CHAPTER III

HOSPITAL PROFILE
3.1 AMPPIPAL HOSPITAL
3.1.1 Introduction
The hospital in Amppipal was founded in 2015BS by the United Mission to Nepal (UMN). It
replaced a pharmacy, which served for 12 years as the only medical place in the entire area.
In 2058 BS United Mission suddenly stopped operating the hospital in Amppipal.Since 2058
BS Amppipal is a governmental hospital.In April 1997, the Amppipal Hospital started with
the “DOTS”-treatment of tuberculosis (Directly Observed Treatment, Short course), being
the first hospital in Nepal.

Since the end of 2013, Patan Academy of Health Sciences (PAHS) cooperates with
Amppipal. PAHS sends medical students and young doctors for training. Amppipal Hospital
is now a teaching hospital. Since 2012 various specialists from all over the world visit
hospital to give training sessions.

The Amppipal Hospital is currently the only medical facility with a continuing surgical
treatment in the district. The majority of the patients comes from the districts of Gorkha,
Lamjung and Tanahun and sometimes even from Chitwan. Patients endure walking times
between 1/2 and more than 12 hours. Some have to walk for more than 3 days.

A local committee steers the governmental Amppipal Hospital. The district government plans
14 beds for Amppipal which is upgraded to 46 beds due to the high demand. In Gorkha
district there are only two hospitals for 3,50,000 inhabitants: Amppipal and Gorkha which
increases the patient load in the hospital.

The hospital covers an area of 39 ropani of land in Amppipal, Palungtar -3. It has one OPD
block, one ward and an OT block, an administration block and 7 guest houses and quarters
for the staffs and the guests. There are two transport cars, an ambulance and its own bus
service for the patients visiting the hospital.

3.1.2 Objectives of the hospital

• To provide local level health service facility from experts
• To provide Emergency, Surgical and Medical Services at affordable cost at the local level
• To promote the health and well-being of underprivileged and marginalized people by
providing them charity in health service
• To develop a center for international training
• To collaborate with different national and international organizations and organize various
health programs.

3.1.3 Goals
• To improve the health care delivery system using modern equipments.
• To coordinate with other governmental and private medical institutions for improving heath
delivery system and health education.
• To develop a sustainable way of running a community-based hospital in rural areas
3.1.4 Policy
Amppipal Hospital adopts a non-profit policy depending on internal sources for
sustainability. A management supporting committee formed by members from Hospital
Administration, head of the departments of the hospital, local authorities and their leaders,
representatives of Municipality and other concerned agencies has been formed. The executive
director implements the decisions and suggestions made by the committee and these
decisions are chiefly aimed at sustaining the good quality of care while keeping the services
accessible and affordable to all.

3.1.5 Hospital Management

The Hospital is run by a Hospital Development Committee (HDC) under which is the Internal
Management Committee (IMC). The IMC holds regular meeting about the needs and work
progress of each department which is then presented to the HDC for further discussions and
confirmation.
The IMC consists of
i) Hospital Administrative Officer
ii) Asst. Hospital Administrative Officer
iii) Head of Departments
iv) Concerned Staffs from all departments
The HDC is an 11 member committee compromising of
i) Mayor- Chairperson
ii) Ward Chairperson- 5
iii) Elected from civil society – 4 (at least one woman)
iv) Medical Superintendent – 1

3.1.6 Financial management

3.1.6.1 Income sources

The hospital receives its income mainly from the following sources:
1) Patient income
a) Inpatient income
b) Outpatient income
c) Health Insurance Claim Payment
d) Charity
2) External income
a) Nepalmed Nepal
b) Nepalmed Germany
c) UMN Endowment fund Interest
d) Government Donation
e) Municipality Donation
3) Others:
a) Quarter
b) Canteen
c) Vehicle
d) Student Fees
e) Auctions
3.1.6.2 Expenditure
• Salary
• Patient and patient related cares
• Capital Investment
• Quarter and Hospital constructions and renovation
• Training and Human Resource Development
• Staff Health Insurance
• Travel and Transportation
• Electricity/ Fuel/ Telephone/ Internet
• Administrative Expenses

Table 3.1 Total Income and Expenditure of Amppipal Hospital

Fiscal year 2072/73 2073/74 2074/75

Total income (NRs.) 25, 701,767.55 22,727,977.92 23,781,304.67

Total expenditure 24,876,318.70 22,381,767.20 25,083,956.01

Net surplus/deficit +825,448.85 +346,210.70 -1,302,651.34

Source:
3.1.6.3 Budgeting
Meeting is organized with all department in-charge and internal management committee
and planning is done. The budget is then forwarded to Local Management Committee for
finalization. Internal Management Committee then works on the allocated budget.

