Presentation on Health Service

Management

Bhanu Municipality, Tanahun, Nepal

Group E
MBBS 8th batch
Chitwan Medical College
Group Members
1. Sarbin Nepal (Leader)
2. Nidhi Bhatt (Vice Leader)
3. Alisha Lama Tamang
4. Aashish Sapkota
5. Bikram Kaliraj
6. Gaurav Upreti
7. Prasanna Rana
8. Diana Rayamajhi
9. Saroj B.K
10. Anish Karna
Methodology
Study Area:
1. Bhanu Municipality, Tanahun District (Municipal Office, Health
post, Basic Health support unit, Community health unit, I/NGO)
2. Namuna Community Hospital, Sudbar Bazar, Lamjung
3. Purundihi Panchanagar local Hospital, Sephako Bagaicha, Bhanu
Study Design:
Descriptive, Cross-sectional study of the management of health system
along with Retrospective study of a particular disease epidemiology was
done at the municipality level.
Study Duration:

We were posted for 6 weeks:

 1st week in Bhanu municipality
 2nd week in Namuna community hospital, Sundar bazaar, Lamjung
 3rd and 4th week: Local hospital, Sephako bagaicha, Bhanu
 5th and 6th week: PHCC, HP, I/NGO, CHU
List of activities performed:
Table 1: List of activities performed
S.N. Type of institution Institution visited Duration Task performed
1. Municipality Office Bhanu Municipality office 1 week •Municipality
Programme
•Epidemiological
study
•Five Year Plan

2. Community Hospital Namuna Community 1 week Hospital Profile

Hospital, Lamjung
3. Local Hospital Purundihi Hospital, 2 weeks Hospital Profile
Sephako Bagaicha Critical analysis
4. HP, I/NGO, UHC Bhanu Health Post, 2 weeks Institution profile
Salbisne BSHU, Bhanu
community center
Municipality Profile

Fig 1. Map of Bhanu Municipality

Background
• Bhanu municipality is in the Gandaki province of Tanahun district,
which is named after the famous poet of Nepal Bhanubhakta Acharya
as his birth place Chaudi Ramgha is situated in this municipality.
• In 2072/06/09 from the decision taken by cabinet of government of
Nepal the existing VDCs such as Bhanu and Barbhanjyang were merged
to form Bhanu municipality. According to the decision made by
government the municipality was established in 2072/06/15. Later in
2073 as per the restructuring of local level, Basantpur, Mirlung, Risti(6),
Satiswara(1-5), Tanahusur(1-3), Chowk Chisapani and Rupakot VDCs
were included in previous municipal boundary. The municipality is
divided into 13 wards.

Source: https://bhanumun.gov.np/en
Municipality Profile
• Borders:
- East: Gorkha and Lamjung
- West: Byas municipality
- North: Lamjung District
- South: Bandipur Municipality
Population: 48,972
Area: 184 sq. km
Number of Wards: 13

Source: https://bhanumun.gov.np/en
 Account, legislation,
Municipality good governence and
other committees

Economic development,
Municipal social development,
Infrastructure
development and
environmental and *
management committee

Mayor
deputy mayor judicial committee

Chief
Administrative
Officer

Administration Infrastructure Financial Financial

Education youth Health and social
Planning and devlopment and development Internal audit unit Law department administration
and sports branch development
Monitoring Branch environment branch branch

Ward office Service centers Unit service center

Fig 2. Organogram of Bhanu Municipality

 INTERNAL
ENVIRONMENT

PROCESS
INPUT Planning
OUTPUT
Infrastructure Organization Health Program
Indicators
Human Resource Staffing
Co-ordination Morbidity & Mortality
Budgeting Indicators
Recording & Reporting
Logistics Service utilization
 
     

FEEDBACK
 

EXTERNAL ENVIRONMENT
Political Instability

Climate & Geography

 
Fig 3: IPO model of Administrative of office of municipal executive, Bhanu Municipality
 Municipality

Health Section

Modern Health Care Alternative Health Care Supporting Agenices

System System

Governmental Private Ayurveda INGOs, NGO

Hospital- 3
Hospital- 2 Hospital -

Health Post- 6 Gorkha

Polyclinics - 1
CHU- 2

BHSU- 6
Fig 4: Health care delivery flow chart
Budget

Fig 5: Budget Pattern of Municipal Health System

• Distributed by provincial government to local government of Bhanu
Municipality under heading of conditional (ससर्त ) and non-
conditional (निसर्त )
 Logistics
Logistic Management
Division, DOHS

Province Health Material Central Store, Teku

Procurement and Supply Center

Health Office

Local Level

Health Post Hospital PHC CHU BHSU NGO/INGO

Fig 6: Logistics Flow of Office of Municipal Executive, Bhanu, Tanahun, Nepal

 DOHS, Ministry of Health
HMIS 15
Provincial Health Directorate

Health and Social Development Division of

Municipal Executive (cc to DHO)

1st week of every month

BHSU/HP/CHU

Last day of every month

FCHVs

Fig 7 : Flow of HMIS Information among different Health

Authorities of Bhanu Municipality, Tanahun ,Nepal
Planning
Plans are implemented

Further passed by Municipality assembly

Policy passed by Social Development Working Committee

Policy is proposed to Social Development Committee

Health division of Municipality

Information obtained from institutions

Fig. 8: Planning process
Achievement of major Health Indicators
 Immunization Programme
Vaccine
70 64.2
Percentage of Children immunized

60 56.2 56.3 55.4 54.6

50.6 52.1
50

40
36.2

30

20 15.1

10

0
BCG DPT OPV IPV PCV MR 1 MR 2 JE Td

Vaccine
Fig 9: Percentage of Children immunized as per NIP schedule (Bhanu Municipality 2076/77)
Nutrition Programme
Table 2: Nutrition programme indicator (Bhanu Municipality 2076/77)
S.N. Indicators Percentage

