Annual health report 2072/73 (2015-2014)

Abstract

Executive Summary A. introDUCtion The annual report of the Department of Health Services (DoHS) for fiscal year 2072/73 (2015/2016) is the twenty-second consecutive report of its kind. This report focuses on the objectives, targets and strategies adopted by Nepal’s health programmes and analyses their major achievements and highlights trends in service coverage over three fiscal years. This report also identifies issues, problems and constraints and suggests actions to be taken by health institutions for further improvements. The main institutions that delivered basic health services in 2072/73 were the 104 public hospitals, the 303 private hospitals, the 202 primary health care centres (PHCCs) and the 3,803 health posts. Primary health care services were also provided by 12,660 primary health care outreach clinic (PHC- ORC) sites. A total of 16,134 Expanded Programme of Immunisation (EPI) clinics provided immunisation services. These services were supported by 49,523 female community health volunteers (FCHV). The information on the achievements of the public health system, NGOs, INGOs and private health facilities were collected by DoHS’s Health Management Information System (HMIS). B. CHILD HeaLTH Immunization — The National Immunization Programme (NIP) is one of the government’s highest priority programmes. It made a large contribution to Nepal’s achievement of Millennium Development Goals (MDG) 4 and 5 by reducing morbidity and mortality among children and mothers from vaccine preventable diseases. Nepal’s constitution 2015 puts access to health care as a fundamental right of the people. The Immunization Act endorsed (BS 2072) says that every child has the right to access quality vaccines. The coverage of all antigens reduced in 2072/73 compared to 2071/72. The highest coverage was of BCG (87%), DPT-HepB-Hib3 (81%) and oral polio vaccine 3 (79%), which were however all less than the previous year. The measles-rubella second dose was introduced in 2072/73 and had the lowest coverage. The number of ‘fully immunized’ VDCs, municipalities and districts indicates that the number of children immunized was no different to last year. The lower coverage of all the antigens was probably due to the 8.5% increase in the target population in this year and the frequent strikes and the disruptions caused by the April and May 2015 earthquakes. Nutrition — The national nutrition programme is also a priority programme of the government. It aims to achieve the nutritional well-being of all people so as they can maintain a healthy life and contribute to the country’s socioeconomic development. There is high level commitment to improving the nutritional status especially of women and of young children. In 2072/73, an average of 3.2 growth monitoring visits was carried out by 0 to 24 months children, a slight increase on 2071/72. Seventy-eight percent of children aged 0–11 months were registered for growth monitoring, which is 19 percent less than 2071/72. And 2.7 percent of 0-11 month olds and 4.2 percent of 12-23 month olds were underweight, only 31.7 percent of 0 to 12 month olds had been exclusively breast fed while only 32.3 percent of children aged 6-8 months had been fed solid foods, which is a slight increase on the previous year. Community Based Integrated Management of Childhood Illness — In October 2014 the childhood (CB-IMCI) and newborn (CBNCP) care programmes were merged into the Community Based Integrated Management of Childhood Illness (CB-IMNCI) programme to give a more integrated approach. The integrated programme was expanded to 30 new districts in 2072/73. It is an integrated package of DoHS, Annual Report 2072/73 (2015/16) VII child‐survival interventions and addresses major newborn care conditions including birth asphyxia, bacterial infection, jaundice, hypothermia, low birth weight, and encouragement of breastfeeding. It addresses the major illnesses of 2 to 59 month old children — pneumonia, diarrhoea, malaria, measles and malnutrition, in a holistic way. In 2072/73, 26,322 newborns cases (aged 0-28 days) were registered and treated at health facilities and PHC-ORCs of whom 12,871 were treated for local bacterial infections and 3,768 for possible severe bacterial infections (PSBI). In the same year, 32,679 infants (29-59 day olds) were treated at health facilities and PHC-ORCs of whom 2,957 were treated for PSBI. At the national level 1.06 percent 0-59 day old (among expected number of live births) suffered from PSBI. And 64 percent of all PSBI cases were treated with a complete dose of gentamycin. In 2072/73, 1,248,093 cases of diarrhoea were reported of which 0.2 percent suffered from severe dehydration (a decrease from 0.3 percent the previous year). The national incidence of diarrhoea per 1,000 under‐5 year olds decreased from 510/1,000 in 2071/72 to 422/1,000 in 2072/73. In the same year, 1,916,250 acute respiratory infection (ARI) cases were reported among under-5 years olds of which 435,582 were treated for pneumonia (including pneumonia and severe pneumonia) accounting for 23 percent of cases, a slight decrease from the previous two years. The proportion of severe pneumonia cases decreased from 0.4 percent in the previous year to 0.3 percent