3.1.6.4. Auditing
The auditing of the hospital's financial statements and accounts is done annually by an
auditor appointed by the IMC.

3.1.7 Human resource management

3.1.7.1 Staffing pattern of Amppipal Hospital

Table 3.2 Staffing Pattern of Amppipal Hospital

SN DESIGNATION CATEGORY QUANTITY

1 Consultant Doctor 1

2 Medical Officer 1

3 Nurse 3

4 A.N.M 8

5 Paramedics 10
 6 Administration 8

7 Supporting Staffs 12

Total staffs 43

Source:

3.1.7.2 Recruitment
For vacancies, the recruitment is done by the IMC of the hospital itself. A vacancy is
announced in a local newspaper and applicants have to appear for the written
examination. The selected candidates then have to pass the interview. The requirement
process takes about 1 month.
In case of the Nepal Government employees, the employees are sent by the Ministry of
Health, Government of Nepal.

3.1.7.3 Retirement
• There is no system of pension but Donation Fund and Provident Fund is awarded,
only to the permanent staffs.
• Donation Fund= As decided by the IMC after minimum of 5 years of service
• Provident Fund=10 % of salary and 10% by the hospital.

3.1.8 Operation of the hospital

• Working days:Sunday to Friday
• Working hours:
Sunday to Friday – 9:00 AM to 4:00 PM
Saturday - Leave
3.1.9 Organogram
3.1.10 Information record management

3.10.1 Recording and Reporting

The individual department of hospital maintains a register book for data entry which is
submitted to medical record attendant monthly. The records of maternity ward and children
ward are also maintained in the record book maintained by the respective departments. All
the records of other programs running in the hospital are kept by medical record attendant.
The collected data after analysis are recorded by medical record supervisor using Health
Management Information System every month.
The reporting is done using HMIS tool every month. The final report is thus presented to
DPHO.

3.1.11 Services provided by Amppipal Hospital

3.1.11.1 Curative service:

1. OPD service
a. General OPD
b. Dental OPD
c. Eye OPD
d. Physiotherapy
e. ANC
2. Indoor service:
a. Pediatric ward
b. Male ward
c. Female ward
d. Maternity ward
e. Critical ward
f. Labour room
3. Emergency service
4. Operation theatre
5. Dispensary
3.1.11.2 Diagnostic Services
1. Laboratory Services
2. Radiology
a. X-ray Service
b. USG Service
3. Electrocardiography Service

3.1.11.3 Preventive Services

1. Maternal and Child Health
a. ANC service
b. Delivery services
c. PNC services
d. Immunization
2. Family Planning Services
3.1.11.4 Supportive Services
1. Dispensary
2. Store
 3. Waste Disposal
4. Laundry and House-keeping
5. Security service
6. Electricity
7. Water Supply
8. Transportation

3.1.11.5 Curative Services

1. OPD Service:
OPD services operate for 6 days a week from Sunday to Friday from 9:00 A.M. to 4:00 P.M
and. Saturday is an official holiday except for the emergency department. The OPD Block is
located in the main hospital building. There is one in-charge for all the OPDs. Registration
fee for new cases is 100 rupees and for follow-up cases is 50 rupees. There is a separate
screening room for taking vitals. After screening, the patient is sent to respective OPD.
a. General OPD
There is one General Physician, one Medical officer and two health assistants. Normal patient
flow is from about 10 to 60 per day.
b. Dental OPD
There are two dental assistants. Dental services provided includes tooth extraction, filling,
scaling, and polishing. All other complicated cases are referred to higher centre.
c. Eye OPD
There is one ophthalmic assistant who provide services like FB removal, conjunctivitis, and
red eye management.
d. Physiotherapy:
There is one physiotherapy assistant. Physiotherapy department receives 3-5 patients per day.
Service provided by aforementioned department includes ultrasound therapy, vibrator,
electrotherapy, infrared therapy, game ball, and ice therapy.
e. ANC
One ANM is appointed for ANC services. Complicated cases are looked by doctor.