1 Percentage of children aged 0-11 months registered for Growth Monitoring 76

2 Percentage of children aged 12-23 months registered for Growth Monitoring 55.5

3 % of children with moderate malnutrition among registered children (new) 0.81

4 % of children with severe malnutrition among registered children (new) 1.48

5 % of coverage of Vit A tablets distribution to the children aged below 5 years 70.24

6 % of coverage of deworming tablets distribution to the children aged 63

below 5 years
7 % of pregnant women receiving iron tablets for first time 54.6

8 % of pregnant women receiving deworming tablets 43.5

9 % of postpartum women receiving Vit A supplements 3.5

 CB-IMNCI Programme
Acute Respiratory Infection
700

608
600

500

400

300

177.2
200 163
110.8
83
100
11
0
ARI incidence per 1000 < 5 year child Pneumonia incidence per1000 <5 yrs child % of Pneumonia Treated with antibiotic

Fig 10: ARI Indicator Bhanu 2076/77 National data 2075/76

 Chronic Diarrhoea Disease
400 375
350

300

250

200

150
93.6 92.1
100
58.5

50 0.38

0
Incidence of diarrhoea per 1000 <5yrs % of severe dehyration among total cases % of <5 yrs diarrhoea case who were treated with
zinc and ORS

Fig 11: CDD Indicator Bhanu 2076/77 National 2075/76

Safe Motherhood Programme
Table 3: Safe motherhood programme indicator (Bhanu Municipality 2076/77)
S.N. Indicators Percentage

1 Pregnant women who had first ANC visit as per 45.2

protocol
2 Pregnant women who had four ANC visits as per 13.9
protocol
3 Deliveries attended by SBA as % of expected birth 34.5

4 Women who had 3 postnatal checkup as protocol as % 3.5

of expected live births
Leprosy Control Programme
Prevalence Rate per 10000 Population
1
0.9
0.9

0.8

0.7

0.6

0.5

0.4

0.3
0.2
0.2

0.1
0
0
Bhanu Municipality 2075/76 Bhanu Municipality 2076/77 National 2075/76

Prevalence Rate per 10000 Population

Fig 12 : Leprosy control programme indicator
TB Control Programme
Table 4: TB control programme indicator
S.N Indicators Bhanu municipality
2076/77
1 Case notification rate all form of TB per 100000 67
population
2 Treatment success rate 36.3
3 Sputum conversion rate
4 Treatment failure 0

5 Died 0

6 Lost to follow up 0
Top Ten Disease
Table 5: Top ten disease in OPD 2076/77
Namuna Community Hospital,
Sundarbazar, Lamjung, Nepal
Introduction

• Namuna Community Hospital (NCH) is a community hospital situated

at Ward No 6 of Sundarbazaar Muncipality in Lamjung district of
 Province No. 4. It was established in 2062 B.S

• The Hospital compound spans in an area of 4 ropanis. The area of the

hospital is donated by the community members.
Organogram

Fig 13. Organogram of Namuna Community Hospital

• Staffs appointed by HMC contract
23 Staffs are appointed by Hospital Management Committee on contract basis
Table 6: Staffs Appointed by HMC Contract

Post Fulfilled
Health Asistant 1
Lab Technician 2
Radiographer 2
Pharmacy Assistant 3
Office Assistant 8
A.N.M 2
A.H. W 5
Total 23
 Post Fulfilled Remarks
MDGP 1 Scholarship Contract
Medical Officer 6 Scholarship Contract
Program Contract Appointed Dental Surgeon 1 Scholarship Contract
24 staffs are appointed by Nursing Officer 3 Scholarship Contract
government on program contract Pharmacy
basis
Officer 1 Scholarship Contract
Table 7: Human Resources at Namuna community Hospital Integrated Public Health
District Hospital
Manager 1 Program
Safe Motherhood, OCMC,
Staff nurse 3 ART
A.O.C 1 Safe Motherhood
Lab Assistant 1 Safe Motherhood
ANM 4 Safe Motherhood
Office Assistant 2 Safe Motherhood
Services provided:
• OPD services • Dental Services

• 24 Hr emergency services • 24 Hr Ambulance services

• Indoor service • Plaster, Dressing and

Injections
• Lab services
• Community Drug Pharmacy
• Pregnancy Test
• Free Health Services
•X-Ray
Purundihi Panchnagar Primary Health Care
System, Sephako Bagaicha, Bhanu
municipality, Nepal
Introduction

Purundihi PHCC is located in Bhanu-5, Sephako Bagaicha

(Panchanagar), Tanahun, Nepal. In 2028 B.S it was established as
Health Post and later in 2058/60 B.S was converted into Primary Health
Centre. Recently in 2076/77 Purundihi PHC was declared as 15-bedded
Local Hospital of Bhanu Municipality.
 Table 8: Human Resources of Purundhihi Panchanagar PHCC
S.N, Posts Government Currently Available
Sanctione Fulfilled Governmen Contracte Local and
d Post Post t d from other
Sanctioned MoHP Resources

