to the National Ayurveda Health Policy , 2052 BS, GoN is to establish new Ayurvedic health services and equip them well in proportion to population density, public demand and participation. Ayurvedic health services will be established in different parts of the country, not only in the government sector but also in the non-state sector. The top ten diseases identified for Ayurvedic systems are: Amlapitta (gastritis), Udara roga (abdominal disease), Swas Vikar (respiratory disease), Vatavyadhi (Vataja disease), Bal rog (paediatric diseases), Stri rog (gynaecological diseases), Karna, Nasa, Mukha, Danta and Kantha roga (ENT, oral, and dental diseases), Jwar (fever), Vrana (wounds, abscesses) and Atisar/Grahani (constipation, diarrhoeal disease). The Ayurvedic system of medicine will be promoted as the National System of Medicine. 2. Goals To contribute towards improving the health status of Nepalese citizens To ensure the optimum utilisation of local herbal resources to strengthen the national economy. 3. Objective To increase access to and utilisation of the Ayurvedic system of medicine. 4. Major Strategies Increasing awareness of the Ayurvedic system of medicine Expanding the Ayurvedic system of medicine Piloting integration of Ayurvedic services Promoting evidence based practice Improving the quality of Ayurvedic services Developing HR for Ayurvedic services Enhancing M&E of Ayurvedic services Developing infrastructure for Ayurveda-related institutions Developing Ayurvedic specialist services in Ayurvedic institutions Review of the Ayurveda Health Policy 2052. 5. Major Challenges and Issues Promoting Ayurvedic services Expanding Ayurvedic services at the grassroots level Developing HR for Ayurvedic services Developing a research and M&E system Ensuring the availability of Ayurvedic drugs Developing Ayurvedic institutions and expanding their coverage Expanding the Ayurvedic specialties (Panchakarma, Kshar sutra and Yoga) Piloting the integration of Ayurvedic services Reviewing the Ayurveda Health Policy 2052 and other policy issues Promoting herbal resources for economic growth Developing a Data Bank of Ayurvedic and traditional medical resources with their Intellectual Property Rights (IPR).
151
Accountable Officer: D-G, Department of Ayurveda (DoA) , MoHP Major Strategies Major Activities Responsibility Increasing awareness of the Ayurvedic system Expanding Ayurvedic services Develop and implement a BCC strategy on Ayurveda Continue treatments with special focus on the top ten diseases Develop model herb farms to encourage herbal production Establish one regional hospital Establish 19 Ayurvedic Aushadhalayas Produce, collect, and promote locally available herbs Continue the Senior Citizen Rasayana Programme (no. of persons) Introduce Local Ayurveda Kits for Health (LAKH) Programme Continue the Lactating Mother Programme (no. of persons) Continue the Ayurveda School Health Programme Establish and operate an Ayurvedic Medicine Examination Committee and Laboratory Develop Naradevi Ayurveda Hospital (central hospital) as a specialised Ayurvedic medical service centre Develop a quality assurance mechanism for Ayurvedic drug manufacturing DoA
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X DoA DoA DoA DoA DoA DoA DoA DoA DoA DoA 7,500 X PPICD PPICD X 3,750 X X
X X X X
X X X X 6
X X X
X X X
X X X
6 X 6,000 X 10,500 X X
7 X 6,750 X 7,500
X 4,500
X 5,250 X
8,250 X X
9,000 X X
11,250 X X
12,000 X X
Improving the quality of services
DoA X DoA DDA X
152
Major Strategies Reviewing the Ayurveda Health Policy 2052 Integrating Ayurvedic services
Major Activities Create a high-level committee to review the Ayurveda Health Policy Pilot integration of Ayurvedic services with alternative and allopathic medicine through Ayurvedic service centres Establish a National Ayurvedic Research and Training Centre Prepare an Ayurveda research strategy with prioritised research activities Prepare an inventory of indigenous knowledge and skills Produce a peer-reviewed journal of Nepal's Ayurvedic practice Produce postgraduates specialising in Ayurveda from the National Ayurveda Academy and other institutions Provide refresher training to service providers Provide management training to officer level service providers Increase opportunities for specialised Ayurvedic education Revise and improve the Ayurveda monitoring mechanism Develop a data bank of Ayurvedic and alternative medicine with IPR Conduct process and impact evaluation of the LAKH, Lactating
Responsibility DoA
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X DoA X DoA DoA DoA DoA National Ayurveda Academy DoA DoA DoA DoA MoHP X X X X X X X X DoA X X X X X X X X X X X X
Promoting evidence-based practice
X X X X X
Developing HR for Ayurvedic services
Enhancing M&E
153
Major Strategies
Major Activities Mother, and Ayurveda School Health Programmes Provide herbal cultivation training for local farmers Prepare/revise an infrastructure development plan for the DoA and its institutions Prepare the infrastructure for a data bank of Ayurvedic and traditional medical resources in the DoA
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Enhancing local economy through herbal medicine Developing infrastructure for Ayurveda-related institutions Developing a data bank of Ayurvedic and traditional medical resources with IPR Promoting other alternative medicines
DoA X DoA X DoA X X
Promote the use of the naturopathy, Unani, Amchi and homeopathy systems of medicine
DoA X X X X X X
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2.23 Health Education and Communication Programme
1. Introduction Health education and communication are a priority of the MoHP, and are designed to create demand and increase the utilisation of EHCS through the dissemination of messages using appropriate multiple channels of communication to support the achievement of programme goals and objectives. As health education and communication are cross-cutting in all health programmes, they aim to increase knowledge and improve behaviour regarding key health issues of all castes and ethnic groups, and disadvantaged and hard-to-reach populations. Health education and communication also aim to create demand for quality EHCS, thereby improving access, creating public trust in health services, and ultimately encouraging people to utilise the existing health services, as well as mitigating public panic and responding to communication needs during emergency situations. The Health Education and Communication Programme designs and implements advocacy, social mobilisation and IEC/BCC programmes for desired behaviour changes of individuals and communities. Strategic plans are developed and adopted while implementing different IEC/BCC programmes at the national, regional, district and community levels, following the principles of decentralisation. As stated in NHSP-2, health education and communication will prioritise certain focused EHCS programmes, such as MCH, adolescent health, communicable and Non-communicable Diseases, tobacco control, GESI, occupational and environmental health, and emergency and disaster preparedness, including pandemic influenza. 2. Goal To contribute to attaining the national health programme goals and objectives by providing support for all national health services and programmes. 3. Objectives To increase knowledge, improve skills and promote desired behaviour change on EHCS and beyond To create a demand for quality EHCS among all castes and ethnic groups, and disadvantaged and hard-to-reach populations To advocate for required resources (human and financial) and capacity development for effective communication programmes and interventions to achieve the NSHP-2 goals To increase access to new information and technology on health programmes To raise awareness among the public on communicable and Non-communicable Diseases and to encourage all to seek preventive measures To intensify and strengthen action against tobacco use, both smoked and smokeless, excessive use of alcohol, unhealthy diets, and physical inactivity To mitigate public panic and respond to communication needs during emergency situations. 4. Major Strategies NHEICC plans and proposes needs-based IEC/BCC programmes every year at the national, regional, district and community levels to achieve national health goals. The Health Education And Communication Units in the DHOs are empowered to run health education and promotion activities by implementing needs-based IEC/BCC programme activities using local media. They should also consider the districts social and cultural contexts so that the messages, materials and activities reach their target
155
audiences and encourage health-seeking and healthy behaviour. The NHSP-2 IP for health education and communication includes the following major actions: Mutually reinforcing approaches of ACSM, BCC, and IEC linked to service availability of EHCS and beyond Advocacy activities carried out to gain support for EHCS, occupational and environmental health, and tobacco control, and for political and social commitment, as well as resources for implementing the programme Social mobilisation of local-level resources, mobilisation of HR in existing networks as well as support for FCHVs and HWs Informing people about EHCS, social issues and service availability, and promoting positive behaviour Disseminating and reinforcing messages through mass media, community-based media and IPC Catering to specific gender needs and to the needs of the poor, socially excluded, and disadvantaged communities, and making efforts to produce and disseminate messages and materials in local languages and for different socio-cultural contexts Promotion of health as a right, especially in the context of Nepals political restructuring and decentralisation Strengthening institutional capacity, and in hospital settings providing appropriate health education and communication programmes at all levels Coordination with other ministries and academic institutions to ensure in-service and preservice training specifically on health education Multi-sectoral collaboration to implement communication programmes Ensuring that the impact of communication interventions is captured by the HMIS and that additional resources are available for periodic surveys. The strategies and activities in this IP are set under the overall strategic directions of NHSP-2 and the strategies of the services and programmes, as this is a supporting programme for health programmes and services. Similarly, this plan has been prepared following two major national communication strategies approved by MoHP to move forward and achieve the NHSP-2 health education and communication goal, objectives and major strategies. The two approved major communication strategies are: National Communication Strategy for MNCH, 2012-16 National Communication Strategy for ASRH, 2012-16. In addition to these two strategies, an updated national communication strategy for other priority programmes of EHCS and beyond will guide all health education and communication activities at all levels. Health education and communication activities will be coordinated to minimise duplication and maintain the uniformity, consistency and effectiveness of health messages through NHEICC. These strategies have been developed considering the GESI perspective, with a special focus on the poor and excluded, and will be continued as such. 5. Indicators % increase in knowledge on key health promotion and disease prevention issues among intended audiences % increase in utilisation of EHCS among intended audiences % of people practising key health behaviours to prevent disease and promote health % increase in funds for key health issues and health communication programmes
156
Increase in qualified HR for health education and communication The number of people trained in health education and communication Strengthened system of health education and communication/BCC down to the VDC level.
Indicators and Targets Coverage Prevalence of tobacco use among men (%) Prevalence of tobacco use among women (%)
2010/11 2011/12 29.8 15.4 27 14
2012/13 24 13
2013/14 22.5 12
2014/15 21.5 11
2015/16 20 10
6. Major Challenges and Issues Less priority is given in practice to the health education and communication required for health promotion Insufficient dedicated HR for health education and communication Need to strengthen the institutional capacity of MoHP, NHEICC, RHDs, and DHOs on health education and communication Inadequate capacity and technical skills of staff involved in health education and communication at different levels Weak mechanisms and resource constraints for research and quality M&E of health education and communication programmes Inadequate focus on in-service and pre-service training for health education and communication Less priority given to IPC through FCHVs and other health volunteers, MGHs and other community groups, and CBO/NGOs Insufficient attention given to the production and delivery of messages and materials according to the local context Inadequate PPPs The one-door system through NHIECC is not always followed to ensure the quality and consistency of messages and to maximise the effectiveness of resources Unequal access to information among the population Inadequate focus on targeted health education programmes, including the localisation of IEC/BCC materials, to cater to specific gender needs and to the needs of socially excluded and marginalised groups Inadequate supportive service delivery mechanisms in place in conjunction with health education and BCC efforts.
157
Accountable Officer: Director, NHEICC Major Strategies Major Activities Advocacy activities carried out to gain support for Safe Motherhood and Neonatal Health (SMNH), FP, ASRH, IMCI, EPI, nutrition, free health care, oral and eye health, as well as promotion of GESI. Providing information on TB, leprosy, HIV/STIs, VBD and neglected tropical disease prevention and beyond, and promoting political and social commitment, as well as allocating resources for programme implementation Advocacy meetings, orientations, workshops with policy makers, planners, professional organisations, influential people and media Develop, produce and disseminate advocacy toolkit Organise press meetings involving all sectors of media people Develop, produce and distribute media kits Undertake advocacy/ awareness campaigns for promoting health issues, particularly focusing on decision makers Make a proposal to MoHP for the required and trained manpower at the centre and in the districts Celebrate health days, weeks, and months for raising awareness and advocating on the issues
Responsibility Supporting Agencies NHEICC Partners
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
NHEICC
Partners X X X X X X
NHEICC
Partners X X X X X X X X X X X
NHEICC NHEICC
Partners Partners
NHEICC
NHEICC
158
Major Strategies Social mobilisation of resources at the local level, mobilisation of HR of existing networks as well as support for FCHVs and HWs for SMNH, FP, ASRH, IMCI, EPI, nutrition, free health care, oral and eye health, as well as promotion of GESI. Providing information on TB, leprosy, HIV/STIs, VBD and neglected tropical disease prevention and beyond
Major Activities Hold planning meetings at central, regional and district levels involving related stakeholders Develop, produce and distribute toolkits for social mobilisation Identification and formulation of social mobilisation networks at different level of health services Organise social mobilisation events, including mass gathering, rallies, and communication events, and inter-school or group competitions to promote EHCS Mobilise large networks of HWs, volunteers and other existing networks and groups (particularly MGHs) to reach hard-to-reach families Organise funfair activities at the community level to promote health messages and materials
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
X NHEICC Partners X NHEICC Partners X NHEICC Partners X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
159
Major Strategies Informing people about SMNH, FP, ASRH, IMCI, EPI, nutrition, free health care, oral and eye health, as well as promotion of GESI. Providing information on TB, leprosy, HIV/STIs, VBDs and neglected tropical diseases, and a discussion of social issues, service availability and the promotion of positive behaviors
Major Activities Conduct media and IPC activities for informing women and families on dangers signs and harmful practices as well as healthy practices Prepare and implement specific IEC/BCC plans to reach hard-toreach and migrant families who may not be aware of EHCS Conduct media and IPC IEC/BCC activities focusing on women, children, adolescents, youths and men to provide comprehensive and correct information and knowledge to target audiences Research on knowledge, practices and behavior of specific groups and social issues Provide orientation on health rights to service providers and communities Develop and pre-position messages and materials for all media Support the dissemination of health messages and materials, and promote IEC activity during epidemics and disasters
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
NHEICC
Partners X X X X X
NHEICC
Partners
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
160
Major Strategies Disseminating and reinforcing messages through mass media, community-based media and IPC on SMNH, FP, ASRH, IMCI, EPI, nutrition, free health care, oral and eye health, as well as promotion of GESI. Providing information on TB, leprosy, HIV/STIs, VBD and neglected tropical disease prevention and beyond
Major Activities Develop and disseminate service-friendly messages and materials Engage media in order to improve health-seeking behavior of people Disseminate messages through new media, using mobiles or PC games Develop, produce and distribute print materials i.e. flip wall charts, posters, pamphlets, booklets Conduct exhibitions on health issues and messages and materials on important days and occasions Launch campaigns by celebrities or key influential leaders and goodwill ambassadors, making announcements through mass media and megaphones Disseminate messages at rallies, fairs, haat bazaars, melas, religious ceremonies, processions, public meetings Provide orientation on IPC skills to EHCS service providers
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
X NHEICC Partners X NHEICC Partners X NHEICC Partners X NHEICC Partners X NHEICC Partners X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
161
Major Strategies
Major Activities
Responsibility Supporting Agencies Undertake advocacy/awareness NHEICC Partners campaigns to promote health issues, particularly focusing on adolescents, youths, mothers, husbands and mothers-in-law Organise sensitisation NHEICC Partners programmes for women, community people, local leaders, teachers, journalists, health workers and FCHVs Organise interaction NHEICC Partners programmes for journalists, women, community people, local leaders, teachers, adolescents and youth Organise orientation on NHEICC Partners programmes for FCHVs, MGHs, HWs and social mobilisers Conduct mass media NHEICC Partners campaigns: develop, produce and disseminate messages and materials through radio, television, Frequency Modulated (FM) radio, newspapers and print media to promote EHCS programmes Promote service sites through NHEICC Partners mass and other communication media
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
162
Major Strategies
Major Activities Use locally available means of information and local cultural performances to disseminate health messages Make efforts to produce and disseminate messages and materials in local languages and for different socio-cultural contexts Promote health as a right, especially based on the policy documents available Develop gender-friendly messages and materials and disseminate them Conduct IEC/BCC activities to discourage GBV Conduct regular technical staff, intra-divisional, EDP and INGO meetings at the central level Conduct National IEC/BCC Coordination and Technical Committee meetings to implement a one-door system of IEC/BCC programmes in order to maintain uniformity and appropriate and consistent health messages
Responsibility Supporting Agencies
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
Catering to specific gender needs and the needs of the poor, socially excluded and disadvantaged communities
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X X X X X X X X X
NHEICC NHEICC
Partners Partners
X X
Strengthening institutional capacity in health and in hospital settings to provide appropriate health education and communication programmes at all levels
NHEICC
Partners
163
Major Strategies
Major Activities Hold annual regional IEC/BCC review and orientation meetings Conduct IPC/BCC skill enhancement, orientation and training for district-level IEC/BCC focal persons and other HWs and volunteers on a yearly basis Involve and orient central and district IEC/BCC focal persons, building their capacity to design, introduce and implement evidence-based tools, materials and programmes NHEICC staff to make regular monitoring visits in the region, in the districts and at community level Prepare and manage welldocumented reports and materials in print or e-copy for health professionals and students Provide necessary communication equipment, materials and other logistics at NHEICC, in the regions and
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
X NHEICC Partners X
NHEICC
Partners
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
164
Major Strategies
Major Activities districts and below, and in hospitals Develop guidelines for health education and communication programmes Develop, review, revise and implement national communication strategies and plans for EHCS Hold Technical Committee meetings with stakeholders, including academics Hold meetings with academics for orientation and training on health education and communication Orient academics and public health and other students on IEC/BCC programmes Hold meetings to coordinate with MoE, DoE, the Ministry of Urban Development (MoUD), DWSS, MoLD, the Ministry of Information and Communications (MoIC), the
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
Coordination with other ministries and academic institutions to ensure in-service and pre-service training specifically on health education for EHCS and beyond
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
165
Major Strategies
Major Activities Ministry of Agriculture Development (MoAD), MoWC&SW, MoEST, local bodies and other concerned government, non-government, EDPs and UN organisations to develop and disseminate health messages Conduct periodic research on BCC Conduct assessments of needsbased IEC/BCC messages, methods and channels Review, revise and pretest IEC/BCC messages and materials Update the NHEICCs HMIS form in coordination with the HMIS sections Conduct meetings and workshops for multi-sectoral collaboration in health communication Promote PPPs in health education and communication and engage private partners in health promotion Conduct gap identification exercises
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
Multi-sectoral collaboration to implement communication programmes. ensure that the impact of the communication interventions is captured by the HMIS, and that additional resources are available for periodic surveys
NHEICC NHEICC
Partners Partners
X X
X X
X X
X X
X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners
166
Major Strategies Establishing National Resource Centre for proper management and dissemination of IEC/BCC materials Strengthening of School Health Education Programme involving students and teachers in and out of schools for EHCS and beyond