Outpatient
25000

18787 19062
20000 17580
16771 15866
15000

Outpatient
10000

5000

0
F.Y.2070-71F.Y.2071-72F.Y.2072-73F.Y.2073-74F.Y.2074-75
 Physiotherapy
2500
2031
2000 1810
1615 1587
1500 1378

1000 Physiotherapy

500

0
F.Y. 2070- F.Y. 2071- F.Y. 2072- F.Y. 2073- F.Y. 2074-
71 71 73 74 75

Dental service
900 832
800 758
722
700 638
600
489
500
400
300
200
100
0
F.Y. 2070-71 F.Y. 2071-72 F.Y. 2072-73 F.Y. 2073-74 F.Y. 2073-74

2. Indoor Service:
The admissions are done either through the emergency or the OPD. A fixed amount of money
should be deposited at the time of admission. The total no. of beds in In-patient departments
along with their staffing pattern is presented below:
S.N. Ward Beds No of staff Most commonly admitted
cases

1. Pediatric ward 6 All wards managed Bronchiolitis

by same team of Acute gastroenteritis
staff. Pneumonia
 2 PCL nurse Tonsillitis
 8 ANM Fever
3. Male ward 8  First on call: 2 Alcohol liver disease
HA Benign hypertrophy of
 Second on call: prostate
Medical officer COPD
 Third on call: Asthma
 General Lung CA
Physician
3. Female ward 6 PV bleeding
PV discharge
Fibroid
4. Critical 4 Road traffic accident
Farm yard accidents
5. Maternity 5 Abortion
Delivery
Pre-eclampsia
6. Labour room 1 All uncomplicated delivery
7. Total 30

Inpatient
1700
1640
1650
1609
1590 1580
1600
1550
1500 Inpatient
1460
1450
1400
1350
F.Y.2070-71 F.Y.2071-72 F.Y.2072-73 F.Y.2073-74 F.Y. 2074-75

3. Emergency services:
There is a new emergency in the main building with three beds, but not yet functional. Thus
emergency service is currently provided via old critical ward. Emergency services is given
from 4pm to 9 am. All the emergency cases seen during day time are regarded as OPD cases.
Emergency department admission charge is 400 rupees. Patient flow is high during summer
and low during winter. Staffs from indoor service handle all the emergency cases.
a. Equipment available:
AMBU bag, ECG leads, Defibrillator, Laryngoscope, ET tube, Ventilator, Suction apparatus,
and Radiant warmer
b. Emergency drugs:
Digoxin, Atropine sulfate, Furosemide , Adrenaline , Diazepam , Hyoscine butylbromide,
Hydrocortisone, Midazolam, Tramadol , Haloperidol , Declofenac , Ranitidine ,
Promethazine , and Dexamethasone. Additional drugs required for emergency service is
acquired from hospital storage.

4. Operation Theatre:
There was one modern well equipped OT and one minor OT in this hospital. There was no
separate emergency OT room. There were 6 staffs that include 1 OT incharge (ANM), 2
ANM and 1 helper, 1 cleaner and 1 doctor. Hospital has categorized operations based on
operation charge and complexity.
The common major operation performed are:
ORIF, LSCS, Mesh repair, CRPP, Appendectomy
The common Intermediate operation performed are:
Implant removal, I and D under ketamine, CR under ketamine, K wire removal, Necrotic
fasciitis, Circumcision
The common minor operation performed are:
I and D under LA, POP, Dressings
OT Equipment:
Laparotomy set, LSCS Set, Orthopedic set, Dilatation and curettage set, 2 OT tables, C-
ARM, Oxygen concentrator, Ventilator, Cautery, and Drill machine.

900
789 771
800
688 683
700 654
600
500
400
300
200 165
127 114 107 104
79 51 53 69
100 35
0
Surgery

Major Surgery

Intermediate

Minor Surgery

Major Surgery

Minor Surgery

Major Surgery

Minor Surgery

Major Surgery

Minor Surgery

Major Surgery

Minor Surgery
Intermediate

Intermediate

Intermediate

Intermediate
Fiscal F.Y.2070-71 F.Y.2071-72 F.Y.2072-73 F.Y.2073-74 F.Y.2074-75
Year

5. Dispensary
There are two dispensary in Ampippal hospital. One is run by hospital committee and another
one by government of Nepal. Both are situated in new OPD building.
The record of distribution and sell is maintained by the pharmacy staffs. There are a total of 4
staffs in the two dispensaries. The medicines and the equipment for sale are bought either by
purchase committee (for smaller budget items) or by opening tender (for larger budget items-
once a year).
There are 325 types of medicines which come in 928 different preparations. Out of which,
903 preparations are Allopathic and 25 are Ayurvedic. They do not offer any discount on
drugs except for the drugs provided by GON (72 drugs), which are free of cost.
Stock is made for 3 months.
3.1.11.6 Diagnostic Services
1. Laboratory services
The laboratory services are available since the establishment of hospital and the lab
department is present in the OPD block. The lab department consists of single room in which
samples from the patient are collected, laboratory procedures are carried out and reports are
issued. Routine lab services are available from 9 am to 4pm (Sunday to Friday). However the
emergency laboratory services are available 24hrs.