1 Medical Officer 1 2 0 1 1
2 Health Assistant 1 1 1 0 0
3 Staff Nurse 1 0 0 0 0
4 Lab Assistant 1 1 1 0 0
5 AHW 3 3 2 0 1
6 ANM 3 3 1 0 2 (SBA)
7 Office Helper 2 3 2 0 1
8 Dark Room 0 1 0 1 0
Assistant
  Total 12 14 7 2 5
 Services provided:
1. Clinical services 2. Community services
2. OPD and emergency se
• Curative services( OPD and emergency services) • Immunization center
• PHC/ORC
• Lab services • FCHVs services
•Immunization services
•Nutrition services
•Diarrhea related services
•Respiratory Disease control services
•Safe motherhood services
•Obstetrics services
•Family planning services
• Disease control services (Malaria, TB, leprosy,
Aids and STIs)
B.P Koirala Memorial Cancer Hospital
B.P Koirala Memorial Cancer Hospital
• B.P Koirala Memorial CancerHospital is a tertiary cancer hospital
located otside Kathmandu Valley in Bharatpur, Chitwan.
• The hospital was built with assistance from the government of the
People’s Republic of China in the year 1998 and has been in service
since then.
Services provided
• Surgical oncology unit: Gynae, GI,Breast, Neuro, ENT, Thoracic, Urology,
Orthopaedic, Plastic and reconstructive services
• Radiation oncology unit
• Medical oncology unit: General medicine and pediatric medicine
• Anesthesiology Unit: ICU, Palliative care and Hospice unit
• Pathology unit: Histopathology unit, microbiology unit, blood and emergency
laboratory unnit
• Cancer preventio and research Unit: Research and development unit, Awareness unit
• Day care
• Blood transfusio and critical care unit
• Physiotherapy unit
Peripheral health institutions of Bhanu
municipality
Health Post
Table 9: List of Health Post in Bhanu Municipality

Bhanu Health Post Chowkchisapani Health Post

Basantapur Health Post Rupakot Health Post

Purkot Health Post Jhamruk Health Post

Bhanu Health post
• Bhanu health post is located at present in Bhanu Municipality Ward
no. 3, Tanahun. It was established in 2053 B.S. It is functioning under
Bhanu Municipality.

• Bhanu Health Post has 2 Ropani of land which has three (One under
construction) one storied building. It consists of different sections out
of which one is OPD (also used as administrative room), one is
dispensary, one ANC checkup room, one labour room, and one storage
room
 Table 10: Human Resource of Bhanu Health Post

Posts Sanctioned posts Fulfilled posts

Health Assistant 1 1

AHW 2 2
ANM 1 1
SBA 1 1
Helper 1 1
Services provided:
• Out-Patient Service
• Immunization program
• Outreach clinics
• Safe motherhood program
• Family planning program
• Nutritional program
• Sexually transmitted disease and HIV/AIDS program
• Health education
• Epidemic control program
• FCHV program
• Free Medicine
•Additional Programs
1. Providing regular checkup, counselling and distribution of drugs to
elderly people above 84 years of age once a month at home.

2. “Samaye jach tatha paramarsa sewa” every Friday from health post.

3. “Adolescent friendly site” since Magh, 2077 B.S

Basic Health Service Center
Table 10: List of Health Post in Bhanu Municipality

Salbisne BHSU Badare BHSU

Tutye-pani BHSC Nareshwortar BHSU

Rana gau BHSC Padkye pasal BHSU

Salbisne Basic Health Service Center
• Salbisne BHSC is located in Ward 1, Bhanu Municipality. It was
established on 2076 B.S, Asar as a part of Basic Health Service
Package -2075. The aim of Basic health service center is to provide
free health services through local level and ensure Universal Health
Coverage.
 Table 11: Human Resource of Bhanu Health Post

Posts Sanctioned Fulfilled Vacant

Posts Posts Seats

AHW 2 1 1

ANM 2 1 1

Office 1 1 0
Helper
Services provided:
• Out Patient Service
• Immunization program
• Outreach clinics
• Safe motherhood program
• Family planning program
• Nutritional program
• Health education
• Epidemic control program
• FCHV program
• Free Medicine
Bhanu Community Health Center(ASIAN
FORUM)
• Bhanu Community Health Centre is located in Bhanu-2, Nareshwortar.
It was established in 2070 B.S. It was built with the help of Asian
Forum and collecting money from the community. “Maha Yagya” was
called to collect funds to build this Community Health Centre.

• Bhanu Community Health Centre provides its services from its one-
story building in Nareshwortar. Nareshwortar Basic Health Support
Centre is located in the same building and they work in coordination.
Table 12: Human Resource of Bhanu Community Health Centre

Post No.
AHW (In-Charge) 1

Pharmacist 1
Lab Worker 1
Office Assistant 1
Services provided:
• OPD services
• Lab services
• Eye service
• Immunization program
• Family planning
• Pharmacy services
Bhanu Ayurveda Ausadhalaya
• Bhanu Ayurveda Ausadhalaya is located in Bhanu -4, Chudi Ramgha.
It was established in 2054 B.S.

• A total of four posts are sanctioned for Bhanu Ayurveda Ausadhalaya

for which there are four workers which includes 1 Kabiraj, 2 office
helper.

Services : OPD Services, Free Ayurvedic Health Camp , Free Medicine

Table 13: Human resources of Bhanu Ayurveda Ausadhalaya

Post Sanctioned Vacant Fulfilled

Kabiraj 1 1 0

Baidhya 1 0 1

Office 2 1 1
Helper
 Table 14: Other NGO/INGOs in Bhanu Municipality

S. Name of Work Area

N Organization Involved
1 Jantra TB Bhanu
Municipality
2 Kosis Nepal Mental Bhanu
Health Municipality
3 FPAN Safe Bhanu
Motherhood Municipality
4 Asian Forum General Ward 2
OPD
Epidemiological study of Intestinal Worm,
Bhanu Municipality
Epidemiological Study on Intestinal Worm
•Global distribution and prevalence
More than 1.5 billion people, or 24% of the world’s population, are infected with
soil-transmitted helminth infections worldwide. Over 267 million preschool-age
children and over 568 million school-age children live in areas where these parasites
are intensively transmitted and require treatment and preventive interventions.