Major Activities Digitise all IEC/BCC materials and documents for reference, reprint and reproduction Develop and implement an efficient annual IEC/BCC materials distribution plan Conduct School Health Programmes targeting adolescents and their parents Develop or link with tailormade community-level programmes to reach out-ofschool adolescents, marginalised communities, migrants, sexual minorities, and most-at-risk adolescents about AFS Coordinate with MoE and the Curriculum Development Centre to incorporate health content into textbooks and resource materials Orient school teachers on the school health education programme and its contents Conduct orientation to FCHVs to discuss harmful and unhealthy socio-cultural practices with communities
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
NHEICC
Partners X X X X X
NHEICC
Partners
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
Mobilisation of FCHVs and other influential persons of the community
NHEICC
Partners X X X X X
167
Major Strategies to support implementation of community health education and communication activities for EHCS and beyond
Major Activities Conduct orientation programmes for FCHVs and other influential persons to enhance skills on IPC Organise a FCHV promotion programme to promote the Health Education Programme at the community level Develop, produce, and provide IEC/BCC materials and toolkits for FCHVs to update health information Tobacco control: develop and implement a tobacco control plan in line with the WHO Framework Convention on Tobacco Control (FCTC), implement strategy of MPOWER6, and South East Asia Regional Office (SEARO) regional strategies Undertake capacity enhancement and law enforcement on tobacco use restrictions Ban advertising, promotion and sponsorship
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
X NHEICC Partners X NHEICC Partners X NHEICC Partners, WHO
Promoting interventions on tobacco control, reduction of harmful use of alcohol, promotion of a healthy diet and physical activity to reduce the burden of NCDs, i.e. cancer, cardio-vascular diseases, diabetes and chronic respiratory
6
NHEICC
Partners, WHO
NHEICC
Partners, WHO
MPOWER: M Monitor prevention, P Protect people, O Offer help to quit, W Warn about dangers, E Enforce bans, R Raise tax
168
Major Strategies diseases
Major Activities Protect people from tobacco smoke by expanding the coverage of non-smoking areas Undertake BCC and social mobilisation Increase tax on tobacco products Control packaging and labeling of tobacco products Promote the cessation of tobacco use Develop a supply reduction strategy Undertake surveillance and research Counter tobacco industry interference Networking and coordination
Responsibility Supporting Agencies NHEICC Partners, WHO NHEICC NHEICC NHEICC NHEICC NHEICC NHEICC NHEICC NHEICC Partners, WHO Partners, WHO Partners, WHO Partners, WHO Partners, WHO Partners, WHO Partners, WHO Partners, WHO
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
X X X X X X X X X
X X X X X X X X X
X X X X X X X X X
X X X X X X X X X
X X X X X X X X X
169
Major Strategies
Major Activities Reduce the harmful use of alcohol, promote a healthy diet and physical activity by developing and implementing a plan in line with the WHO Global Strategy for Diet, Physical Activity and Health; and the Global Strategy to Reduce the Harmful Use of Alcohol, as well as the SEARO regional strategies Harmful use of alcohol: restrict access to retail alcohol, enforce restrictions and bans on alcohol advertising, raise taxes on alcohol Unhealthy diet: reduce salt intake, replace trans-fats with polyunsaturated fats, promote public awareness about diet Physical inactivity: promote the importance of physical activity through different mechanisms including the mass media Conduct activities for finding out evidence for advocacy, social mobilisation, and IEC/BCC intervention
Responsibility Supporting Agencies NHEICC Partners, WHO
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
NHEICC
Partners X X X X X
Strengthening advocacy, social mobilisation, and IEC/BCC
NHEICC
Partners X X X X X
170
Major Strategies interventions for the prevention for NCDs, cancer, cardio-vascular diseases, diabetes, and chronic respiratory diseases
Major Activities Develop and implement plans for advocacy, social mobilisation and IEC/BCC intervention Coordinate and collaborate with other sectors for the prevention of NCDs Hold meetings of the IEC/BCC Technical Committee on NCDs Develop, produce and disseminate NCD prevention and control messages through mass media, IPC, and social media Conduct interaction programmes at community level Mobilise media for the prevention of NCDs Orient professional organisations on the prevention of NCDs Conduct IEC/BCC activities about other risk factors for NCD prevention and control Develop and implement a mental health promotion plan in line with WHO strategies in
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
X NHEICC Partners X NHEICC NHEICC Partners Partners X X
X X
X X
X X
X X
NHEICC
Partners X X X X X X X X X X X X X
NHEICC NHEICC
Partners Partners
X X
NHEICC
Partners X X X X X
Promoting mental health in collaboration with
NHEICC
Partners X X X X X
171
Major Strategies relevant sectors Raising awareness about road safety and the prevention of accidents
Major Activities coordination with relevant agencies Develop and Implement a plan for the promotion of road safety and prevention of accidents in coordination with the relevant agencies
2010/11 2011/12 2012/13 2013/14
2014/15
2015/16
NHEICC
Partners X X X X X
172
2.24 Environmental Health
1. Introduction Available epidemiological findings suggest that the provision of safe water, sanitation and hygiene are still in a critical state in Nepal. WASH-associated diseases, including skin diseases, ARI, and diarrhoeal diseases, are the top three leading preventable diseases among infants and children, and ARI and diarrhoeal diseases remain the leading causes of child deaths. Evidence also shows the role of poor hygiene, leading to the burden of malnutrition and VBDs. Sanitation and hygiene are poor in many parts of Nepal, especially in rural areas. Outbreaks of diarrhoea and cholera still occur in different parts of the country. Many of these problems could be solved by raising awareness and promoting desired behaviours and hygiene practices, particularly hand washing. There is a growing need to focus on health education and BCC to prevent and respond to newly emerging diseases like human and pandemic flu, as well as NCDs and occurrences of epidemics such as diarrhoea and cholera. Environmental Health and Hygiene (EHH) thus must be improved through health sector interventions to prevent WASH-associated diseases. The EHH Programme aims to improve water quality through water quality surveillance and monitoring, to promote hygiene and sanitation practices and to manage solid, liquid, and health care wastes effectively. Chemical safety, air pollution, climate change, and occupational hazards are also issues in the present context which will be addressed by MoHP through its EHH Programmes. 2. Goal To reduce health risks by improving Environmental Health, Hygiene and Sanitation (EHHS) conditions in Nepal. 3. Objectives Promote the critical time of hand washing with soap and water as a priority health programme Mainstream hand washing with soap and water into EHHS programming Promote EHH practices at the individual household, community and institutional levels, considering the GESI perspective Promote safe and healthy individual, domestic and community behaviour through proper management of household and health care waste, the prevention of indoor air pollution and the prevention of chemical, environmental, and occupational hazards Promote hygienic food and safe water handling and preservation Minimise the risks related to climate change and disasters by promoting safe practices Strengthen knowledge management through research- and information-related development activities Establish and implement water quality surveillance through the MoHP system. 4. Major Strategies Promote hygiene and sanitation through the existing institutional infrastructure
173
Promote hygiene and sanitation in conjunction with other EHCS to mainstream hygiene and sanitation promotion. Adopt key performance indicators for behaviour change towards improved hygiene practices In partnership with related agencies, establish a water quality surveillance system and promote the use of safe water MoHP, MoE and partners will promote use of cleaner fuels for cooking such as biogas, along with improved cook stoves and improved ventilation in cooking areas Further develop specific standards on Health Care Waste Management (HCWM) and for the disposal of various categories of health care waste such as needles, mercury, infectious waste, liquid water, etc. Enhance the HR capacity to enforce and monitor the implementation of medical waste management to the required standard Establish a knowledge network with academia and practitioners on health promotion and behaviour change interventions related to climate change, and operationalise a public health response team to address the effects of climate change and disasters Collaborate with other ministries and NGOs, and take steps towards preventing the harmful effects of environmental hazards, particularly in urban areas where large numbers of people are exposed every day.
5. Indicators and Targets Major Outcome % of households with soap and water at a hand washing station inside or within 10 paces of latrines % of households using water treated with appropriate methods % of health institutions with toilets/water facilities % of households with improved toilet facilities with flush % health institutions adopting proper HCWM practices
2010/11 13
2011/12 2012/13 2013/14 25 37 45
2014/15 2015/16 53 55
17.6
50 80
38.2 10 20 30 40
60 50
174
6. Major Challenges and Issues Multi-sectoral coordination and harmonisation of strategy and operational plans Access to and utilisation of services with regard to geography and GESI EHHS are not perceived as equally important by many development partners and civil society Poor housing and its relationship to communicable disease Emerging and re-emerging of diseases over the years Inappropriate waste management by local authorities Current norms, values and cultural practices with adverse effects on human health Industrialisation, migration and urbanisation, as well as increased numbers of automobiles and vehicles Natural degradation and disasters, climate change, air pollution High levels of poverty in meeting basic sanitation services.
175
Accountable Officer: Director, NHEICC, DoHS Major Strategies Major Activities Promote hygiene and sanitation through the existing institutional infrastructure Coordinate and hold regular meetings/discussions of the Technical Committee on EHHS
Develop and implement a WASH strategy for the health sector which will be a basis to implement the WASH-related activities mentioned in NHSP-2 Orient and mobilise schoolteachers on environmental health and climate change to reach people at household level, promote sanitation, and control vectors and vermin Launch, introduce and activate the hand washing programme at national and district levels
NHEICC
NHEICC
Supporting Agencies MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
NHEICC, UNICEF, media and private sector to orient the national team on hand washing
NHEICC
DWASHCC Orientation And Activation Programme to promote waste management,
NHEICC
MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO,
176
Major Strategies
Major Activities hand washing and oral hygiene Hand washing and communication training for district-level trainers
Responsibility
NHEICC
Exposure and programme support visits on hand washing
NHEICC
Regular programme meetings of DWASHCC on hand washing and safe water
NHEICC
Develop and implement solid and liquid waste management guidelines in coordination with concerned bodies and authorities for all sectors Develop and implement food hygiene guidelines in coordination with concerned bodies and authorities for all sectors NGO training of trainers along with District (Public) Health Offices (D(P)HOs), District
NHEICC
NHEICC
NHEICC
Supporting Agencies WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO,
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
177
Major Strategies
Major Activities Education Offices (DEOs), and WASH on hand washing Facilitators and supervisors training promoting waste management, hand washing and oral hygiene Education sector's resource person orientation promoting waste management, hand washing and oral hygiene Implement school-based hand washing programmes in all schools and train peer educators in schools to promote proper waste management, hand washing and oral hygiene FCHVs to educate mothers of children under five in VDCs to promote proper waste management, hand washing and oral hygiene Implement community interaction programmes on the importance of hand washing with soap and water; adapt and promote proper waste management and oral hygiene
Responsibility
Supporting Agencies WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
NHEICC
NHEICC
NHEICC
NHEICC
MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners
178
Major Strategies
Major Activities Provide household events and demo stalls for mothers (MGHs) in each VDC and distribute IEC materials on hand washing Street theatre and flash mob in communities and haat bazaars, and distribution of collateral materials on hand washing at the community level Monitoring and supervision by NGOs in all programme VDCs on hand washing and other hygiene issues Promotion of proper waste management in both municipal and rural areas
NHEICC
NHEICC
NHEICC
Conduct regular Technical Committee meetings to strengthen inter-sectoral collaboration between WASH, Education, and Health Programmes to support Opendefecation-free (ODF) VDCs to integrate GESI into all programmes and activities
NHEICC
Supporting Agencies MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
179
Major Strategies
Major Activities Integrate sanitation into the Fit for School" Programme and allocate programme budget to conduct school- and community-level programmes in the district Promote and ensure the use of clean and hygienic toilet facilities in the ministry, divisions, centres, directorates and HFs Provide a yearly award for clean and hygienic toilet facilities in health institutions and schools Design, develop, produce and disseminate mass media materials
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
NHEICC
NHEICC
Establish partnerships with private manufacturers and companies to promote separate toilets for boys and girls in schools and costeffective toilet-building options in communities to cater for the needs of poor and unreached populations
NHEICC
180
Major Strategies
Major Activities Mobilise FCHVs and service providers as role models in hard-to-reach and vulnerable communities to promote toilet construction Support ODF events and activation programmes in districts, municipalities and VDCs to reach poor, vulnerable and marginalised populations Implement school-based sanitation promotion programmes in schools through the regular programme budget and mobilise students in vulnerable communities Implement community interaction in partnership with the private sector to promote toilet building in hard-to-reach and vulnerable communities Develop surveillance tools for predicting epidemics, vectors and helminthes infections in coordination with EDCD and promote local technology and preventive and protective measures for vector control Carry out regular information sharing, monitoring and review of all sector activities to
NHEICC
NHEICC
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
Promote hygiene and sanitation in conjunction with other EHCS to mainstream the promotion of hygiene and sanitation, and adopt key performance
NHEICC
NHEICC
MoUD, UNICEF, WHO,
181
Major Strategies indicators for behaviour change towards improved hygiene practices
Major Activities promote coordination, collaboration and partnerships at all levels Develop and implement an advocacy and BCC plan of EHH
Responsibility
Supporting Agencies WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
Design, develop, produce and disseminate mass media Public Service Announcements (PSAs) and print materials Produce and install signage and hoarding boards in districts; organise a wall-painting event during the programme period Disseminate messages through radio, television, Frequency Modulated (FM) radio, and newspapers at national and district levels Conduct orientation training for people in the districts, involving at least one staff member from each HF
NHEICC
NHEICC
NHEICC
NHEICC
182
Major Strategies
Major Activities Ensure adequate sanitation facilities and promote hygiene in all health institutions
Promote personal, domestic, and environmental hygiene through different health promotion programmes Integrate hygiene and sanitation promotion through different health programmes such as IMCI, health promotion, HIV/AIDS, training, SM etc. Conduct regional-level Communication for Development Network (C4D) exercises (workshops) to harmonise the communication plan with the district context Conduct periodic formative research on EHH
NHEICC
NHEICC
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
NHEICC
183
Major Strategies
Major Activities Provide orientation on hygiene to FCHVs
Establish a water quality surveillance system and promote the use of safe water in partnership with related agencies
Promote inter-ministerial and multi-sectoral coordination to ensure the public health safety of water facilities at the national, regional, district, and VDC levels, focusing on poor, vulnerable and hard-to-reach populations Coordinate water quality and safety measures, develop guidelines and promote the use of safe water Provide district-level orientation and activation programmes for media and stakeholders in coordination with DWASHCC to ensure that the district plan includes water schemes to reach poor, vulnerable, and marginalised populations Orient FCHVs and community service providers on the prevention of waterborne diseases; disseminate
NHEICC
Supporting Agencies MoUD, UNICEF, WHO, WaterAid, partners MoUD, UNICEF, WHO, WaterAid, partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
NHEICC
MoUD, UNICEF, WHO, WaterAid, partners MoUD, WHO, UNICEF, EDPs, partners
NHEICC
MoUD, WHO, UNICEF, EDPs,
184
Major Strategies
Major Activities messages through MGHs, EPI, and outreach clinics, especially in areas where people are poor and vulnerable Design, develop, produce and disseminate messages and materials on water quality and safety measures Develop a School Health Education Programme on water quality and safety for use in child-to-parent and child-tocommunity approaches Promote safe drinking water or the treatment of water at the household level through Community Health Education and FCHV Programmes Coordinate with NPHL and other sectors, particularly DWSS, for water quality monitoring
Responsibility
Supporting Agencies partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
NHEICC
NHEICC
NHEICC
Promote the use of cleaner fuels, such as biogas for cooking, along with improved cook stoves and improved
Develop and implement national standards on protection from the hazards and risks of air pollution, especially among poor, vulnerable and marginalised populations
NHEICC
MoUD, WHO, UNICEF, EDPs, partners MoUD, WHO, UNICEF, EDPs, partners MoUD, WHO, UNICEF, EDPs, partners MoUD, WHO, UNICEF, EDPs, partners MoEST, MoE, MoUD, WHO, EDPs, partners
185
Major Strategies ventilation in cooking areas, in coordination with different ministries and MoE and other partners
Major Activities Monitor air pollution and air quality and disseminate the findings for further programme development and implementation Conduct awareness activities to promote pollution-free cooking practices and technology
Supporting Agencies MD, NPHL, partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
Establish further specific standards on HCWM and for the disposal of various categories of health care waste such as needles, mercury, infectious waste, liquid water, etc. Enhance MoHP capacity, including HR capacity, to enforce and monitor implementation of medical waste
Develop an implementation strategy and action plan on chemical safety, focusing on the elimination of mercury in health care, the elimination of lead in paint, and the management of arsenic in food and water Promote proper HCWM practices at health institutions Develop and implement proper medical waste management standards jointly with stakeholders Coordinate with MD and other relevant agencies to build capacity on medical waste
NHEICC
MoEST, MoE, MoUD, WHO, EDPs, partners MoEST, MD, WHO, EDPs, partners
NHEICC
NHEICC
NHEICC
MoEST, MD, WHO, EDPs, partners MoEST, MD, WHO, EDPs, partners MoEST, MD, WHO, EDPs,
186
Major Strategies management to the proper standard
Major Activities management Promote implementing and enforcing medical waste management standards Facilitate national working groups, NGOs, civil society and experts to develop and implement coordinated mitigation and adaptation plans for climate change and health Integrate surveillance for an early warning and risk communication plan to contain the spread of diseases as per IHR Develop national capacity to undertake studies on the health implications of climate change Develop and disseminate messages through the Internet as well as through print materials Develop and implement adaptation plans for climate change and health in line with the WHO SEARO regional strategy
Responsibility
NHEICC
Establish a knowledge network with academics and practitioners on health promotion and behaviour change interventions, and climate change. Operationalise a public health response team to address the effects of climate change and disasters
NHEICC
Supporting Agencies partners MoEST, MD, WHO, EDPs, partners MoEST, WHO, other EDPs
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
MoEST, WHO, other EDPs
NHEICC
MoEST, WHO, other EDPs MoEST, WHO, other EDPs MoEST, WHO, other EDPs
NHEICC
NHEICC
187
Major Strategies
Major Activities Conduct a vulnerability study on the impact of climate change on health Develop and produce media materials based on the vulnerability assessment Support and strengthen community-based neighbourhood support/watch schemes and other empowering measures through stakeholders' orientation and activation events at the community level Implement community interaction programmes to adopt local measures to minimise climate risks Provide orientation the Rapid Response Team (RRT) on climate change
NHEICC
NHEICC
Supporting Agencies MoEST, WHO, other EDPs MoEST, WHO, other EDPs MoEST, WHO, other EDPs
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
NHEICC
MoEST, WHO, other EDPs MoEST, UNICEF, WHO, WaterAid, partners MoEST, WHO, other EDPs EDPs, other partners
NHEICC
Collaborate with other ministries and NGOs, and
Promote construction of ecofriendly/green and climateproof cooler urban layouts Develop and implement occupational health standards jointly with stakeholders
NHEICC
NHEICC
188
Major Strategies take steps to prevent the harmful effects of occupational health hazards, particularly in urban areas where large numbers of people are exposed every day
Major Activities Coordinate and collaborate with other relevant agencies Formulate regulations and implement the prevention of occupational health hazards Promote occupational hygiene
NHEICC
NHEICC
Supporting Agencies EDPs, other partners EDPs, other partners EDPs, other partners
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
189
PART THREE: HEALTH SYSTEM STRENGTHENING