in 2072/73. C. FamiLY HeaLTH Family planning — The national health service makes available modern methods of contraception through health institutions at static clinics and through mobile outreach services. The contraceptive prevalence rate (CPR) is the main indicator for monitoring the achievements of the National Family Planning Programme. The CPR for the use of modern family planning methods remained at 43% nationally in 2072/73, the same as the previous year. There is however a wide variation between the CPR at the Western Development Region and Eastern Development Region, 34% and 48% respectively. Safe motherhood — During 2072/73, 51% of the number of pregnant women (expected pregnancies) carried out four antenatal visits as per the protocol, a one percentage point decrease from the previous year. The proportion of institutional deliveries also slightly decreased, to 55% in 2072/73 from 57% the previous year. The percentage of mothers who received first postnatal care at a health facility among expected live births also slightly decreased from 59% in 2071/72 to 57% in 2072/73. During 2072/73, 89,284 women received comprehensive abortion care (CAC) services, of which 53% were medical abortions. About 69% of these women received post-abortion family planning services of which only 14 percent took a long acting method. Female community health volunteers — Nepal’s 51,470 female community health volunteers (FCHVs) promote safe motherhood, child health and family planning, and provide other community based health services to promote health and the healthy behaviour of mothers and community people with support from health workers and health facilities. FCHVs contribute significantly to distributing oral contraceptive pills, condoms and oral rehydration solution (ORS) and to counselling and referring mothers to health facilities. FCHVs distributed 10 million packets of condoms FY 2072/73. Service statistics show that more than a half of diarrhoea and ARI cases were treated by FCHVs in this year. Primary health care outreach clinics — PHC-ORCs should be conducted every month at fixed locations in all VDCs on specific dates and time to extend basic health care services to communities. The clinics are conducted within half an hour’s walking distance for local people. In 2072/73, 85% of the expected number of monthly clinics was conducted, with each serving an average of 14 clients, a decrease from 21 per clinic in 2071/72. VIII DoHS, Annual Report 2072/73 (2015/16) Adolescent sexual and reproductive health — The National ASRH programme is being gradually scaled up to meet the NHSP-2 target of making 1,000 public health facilities adolescent‐friendly by 2015. As of July 2016, a total of 1,134 health facilities in 63 districts were providing adolescent‐friendly services. Demography and reproductive health research — The planning, monitoring and evaluation of reproductive health activities are the key functions of the Programme, Budget and Demography Section. This section conducts studies and coordinates reproductive health-related research in Nepal. In addition to its development of the annual programmes and budget, setting target populations, and producing guidelines, the section’s implementation of the maternal and perinatal death surveillance and response (MPDSR) system was a major activity in 2072/73. A total of 1,076 health facility personnel and district stakeholders were trained on MPDSR during 2072/73 while all FCHVs in the five MPDSR implementing districts were orientated on MPDSR. Community-level MPDSR started in five districts while facility-based MPDSR started in 42 hospitals in 2072/73. D. Disease ControL Malaria — Nepal surpassed MDG 6 by reducing malaria morbidity and mortality rates by more than 50% between 2000 and 2010. Subsequently the government committed to a malaria free Nepal by 2025. The number of confirmed malaria cases dropped from 1,674 in 2070/71 to 991 in 2072/73. Although the proportion of Plasmodium falciparum infections decreased to 16.3 percent from 20.3 percent in the previous year, the proportion is still high, which may be due to the high number of imported P. falciparum cases. The trend of clinically suspected malaria cases, confirmed cases and case severity continued to decrease year by year, mainly due to the increased coverage of rapid diagnostic tests (RDT), microscopic laboratory service at peripheral facilities, the high coverage of long lasting insecticidal bednets (LLINs) in endemic districts and increased socioeconomic status. The slower rate of decrease of indigenous Plasmodium vivax cases indicates that it remains a challenge for malaria elimination in Nepal. Kala-azar — Kala-azar is a major public health problem in 18 districts although the number of cases is decreasing. In 2072/2073, 228 cases were reported of which 213 were native cases from 40 districts. A total of 168 cases were from 15 of the 18 programme districts while the other 45 cases were from 25 non-programme districts. The national and district incidence of kala-azar is less than 1/10,000 people. At the district level, the incidence ranges from 0.53 in Morang to 0.01 in Kailali with an average of 0.28 per 10,000 people in the 18 programme districts and 0.11 nationally (excluding foreign cases). The case