•National Scenario
Soil-transmitted helminth infections are widely distributed in tropical and
subtropical areas i.e., countries like Nepal. It is one of the major neglected tropical
diseases in Nepal.
Rationale
 Intestinal worm is one of the leading causes of morbidity in Bhanu
Municipality.
 Cases of intestinal worm are in increasing trend in Bhanu
Municipality.
 Being a preventable disease, epidemiological studies on Intestinal
worms can encourage the prevention of socioeconomic factors like
lack of sanitation, proper hygiene, contaminated food, and water,
which are still prevailing in the community.
 As it is a treatable disease, emphasis can be put on proper
management of cases, including prevention of complications and
deaths due to Intestinal Worm.
Prioritization Matrix
Table 15: Prioritization Matrix

Criteria COPD APD Intestinal Worm Enteric Fever

Magnitude of +++ ++++ ++++ ++++

problem
Need for study ++ +++ ++++ ++++

Availability of data ++ ++ ++ ++

Feasibility ++ ++ ++ +

Cost +++ +++ +++ +++

Total 12 14 15 14
Objectives
General:
• To analyze the epidemiological trend of Intestinal Worms in Bhanu
Municipality.

Specific:
• To find the magnitude of disease in Bhanu Municipality.
• To study the distribution of the disease according to age, sex, time,
place, and ethnicity.
• To find preventive measures to control Intestinal Worms in the
locality.
Epidemiological Determinants
Agent

Ascaris Lumbricoides
Environment
Hookworm- Ancylostoma Duodenale and
Necator Americanus  Soil, Temperature, Oxygen, Sunlight, and
moisture are essential.
 Human habitats where indiscriminate open
field defecation and improper sewage
disposal is practiced
Host
• Age (High rate of infection in
children)
• Sex (Male = Female)  
• Low immunity/
Immunocompromised
• Poor nutrition  Fig 14: Epidemiological Determinants of Intestinal Worms
• Farming occupation
Fig 15: Life cycle of Ascariasis Fig 16: Life cycle of Hookworm
lumbricoids
Findings and discussion
Table 16: Year wise distribution
  2074/75 2075/76 2076/77
Bhanu Municipality 741 719 811

Annual Cases of Intestinal Worm

820

800

780

760

740

720

700

680

660
74/75 75/76 76/77

Intestinal Worm

Fig 17. Trend of Intestinal worm in Bhanu Municipality

Month-wise Distribution
140
126
120

103
100 97

80
80
71

59 59 60
60
51
40
40 37
28

20

0
Shrawan Bhadra Asoj Kartik Mangsir Poush Magh Falgun Chaitra Baishak Jestha Asar

Month-wise Distribution of Intestinal Worm Patients

Fig 18. Month wise distribution of Bhanu municipality 2076/77

Ward-wise distribution
Ward-wise distribution of Intestinal Worm patients

195
130

114

104

79
58
49

37
23

11
10

1
0

1 2 3 4 5 6 7 8 9 10 11 12 13

Fig. 19: Ward wise distribution of Bhanu municipality 2076/77

 
Sex- wise Distribution
Sex- wise Distribution of Intestinal Worms in last 3 years

425 432
414
379

316 305

74/75 75/76 76/77

Male Female

Fig 20: Sex wise distribution of intestinal worms in last 3 years of Bhanu municipality
Conclusion
 Intestinal Worm is one of the most prevalent disease and still one of
the major public health problems in Bhanu Municipality.
 The number of Intestinal Worm has been increasing past three years
which might be due to lack of proper sanitation, water hygiene and
waste management in the Municipality.
 Incidence is high among males due to higher exposure to out-door
field work.
 Incidence is higher in rainy seasons due hot and humid climate which
is favorable for bacterial growth and transmission
Recommendations

• Recording and reporting should be done properly so the reported data

reflects a more accurate picture.
• Proper awareness campaigns should be launched in community level
to help in prevention from disease and to seek for proper diagnosis and
management of the diseased.
• Biannual deworming programs should be conducted properly
Critical analysis on Antenatal care Services
in Purundihi panchanagar PHCC ,
Bhanu municipality
Objective of study
General objectives
 To analyze the Antenatal care services critically in Purundihi
Panchnagar PHCC.

Specific objectives
 To identify the present situation of Antenatal care services.
 To identify major issues concerned with the Antenatal care services in
PHCC.
 To find out potential solutions to the identified problem and their area
of improvement.
Rationale
 Study Antenatal care services of Purundihi PHCC.
 Important program of one of the priority program i.e. Safe
Motherhood of Government of Nepal.
 Poor ANC visit Status among the pregnant women of Bhanu
Municipality.
 Decreasing trend of ANC visit status.
 ANC visit Status in Bhanu Municipality
First ANC visit (Anytime) First ANC visit as per protocol (4th month)
4 complete ANC visit

57.5

45.2
42.8

35.6
Percentage

34.1
32.5

19.1 18.2
13.9

2076/77 (n= 1355) 2075/76 (n=1364) 2074/75 (n=1376)

Fig 21: ANC Visit Status of last 3 years

 ANC Visit Status
200

180

160

140

120

100

80

60

40

20

0
2076/77 2075/76 2074/75

First ANC Visit (anytiume) First ANC visit as per protocol (4th month) 4 complete ANC visit

Fig 22: ANC visit Status of last 3 year in PHC

Human Resource
Table 17: SWOT analysis on Human resource for ANC services in Purundihi PHCC
Strength (S) Weakness (W)
1. Presence of Skilled-Birth attendant. 1. Lack of proper SBA training programs.
2. Adequate number of medical staff in 2. Lack of skilled manpower to operate
PHC. USG.
  3. Lack of qualified staff involved in
reporting.
 

Opportunities (O) Threats (T)

1. Increase in the number of technically
competent manpower in the country.
2. Awareness program capacity building
through regular conduction of health
mothers’ group's discussion (ANC,
PNC, Exclusive breastfeeding).
1. Poorly educated FCHVs.
2. Personal bias, Attitude
3. Political Threats
4. Vacant post
Table 18: TOWS matrix on Human resource for ANC services in Purundihi PHCC

  Strengths Weakness
Opportunities  Enough skilled manpower for  Skilled Birth Attendant
ANC services. training program.
 Effective ANC provision in  USG training program.
PHC.