The WHO defines health systems as all the organisations, institutions, and resources that are devoted to producing health actions. This definition includes the full range of players engaged in providing and financing health services including the public, non-profit, and for-profit private sectors, as well as international and bilateral donors, foundations and voluntary organisations involved in funding or implementing health activities. Health systems encompass all levels: central, regional, district, community, and household. Health sector projects engage with all levels and elements of the health system and frequently encounter constraints that limit their effectiveness. The World Health Report 2000 (WHO 2000) identifies the four key functions of the health system as: (1) stewardship (often referred to as governance or oversight), (2) financing, (3) human and physical resources, and (4) the organisation and management of service delivery. NHSP-2 includes the following building blocks of the health system: 1. 2. 3. 4. 5. 6. 7. 8. 9. Health governance Human resources for health Gender and social inclusion Health financing State and non-state partnerships Procurement and supply Physical facilities and maintenance Monitoring and evaluation Sector Wide Approach and Health Sector Reform
The detailed implementation plans are given under the following sub headings.
190
3.1 Health Governance
1. Introduction The government must play the role of a steward since it spends revenues that people pay through taxes and social insurance, and makes many of the regulations that govern the operation of health services in other private and voluntary transactions (WHO 2000). Government exercises its stewardship function by developing, implementing and enforcing policies that affect the health system functions. WHO has recommended that one of the primary roles of a Ministry of Health is to develop health sector policy, with the aims of improving health system performance and promoting peoples health (WHO 2000). New constitutional provisions will require a re-definition of roles, responsibilities, powers and structures of the MoHP and its departments and Regional Directorates, and a remodelling of roles throughout the health system. The intention is to bring power and service provision nearer to the people or to the lowest level of government. In Nepals health sector, the MoHP needs to prepare for transitioning the health system. Managing health systems under a federal structure requires serious dialogue and continuous consultation with stakeholders because of the serious implications for the existing institutional framework, referral system, research and training, HR management, and delivery of health services at different levels. Lessons from current decentralisation- and restructuring-related initiatives will need to be redefined in the context of federalism. Recently, the MoHP prepared a plan for a smooth transition that has been integrated into this document. Work has been done to establish a functional downward accountability mechanism. For example, programme directors are made accountable for programme planning and implementation, and they must report progress against the Governance and Accountability Plan (GAAP). However, programme managers (section heads) are not so accountable for the performance of their programmes. Although a local health governance pilot programme has been developed and piloted in a few districts, it is moving at a snails pace, with the stakeholders in half the piloted districts still not oriented on issues of local health governance and fund management. Gaps were found in the capacity building of local government units and in strengthening collaboration among local-level institutions. A training package was developed for the HFOMC and HWs, but training has been provided to only half of the planned districts. A formula was developed to provide grants to the district level and below, but it has not been used. The budget allocated for the districts could not be used due to the lack of a joint village health development plan. Budget was allocated to the districts as capital grants, and they thus had difficulty using the funds for recurrent costs. In many cases, the authority for hiring staff is limited to DHOs and not provided to local HFOMCs. Regarding FM, gaps have been observed in establishing and maintaining computerised systems of accounting with networking, establishing mechanisms to reduce irregularities, and for effective fund management including fund tracking. 2. Goal To develop a responsive and accountable health system. 3. Objectives To develop transparency in the health system To develop an accountability mechanism in health system service delivery To address the implications of federalism.
191
4. Major Strategies Functional downward accountability Transparency Promoting GESI Strengthening linkages between bottom-up and top-down planning Effective fund management Coping with the implications of federalism Allocation of health institutions, health workforce and financial resources between the central and provincial levels. 5. Indicators and Targets Indicator % of actions identified in the GAAP that will have been implemented % of district facilities that will have been subjected to social audits % of the MoHP budget spent
2010/11 90
2011/12 90
2012/13 90
2013/14 90
2014/15 90
2015/16 90
10
15
19
22
25
83
84
84.5
85
85.5
86
6. Major Challenges and Issues Adequate allocation of health institutions and HRH Addressing the implications of federalism Capacity building of local government units Strengthening collaboration among local-level institutions Developing and using computerised accounting system Effective fund management Reducing irregularities.
192
Accountable Officers: D-G, DoHS; Chief, HR and FM Divisions, MoHP Major Strategies Major Activities Responsibility Establish a functional downward accountability mechanism Prepare and implement a downward accountability plan Develop and implement guidelines for an integrated social audit Adapt and implement the GAAP at district and lower levels Update financial regulations for hospitals Health Facility Operation and Management Committees to recruit health workers Develop and update a computerised system of accounting linking with the Financial Management Information System (FMIS) Develop software for fund tracking and update it monthly Update health-related websites Document the lessons learned on Local Health Governance Support Programme (LHGSP) Review and revise HFOMCs to make them more inclusive Health Sector Reform Unit (HSRU) PHCRD
Supporting Agencies NHSSP/GIZ/ WHO NHSSP/GIZ/ WHO NHSSP/GIZ/ WHO
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
PHCRD
X X X
Finance Section Personnel Administration Finance Section
Promoting transparency
Finance Section X HSRU HSRU NHSSP/GIZ/ WHO X X X X X X X X X
Promoting GESI
MD/PHCRD
NHSSP
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Major Strategies
Major Activities Develop a guideline for increasing the participation of women, the poor, and excluded in health care management Adapt AWPB formulation guidelines (MoF) with topdown and bottom-up linkages Coordinate with NPC and MoF for building linkages in planning Structural and functional analysis of health system Develop and implement a training package for HFOMC members, HWs, and other stakeholders Develop and implement a capacity development package for local offices Update financial regulations for hospitals Form and activate the Audit Committee Develop and implement the FM Improvement Plan 2 Develop transitional plan for service delivery between all levels
Responsibility MD/PHCRD
Supporting Agencies NHSSP
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Strengthening linkages between bottom-up and top-down planning
Finance section/MoHP
Planning X HSRU NHTC Staff College MD X NHTC X Finance Section, MoHP Finance Section, MoHP HR and FM Divisions HR and FM Divisions Curative Division, MoHP X X X GIZ, other partners X X X X X X
Capacity development
Effective fund management
Prepare for health system administration in
194
Major Strategies a federal structure
Major Activities
Responsibility
Assign functions, HR, and HR and FM financial resources in a Divisions federal structure to all X relevant levels from federal to local Note: Health systems as a whole are the mandate of MoHP; thus, the Secretary of MoHP is responsible for the entire range of activities. However, authorities are delegated to various officials in the respective departments, centres, and divisions that are reflected in the table above.
Supporting Agencies GIZ, other partners
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
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3.2 Human Resources for Health
1. Introduction Nepals health policy and strategy documents over the past several decades repeatedly identify issues regarding the deployment and retention of health sector staff as a major problem facing Nepal. The health sector constitutes about one-quarter of the public sectors total personnel. The HR Development Strategic Plan of 2003 must be revisited in the context of the health-related MDGs, free health care, health system development, and the above-mentioned transition. A new projection of HR by categories and sub-categories is imperative to support service delivery. The market has supplied sufficient HR for health. However, a shortage of critical HR for service delivery still exists. For example, 7,000 trained SBAs are needed, but the current supply is only 1,000; 90 MDGPs are needed but only 34 are available. Shortages of other clinical and non-clinical HR are chronic. These include anaesthetists/AAs, psychiatrists, radiologists, radiographers, physiotherapists/physiotherapy assistants, optometric technicians/ophthalmic assistants, and dental assistants. In addition, there is a shortage of HR related to health systems management: procurement specialists, health legislation experts, epidemiologists, health economists, and health governance experts. The inequitable distribution of HR remains a problem. Out of a national stock of 8,118 medical doctors, 1,062 work in sanctioned government posts and about 300 are working in government posts under the MoHPs scholarship programme. Two-thirds are in the Kathmandu valley or in other cities. Overall, the national stock of medical doctors in some of the key specialities related to the health MDGs appears to be sufficient. For example, the Medical Council in March 2009 registered 182 specialists in obstetrics and gynaecology, and 139 paediatricians. The problem is one of poor distribution of doctors and specialists nationwide. The retention of medical doctors and nurses remains a major concern. Evidence on the average length of stay of care providers is lacking. Health facility surveys showed that only 64-80% of posted medical doctors were available at the time of the surveys. The availability of nurses was 68-81% and of paramedics, 81-92%. 7 The situation is worse in the most remote districts. Productivity is also a continuing challenge. Paramedics at HPs and SHPs conduct as few six clinical consultations per day (HMIS, 2006/07), which is low even when considering their involvement in both preventive and curative services. Daily output per physician varies between the ecological regions. Training activities can be broadly classified into two types: in-service training and international training. The process of including Dalits and other excluded groups in the health care workforce will be initiated during NHSP-2. An additional ANM from Dalits and/or other excluded groups will be provided to HPs in underserved areas and trained as Rahat (welfare workers). A total of 1,000 ANMs will be provided as Rahat (200 per year) during the planned period. Similarly, MGHs will be facilitated to select FCHVs from among Dalits and other excluded groups, who will then be trained. As mentioned in NHSP-2, all remaining SHPs will be gradually upgraded to HPs. Posts for an HA and an ANM will be added in HPs. Additional training and orientation will be provided to MCHWs to upgrade to ANMs. 2. Goal To reduce mortality and disability and effectively address morbidity by producing and distributing HR across the country. 3. Objectives To supply HWs for labour markets
7
RTI International (December 2009). Assessing Implementation of Nepals Free Health Care Policy: Third Trimester Health Facility Survey Report. Research Triangle Park, NC, USA.
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To ensure the equitable distribution of HWs To improve the performance of HWs To coordinate HR planning and management. 4. Major Strategies Improve HR planning Improve the attractiveness of jobs in remote areas to retain HWs Ensure basic and pre-service training Implement compulsory service to improve rural health service provision Use NGOs and private health providers Provide staff with leadership and clear direction Strengthen the skills/capacity of HWs Reduce staff absences Ensure appropriate structure systems, and capacity development Provide effective coordination. Operational strategies Developing teaching and learning materials Offering training Improving the quality of training Strengthening training institutions Enhancing the capacity of training institutions Promoting PPPs Improving monitoring and supervision Conducting operations research Increasing SBA training sites. 5. Indicators and Targets Indicator % of posts at PHCCs and district hospitals filled by doctors and staff nurses % of hospitals with at least one obstetrician/ gynaecologist, one anaesthesiologist, six staff nurses and blood service workers Number of SBAs trained
2010/11 NA
2011/12 85
2012/13 86.5
2013/14 88
2014/15 90
2015/16 90
NA
60
70
75
80
1,500
1,500
2,000
1,000
1,000
1,000
6. Major Challenges and Issues Uneven distribution of HR Deployment and retention of care providers in remote areas Low productivity of care providers Low incentives to care providers Lack of skill mix among care providers and trainers Vertical approaches and fragmented training.
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Accountable Officers: Chief, HR and FM Division, MoHP; Director, NHTC, DoHS Major Strategies Major Activities Responsibility Supporting Agencies Improve HR Strengthen the Human HR and FM M&E, NHTC, planning in the Resource Information Divisions HMIS health sector System (HuRIS) and Training Management Information System (TMIS) and use the information in HR planning Develop an HR HR and FM development strategy Divisions Medium- and long-term HR and FM HR and FM forecasting of HR needs Divisions Divisions Make jobs in Conduct a bottleneck HR and FM NHRC remote areas study on training and Divisions more attractive in utilisation order to retain Assess, develop, and HR and FM FM and GESI HWs implement an incentive Divisions Unit scheme to retain care providers in remote areas. Develop a GESI perspective retention scheme Develop and implement HR and FM LMD multi-year service Divisions contract guidelines Ensure basic and Coordinate with academic HR and FM Curative pre-service institutions for Divisions Division training accreditation Implement Review and develop a HR and FM Curative compulsory compulsory service Divisions Division service provision framework for HWs
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X X X
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Major Strategies to improve rural service delivery Use NGOs and private health providers Provide staff with leadership and clear direction Strengthen the skills and capacity of HWs Reduce staff absences
Major Activities
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Prepare and expand a PPP modality Design and implement a leadership development training programme Provide in-service training to HWs
HR and FM Divisions NHTC
NHTC
NGO Coordination Section HR and FM Divisions/ Staff College Partners X X
Develop and implement absence management mechanisms Ensure Review the existing appropriate structure, system and structure, system capacity from a GESI and capacity perspective development Prepare the restructuring required for federalism Effective Strengthen the Country coordination Coordination Forum (CCF) Operational-level activities developed by NHTC Assessing training needs Determine the training requirements of health workers through research/assessments Prepare training materials
HR and FM Divisions HR and FM Divisions
Partners X X X X X
HR and FM Divisions HR and FM Divisions NHTC INGOs X NHTC INGOs X
X X X
X X X X
Developing teaching/learning materials
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Major Strategies Offering training
Major Activities
Supporting 2010/11 2011/12 2012/13 Agencies International and national in-service training programme management and implementation (Basic, refresher, upgrading, and specialised training and orientation programmes) 1. Health institution management training 2. GBV training 3. GESI and GBV training 4. SBA training 5. FP training 6. BCC training 7. Safe abortion training 8. OT management training 9. Management training 10. HFMC management etc. training 11. Upgrading training 12. Training to biomedical technicians 13. Clearing the backlog of training for newlyappointed FCHVs 14. Post-training follow-up Certification and accreditation Upgrade TMIS Training quality assessment Train 1,000 ANMs from Dalit and/or other NHTC NHTC NHTC NHTC NHTC NHTC NHTC NHTC NHTC NHTC INGOs INGOs INGOs INGOs INGOs INGOs INGOs INGOs INGOs INGOs 1,500 X X X X X X X X X 3,000 X X X X X X X X X X X 5,000 X X X X X X X
Responsibility
2013/14
2014/15
2015/16
X X X 6,000 X X X X X X X
X X X 7,000 X X X X X X
X X X 7,000 X X X X X X
X NHTC NHTC NHTC INGOs X X X
X X
X X
X X
Improving the quality of training
HR Section, MoHP 200 200
X 200 200
X 200
Making the health workforce
NHTC
200
Major Strategies inclusive
Major Activities excluded groups Train FCHVs from poor and excluded groups
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X NHTC MoHP/ MoGA/MoF
Institutional development
Enhancing the capacity of training Institutions
Conduct preparatory work for establishing a National Health Training Academy (O&M survey, planning, financial and strategic implications, structural and functional analysis of training) Establish a semiautonomous National Health Training Academy Review the capacity of training centres in the context of developing HR resources for DoHS, DDA and DoA Review training and capacity-building packages Prepare quality trainers for training with the right mix of skills (abroad/incountry) Enhance the capacity of regional training centres (for training, equipping and networking) Develop the capacity of district-level training units
MoHP
MoHP/ MoGA/MoF
MoHP MoHP WHO, UNFPA, UNICEF, NHSSP, NFHP
NHTC X NHTC INGOs/ private X X
201
Major Strategies
Major Activities (for training, equipping, and networking) Increase SBA training sites with quality maintenance Provide block grants to district-level offices to provide training based on their perceived needs Prepare a framework for integrating training Integrate training
Responsibility
Supporting Agencies institutions INGOs/ private institutions Finance Section, MoHP Programme divisions/ DOA, DDA Programme divisions/ DOA, DDA INGOs/ private institutions INGOs/ private institutions
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
NHTC
PPICD, MoHP
Integrating training programmes
HR section, MoHP HR section, MoHP NHTC
Promoting PPPs
Improving monitoring and supervision Operational research
Explore the possibility of PPP in training programmes Organise physiotherapy training and other related skill development initiatives through PPP Supervise, monitor, follow-up, and evaluate the training activities Conduct operational research on the effectiveness of the training
NHTC
NHTC X NHTC X X X X X X X X X X X
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3.3 Gender Equality and Social Inclusion
1. Introduction The health sector has responded positively to the national mandate8 of inclusion through its pro-poor and pro-women programmes. Since 2007, the GoNs initiatives of pro-poor targeted free health care policies, coupled with the Aama programme for maternity services, have seen considerable success. NHSP-2 includes a specific objective of addressing the barriers of the poor and the excluded, incorporates disaggregated evidence on health outcomes, and embraces the GESI strategy for the health sector. GESI indicators are part of NHSP-2s GAAP. A National Action Plan on GBV, coordinated by the Office of the Prime Minister and the Council of Ministers and with commitments from 11 ministries, including MoHP, was implemented in November 2010. Although disparities in access to and use of EHCS between the poor/excluded and wealthier/advantaged social groups have significantly declined over the years, financial and cultural barriers remain. Unless NHSP-2 programmes and services directly address structural social issues, geographic-, gender- and caste-/ethnicity-based discrimination, and the stigma associated with HIV/AIDS, leprosy, disability and sexual orientation, these barriers will not be overcome. In the MoHP GESI Strategy for the Health Sector, three objectives and eight strategies highlight the need to develop and implement programmes and services that address the barriers to access and utilisation by women, the poor, and the excluded. MoHP has fully adopted the strategy. (See the detailed strategy framework of NHSP-2 or see the Health Sector GESI Strategy, Government of Nepal, Ministry of Health and Population, 2010, for further information.) Recent evidence (NDHS 2011) indicates the progress made in improving the health outcomes of different groups: TFR has come down to 2.6, use of modern contraceptive methods has increased by 66% in the past 15 years, and neo-natal mortality has been reduced to 33 deaths per 1,000 live births. But disparities still exist: the proportion of pregnant women attending antenatal care visits is 88% in urban areas but only 55% in rural areas; 50.2% of children in the tarai are underweight, while the national average is 38.6%. These issues need to be addressed. Efforts have been made to strengthen gender-responsive budgeting according to the guidelines of the MoF: the e-AWPB analyses the budget by gender-responsive categories. However, there is a need to revisit programmes for robust categorisation. Additionally, GESI-responsive budgeting practice must be initiated. Other areas of improvement include: the creation of mechanisms for institutionalising GESI (creating institutional structures responsible for providing technical support, dedicating time for GESI-related work); systematic inclusion of GESI in policies and plans; defining the roles of MoHP/DoHS and D/PHOs in implementing the GESI strategy; mainstreaming GESI into programmes and their guidelines; piloting of the GBV programme;
Interim Constitution: Section 3: Fundamental rights: Article 13 states: No one will be discriminated against on the basis of religion, caste, ethnicity, gender or language (p. 4); affirmative actions can be taken for women, Dalits, Adibasi Janajatis, Madheshis, and socially or culturally discriminated groups (p. 5). The Three Year Plan has also prioritised the inclusion of persons with disability, women, Dalits, Adibasi Janajatis, Madheshis, Muslims and people who live in backward regions.