fatality rate was 0.94% in 2072/2073. Lymphatic filariasis — Lymphatic filariasis is a public health problem in Nepal. All endemic districts should complete the recommended six rounds of mass drug administration (MDA) by 2018. The elimination programme has contributed to strengthening the health system through trainings and capacity building. Over the last 13 years, more than 90 million populations at risk have been treated with MDA medicines. In this fiscal year, 12,470,213 people from 35 districts were targeted for MDA, of whom 8,887,666 (71.3%) were treated, a small proportional increase on the previous year. Dengue — The number of cases of the mosquito-borne disease dengue has decreased over the past few years. The number of cases in 2072/73 (134 from 26 districts) was only 44% of the number reported in 2071/72. The most cases (70) were reported from Chitwan and there were two confirmed deaths, one each from Dang and Chitwan. Zoonoses — About 60 zoonotic diseases have been identified in Nepal. Taeniosis/cysticercosis, neurocysticercosis, leptospirosis, hydatidosis, brucellosis; toxoplasmosis and avian influenza are the priorities zoonotic diseases with epidemic potential in Nepal. During 2072/73, 3,268 cases of snake DoHS, Annual Report 2072/73 (2015/16) IX bites were reported of which 663 were poisonous resulting in 20 deaths. A total of 22,627 animal bite cases were reported of which 88% were dog bites. Six deaths were reported from rabies. Leprosy — A total of 3,054 new leprosy cases were detected and put under multi drug therapy (MDT) in 2072/73, of which 2,559 were under treatment and receiving MDT at the end of the fiscal year. A national registered prevalence rate of 0.89 cases per 10,000 population was reported this year which is below the elimination cut-off point of 1 case per 10,000 population as set by WHO. Among new cases 109 (3.6%) had Grade 2 disability (G2D) and 220 (7.2%) were child cases. The increasing registered prevalence rate since elimination in 2009 is a serious concern. The Disability Prevention and Rehabilitation Focal Unit of the Leprosy Control Division is coordinating with disabled people’s organisations for disability prevention and rehabilitation. Tuberculosis — TB remains a major public health problem in Nepal. The Directly Observed Treatment short course (DOTS) has been successfully implemented since 2001 with 4,344 DOTS treatment centres providing TB treatment services. In 2072/73, 32,379 cases of TB were registered among which 53.2% were pulmonary bacteriologically confirmed (PBC). Most cases were reported among middle-aged people with the most among 15-24 year olds (19%). Childhood TB accounted for 5.5 percent of new cases. The case notification rate (CNR) was 113 per 100,000 population with the central region (127) and Tarai (123) having the highest rates. The overall treatment success rates of drug susceptible TB was 91 percent. The treatment success rates of pulmonary bacteriological confirmed TB was 90 percent compared to 86 percent in retreatment cases, 92.7 percent in new pulmonary clinically diagnosed and 92.2% of extra pulmonary cases. The National Tuberculosis Programme is estimated to have saved 31,434 lives in 2072/73, although 919 deaths were reported this year. HIV/AIDS and STI — In 2015, 1,589 children aged up to 14 years made up about 4 percent of the 39,397 people living with HIV (PLHIV) in Nepal, while the adults aged 15 years and over accounted for the rest. Almost 73 percent of total estimated infections (30,074) are among 15-49 year olds. Males account for two-thirds (62%). The prevalence of HIV among 15-49 year old was 0.2% in 2015. A total of 12,446 PLHIVs were on antiretroviral treatment at the end of 2072/73. Eye care — Nepal’s eye care programme is run by Nepal Netra Jyoti Sangh and is a successful example of an NGO-run eye care programme. The prevalence of blindness in Nepal has reduced from 0.84 percent in 1981 to 0.35 percent at the current time. In 2072/73, Nepal’s hospitals, eye care centres and outreach clinics provided 3.2 million outpatient consultations and performed 309,919 eye surgeries 5 Entomology — DoHS’s Entomology Section is responsible for the surveillance, risk assessment and operational research on the means of transmission of malaria, kala-azar, filariasis, dengue, chikungunya, zika, Japanese encephalitis, chandipura encephalitis, scrub typhus, leptospirosis, plague, gastroenteritis and other emerging and re-emerging diseases with potential of outbreaks or epidemics. It is also responsible to assure quality of tests performs to diagnose vector borne diseases. In 2072/73, the section investigated a number of outbreaks across the country and engaged in water quality testing. Epidemiology and outbreak management — The Epidemiology and Outbreak Management Section is responsible for preparedness planning for outbreaks and epidemics; for managing rapid response teams; and for the regular monitoring of outbreaks and epidemics. The section recorded 23 communicable disease outbreaks in 2072/73, which affected 7,151 people and resulted in 28 deaths. These included outbreaks of acute gastroenteritis and diarrhoea, cholera, scrub typhus, influenza, food poisoning, mushroom poisoning and viral hepatitis A. Water and food-borne diseases