The laboratory provides the following services:

Hematology
1. Blood grouping and Rh
2. Cross-match and blood transfusion set
3. Phlebotomy and blood bag
4. Platelet count
5. Hematocrit
6. WBC
7. Differential count WBC
8. ESR
9. Bleeding time and clotting time
10. Malarial parasite
11. Blood urea
12. Sodium and potassium

Urine
1. Urine routine examination
2. Ketone
3. Urobilinogen
4. Pregnancy test

Immunology/Serology
1. VDRL test
2. HIV test for pregnant
3. HIV test for others
4. Hepatitis B
5. Hepatitis C

Biochemistry
1. Blood sugar
2. Blood sugar/ quick test
3. Creatinine
4. Alkaline phosphatase
5. Total bilirubin + direct
6. SGPT
7. GOT
8. CRP
9. ASO
10. RA factor
11. Uric acid
12. Serum total protein test
13. Gamma GT
 14. Cholesterol test
15. Triglyceride test
16. H. pylori test

Microbiology
1. Gram stain
2. AFB stain
3. Fungus test(KOH)
4. Widal test
5. Stool test and occult blood

Miscellaneous
1. Semen analysis
2. CSF analysis
3. Pap smear
4. Vaginal swab test(gram stain)
5. Biopsy

Instruments and Materials Available

1. Human auto-analyzer -1
2. Coulter counter-1
3. Na-K device -1
4. Waterbath-1
5. Kent centrifuge-1
6. Bilirubin meter-1
7. Microscope-4
8. Fridge-1
9. Hematocrit centrifuge-2
10. Hot air oven-1

Staffs
Total no. staffs- 3
Lab technician-2
Lab assistant-1

2. Radiology Services

Radiology Department is also being run from the establishment of the hospital and provides
X-Ray and USG Services. Routine radiology services are available from 9 am to 4pm
(Sunday to Friday). However the emergency radiology services are available 24hrs.

a. X-Ray
X-Ray room is located within the OPD building which has 4 rooms; 1 room for processing, 1
room for X-Ray, changing room, 1 room for issuing report. There are 2 staffs in x-ray
department (dark room assistant-1, radiographer-1)
The regular X-ray service is provided as per above mentioned working hours however
Emergency service is provided on call for 24 hours.

Equipment: X ray machine: 2 (10 Kw and 2 Kw)

b. USG

It has a separate room and is seen by 1 doctor and 2 assistants (typist-1 nurse-1). There are 1
USG machine and 1 computer

3. Electrocardiography Service
The ECG is done by trained personnel.

Table: Diagnostic investigations over 3 fiscal years.

Investigations 2072/2073 2073/2074 2074/2075
1. X-ray 1933 2130 1939
2. USG 878 1058 693
3. Lab services 11486 13559 14443
4. ECG - - -
Source: Annual report Amppipal Hospital

3.1.11.7 Preventive Service:

1. Maternal and Child Health:
a. ANC Service:
ANC service is provided in a separate ANC clinic along with Immunization clinic.
It is conducted twice a week-Monday and Wednesday. It is provided by a mid
wife. The number of ANC visit is 4 which is according to Nepal Government
protocol.
Services:
• Issuance of ANC Card
• Surveillance of Vitals
• Counseling regarding danger signs like edema, decreasing or absent fetal
movement, inappropriate weight gain.
• Iron, folic acid, Calcium and Td injection, albendazole services
• Investigations:
Blood: hemoglobin, Random blood sugar, VDRL, retrovirus, HbsAg,
blood grouping
Urine: RE/ME
Ultrasonography

All the ANC services are free of cost except the price of calcium tablet.

b. Delivery services:
Delivery is carried out by normal vaginal delivery, vacuum delivery and caesarean
section.
Vaginal delivery is carried out in a separate delivery room. The room is well-
equipped.It is conducted by 2 midwives – one to conduct delivery and one to
receive the baby.
Equipment Quantity
 Delivery Table 2
Delivery Set 5
Sim’s Speculum 2
Episiotomy Set 2
Vacuum 6

Caesarean section is carried out in OT. It is performed by one doctor, one midwife
and a helper.