203
improving the care-seeking behaviour of the poor and excluded; and ensuring access to services for all, including women, the poor, and excluded. 2. Goal and Objectives GESI is included in the mission, strategic direction, objectives, outputs and indicators of NHSP-2. Objective 1 of NHSP-2 demands disaggregated indicators and has set disaggregated targets. Objective 2 is clearly focused on addressing the cultural and economic barriers facing women, the poor, and excluded in order to enhance these groups access to and use of health services. 3. Major Strategies Mainstreaming GESI into policies and programmes Institutionalising GESI into health systems and practices Promoting an inclusive and GESI-competent health work force Promoting state/non-state partnerships for GESI Maintaining equity in delivering health care services Addressing the social, cultural and economic barriers faced by the unreached Addressing the health needs of GBV survivors Empowering women, the poor, and excluded so they can access health services Improving the care-seeking behaviour of women, the poor, and excluded Enabling GESI-related evidence-based M&E. 4. Indicators and Targets Outcome Indicators CPR (modern methods) for the poor (lowest and second-lowest wealth quintiles) and excluded castes (%)
Baseline/Year 2010/11 Poor: 43 Dalit: 52 Janajati: 55 Muslim: 25 Poor: 77
Poor: 35.5 Dalit: 44 Janajati: 47 Muslim: 17 (2006 for all) % of women who are poor Poor: 44.9 (lowest and second-lowest (2006); 76.7 wealth quintiles)/from excluded (rural, 2009) castes (Dalit) who took iron Hill Dalits: 78 tablets or syrup during their last (rural, 2009) pregnancy Tarai Dalits: 90 (rural, 2009) % of deliveries attended by SBAs Poor: 7.5 for the lowest and secondDalit: 11 lowest wealth quintiles and Janajati: 14 excluded castes (Dalits) Muslim: 13 Other Tarai Madheshi: 13 (2006 for all)
Target 2013 Poor: 46 Dalit: 55 Janajati: 58 Muslim: 28 Poor: 81
2015 Poor: 49 Dalit: 58 Janajati: 61 Muslim: 31 Poor: 85
Dalit: 82
Dalit: 85
Dalit: 88
Poor: 20.3 Dalit: 23 Janajati: 25 Muslim: 24 Other Tarai Madheshi: 24
Poor: 30 Dalit: 32 Janajati: 35 Muslim: 34 Other Tarai Madheshi: 34
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Outcome Indicators % utilisation of EHCS (OP, inpatient, especially deliveries and emergency) by targeted groups and disadvantaged castes and ethnicities, proportionate to their populations (as % of highest)
Baseline/Year 2010/11 Poor: 62 (2006); 90 57 (rural districts, 2009) 90
Target 2013 90
2015
Dalits: 14 (OP) 17.1 (inpatient) 16.7 (emergency) (2008) % of clients among targeted 68.4 (2008) groups, disadvantaged castes (based on and ethnicities who are satisfied availability of with their health care at district range of facilities services) % use of available communitybased emergency funds in districts with EAPs by the poor and socially excluded groups Number of districts providing services for GBV
68
74
80
19
30
50
Three districts
Thirteen districts
Strengthening existing districts and expanding into four additional districts
5. Major Challenges and Issues Mainstreaming GESI in policy, planning, programming, budgeting and disaggregated monitoring systems, processes, and formats Establishing and strengthening institutional modalities with specific responsibility for GESI mainstreaming Skills and competencies of health service providers to provide GESI-responsive services Low access to and poor quality of health care services (including frequent absenteeism of health care providers) for women, the poor, and excluded Changing the care-seeking behaviour of women, the poor, and excluded, and sustaining demand-side programmes like the EAP Empowering women, the poor, and excluded Need for a multi-sectoral approach to address the cultural, social, and religious determinants that impact the health of women, the poor, and excluded Addressing GBV and providing health services to GBV survivors.
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Accountable Officer: Chief, Population Division, MoHP Major Strategies Major Activities Responsibility Mainstreaming GESI in the health sector Develop GESI operational guidelines for the health sector Population Division and PPICD Population Division and PPICD PPICD
Review and revise selected policies from GESI perspectives
Ensure GESI integration in new policies, strategies and guidelines
Review national programmes (e.g. kala-azar, nutrition) from a GESI perspective and address GESI integration Include GESI related activities in all programmes of MoHP Mainstream GESI in the annual programme guidelines of divisions and centres Institutionalising GESI in the health sector Develop a MoHP approved concept note for mainstreaming GESI in the health sector Form a GESI Steering Committee at MoHP and a GESI TWG at DoHS, RHD and district level
PHCRD
PPICD
PPICD
Population Division Population Division
Supporting Agencies All divisions and centres of MoHP and DoHS PPICD and concerned divisions and centres Population Division and concerned divisions and centres All concerned divisions and centres of DoHS PHCRD and Population Division PHCRD and all concerned divisions and centres PPICD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X PHCRD, RHDs and D/PHOs
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Major Strategies
Major Activities Strengthen and make functional GESI TWGs and Focal Persons at all levels (DoHS, RHD and DHO) Strengthen the capacity of the HFOMC to address GESI- and governance-related issues Strengthen the capacity of the health workforce to work in a GESI-responsive manner (orientation, training, on-the-job coaching, mentoring) Support the implementation of HR Strategy to promote diversity in the health work force Select, train and deploy ANMs from among Dalit and other disadvantaged groups (rahat) Facilitate MGHs to select FCHVs from among Dalits and excluded groups Review and revise selected training curricula from a GESI perspectives Strengthen the capacity of NHTC on GESI integration in training programmes Develop and implement context-specific IEC materials targeting issues constraining health outcomes of women, the
Responsibility Population Division and PHCRD MD
Supporting Agencies RHDs and D/PHOs DHOs
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X Population Division and PHCRD RHDs and DHOs X X
Inclusive and GESI-competent HR (cross reference HR, SM)
HR Division
Personnel Administration and DoHS NHTC and FHD PHCRD and D/PHOs FHD D/PHOs and programme divisions Concerned divisions and centres Population Division PHCRD and other programme divisions
X 200 200 200
X 200 200
Review training curricula of health sector and GESI integration
NHTC
NHTC
Improve the care-seeking behaviour of women, the poor
NHEICC
207
Major Strategies and excluded
Major Activities poor, and excluded Air messages on community radio in local languages about addressing structural GESIrelated issues and on health services in general
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
NHEICC
Empower women, the poor, and excluded
Maintain and promote equitable universal health coverage for the delivery of health care services
Develop and implement targeted programmes to empower the target groups to claim their rights (promoting equity and access) Develop and make functional GoNs and NGOs multi-year partnership model to promote equity and access Promote active participation of women, the poor, and excluded in social audit programmes Establish HFs in underserved areas Mainstream GESI into initiatives and programmes of other divisions (e.g. of CHD, FHD, MD) Conduct operational research as required to identify good practices Develop and implement healthsector-specific genderresponsive budgeting guidelines
PHCRD
PHCRD, concerned programme divisions, centres and D/PHOs PPICD
PHCRD
PHCRD
Concerned divisions and centres of DoHS D/PHOs
X MD PHCRD GESI TWGs Programme divisions PPICD and EDPs Finance Section, Population
X X
X X X
X X X X
PHCRD and Population Division PPICD
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Major Strategies
Major Activities
Responsibility
Supporting Agencies Division and EDPs Concerned divisions PPICD, Population Division and NHTC MD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Addressing GBV
Identify and address socioeconomic and cultural barriers of specific target groups Review and revise the HFOMC guidelines to make them more inclusive and governanceresponsive Strengthen the capacity of the HFOMC from GESI and governance perspectives Develop OCMC Implementation Guidelines and revise based on review and assessment Pilot hospital-based OCMC in seven districts and roll out to additional districts Provide capacity strengthening of OCMCs on providing services (treatment, psychosocial counseling, and coordination) to make them effective and functional Develop screening and referral protocols for GBV cases and a users guide on GBV Develop unified guidelines for addressing GBV (MoHP, MoLD, MoWC&SW, MoHA and Ministry
Population Division MD and Curative Division NHTC
X Population Division Population Division Population Division RHD X RHD X X X
Population Division Population Division
UNFPA X MoWC&SW and the Office of the Prime
209
Major Strategies
Major Activities of Law and Justice (MoLJ))
Responsibility
Establish and strengthen a Social Service Unit (SSU) at central, regional and zonal hospitals
Promote accountability
Gender audit in health sector
Conduct a study of existing practices of social services in central, regional and zonal hospitals Establish and strengthen SSUs as a pilot Assess the piloting of SSUs, revise guidelines and roll out in additional hospitals Conduct social audits up to the level of selected district hospitals and peripheral HFs in selected districts Develop a Gender Audit Framework and Terms of Reference (TOR) for the audit Conduct a gender audit of MoHP Revise the existing supervision checklist and methods from GESI and governance perspectives Develop monitoring tools and checklists for service delivery from GESI perspectives Data management disaggregation by
Population Division
Supporting Agencies Minister and the Council of Ministers (OPMCM) PPICD, MD, and Curative Division PPICD, MD and RHD PPICD and MD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Population Division Population Division PHCRD
X X X X
D/PHO and HFOMC
Population Division Population Division M&E Division
UNFPA and PPICD UNFPA and PPICD MD
X X X
Supervision and M&E
X M&E Division MD X M&E Division MD X X
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Major Strategies
Major Activities caste/ethnicity and wealth quintiles Integrate GESI-related variables in health financing, the Service Tracking Survey and the HHS
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
PPICD
Population Division
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3.4 Health Financing
1. Introduction Health financing is the centre of the health system, contributing to health sector reform and system development. Government financing of EHCS has gradually expanded beyond the free provision of FP and MCH services to include a broader range of preventive and curative services free of charge or highly subsidised. The abolition of user fees at district-level peripheral facilities has led to a major increase in demand and a narrowing of inequity in the utilisation of services. Further planned expansion to district hospitals of free-of-charge universal care should lead to additional increases in utilisation by the poor and excluded. Although NHSP-2 presents a strong rationale for the modest extension of free-to-user services, the MoHP recognises that it will face increasingly difficult choices as to which curative services it can finance, and how to allocate limited budget funds. Already, 80% of outpatient contacts are for NCDs and injuries. The expanded prevention efforts proposed under NHSP-2 should help slow the growth in the burden of NCDs, but will not prevent continued growth in demand for curative services of an increasingly complex and expensive nature. Government already provides some financial support for certain types of tertiary care and for those facing catastrophic health costs. Demands will inevitably increase on the limited funding available and will raise difficult choices about how to provide some social protection to those facing catastrophic illness, while ensuring that the increased spending on expensive curative care does not come at the cost of less than adequate funding for the core programmes that have delivered substantial improvements in health outcomes in recent years. The MoHP will need to continue developing partnerships with nonstate actors with other resources to expand curative services. Expenditure in health remains low, at 5.3% of Gross Domestic Product (GDP) in 2006. Per capita health expenditure stood at 18.09 US Dollars (USD) compared to USD 65 in Bhutan, USD 44 in Sri Lanka, USD 29 in India, and USD 19 in Afghanistan (WHO 2008). The composition of total health expenditure is 44% public expenditure, with the remaining 56% coming from private sources. The GoN share stands at 24% (USD 4.28) of the total health expenditure, while external partners contribute the remaining 21% (USD 3.75). More than 55% (USD 9.00) of the total health expenditure is financed through out-of-pocket expenditure by households at the time of service. There is scope for introducing a social health protection scheme for catastrophic illness. Some studies have been done regarding introduction of social health insurance; however, they are still inadequate to inform the policy, mechanism, and tools. 2. Goal To develop a responsive and fair financing system to move towards universal coverage. 3. Objectives To increase allocative and technical efficiency in the health sector To enhance equity in the distribution of resources To develop a social health protection strategy in health sector. 4. Major Strategies Developing policies and strategies for health financing Enhancing technical efficiency Enhancing equity Splitting the roles of purchasers and providers Developing and implementing social health protection Capacity development.
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5. Indicators and Targets Indicator % of the MoHP budget spent % of the budget of local bodies allocated to the health sector (borrowed from MoLD) % of the budget allocated to EHCS Health Financing Strategy
2010/11 83 10
2011/12 83.5 10
2012/13 84 10
2013/14 84.5 10
2014/15 85.5 10
2015/16 86 10
75
75 Health Financing Strategy developed
75 Health Financing Strategy implemented
75
75
75
6. Major Challenges and Issues High out-of-pocket expenditure (56% of total health expenditure) Low fiscal space Low level of efficiency Equitable distribution of resources Fragmented health programme/activities Inadequate alternative health financing schemes.
213
Accountable Officer: Chief, PPICD, MoHP Major Strategies Major Activities Developing policies and strategies for health financing Collect more evidence to inform Health Financing Strategy Prepare background papers to inform Health Financing Strategy Develop a draft of Health Financing Strategy Develop and implement resource allocation criteria Develop guidelines for Output-based Budgeting (OBB) Implement OBB Monitor cost information during programme review Provide OBB training to programme officers Coordinate with NPC, MoF and MoLD for providing block grants to DHOs/hospitals Assess the equity analysis/ benefit incidence analysis Conduct a study on the implications of splitting the roles of purchasers and providers
Responsibility HEFU
Supporting Agencies Health Financing TWG PPICD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
HEFU
X PPICD HEFU, Health Financing TWG X X Finance Section Finance Section Finance Section Finance Section Finance Section PPICD X PPICD PPICD NHTC MLD, NPC X PPICD Partners X X X X X X X X X X X X X X
Enhancing technical efficiency
Enhancing equity Splitting the roles of purchasers and providers
HEFU PPICD
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Major Strategies
Major Activities Prepare an institutional and legal framework for splitting the roles of purchasers and providers Develop an institutional framework for purchasing agencies Develop a coping strategy for splitting the roles of purchasers and providers Generate additional evidence for social health protection Develop a policy on social health protection Develop and pilot a social protection scheme for the formal sector not covered by other schemes Develop a policy on social health insurance Design, plan, and pilot social health insurance
Responsibility PPICD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X PPICD Partners X HEFU/Finance Section, MoHP HEFU Partners
X Partners X
Develop and implement social health protection/social health insurance
PPICD HEFU
Partners Partners
X HEFU HEFU HEFU Partners Partners Partners X X
X X
Capacity development
Develop and implement a capacity development package for strategic purchasing of health services
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Major Strategies
Major Activities Develop the capacity of HEFU (through training and networking)
Responsibility PPICD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
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3.5 State and Non-State Partnerships
1. Introduction The non-state sector has contributed to meeting the goals of NHSP-1 in almost all areas, notably TB control, expanding contraceptive use, controlling HIV/AIDS, eye care, and WASH promotion. Although immunisation services are mainly provided through government facilities, the for-profit private-sector and NGO clinics also provide immunisation. The private sector provides immunisation services mainly in urban areas through hospital clinics, nursing homes, and NGOs. GoN supplies vaccines, related logistics and technical assistance, including monitoring and supervision to ensure uniform quality service. NGOs provide 44% of male and female VSC, with Sunaulo Pariwar Nepal (SPN) accounting for 75% of NGO-provided VSC. The private sector is also involved in the social marketing of contraceptives. Apart from private pharmacies, the private for-profit sector is primarily involved in medical education and tertiary care in urban areas, catering to the better-off. The sector now produces almost 90% of MBBS-level doctors in Nepal, and a similar share of staff nurses. In 2005-6, the private health sector had two-thirds of hospital beds, 13,400 compared to 6,796 government hospital beds. It also operates over three times more health laboratories (1,000) than the Government (277) (DoHS, 2008). By reducing the need for Nepalese to go abroad for medical education or for specialist care, the sector is estimated to save Nepal more than NRs 500 million per year in foreign exchange (Rijal, 2008). The private health sector also contributes through taxes and employs around 20,000 people in private health facilities (Rijal, 2008). Regulation of the sector has been minimal, and major differences are found in the quality of the services offered and the prices charged for similar services (Resource Centre for Primary Health Care (RECPHEC), 2005). Utilisation of private-sector facilities is very low, especially in medical colleges where students need patients to study. Nepal has also developed a private pharmaceutical industry that meets around 32% of total domestic consumption and is worth NRP 9,719.3 million. Sixteen companies have WHO Good Manufacturing Practice certification for drug production. The private sector produces almost all domestic drugs. Formal contractual relationships with non-state organisations to deliver services have mainly been financed by EDPs outside GoN budget procedures, although they work closely in support of government programmes. A number of more formal partnerships have been made between GoN and non-state providers, although these have not developed to the extent envisaged when NHSP-1 was approved. The partnerships include the following: Partnerships with NGOs to deliver health services at district and sub-district level Lamjung Community Hospital (the contracting-out model for PPP), and Bayalpata Hospital, Achham Partnerships with district-level local governments and local communities (Jiri District Hospital) Partnerships with private hospitals and medical colleges in prevention and treatment of uterine prolapse. 2. Goal To bring resources from non-state actors to fill the resource gap in the health sector. 3. Objectives To use the skills, expertise and capital of the non-state sector in public service delivery and health system development
217
To increase the role of the non-state sector in service delivery.
4. Major Strategies Enhancing technical efficiency Enhancing equity Splitting the roles of purchaser and provider Developing and implementing social health protection Capacity development. 5. Indicators and Targets Indicator Develop, adapt and implement state/non-state and community partnership models
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
6. Major Challenges and Issues Unclear policy on PPP Quality assurance Coordination Scaling-up of successful practices and expanding credible specialised services Monitoring.
218
Accountable Officer: Chief, HSRU, MoHP Major Strategies Major Activities Formulate policy and strategy Collect evidence to inform policy makers on PPP Formulate a sectoral PPP policy Develop hybrid models of PPP Develop a quality assessment mechanism including policy, legal framework and tools, both for state and non-state institutions Document case studies on PPP Build PPP arrangements with private medical colleges to expand the specialised care in districts Prepare and implement the scaling-up plan (PPP arrangements) Reactivate the PPP forum Collect and analyse the inputs, the public and private service utilisation dates
Responsibility HSRU HSRU HSRU HSRU
Supporting Agencies Partners Partners Partners Partners
2010/11
2011/12 X
2012/13
2013/14
2014/15
2015/16
X X
Develop PPP models Quality assurance/ accreditation
HSRU Curative Division
Partners Partners
Expand specialised credible services Scale up successful practices Reactivate the PPP forum Monitoring
X Partners X
HSRU
X X
X X
X X
HSRU HMIS
Partners Partners
219
3.6 Procurement and Supply