were more prevalent this year. X DoHS, Annual Report 2072/73 (2015/16) Disaster management — Nepal’s health sector disaster management programme is a collaborative programme between MoH, DoHS, the Epidemiology and Disease Control Division (EDCD) and WHO Emergency Risk Management (WHO-ERM). It is enhancing health sector emergency preparedness, disaster response and epidemiology and outbreak management capabilities. In 2072/73 the programme expedited contingency planning, trained health workers on emergency preparedness and disaster response and strengthened multi-sectoral coordination and collaboration for disaster management. Surveillance and research — The Epidemiology and Disease Control Division was formed in August 2013 to carry out the surveillance of reportable diseases by collecting, analysing, interpreting, and reporting information for infectious diseases. The section maintains the Early Warning and Reporting System (EWARS). In 2072/73 the section expanded and strengthened its sentinel sites, maintained the regular functioning of its control room and strengthened water quality monitoring and surveillance. E. Curative serviCes The Interim Constitution of Nepal, 2007 gave every citizen the right to basic health services free of cost. The government subsequently decided to provide essential health care services (emergency and inpatient services) free of charge to destitute people, poor people, disabled people, senior citizens, FCHVs, victims of gender violence in up to 25 bedded district hospitals and PHCCs. The government also committed to improving the health of rural and urban people by delivering high-quality health services. In 2072/73, curative health services were provided to outpatients, including emergency patients, and inpatients including free health services. Inpatient services were provided different level of hospitals including INGOs/NGOs, Private medical college hospitals, nursing homes, and private hospitals. In 2072/2073, 66% of the total population received outpatients (OPD) services, 975,280 patients were admitted for hospital services and 1,263,992 patients received emergency services from hospitals. F. SUPPORTING PROGRAMMES Health training — The National Health Training Centre is the apex body for human resource development in Nepal’s health sector. The NHTC has five regional training centres, one sub-regional centre, 34 clinical training sites and 75 district training units. The Training Working Group ensures the efficient running of national health training programmes, maintains the quality of training and improves the coordination of all training provided under NHTC. In 2072/73 NHTC developed and revised a number of training manuals and initiated a number of new training programmes including on primary trauma care management, on-the-job training for gynaecologists and obstetric fistula training. Health education, information and communication —The National Health Education, Information and Communication Centre (NHEICC) is responsible for health promotion, education and communication for all MoH health services and programmes. It is thus responsible for creating more demand for health care services. The main 2072/72 achievements at the central level were the development and implementation of policies, strategies, and programmes; the development of programme guidelines and the development, production and broadcasting of health messages through various media. At the district level the centre ran sensitisation programmes for preventing and controlling epidemics, produced need-based IEC materials and distributed IEC materials to health facilities. Logistics management — The Logistics Management Division (LMD) supports the procurement of equipment, vaccines, family planning commodities and free health drugs by programme divisions and DoHS, Annual Report 2072/73 (2015/16) XI centres. Its major function is to forecast, quantify, procure, store and distribute health commodities, equipment, instruments and to repair and maintain biomedical equipment and transport vehicles. The quarterly Logistics Management Information System (LMIS) and monthly Web‐based LMIS facilitate evidence based logistics decision making and annual logistics planning, quarterly national pipeline review meetings, the consensus forecasting of health commodities and the implementation of the pull system. In 2072/73, LMD carried out regional procurement and supply chain workshops in all regions to address problems and issues faced by district health offices on procurement and supply chain management. Health laboratory services — The National Public Health Laboratory (NPHL) is the nodal institute for building capacity building and for the development of the public health laboratory sector. There are diagnostic health laboratories in 8 central hospitals, 3 regional hospitals, 3 sub-regional hospitals, 10 zonal hospitals, 62 district hospitals, 16 other district level hospitals, 202 PHCCs and more than 1,500 private health institutions. In 2072/73, NPHL provided eight types of routine and specialized laboratory services with more biochemistry, haematology, parasitology, immunology, virology, endocrinology, and microbiology tests carried out than in the previous year. Personnel administration — The Personnel Administration