Threats  Good political connections will  Proper management of PHC.

help in better budget and
logistic allotment.
 Appointment of competent
manpower through the
announcement of the vacancy.
 Upgrade quality of health
services.
 Responsible manpower.
Physical Infrastructure
Table 19: SWOT analysis on Physical Infrastructure for ANC services in Purundihi PHCC

Strength (S) Weakness (W)

1. Satisfactory infrastructure to support 1. Same room for ANC, PNC, FP, and
the program. immunization programs.
2. Satisfactory sanitation and lighting. 2. Overcrowding.
3. Separate bins for waste collection.
4. Attached toilet.

Opportunities (O) Threats (T)

1. Support from donor organization.
2. Government Aid.
 
1. Patient overflow in PNC. FP and
immunization programs affect ANC
services.
2. Interruption of budget provision and grant.
3. The problem of transportation.
Table 20: TOWS matrix on Physical Infrastructure for ANC services in Purundihi PHCC

  Strengths Weakness
Opportunities  Donor organizations and  Building separate rooms for
Government aid help in ANC, PNC, FP, and
building the necessary immunization through the
infrastructure. funding of donor
organizations.

Threats  Better transportation  A separate room is specified

facility for ANC services to
mitigate overcrowding.
Logistics
Table 21: SWOT analysis on Logistics for ANC services in Purundihi PHCC

Strength (S) Weakness (W)

1. Provision of essential logistics from
1. Poor infrastructure and inadequate
the center. supply of commodities, medical
2. Multiple sources of logistics. equipment (delivery kits), and drug
supply.
2. Lack of space and equipment’s for
quality maternity services at health
3. Unutilized logistics.
Opportunities (O) Threats (T)
1. Support from donor organization 1. Geographical inaccessibility.
2. Required equipment can be 2. The problem of transportation.
procured with municipality support. 3. Out-of-pocket Expenditure.
3. Skilled manpower.
Table 22: TOWS matrix on Physical Infrastructure for ANC services in Purundihi PHCC

  Strengths Weakness
Opportunities  Essential equipment can be  Utilization of logistics by
procured with the help of skilled manpower.
donor organizations.

Threats  Proper utilization of available  Capacity building

logistics before procurement.
Recording And Reporting
Table 23: SWOT analysis on Recording and Reporting for ANC services in Purundihi PHCC

Strength (S) Weakness (W)

1. Information of patient recorded on the 1. Information recording is difficult due to
register on daily basis. the less number skilled human resources.
2. Information reported to higher
authorities.
3. Recording and reporting are done
according to HMIS tools.

Opportunities (O) Threats (T)

1. Internet availability and enhanced 1. Data under security and hacking threats.
bandwidth. 2. Rapid changes in technologies and IT
2. Unification and integration of public systems.
and private sector health records. 3. Load shedding and electrical surges.
Table 24: TWOS analysis on Recording and Reporting for ANC services in Purundihi
PHCC

  Strengths Weakness
Opportunities  Daily online HMIS  Online training on
data entry. HMIS.
Threats  Skilled IT technicians  Develop a system for
to prevent hacking rationale linkage of
threats. information system
data for planning and
policymaking.
 
Budgeting and Finance
Table 25: SWOT analysis on Budgeting and Finance for ANC services in Purundihi PHCC

Strength (S) Weakness (W)

1. Financial input from internal sources.  
(OPD, Lab charges)
2. Budget from Municipality level.
3. Provision of incentive for 4 complete
ANC visits and transportation fee.
 
Opportunities (O) Threats (T)
1. Availability of financial aid through 1. Political instability.
multiple sources.  
 
Table 26: TWOS analysis on Budgeting and Finance for ANC services in Purundihi PHCC

  Strengths Weakness
Opportunities  Utilize enhanced  
finance and
budgeting tools.
Threats  Revenue collected  Create a governance
from PHC services structure to ensure
can be used as ANC integration of budget.
incentives and
transportation fees.
Service Delivery
Table 27: SWOT analysis on Service Delivery for ANC services in Purundihi PHCC
Strength (S) Weakness (W)
1. High success rate and cost-effective intervention. 1. No provision of CS services
2. Promotion and counseling on birth preparedness 2. No provision of USG services.
package. 3. Out-of-pocket expenditure.
3. Early identification of danger signs and timely  
referral.
4. 24 hr delivery service.
5. Different supportive programs like Nutrition
program, Immunization program, CBIMNCI
program, Disease control program, Family planning
program.
Opportunities (O) Threats (T)
1. Health service camp by a private organization 1. Unmet need for Family Planning
(Permanent family planning services, uterine 2. Hindrance in service delivery due to the hesitance of
prolapse) new consultants to work in PHC.
2. Proper plans and policies can be developed  
benefitting the ANC services.
3. Collaboration with FCHVs and volunteers.
Table 28: TOWS analysis on Service Delivery for ANC services in Purundihi PHCC
  Strengths
Opportunities  Knowledge of ANC
services can be imparted
to the general public
through FCHVs.
Threats  Family planning programs
to reduce unmet need.
 
Weakness
 Job opportunities can be
created to maximize the
utilization of available
resources.
 Trained surgeon to perform
CS.
 Consultant for family
planning;
Recommendation
• Government should recruit the human resources in vacant seats and ensure the
provision of additional human resources as needed.
• PHC should start a training program in PHC itself to produce skilled health
workforce.
• PHC should conduct a comprehensive study regarding its infrastructure and
formulate effective plans and policies.
• PHC should coordinate with the local government to initiate public
transportation services to PHC.
• Temporarily hire/Monthly visit from private consultants to work in the PHC
and address the problems till the problem is solved.
Five-year plan on Immunization Program,
Bhanu municipality
Introduction
• Immunization is the process whereby a person is made immune or
resistant to an infectious disease, typically by the administration of
vaccines.
• NIP of Nepal (Expanded Program on Immunization) was started in
2034 BS and is a priority 1 program. It is one of the successful public
health programs of Ministry of Health and Population, and has
achieved several milestones contributing to reduction in morbidity and
mortality associated with vaccine preventable diseases.
National Immunization schedule
Table 29: National Immunization schedule of Nepal
Types of vaccines No of doses Recommended age