1. Introduction Procurement has received considerable attention from policy makers and EDPs in recent years. MoHP reviews at all levels the supply of drugs, equipment, facilities and their quality or condition. Obviously, major contributing factors to quality health care delivery include the supply of various commodities (medicines, instruments, equipment, furniture, and other supplies), physical infrastructure (peripheral facilities, hospital, laboratories, etc.) and consulting services as part of a capacity enhancement and research programme. In order to correct procurement-related anomalies that have existed in Nepal for decades and have delayed the development process, GoN enacted a Public Procurement Act (PPA) in 2007 that addresses the procurement of commodities, public works and services. Under MoHP, commodities are procured by the DoHS, RHDs, and D/PHOs. The responsibilities of constructing physical facilities, including repair and maintenance work costing NPR 1,000,000 or more, have been handed over to DUDBC. Offices under the MoHP carry out procurements costing less than that amount. Regarding services, major consultancies are procured from the central level, and hiring of temporary staff is carried out locally. Health commodities are distributed from the central store (and Regional Directorates) to the regional medical stores, and then to the district stores, which dispatch them to the service delivery points. 2. Goal To ensure an efficient, effective, transparent and accountable, and value-for-money procurement system in the health sector. 3. Objectives To develop the capacity of procurement-related staff To advance the procurement process To increase the efficiency gains To ensure the quality of medical and other products To promote transparency and honesty in the bidding process. 4. Major Strategies Revised procurement-related policies Consolidated procurement planning Enhance capacity, Quality Assurance (QA) Enhance efficiency gains Promote transparency Coordination with other divisions and centres Train procurement professionals within the civil service. 5. Indicators and Targets Indicator % of HFs without stockouts of tracer drugs 2010/11 90 2011/12 90 2012/13 90 2013/14 90 2014/15 90 2015/16 100
220
6. Major Challenges and Issues Developing procurement as a speciality in the civil service Fair competitive bidding Multi-year contracts Transparency Efficiency gains Revising procurement related laws/bylaws Capacity development Consolidated procurement planning.
221
Accountable Officer: Director, LMD, DoHS Major Strategies Major Activities Revised procurementrelated policies and guidelines Supporting legislation to develop procurement as a speciality
Responsibility Legal Section
Advance procurement
Integrate procurement plans
Revise MoHP procurement policy and guidelines Revise logistics management policy and guidelines Amend the Drug Act and give the Nepal Drug Research Laboratory independent status Prepare guidelines for the publicprivate mix for supply and delivery of essential drugs Develop criteria to HFs Conduct a needs assessment for equipment and instruments Carry out forecasting of drugs and other commodities Develop a specification bank or link with a specification bank Conduct a market survey Prepare standard bidding documents (international/national competitive bidding) Prepare consolidated annual procurement plans (consolidated goods, public works, services for the entire ministry regardless of financing source)
LMD LMD DDA
Supporting Agencies Public Procurement Monitoring Office (PPMO) PPMO/PPICD PPMO Partners, GIZ
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X X X X
LMD
PPMO X
DUDBC LMD/MD LMD/MD LMD LMD LMD
MD Partners Partners Partners Partners Partners X X
X X X X X X X X X X X X X X X X X X X X X X X
LMD
All divisions and entities X X X X X X
222
Major Strategies Capacity development
Major Activities Provide training for strengthening of procurement capacity at central and district levels Increase numbers of LMD staff Engage procurement support for NHSP-2 implementation Provide training to the staff (Procurement Unit) on procurement Support district offices on procurement Develop a sound QA system including pre- and post-shipment review at central and district levels to monitor the quality of procured drugs Develop local capacity at district level to comply with QA Adopt multi-year framework contracting for essential drugs, commodities, equipment, and services Assess the multi-year service contract to document efficiency gains Introduce e-procurement Make the annual procurement plan available on the website to all interested parties at cost price six months before the beginning of the FY Conduct coordination meetings with
Responsibility LMD
Supporting Agencies NHTC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X LMD LMD LMD LMD DDA Partners LMD
X X
X X X
X X X
X X X
X X X
X X X
QA
LMD LMD
DDA PPMO X
Increasing efficiency gains
LMD
PPMO X
Promote transparency
LMD LMD
PPMO MoHP X
Foster coordination
223
Major Strategies
Major Activities other divisions/centres and EDPs to avoid duplication, and obtain the benefit of economies of scale
Responsibility
Supporting Agencies
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
224
3.7 Physical Facilities and Maintenance
1. Introduction In the context of expanding EHCS coverage to meet the needs of all citizens, particularly the poor and excluded, functional health infrastructure is needed to provide an enabling environment to deliver quality health services. Therefore, delivering ECHS requires substantial investment in both new construction and the refurbishing and upgrading of existing facilities. At the same time, repair and maintenance of existing facilities will be a regular activity. The key areas of concern during NHSP-2 include the following: Strengthening, institutionalising and decentralising the existing Health Infrastructure Information System (HIIS) Developing standard designs and guidelines that help increase quality, accountability, and transparency Ensuring a sufficient number of appropriately located facilities Implementing a predictable and timely financing, budgeting, and resource allocation mechanism Ensuring repair and maintenance of existing facilities through more rational budgeting using HIIS Promoting community participation and enhancing local ownership of public facilities. 2. Goal To support providing quality health services through quality infrastructure. 3. Objectives To develop infrastructure for the expansion of service delivery To upgrade HFs for comprehensive care. 4. Major Strategies Increasing access to HFs Institutionalising/capacity development Increasing access to HFs, particularly by the poor, vulnerable, and marginalised Improving repair and maintenance Increasing community participation. 5. Indicators and Targets Indicator % of SHPs that have sufficient space as per MoHP standards
2010/11 30
2011/12 40
2012/13 60
2013/14 70
2014/15 80
2015/16 80
6. Major Challenges and Issues Institutionalising HIIS Maintaining quality, accountability, and transparency High demand for infrastructure development and limited budget Construction on inappropriate donated land Preventive maintenance Community participation.
225
Accountable Officers: Director, MD; D-G, DUDBC Major Strategies Major Activities Increasing access to HFs Construct HFs as per the service expansion plan (DHs, PHCCs, HPs/SHPs) Construct CEOC units in major district hospitals Add birthing centres in HPs and PHCCs where required Develop upgrading criteria for HPs, PHCCs, and district hospitals Develop standard designs for HFs (SHPs, HPs, PHCCs and DHs) Prepare infrastructure development guidelines for construction and maintenance work Develop and implement standard construction guidelines Train technicians on standard construction Train and use HIIS for planning and monitoring Establish HFs focusing on communities where poor and marginalised people live
Responsibility DUDBC
Supporting Agencies MD
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X DUDBC MD X MD NHSSP MD X
X X X
X X X
X X X
X X X
Institutionalising/ capacity development
X DUDBC MD X MD DUDBC X DUDBC MD X DUDBC MD MD MD/GIZ/ NHSSP DUDBC DUDBC X X X X X X X X X X
Increasing access to HFs, particularly by the poor, vulnerable, and marginalised
226
Major Strategies Improving repair and maintenance of HFs Increasing community participation
Major Activities Develop repair and maintenance related guidelines Develop a guideline for community participation for the construction and maintenance of HFs
Responsibility MD
Supporting Agencies DUDBC
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X MD DUDBC X X
227
3.8 Monitoring and Evaluation
1. Introduction M&E to measure success, failure, or deviation at different phases of programme implementation is an integral part of any programme or plan. The success or failure of any programme largely depends upon the M&E function. The following must be in place for an effective M&E mechanism: reliable data collection mechanisms, including strong data QA and validation mechanisms; adequate capacity of the M&E system, including sufficient organisational arrangements; adequate resources (human, financial, and physical); good information architecture; and linkages and networking. At present, the MoHP relies on sources such as the HMIS, NDHS, Living Standard Measurement Survey, STS, HHS, and other similar studies. Responding to Output 8, Develop and Implement an Integrated and Comprehensive Health Information System for the Health Sector, of the NHSP-2 IP, MoHP endorsed a Health Sector Information System (HSIS) Strategy. HSIS was thus initiated as a pilot in three selected districts of Nepal in 2009. Two separate information systems are still being used. The existence of two parallel recording and reporting systems is creating confusion among the stakeholders and still remains inconclusive. Data quality is a major concern in routine information systems. Linkage between the different information systems remains a challenge. These include the following: HMIS, Logistics Management Information System (LMIS), HuRIS, Financial Management Information System (FMIS), Ayurveda Information System (AIS), Drug Information Network (DIN), Health Infrastructure Information System (HIIS) and the private sector. 2. Goal To improve the health sector M&E system. 3. Objectives To strengthen the health sector M&E system and mechanism for effective M&E of NHSP-2. To support evidence-based planning and decision making processes To develop policy and legal frameworks (acts, policy, and guidelines etc.) by the end of July 2013 To revise and develop standard health information recording and reporting tools by the end of 2013 To establish functional linkages between different information systems and databases by developing uniform standard codes by the end of 2015 To develop an effective data QA and validation mechanism by the end of 2013 To monitor the goals, objectives, outcomes, and outputs of NHSP-2 at each level To align non-routine information collection mechanisms with the M&E framework of NHSP-2 To develop institutional capacity at the central, regional, and district levels To share information with health sector stakeholders. 4. Major Strategies Develop policy, legal frameworks, and guidelines covering recording, reporting, data management, analysis, and use issues for effective implementation Strengthen institutional capacity at all levels Have a data QA mechanism in place Facilitate the development of a programme-specific M&E plan, framework, and guidelines at the regional level Establish an effective and evidence-based review mechanism linked with planning and management
228
Develop linkages between the different data sources and levels Ensure that timely, complete, and updated data/information are available from all data sources Strengthen the information infrastructure down to the HFs Conduct an analysis and review from the GESI perspective Develop linkages between supervision data and findings with the decision making process and HR capacity development.
5. Indicators and Targets Indicator % of timely and complete data on annually reportable M&E framework indicators reported before the end of December of the following year % of health information systems using uniform standard codes % of tertiary and secondary hospitals (both public and private) implementing International Classification of Disease (ICD) 10 and reporting coded information to the health information system % of HFs (public and private) reporting to the national health information system (by type or level) No. of M&E policy and legal frameworks (act, policy, guidelines etc.) developed No. of standard recording and reporting tools developed by revising existing tools
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
100
100
100
100
Develop
100
100
100
65
75
100
100
80
100
100
Centre No. of data quality assessments performed Region District No. of HHSs conducted No. of STSs conducted No. of mid-term reviews performed No. of NDHSs conducted
1 5 75 1 1 -
1 5 75 1 1 -
1 5 75 1 1 -
1 5 75 1 1
229
6. Major Challenges and Issues At present, the following major challenges exist in the area of health sector M&E: Lack of policy and guidelines Weak institutional capacity Weak data QA and assurance mechanisms Fragmented M&E plan and approaches, lack of a comprehensive M&E plan Limited data analysis and use practice Lack of clarity on roles, responsibilities, and organisational arrangements Lack of appropriate organisational arrangements and clarity on institutional homes No formal linkages between different data sources Lack of an information infrastructure plan Inadequate resources for M&E.
230
Accountable Officer: Chief, PHAM&ED, MoHP9 Major Strategies Major Activities Responsibility Strengthen M&E plan of the National Health Strategy/MNCH Development of a comprehensive health sector M&E policy, plan, and guidelines Regular meetings (one per month) Routine Data Quality Assessment (RDQA) tools and guideline development RDQA by MoHP and RHD Develop an annual calendar for production and sharing of reports (calendar preparation workshop with concerned stakeholders) Production and sharing of the
9
Supporting Agencies
2011/2012
2012/13
2013/14
2014/15
2015/16
PHAM&ED/MoHP X
PHAM&ED/MoHP HMIS
PHAM&ED/MoHP PHAM&ED/MoHP
HMIS X HMIS X X
PHAM&ED/MoHP
HMIS
This M&E plan does not cover programme specific monitoring and evaluation, such as M&E of HIV/AIDS, Malaria, TB etc.
231
Major Strategies
Major Activities reports including annual report Establish wireless networking between MoHP and the DoHS central server Internet provision for all public hospitals and D(P)HOs Revisit the organisational structure (O&M Survey) at all levels for M&E Strengthen the routine information system to provide information for results-based monitoring (covering integration, uniform code, and other routine system strengthening activities for HuRIS, LMIS, HMIS etc.)
Responsibility
Supporting Agencies
2011/2012
2012/13
2013/14
2014/15
2015/16
PHAM&ED/MoHP
HMIS X X X
PHAM&ED/MoHP
HMIS X X X
PHAM&ED/MoHP X
Strengthen monitoring of results
PHAM&ED/MoHP, Divisions, HEFU centres, DoHS, MoHP
232
Major Strategies
Major Activities Print tools Conduct the annual STS Complete the Health Facility Mapping Survey (HFMS) through use of the Geographical Information System (GIS) Update HFMS database Conduct NDHS, HHS, STS HR recruitment and deployment (M&E, Management Information System (MIS) etc.) Training on statistical analysis (basic, seven days, one batch per year, 15 persons) M&E training (70 persons, eight days) Training on statistical analysis
Responsibility
Supporting Agencies
2011/2012
2012/13
2013/14
2014/15
2015/16
PHAM&ED/MoHP, HEFU PHAM&ED/MoHP PPICD, NHSSP HMIS NHSSP
X X
X X
X X
HMIS
NHSSP USAID, NHSSP
X X
X X
X X
PHAM&ED/MoHP
Partners X X X
HMIS X X X
HMIS HMIS
X X
X X
X X
233
Major Strategies
Major Activities
Responsibility
Supporting Agencies
2011/2012
2012/13
2013/14
2014/15
2015/16
(advanced, 10 days, one batch per year, 10 persons) Develop reporting HMIS tools and guidelines for the private sector Training/orientation HMIS Strengthen institutional capacity Develop an ICD 10 training group and institutionalise within NHTC Develop the institutional capacity of NHTC to conduct data management, analysis and report writing training Develop the Health Policy Establish a national health data repository at MoHP (including necessary hardware) Assess and prepare system design and plan for electronic PHAM&ED/MoHP
NHSSP X X HMIS X X X X X
HMIS
NHTC
Develop a digital health strategy
PPICD PHAM&ED/MoHP HMIS, Population Division/MoHP
HMIS
Partners X X
234
Major Strategies
Major Activities health recording systems for public health centres Strengthen ICD 10 at primary-, secondary-, and tertiary-level public and private hospitals Support for strengthening vital registration system (piloting FCHV mobilisation in 10 districts) Strengthen the MPDR system
Responsibility
Supporting Agencies
2011/2012
2012/13
2013/14
2014/15
2015/16
HMIS X X X
Strengthen registration
Population Division/MoHP
MoLD, Partners X X X
Institute Maternal and Perinatal Death Reviews (MPDRs) and QoC assessments Resource tracking through National Health Account (NHA) and institute subaccounts for MNCH Carry out reviews and action
FHD
Partners X X X
Institutionalise and strengthen NHA, sub-accounts and Public Expenditure Review (PER)
HEFU
CBS
Strengthen national-, regional-,
MD
RHD, DPHO
235
Major Strategies
Major Activities and district-level reviews Regional level (two times a year, three days) District level (two times a year, four days) Independent evaluation of the major health programmes Data analysis and use of information from the GESI perspective at district and community levels Social analysis and action at HFs to improve service delivery for socially excluded groups Regular supervision and monitoring of major health programmes at all levels
Responsibility
Supporting Agencies
2011/2012
2012/13
2013/14
2014/15
2015/16
MD
RHD, DPHO
MD
RHD, DPHO X X X
PHAM&ED/MoHP
Partners X X X
Population Division/MoHP, PHAM&ED/MoHP
HMIS X X X
PHAM&ED/MoHP, HMIS Population Division/MoHP
MD
Divisions and centres X X X
236
Major Strategies
Major Activities Analysis and review of the activities in line with the NHSP-2 M&E framework output and outcome (desk review) High-level advocacy and monitoring with parliamentarians, policy makers and decision makers
Responsibility PHAM&ED/MoHP
Supporting Agencies Population Division, HMIS and partners
2011/2012
2012/13
2013/14
2014/15
2015/16
Advocacy and outreach
PHAM&ED/MoHP X X X
237
3.9 Sector-wide Approach and Health Sector Reform
1. Introduction The Paris Declaration on Aid Effectiveness 2005 and the Accra Agenda for Action 2008 shared the following major objectives: to focus all external assistance on common objectives, and to deliver the assistance through harmonised approaches aligned with those of government. Increased use of government systems is not an end in itself, but is intended to be a route towards improving aid effectiveness, improving coordination and reducing costs by gradually replacing the multiplicity of EDP systems for planning, budgeting, implementing, reporting, and accounting for aid with a single set of procedures that all partners use. Achieving the potential benefits of increased harmonisation and alignment depends on ensuring that the common procedures are efficient and effective, and are seen to be so. During NHSP-1, considerable progress was made in improving the effectiveness of GoN procedures in the health sector: Since 2004 MoHP has moved towards a SWAp Budget implementation has steadily improved, with an increased focus on overcoming bottlenecks through approaches including more realistic budgets, earlier fund release, and more delegation. The improvement has been reflected in a higher volume of services being delivered, made possible partly by improved availability of essential supplies and operating budgets Lessons learned and best practices of the SWAp will be capitalised upon and used in the continuing implementation of the SWAp Since 2004-5, the separate district-level projects for FP/MCH, Control of Diarrhoeal Disease (CDD) and ARI, nutrition, EPI, construction, and supervision have been merged into a single integrated District Development Programme. Before the merger of the projects and the integration of supervision and reporting, each of the 75 districts had to maintain separate accounts on each project; a total of 13,500 reports were required each year. The merger of programme and budget heads has saved time and resources. Efforts are on-going to further reduce the number of budget headings, and hence the transaction costs. The integration has been deeper than a simple change in reporting: merging CDD and ARI into IMCI has resulted in a successful, cost-effective, and integrated approach to child health care. Development partners have begun to respond by working in alignment with GoN procedures. In 2004, GoN and EDPs in the health sector signed a joint statement of intent on health, envisaging joint planning, joint programming and joint performance reviews. Since that time, nine joint reviews have been held, two each year. One in December is mainly backward-looking, reviewing performance during the previous year, but it also aims to inform the coming budget and annual plan preparation by providing indications of future funding for the coming budget year. A second review, normally in May, focuses more on discussion of the AWPB for the coming year. Currently, aid flow in Nepal is done in three ways: Pooling of funds for sector budget support by five agencies Non-pooling but specific programme support Project approach by some agencies (the Japan International Cooperation Agency (JICA), the Swiss Development Cooperation (SDC), and the Korean International Cooperation Agency (KOICA)).
238
2. Goal To enhance aid effectiveness in the health sector. 3. Objectives Fostering coordination between EDPs and MoHP Reducing transaction costs Developing mutual accountability between MoHP and EDPs. 4. Major Strategies More balanced partnerships Reducing transaction costs Fostering coordination, especially with INGOs Improving aid predictability Reducing the number of budget headings. 5. Indicators and Targets Indicator 2010/11 No. of budget headings reduced 5
2011/12 -
2012/13 -
2013/14 5
2014/15 -
2015/16 -
6. Major Challenges and Issues Reducing transaction costs Aligning EDPs planning cycles MoHP providing strong direction Coordination of technical assistance Strengthening SWAp management capacity.
239
Accountable Officer: Chief, HSRU, MoHP Major Major Activities Strategies Reducing transaction costs Assess the feasibility of merging the budget headings Coordinate with MoF and NPC and reduce budget headings Develop/adapt a framework for mutual accountability Submit EDPs performance assessments Provide the AWPB to EDPs a week before the joint planning meeting Merge the two joint reviews (GoN and EDPs) Submit background reports for the joint review Organise consultative meetings with EDPs Prepare a budgetary plan with medium-term indications of EDP support (for two/three years) Monitor indications of support Provide financing assumptions to EDPs based on adjusting the budget
Responsibility HSRU
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
X HSRU EDPs X HSRU EDPs X X X HSRU HSRU EDPs EDPs X X HSRU EDPs X X X X X X X X X X X X X X X X X X X X X X
Promoting mutual accountability
Harmonisation
Promoting predictability of EDP support
X HSRU EDPs X
X X
X X
X X
X X
X X
240
Major Strategies
Major Activities year indications Increase the frequency of communication between MoHP and EDPs Prepare a joint TA arrangement Study the feasibility of pooling TA Organise a Joint Annual Review (JAR) Organise a joint annual planning meeting Organise consultative meetings
Responsibility
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
HSRU
X HSRU HSRU HSRU HSRU HSRU EDPs EDPs EDPs EDPs EDPs X X X
X X X
Coordinating TA
X X X
X X X
X X X
X X X
X X X
241
Annex 1: Result Matrix for NHSP 2 (2010-2015)