Section is responsible for routine and programme administrative function. Its major functions include upgrading health institutions, the transfer of health workers, level upgrading of health workers up to 7th level, capacity building as well as internal management of human resources of personnel. MoH has more than 30,000 employees of whom more than 24,000 are technical personnel and 6,300 are administrative staff across the 196 sanctioned types of technical and administrative posts. Financial management — An effective financial support system is imperative for the efficient management of health services. DoHS’s Finance Section is the focal point for financial management for all programmes under DoHS. In 2072/73 exactly 5 percent of the national budget was allocated for the health sector of which NPR 27,984 million (76%) was allocated for executing programmes under DoHS. Health service management — The Management Division is responsible for DoHS’s general management functions. The division’s major ongoing activities were institutionalising the use of geographic information systems for health service planning, developing the Health Infrastructure Information System (HIIS), the construction and maintenance of health facility buildings and other infrastructure (with NPR 2,544 billion spent on health building construction through DUDBC in 2072/73), and health facility upgrading. Other activities included HMIS training for newly recruited health workers, arranging the supply of HMIS recording and reporting tools and managing the provision of free treatment to impoverished citizens including 2,744 cancer,1,900 heart disease and 1,006 kidney free treatment services. Primary health care revitalization — The Primary Health Care Revitalization Division is responsible for expanding the coverage of primary health services particularly by addressing the needs of disadvantaged and unreached population groups. Its main achievements in 2072/73 were related to improving access to free basic health services, improving health social protection and strengthening urban health care. Medico-legal services — Medico-legal services include forensic, pathology, autopsy, clinical forensic medicine and toxicology services. Medico-legal services have been neglected in Nepal’s health system. The report presents five recommendations for improving medico-legal services in Nepal: recognising the specific nature of the forensic/medico-legal service sector, training district medical officers and other health professionals to provide medico-legal services, providing facilities, providing incentives and remuneration and improving coordination between investigating authorities. XII DoHS, Annual Report 2072/73 (2015/16) Monitoring and evaluation — As in previous years the Health Management Information System (HMIS) Section collected, collated and provided information on the activities undertaken at the district level to all DoHS divisions, centres, regional directorates, and the 75 district health and district public health offices. Annual performance review workshops were conducted in all districts and regions and at the national level. Several trainings were conducted on programme management to improve the skills of health workers. Ninety-two percent of targeted activities were carried out in 2072/73. G. PROGRESS OF OTHER DEPARTMENTS The Department of Drug Administration is responsible for regulating all functions related to modern, veterinary and traditional medicines. In 2072/73 it Inspected 35 domestic pharmaceutical industries and 2,909 pharmacies, audited 25 pharmaceutical analytical laboratories, analysed 878 medicine samples and provided information on medicines to the public via media on 19 occasions. It also renewed the licenses of 8,487 pharmacies and registered 1,080 new pharmacies. The Department of Ayurveda manages the delivery of Ayurveda health services. The department runs two Ayurveda hospitals, 14 zonal Ayurveda dispensaries, 61 district Ayurveda health centres and 305 Ayurveda dispensaries. In 2072/73, there were 1,034,029 outpatient consultations and a total of 1.2 million client-visits for Ayurveda treatment at DoA institutions. H. HeaLTH CounCILS The six professional health councils (Nepal Medical Council, Nepal Nursing Council, Nepal Ayurvedic Medical Council, Nepal Health Professional Council, Nepal Pharmacy Council and Nepal Health Research Council) accredit health-related schools and training centres and regulate care providers. I. HeaLTH Care soCiaL seCurity Nepal is committed to access to quality health care for all its citizens. The National Health Insurance Programme was initiated in 2016 in Kailali, Baglung and Ilam districts. As of 15 July 2016, 12,623 people had enrolled in the scheme, just under one percent of the population of the three districts with more than NPR 6 million of deposits collected J. DEVELOPMENT PARTNER SUPPORT The partners who provided the highest levels of financial support in 2015/16 were: • UNICEF: Health: $11.7 million and Nutrition: $9.1 million ($20.8 million) • DFID: £6.65 million financial aid and £5.6 million technical assistance (£12.25 Million) • German Development Cooperation: GIZ: €5.54 million and KfW: €4.06 million (€9.6 million) • World Bank: $5.5 million • UNFPA: $4.89 million