1. BCG 1 At birth or on first contact with health

institution
2. Oral Polio Vaccine (OPV) 3 6,10 and 14 weeks of age
3. DPT- Hep-B Hib 3 6,10 and 14 weeks of age
4. Rota Vaccine 2 6 and 10 weeks of age
5. IPV 1 14 weeks of age
6. PCV 3 6,10weeks and 9 months of age
7. Measles-rubella 2 MR1 at 9 months and MR2 at 15
months of age
8. Low dose Diptheria toxoid (Td) 2 Pregnant women (2 doses of Td)
9. JE 1 12 months of age
Situation Analysis
2076/77 Immunization status of bhanu municipality
80
73 72.9 71.7
68.5 69.8
70
65.1 65.2 63.5 64.2
60.7 59.7 60.5
60 56.2 56.3 55.4 56.3
53.6 54.6
50.6 52.1
50 48.7 48.3

40 36.2

30
22.1
20.1
20
15.1

10

0
BCG DPT OPV IPV PCV MR 1 MR 2 JE Td

77/76 75/76 74/75

Fig 23: Immunization status of Bhanu Municipality 2076/77

Rationale

1. Vaccine coverage in Bhanu municipality is way below the national

target.
2. EPI is one of the main prioritized programme in Nepal.
3. Lack of awareness among the general population about vaccine
preventable diseases.
Vision
•All individuals and children will get immunized, in order to promote health and
welfare of family and thus make Bhanu a vaccine-preventable disease-free
municipality.
Mission
•To provide every child and mother high-quality, safe and affordable vaccines
and immunization services from the National Immunization Program through
EPI clinics and health institutes in an equitable manner.
Goal
•Reduction of morbidity, mortality and disability associated with vaccine
preventable diseases in Bhanu Municipality by 2082/82 B.S.
Objectives
General Objectives
 To increase vaccine coverage among children and mothers in Bhanu Municipality
by 2082/83 B.S.
Specific Objectives
 Reach every child for full immunization.
 Accelerate, achieve and sustain vaccine preventable disease control, elimination
and eradication.
 Strengthen immunization supply chain and vaccine management system for
quality immunization services.
 Ensure financial sustainability for immunization program.
 Promote innovation, research and social mobilization activities to enhance best
practices.
 Target
Table 30: Target of 5 year plan on Immunization Program
S.N. Indicators Current Situation Target
2076/77 B.S. 1 Year
st
2 Year
nd
3 Year
rd
4thYear 5thYear
   
 
1 % of BCG Coverage 36.2% 40% 45% 50% 55% 65%
2 % of DPT Coverage 56.2% 60% 65% 70% 72% 75%

3 % of OPV Coverage 56.3% 60% 65% 70% 72% 75%

 
4 % of IPV Coverage 55.4% 60% 65% 70% 72% 75%
5 % of Rota 1 and 2 % 50% 60% 65% 70% 75%
6 % of PCV coverage 54.7% 60% 65% 70% 72% 75%
 
7 % of MR1 Coverage 50.6% 55% 60% 65% 70% 75%
8 % of MR2 Coverage 64.2% 65% 68% 70% 72% 75%
9 % of JE Vaccine Coverage 52.1% 58% 64% 68% 72% 75%
10 % of Td vaccine Coverage 15.1% 20% 28% 33% 38% 45%
 Methodology
Table 31: Methodology of 5 year plan on Immunization Program
Activates Techniques Tools Sources
Selection of topic Secondary data Data review format, HMIS 9.3, Doctor,
review Interview guidelines HA, Public Health
worker
Situation Analysis Secondary data Data review format, Public Health worker,
review, Key Interview guidelines HA, FCHVs
Informant Interview
Stakeholder Secondary data Interview guidelines  
Analysis review, Key
Informant Interview
Problem Analysis Key informant Interview guidelines  
Interview
Objective Analysis Key Informant Interview guidelines  
Interview
Logical framework Group Discussion Logical framework  
matrix matrix
preparation
Budget estimation Key Informant Interview guidelines Municipal Budget
Stakeholder Analysis
Table 32: Stakeholder Analysis of 5 year plan on Immunization Program
Stakeholders Problems Interest Potential Linkages
Municipality Office -There was problem of -They wished to increase
Positive:-Municipality is the -They were dependent on
Immunization coverage in coverage of immunization
functional unit of health provincial government for
municipality due to ineffective by effectively system under federal structure resources and facilities.
Immunization program. implementing and was a prominent,
 
Immunization program.Stakeholder for planning and
managing overall control -Programs were mainly
program. executed through health post
and hospitals in municipality
Negative:-There were
inadequate human resources .
working in the health division
of municipality.
Health Institutions -There was problem of cold- -They would like to expand Positive: They have EPI -They need to coordinate with
chain storage in different health cold-chain storage program one every month in higher center (District Office)
institutions. facilities. BHSC, Health posts. Cold- in order to obtain vaccines.
chain is present in PHCC.
-Lack of skilled manpower. -They wished to have
capacity building
programs.
 