MDG/Impact Indicator MMR (per 100,000 live births) TFR Adolescent Fertility Rate (15-19 years) (per 1,000 women) CPR (modern methods) (%) Under-five Mortality Rate (per 1,000 live births) Infant Mortality Rate (per 1,000 live births) Neonatal Mortality Rate (per 1,000 live births) % of underweight children
10 11
Achievement 1991 1996 2001 2006 2009

10
Baseline / Year 250
Target 2010-11 2013 2015
Means of Verification DHS 2011 and 12 2016 DHS 2011 and 2016 DHS 2011 and 2016
Remarks/Assumptions/Risks Needs innovative programmes and resources at the community level, and high-quality services available to remote, underprivileged, and underserved populations Assumes a continuous linear decline
539
539
415
281
229
11
250
192
134
5.3 NA
4.6 127
4.1 110
3.1 98
2.9
13
3.0 98
3.0 NA
2.75 85
2.5 70
NA
24
26.0
35
44
45.1
14
48
48
52
67
DHS 2011 and 2016
Assumes a continuous linear decline; data source for verification DHS 2011 and 2016. Year-round availability of FP commodities at service delivery sites. GoN budgets adequate each year to procure FP commodities Assumes a continuous exponential decline; data source for verification DHS 2011 and 2016 Assumes a continuous exponential decline; data source for verification DHS 2011 and 2016 More than half of infant deaths are neonatal so this is a focus of the programme Weight-for-age < 2 standard deviations from mean
158 106
118.3 78.5 49.9 49.2
91 64 43 48.3
61 48 33 38.6
50 41 20 39.7
15
55 44 30 34
55 44 30 34
47 38 23 32
38 32 16 29
DHS 2011 and 2016 DHS 2011 and 2016 DHS 2011 and 2016 DHS 2011 and 2016
16
17
18
Achievements for 2009 should not be construed as trends. The sources are not necessarily nationally representative and the estimates may not be significantly different from 2006 estimates. Estimate from Suvedi, Bal Krishna, et al. Maternal Mortality and Morbidity Study 2008/2009: Summary of Preliminary Findings. Kathmandu, Nepal. Family Health Division, Department of Health Services, Ministry of Health and Population, Government of Nepal. 12 NDHS scheduled for 2016 but requested to be conducted early so report is available 2015. 13 Estimate from Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal: A Mid-term Survey for NFHP 2, New ERA, September 30, 2009. 14 Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal 15 Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal 16 Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal 17 Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal 18 Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal
242
MDG/Impact Indicator HIV prevalence among those aged 15-49 19 years (%) TB case detection and success rates (%) Malaria annual parasite incidence (per 1,000)
Achievement 1991 1996 2001 2006 2009