180 164
160 140 141 136 130
140
120
100
80
60 36 40
40 25 21 21 25 23
11 10 16
20
0
C/S

C/S
C/S

C/S

C/S
Complicated
Complicated

Complicated

Complicated

Complecated
Type of Delivery

Normal Delivery
Normal Delivery

Normal Delivery

Normal Delivery

Normal Delivery
F.Y. F.Y.2070-71 F.Y.2071-72 F.Y.2072-73 F.Y.2073-74 F.Y. 2074-75

c. PNC services:
Mother is helped to breastfeed the child immediately after the birth of the child by
a midwife. In case the nipple of the mother is flat or retracted, electronic breast
pump is used to extract the milk. There is a separate maternity ward with 5 beds
and 5 cots.
In normal vaginal delivery, discharge is done after 24 hours. In case of CS,
discharge is done after 5-6 days only if nearby health facility is available and after
11-12 days if health facility is not available nearby the patient’s residence.
General assessment of the neonate is carried out by a midwife. There is 1
incubator, 1 warmer, 1 suction device, 1 neonatal resuscitation set and 1
phototherapy device. There is no facility of ventilator.
d. Immunization:
Immunization clinic is located itself in the ANC clinic. There is 1 midwife same
as that of ANC clinic. Immunization clinic is run 2 days per week i.e. Monday and
Wednesday. The clinic maintains strict cold chain for vaccination program. It has
a fridge for storage of vials with maintenance of the required temperature.
Vaccine Vial Monitoring is done strictly and vaccines are checked before
administering it.
Services: Provides regular EPI vaccines and issues vaccination card.
 2. Family planning and Abortion Service:
Family planning and abortion service is provided in one separate room. The service is
provided by midwives.
Condoms, pills, DEPO, IUCD and implants are the family planning methods provided
in the hospital. All these services are free of cost. IUCD is inserted in OT. PPIUCD
insertion facility is also available. Counseling service is available.
Comprehensive Abortion Care is provided in the center which is free of cost. MA is
frequently performed while MVA is not done usually. Counselling is provided in the
separate room with privacy maintained and the procedure is done in OT.

3.1.11.8 Supportive Services

1. Dispensary

There are two dispensary in Amppipal hospital. One is run by hospital committee and another
one by government of Nepal. Both are situated in new OPD building.
The record of distribution and sell is maintained by the pharmacy staffs. There are a total of 4
staffs in the two dispensaries. The medicines and the equipment for sale are bought either by
purchase committee (for smaller budget items) or by opening tender (for larger budget items-
once a year).
There are 325 types of medicines which come in 928 different preparations. Out of which,
903 preparations are Allopathic and 25 are Ayurvedic. They do not offer any discount on
drugs except for the drugs provided by GON (72 drugs), which are free of cost.
Stock is made for 3 months.
2. Store

The store is subdivided into 5 different divisions:

a. Medicine divisions
b. Surgical division
c. Linens division
d. Maintenance and repair division
e. Fuel division

Its function is to purchase (in coordination with account section), store and maintenance of
general as well as medical equipment and record files. There is a storekeeper for each
division responsible for the maintenance of logistic under supervision of hospital
administrator. It receives request form from different departments and accordingly
purchasing is done directly from supplier. Emergency point order, authorized stock level and
is maintained.

3. Waste Disposal
Waste is collected and burnt and rarely recycled .The incombustible waste is buried.
Incinerator is located about 80-100 meter from the hospital. There is a separate pit for the
disposal of body tissues like placenta, uterus, ovary etc.
4. Laundry and House-keeping
A mixture of washing soda and bleaching powder are used for the laundries.The laundry
division has 2 machines one cleaner and one dryer. The laundries are cleaned every day and
after the patients get discharged. There were sweepers who sweep and mop the floor
according to the need.
5. Security
Security is managed by a member from Nepal police.

6. Electricity
Amppipal Hospital receives a single line from Nepal Electricity Authority with their own
transformer of 25 KV. The hospital has 2 generators 40 KV and 9 KV which provides backup
to the entire hospital. Also, the OT is equipped with an online UPS which provides
Uninterrupted Power Supply for 3-5 hours in case of power cut. Solar power is also installed
and used as back up.

7. Water supply

The hospital has single sources of water from nearby spring which is sufficient. Water is
lifted to the hospital tanks using water pump after which it is distributed to different parts of
hospital.
8. Transportation
The hospital has 2 ambulances for carrying patients to hospital. Bus facility is also provided
by the hospital for the patients of nearby villages. A jeep is used for other miscellaneous
activities regarding hospital.