EPI Clinic -Vaccine coverage was low.
-People were not compliant to
Immunization program.
Community Level -There were inadequate
awareness group incentives for conducting
(FCHVs, Local community level programs.
media, Academic
-There were limited
institutions)
Immunization IEC materials.
-There was high workload to
FCHVs.
-Resources for research in
Immunization was limited.
They wished to increase Positive: -They were dependent on
vaccine coverage. Municipality and District Health
People of rural ward get access
Office of regular supply of
They wished to motivate to immunization in their nearest
goods.
people for vaccination. BHSC once every month.
-They needed to coordinate with
Negative: Happens only once
health posts for vaccine and
every month. Unskilled and
manpower.
under trained man power.
-They would like to have Positive: -They needed to coordinate with
adequate incentives to municipality office, EPI clinics
-FCHVs could effectively
conduct community level and health institutions to conduct
maintain the communication
programs effectively. programs effectively.
between community people and
-They wished to have health institutions.  
adequate Immunization
-Local media could help in
IEC materials.
increasing awareness.
-FCHVs wished to have
-Academic institutions could
work distribution by
run school health programs.
increasing their number.
Problem Analysis

Fig. 24
Objective Analysis

Fig. 25
Log Framework Matrix
Table 33: Log Framework Matrix of 5 year plan
Narrative Summary
Goal:
Reduced morbidity, mortality, and
disability associated with vaccine-
preventable diseases in Bhanu
Municipality by 2082/83 B.S.
Outcome:
Increased vaccine coverage among
children and mothers in Bhanu
Municipality by 2082/83 B.S.
 
Output
1.1 Increased number of EPI
clinics.
1.2 Reached every child for full
immunization
1.3 Strengthened vaccine supply
chain
Objectively Verifiable Indicator
(OVI)
Immunization Coverage
percentage
Immunization Coverage
percentage
Disease incidence rate
 
Child mortality and morbidity
Disease surveillances
Number of immunization center
 
Number of immunized children
Number of Immunized children
 
Disease Incidence rate
Number of immunized children
 
Disease incidence rate
Means of Verification (MOV)
Annual health report from
Municipality,
HMIS 9.3 Data
Annual Health report from the
municipality, HMIS 9.3 Data
Annual health report of
Municipality, HMIS 9.3 data, EPI
clinic records, Immunization card
Annual health report of
municipality, HMIS 9.3 data, EPI
clinic records, Immunization
cards
Logistic record register of health
division of municipality, LMIS,
Annual health report of the
Assumptions
Adequate budget,
Natural Disaster,
Political Stability
National Immunization
Policy support, Involvement
and commitment of local
government, NGO/INGO,
Community participation
Adequate Budget, Enough
Human resources, Optimum
participation of Patients
Proper maintenance of
immunization card
Skilled human resources,
Proper transportation
1.4 Adequately trained health
workers providing immunization
services
1.5 Financial sustainability for
Immunization Program
1.6 Correct recording and Timely HMIS reporting
reporting of Information regarding
immunization data.
Activities
1.1.1 Infrastructure development
for formation of new EPI clinics.
1.1.2 Periodic intensification of RI Rate of Immunization
through immunization month.
1.1.3 Training about ‘Khop Kit
Bag’ and its guideline to
immunization focal person.
1.1.4 Provide tool kit for
maintenance to staff at new EPI
center.
1.2.1 Awareness raising program
Number of health professionals
The budget allocated for the
immunization program
Number of new Immunization
center.
No. of new vaccinators
Number of new tool kits
Number of awareness campaign
about importance of immunization. programs.
School health program
Record register of health division Regular training program,
of the municipality
Annual budget book of
Municipality
HMIS. Annual report of
Municipality
EPI clinic register
Annual health report of
Municipality
EPI clinic register
LMIS
Report about the awareness
Support from provincial and
local government
Plans and Policies
FCHV and other responsible
persons capable enough to
record and report on time.
Adequate Budget
Political Stability
 
 
Support from school
administration.
1.2.2 Community health program
1.2.3 Supervisions and monitoring
1.3.1 Review and Implement the
policy for forecasting, procuring,
storing, and distributing vaccines
and related logistics.
1.3.2 Procure refrigerator van to
transport vaccines
1.3.3 Estimate, order and maintain
stocks of the most commonly used
cold chain spare parts.
1.4.1 Revise, develop, print, and
distribute training material on
immunization.
1.4.2 Conduct refresher training for
vaccinators.
Number of participants in each
health program.
Number of community health
program.
Total Number of Program broadcast
in local FM radio and TV.
Number of supervisions done.
 
Number of totals procured, stored
and distributed vaccines,
Number of refrigerator vans.
Stock of cold chain spare parts.
Number of IEC material distributed. Record registers of municipality
Number of training programs.
 
Assessment scores of acquired
knowledge at the end of the training
Program broadcasted on FM radio Commitment of stakeholder
and TV. at media.
Report from community health Support from community.
program.
Survey report. Sufficient budget allocation
  for supervision programs.
Observation report.
National/Local Plans and Policies. Regular and timely supply of
  logistics.
.
Timely supervision by higher Support from international
authorities donor agencies.
LMIS report  
 
Training program register. Active participation of
  vaccinators.
Score sheets of training
assessment.
1.4.3 Orientation to FCHV for
strengthening immunization
program
1.5.1 Advocacy meeting with
municipality, law makers, policy
makers, and other stakeholders to
ensure availability of funds.
Number of orientation programs to Training program register. Participation of FCHVs
FCHVs regarding immunization.
Number of meeting conduct. Meeting records. Active participation of all
  stakeholder.
Number of participants in such
meetings.

1.5.2 Advocate and track for use of
municipality grant for immunization
at local level.
1.5.3 Adopt a standard for budget
allocation for cold-chain and vaccine
management. (Procurement,
Transport, Distribution, Repair, and
Maintenance)
Municipal grant for immunization
Total logistics (cold chain)
procured, transported, distributed,
repaired and Maintained.
Vaccine wastage rate
Budget book of municipality Adequate budget
LMIS report, Budget Book,  
Annual health report of
municipality.