10
Baseline / Year
20
Target 2010-11 2013 2015
Means of Verification
Remarks/Assumptions/Risks HIV prevalence is currently (2009) concentrated among PWID (20.7%), MSM (3.8%), FSWs in Kathmandu (KTM) (2.2%); migrant workers in Western region (1.4%), migrants in Far Western region (0.8%), and wives of migrants (3.3%) MDG 6 target: Prevalence and death rates associated with TB. TB success rate was 88% in 2009. It should be at least maintained through 2015 MDG 6 target: Prevalence and death rates associated with malaria
NA
NA
NA
NA
NA
0.49
Halt and reverse trend (0.39 in 2010-11 and 0.30 in 2015) 75 89 80 90 85 90
To be determined
NA
48 79 0.54
70 89 0.40
65 89 0.28
71 22 88 NA
21
75 89
HMIS
NA
Halt and reverse trend
HMIS
Specific Objective 1: Increase access to and utilisation of quality EHCS Outcome Indicator Baseline/Year 2010-11 85%
23
Target 2013 85%
Means of Verification 2015 85% HMIS and NDHS in 2011 and 2016
Remarks/Assumptions/Risks
% of children under 12 months of age immunised against DPT 3 (PENTA) and measles (or fully immunised as per HMIS scale up) disaggregated by all wealth quintiles and castes/ethnicities CPR (modern methods disaggregated by method, age, caste/ethnicity, wealth and region) (%) % of women who took iron tablets or syrup during the pregnancy of their last birth % of deliveries performed by SBAs disaggregated by all wealth quintiles and castes/ethnicities % of institutional deliveries disaggregated by all wealth quintiles and castes/ethnicities
83 fully immunised (2006) 89 (rural districts, 2009) 44 (2006) 45.1 (rural districts, 2009) 59.3 (2006) 81.3 (rural districts, 2009) 18.7 (2006) 25 (2008/9) 28.8 (NFHP 2009 survey) 18 (2006)
% of fully immunised children should be above herd immunity regardless of wealth, caste, or ethnicity 55.5% for women 15-49 living with husbands; 22.5% if husbands away (2009) rural
45% 82%
52% 86% 40%
55% HMIS and NDHS in 2011 and 2016 90% NDHS in 2011 and 2016 60% HMIS and NDHS in 2011 and 2016 40% NDHS in 2011 and 2016
Interventions targeted to poorest and excluded are necessary to reduce disparities Wide disparities persist for ANC between wealth quintiles and castes/ethnicities
27%
35%
19 20 21
The Ministry recognises the MDG 6 target of halting and reversing the trend of HIV prevalence among pregnant women aged 15-24 years. However, a data source is not yet available. NCASC 2010 and UNAIDS April 2010 database. 2008 22 2008 23 All targets are national but evidence from 2009 survey of 40 rural districts is not.
243
% of EOC need met % of CS rate Obstetric case fatality rate (%) % knowledge of safe abortion sites % knowledge of safe abortion legalisation Abortion complications (%) % of women 15-49 with comprehensive knowledge about AIDS % of children with symptoms of ARI treated with antibiotics % of underweight children under five years of age
31 (2008/09) 2.7 (2006) 3.6 (2008/09) 19 (2006) 50 (2006) 14 (2009) 19.9 (2006) 25.1 (2006) 29.2 (rural districts, 2009) 38.6 (2006) 39.7 (2009) 33 (2006) 30.6 (2006) aged four/five months 24.8 (rural districts, 2009) 27.7 (2006) 35.2 (2008) 90 (2009) 67.6 ORS + zinc (2007/08) 45.6 ORS 6.6% zinc (rural districts, 2009 Programme coverage: FSWs (KTM): 40.8 (IBBS 2008) MSM (KTM): 75.3 (IBBS 2009) MSWs (KTM): 77.3 (IBBS 2009) PWID (KTM): 56.9 (IBBS 2009) 14% 24% 30% 39% 4.0% <1%
43% 4.3% <1% 35% 60% 10% 32% 40% 34%
49% HMIS and NDHS in 2011 and 2016 4.5% HMIS
HMIS HMIS 2008/09 report from 26 districts
<1% HMIS 50% Annual household 97,378 women received safe abortions in surveys 2007/08 at 202 listed sites 75% Annual household surveys 7% 40% NDHS 2011 and 2016 50% NDHS 2011 and 2016 29% NDHS 2011 and 2016 45.5% stunted (height-for-age < 2 standard deviations from mean); will also be reported by NDHS 25% NDHS 2011 and 2016 60% NDHS 2011 and 2016
% of low birth weight (or small) babies % of children exclusively breastfed in the first six months
32% 35%
27% 48%
% of pregnant women completing at least four ANC visits during pregnancy % vitamin A coverage maintained for children aged 6-59 months % of diarrhoea cases among children under five treated with zinc (and ORS)
45% 90% 7%
65% 90% 25%
80% HMIS and NDHS 2011 and 2016 90% HMIS Consistently almost universal 40% NDHS 2011 and 2016 Combined reporting in HMIS (2007/08). NDHS reports treatment with ORS and zinc separately PWID: 80 UNAIDS-supported MSM: 60 surveys FSWs: 70 HIV Prevalence: PWID (KTM) 20.7% (IBBS 2009) MSM (KTM) 3.8% (IBBS 2009) MSWs (KTM) 5.2% (IBBS 2009) FSWs (KTM) 2.2% (IBBS 2008) Migrants, Western region 1.4% (IBBS 2008) Migrants, Far Western region 0.8% (IBBS 2008) Wives of migrants, Far Western region 3.3%
% coverage of PWID, MSM, and FSW populations with prevention services
PWID: 76 MSM: 54 FSW: 65
244
Migrants, West/Far West: 6.9 (IBBS 2008)
(IBBS 2008)
% of households with soap and water at a hand washing station inside or within 10 paces of latrines
N/A
13%
37%
53% MICS, NDHS 2011 and 2016
This indicator is now accepted globally as the most feasible proxy indicator to measure hand washing practices by observation
Specific Objective 2: Reduce harmful cultural practices and cultural and economic barriers to accessing health care services in partnership with non-state actors Outcome Indicators CPR (modern methods) for the poor (lowest and second wealth quintiles) and excluded castes (%) Baseline/Year 2010/11 Poor: 43 Dalit: 52 Janajati: 55 Muslim: 25 Poor: 77 Dalit: 82 Target 2013 Poor: 46 Dalit: 55 Janajati: 58 Muslim: 28 Poor: 81 Dalit: 85 Means of Verification Remarks/Assumptions/Risks 2015 Poor: 49 Dalit: 58 Janajati: 61 Muslim: 31 Poor: 85 Dalit: 88 NDHS in 2011 and 2016 and HMIS for poor
Poor: 35.5 Dalit: 44 Janajati: 47 Muslim: 17 (2006) % of women who took iron tablets or syrup Poor: 44.9 (2006); 76.7 during the pregnancy of their last birth for (rural districts 2009) women who are poor (lowest and second- Hill Dalit: 78 lowest wealth quintiles) and excluded caste Tarai Dalit: 90 (Dalit) (rural districts 2009) % of deliveries by SBAs for lowest and Poor: 7.5 second-lowest wealth quintiles and Dalit: 11 excluded caste (Dalits), by 2015 Janajati: 14 Muslim: 13 Other Tarai Madheshi: 13 (2006)
NDHS in 2011 and 2016 and HMIS for poor
Poor:30 Dalit: 32 Janajati: 35 Muslim: 34 Other Tarai Madheshi: 34
NDHS in 2011 and 2016 and HMIS for poor
245
Specific Objective 2: Reduce harmful cultural practices and cultural and economic barriers to accessing health care services in partnership with non-state actors Outcome Indicators % utilisation of EHCS (OP, inpatient, especially deliveries, and emergency) by targeted groups, and disadvantaged castes and ethnicities at least proportionate to their populations, by 2015 Baseline/Year Poor: 62 (2006); 57 (rural districts 2009) Dalit: 14% (OP), 17.1 (inpatient) and 16.7 (emergency) (2008); 16.7 (of population in sample districts) 2010/11 90 Target 2013 90 Means of Verification Remarks/Assumptions/Risks 2015 90 HMIS 90% of highest quintile or 90% of population proportion. Targeted groups: based on children under five for whom treatment was sought for fever. Dalits: selected MCH services at district HFs. District HF surveys report Dalits using services proportionate to their population
% of clients satisfied with their health care at district facilities among targeted groups, and disadvantaged castes and ethnicities by 2015 % use of available community-based emergency funds by the poor and socially excluded groups (in districts with EAP) No. of cases recorded and treated related to GBV in HFs
68.4 (2008) based on availability of range of services 19
68
74
80 Annual district HF surveys
30
50
Annual HF surveys
Treatment provided but no recording available
Systems and training materials developed and piloted in three districts
Pilot evaluated and system rolled out in 20 districts
Scaled up intervention nationwide
Annual district HF surveys
246
Specific Objective 3: To improve health systems to achieve universal coverage of essential health care services Outcome Indicators Baseline/Year 2010/11 NA NA Target 2013 60 60 Means of Verification 2015 80 HMIS 80 HMIS, HuRIS and programme surveys 70 HMIS and programme surveys HMIS annual report 2007/08 Remarks/Assumptions/Risks
% availability of post-abortion FP services in HFs % of hospitals that have at least two obstetricians/gynaecologists, two anaesthesiologists, 10 staff nurses and blood service, including VSC % of PHCCs that provide BEOC, including SAC and at least five FP methods
50 (2006)
1 BEOC site; 46 under construction; 15 planned next year (2007/08)
23
50
% of health posts that operate 24/7, including delivery services, and provide at least 5 FP methods % availability at district facilities of zinc supplementation for treatment of diarrhoea cases % of households with at least one LLIN per two residents in all high-risk districts and areas by 2015
45
60
70
HMIS HMIS
% of children under five who slept under LLIN the previous night
95 (in 13 high-risk districts, to be extended to areas in additional 18 districts) 61.2 (in 13 high-risk districts)
90
90
Programme surveys
Programme is expanding to new high-risk areas in 18 new districts. Nets effective for two years. The target for 2015 set by MoHP is 90%, which is the same as for one net per two residents in HHs. 80% is more realistic for use by children under five Reported by e-AWPB
70
80
80
Programme surveys
% of the MoHP budget is spent by 2015
% of the MoHP budget has been allocated to EHCS by 2015 % of posts for doctors and staff nurses at PHCCs and district hospitals filled One health facility per 3,000-5,000 population: one HP (with two SBAs) per 5,000 population; PHCC (with four SBAs) per 50,000 population; and one district hospital bed per 5,000 population
70.16 (FY 2004/5), 75.74 (FY 2005/6), 80.61 (FY 2006/7), and 81.37 (FY 2007/08) 72.1 (FY 2008/09), 75.4 (FY 2009/10) 89 (HPs and SHPs), 82 (DHs and PHCCs) (2008-09)
83
84.5
86
e-AWPB
75 85
75 88
75 90
e-AWPB Annual district HF surveys
EHCS budget should be maintained at 75% Reported by latest trimester district HF survey
NA
Nation- HMIS, administrative New policy wide record
247
% of SHPs that have sufficient space as per MoHP standard (need baseline) % of DFs which will have no stock-outs of tracer drugs/commodities for more than one month per year by 2015 No. of additional FCHVs recruited and deployed in the mountain region and remote districts % of actions identified in the GAAP implemented % of district facilities subjected to social audits A comprehensive health care finance strategy will be approved by 2012 5,000 SBAs by 2012 and 7,000 by 2015
80 70 48,514 (2007/08) 50,000 90 None to date 0 80 52,000 90 15 90 53,514 90 25
To be determined Annual district HF surveys HMIS and HuRIS Delayed budget approval caused massive stock-outs at district facilities in 2009 5,000 additional FCHVs by 2015 plus 2,000 replaced (attrition)
1,134
5,000
7,000
Annual district HF surveys MoHP and MoF approval HMIS and HuRIS
248
Annex 2: Proposed Budget for NHSP-2 (2010-2015) - NPR IN 100,000
Chapter 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 3.1-3.5 3.6 3.7 3.8 3.9
Programme Immunisation IMCI+ CBNCP Nutrition SM FP ASRH FCHV Free Care Urban Health Malaria Control Kala-azar Control LF Control Dengue Control Leprosy Control Laboratory Services HIV & STI Control TB Control NCDs Mental Health Oral Health Curative Services Ayurveda and Alternative Medicine NHEICC Environmental Health System Strengtheningand Procurement Supply Facilities Physical and Maintenance M&E and Research SWAp & HSR Beyond EHCS Total
2010/11
2011/12
2012/13
2013/14
2014/15
Total 70562 14105 33284 113183 26509 21669 69319 6618 8541 1963 16222 1876 5908 33463 54568 74810 503 31274 12012 262339 284170 10201 82231 203426 1433300
15896 15640 11821 12842 14363 1400 1520 3388 3681 4117 1400 1541 9191 9985 11167 18045 20133 22719 24682 27604 4400 4734 5263 5718 6395 Included in Chapters 2.4 and 2.5 (above) 3700 4011 4228 4593 5137 12832 12753 13963 14004 15767 1453 1695 335 1529 1606 1600 1741 1575 1711 1914 500 529 283 307 344 2000 2135 3661 3977 4448 Included in Chapters 2.10, 2.11 and 2.12 (above) 282 294 325 375 600 450 915 1526 1755 1262 2930 6600 6892 7926 9115 6917 10720 11186 12153 13592 14426 13744 15591 15256 15793 Included in Chapter 2.18 (above) 85 93 98 108 119 Included in Chapter 2.18 (above) 5020 5290 6529 6944 7491 1401 1763 2623 2937 3288 Included in Chapter 2.23 (above) 41528 46720 55237 57986 60868 58587 47397 50869 57835 69482 1960 1641 1903 2186 2511 13065 15306 15556 17833 20471 Included in Chapters 2.1 3.5 and 3.8 (above) 3118 18185 32919 61201 88003 208300 235100 277300 327000 385600
Note 1: Health System Strengthening includes the following chapters: Health Governance, Human Resources for Health, GESI, Health Financing and State/Non-state Partnerships. Note 2: Beyond ECHS incorporates whatever is not reflected in the budget.
249

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Nepal Health Sector Programme-2 IMPLEMENTATION PLAN

Government of Nepal Ministry of Health and Population (MoHP)

PART ONE: INTRODUCTION

Piloting and scaling up Piloting and scaling up Scaling up Maintaining

Programme 3. Communicable Disease Control

5. Oral Health 6. Eye Care

Status Scaling up Elimination Maintaining Maintaining

Piloting and scaling up Scaling up

7. Rehabilitation of the Disabled

7.1 Promotive and preventive 7.2 Rehabilitation, surgery and therapy

Piloting and scaling up

8. Environmental Health 9. Curative Care

Piloting and scaling up Increasing access and use

Partnerships with local governments, NGOs and medical colleges

* Including Gender-based Violence (GBV) Services Source: NHSP-2, MoHP, 2010.

PART TWO: PROGRAMMES (ESSENTIAL HEALTH CARE SERVICES)

2.1 Immunisation Programme

90 % in 30 districts 90% in 20 districts

90 % in 50 districts 90% in 30 districts

90 % in 60 districts 90% in 50 districts

90 % in 75 districts 90% in 65 districts

90 % in 75 districts 90% in 75 districts

Reach unreached groups Enhance HR capacity

Responsibility Supporting Agencies EPI section WHO, UNICEF

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Major Strategies Strengthen the vaccine management system

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

LMD EPI section LMD

Strengthen the cold chain system at all levels

CHD, UNICEF WHO UNICEF, WHO

Major Strategies outbreaks of polio

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Conduct cross border activities during Supplementary Immunisation Activities (SIAs)

Achieve and maintain certificate standard surveillance

X National Public Health Laboratory (NPHL) EPI section WHO

Develop and implement posteradication strategies for polio

EPI section EPI section EPI section

Achieve and sustain the immunity level for measles

Responsibility Supporting Agencies EPI section UNICEF, WHO

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

X EPI section EPI section UNICEF, WHO EDCD, UNICEF, WHO

EPI section EPI section

UNICEF, WHO UNICEF, WHO

EPI section EPI section EPI section EPI section

UNICEF, WHO UNICEF, WHO UNICEF, WHO NPHL

Responsibility Supporting Agencies EPI section UNICEF, WHO

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

5 EPI section UNICEF, WHO 2

2.2 Integrated Management of Childhood Illness and Newborn Care Programme

Responsibility IMCI section

Curative Division Adapt Training Package

Responsibility IMCI section

Supporting Agencies Health Management Information System (HMIS)

IMCI section IMCI section

IMCI section IMCI section

Responsibility IMCI section

Inclusion of CBIMCI in the curriculum of pre-service medical and paramedical schools

CHD, WHO, UNICEF

CHD, WHO, UNICEF X X

Responsibility IMCI section