1.6.1 Orientation on recording and Number of orientation program HMIS report, Annual Health report Active participation.
reporting for Immunization data. given. of municipality

1.6.2 Training about importance of Number of retained immunization Training program reports  
child health card/ immunization card cards.
and its retention.
1.6.3 Review and expansion of Number of new electronic HMIS report  
electronic immunization registration immunization registration system.
system.
Plan of action
Table 34: Plan of Action of 5 year plan on Immunization Program
S.N. Activities Target Group Quantification of Target Responsible Institution/Persons Time
  Increase number of EPI clinics
1 Infrastructure development EPI clinics 13 new EPI clinics Contractor Over 5 years
2 Announcement of Immunization Children below 15 Every child below 15 months Public health officer Every 6
month months month
3 Tool kits to staff at new EPI EPI clinic staffs 2000 tool kits Municipal health in-charge Every Month
clinics
4 ‘Khop Kit bag’ training Vaccinator 40 vaccinators Municipality Once every 6
months
 
  Reach every child for full immunization
1 Awareness training program Every child and Every child below 15 months Program in-charge Every month
parents
2 Community health program Community 13 wards Program in-charge Every 3
members months
3 Supervision and monitoring Children under 15 Every EPI clinic Supervisor Every 6
months month
  Strengthen vaccine supply chain
1 Review and implement logistic EPI clinics Every EPI clinic Municipal Health In-charge Every year
related policies
2 Procure refrigerator van Rural village 5 Vans Coordinator Every 5 year
3 Maintain stocks of common cold Cold Chain storage Stock in every EPI clinic Logistic in charge Every year
chain spare parts
  Capacity building
1 Distribute IEC material on General people 500 pieces in every ward IEC department Every 6
immunization month
2 Refresher training for Vaccinators 4 training every year Municipality health in- Every 3
vaccinators charge month
3 Orientation to FCHVs FCHVs 100 FCHVs Training facilitator Every 6
month
  Financial Sustainability
1 Advocacy meeting to Law makers,   Municipal health in charge Every 6
ensure availability of funds Policy makers month
2 Track municipality grant for EPI clinic Every EPI clinic Municipal Health in charge Every year
immunization at local level. workers
3 Adopt a standard for Cold chain Every EPI clinic Financial head Every year
budget allocation for cold storage units
chain and vaccine
management.
  Recording and reporting
1 Orientation on recording Municipal All Municipal health Municipal Health in charge Once every
and reporting. worker worker year
2 Child health Child and Every child below 15 Immunization in charge Once every
card/Immunization card parents months month
3 Electronic immunization Municipal 13 Electronic Ward chairperson Every year
registration system health worker immunization register
(one in every ward)
Budgeting
Table 35: Budgeting of 5 year plan
S.N. Activities Budget (in Rs. 1000)
A Increase number of EPI clinic
1 Infrastructure development 1300
2 Announcement of Immunization month 50
3 Tool kits to staff at new EPI clinics 500
4 ‘Khop Kit bag’ training 600
  Total 2450
B Reach every child for Full immunization
1 Awareness training program 600
2 Community health program 1000
3 Supervision and monitoring 50
  Total 1650
C Strengthen Vaccine supply chain
1 Review and implement logistic related policies 250
2 Procure refrigerator van 12500
3 Maintain stocks of common cold chain spare parts 2500
  Total 15250
D Capacity Building
1 Distribute IEC material on immunization 650
2 Refresher training for vaccinators 1000
3 Orientation to FCHVs 400
  Total 2050
E Financial Sustainability
1 Advocacy meeting to ensure availability of funds 250
2 Track municipality grant for immunization at local level. 50
F Recording and Reporting

1 Orientation on recording and reporting. 250

2 Child health card/Immunization card 600

3 Electronic immunization registration system 650

  Total 1500

  GRAND TOTAL 23300

 Learning Reflections
• We learned about importance of planning, coordination, communication,
supervision and monitoring along with clinical management for delivering
effective services.
• We learned about health system of municipality in terms of Input
(Infrastructure, Human Resources, Logistics and Finance), Process
(Planning, Organization, Recording and reporting, Co-ordination,
Supervision and Monitoring) and Output (Health programs and services).
• We learned the role of health institutions like HPs, UHCs, CHUs,
Ayurvedic centers and private hospitals in delivering health services and
implementing health programs.
• We learned that transition from unitary system to federal system opened
lots of opportunities for upgrading of health system from grass root level.
 Recommendations
• To Department of Community Medicine and Public Health (DCMPH)
1. The department could conduct supervision twice during the field program so that we
could have more interaction and receive more feedbacks from the faculties.
2. A study of our own hospital before the actual field could be done for practical
orientation to students.
• To Bhanu municipality
1. The health division of municipality should conduct regular supervision and monitoring
of peripheral health institutions.
2. The municipality should assign focal persons for different health programs as soon as
possible.
• To Purundihi PHCC
1. The hospital could motivate human resources to work in hospital by providing additional
benefits and incentives.
2. Hospital could coordinate with local government to initiate public transportation services
to hospital.
Acknowledgement
• We are thankful to the School of Public Health, Department of Community
Medicine and Public Health.
• We would like to express our appreciation and sincere gratitude to Associate
Prof. Dr. Niki Shrestha (Head of Department of Community Medicine, CMC).
• We would like to express our regards to our CBL field co-ordinator Mr. Eak
Narayan Poudel and all the faculty members (Associate Prof. Dr. Kishor
Adhikari, Asst. Prof. Harish Chandra Ghimire, Dr. Mamata Chhetri, Dr.
Sharbadha Shrestha, Lecturer Subash Koirala and Lecturer Amrita Poudel) for
guiding us during our exercise through their expertise, valuable suggestions and
encouragement.
• We express gratitude to all the facilitators and resource persons of the respective
institutions we are posted in and those we visited as a part of our field program .
Reference
• Annual Health Review 2076/77, Bhanu Municipality

• Annual Report, Department of Health Services, 2075/76

• K. Park’s Textbook of preventive and social medicine, 23rd.

• Davidson’s principles and Practice of Medicine, 23rd Edition

• HMIS Database, Health Section , Bhanu municipality

• www.publichealthupdate.com
 
• www.mohp.gov.np
PHOTO GALLERY