Annual health report 2073/74 (2016-2017)

Abstract

Executive Summary

A. INTRODUCTION The annual report of the Department of Health Services (DoHS) for fiscal year 2073/74 (2016/2017) is the twenty-third 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 2073/74 were the 123 public hospitals including other ministries, the 1,715 non-public health facilities, the 200 primary health care centres (PHCCs) and the 3,808 health posts. Primary health care services were also provided by 12,180 primary health care outreach clinic (PHCORC) sites. A total of 16,022 Expanded Programme of Immunization (EPI) clinics provided immunization services. These services were supported by 49,001 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 Program (NIP) formerly Expanded Program on Immunization (EPI) was started in FY 2034/35 and is a priority 1 program. It is one of the successful public health interventions of Ministry of Health. It made a large contribution to Nepal's achievement of Millennium Development Goal 4 and 5 by reducing morbidity and mortality among children and mothers from vaccine preventable diseases. Nepal's constitution 2015 ensures access to health care as a fundamental right of the people. The Immunization Act endorsed (BS 2072 Magh 12) says that every child has the right to access quality vaccines. National Immunization Program has included several underused and new vaccines in program and currently there are eleven antigens–BCG, DPT-HepB-Hib (penta), PCV, OPV (bOPV), Measles and Rubella (MR) and Japanese Encephalitis provided through 16,000 service delivery points in health facilities (fixed session), outreach sessions and mobile clinic (sessions). Government of Nepal procures BCG, OPV, Td , JE, measles/rubella 1st dose and co-finances to GAVI supported vaccines DPT-HepB-Hib (penta), PCV and measles component of MR2. Aiming to reach every child in country, some innovative activities have also been carried out in country like Full Immunization declaration initiative, Immunization Act, rule and immunization fund creation. The coverage of all antigens increased in 073/74 compare to 072/073. The highest coverage was of BCG (91%), DPT-HepB-Hib3 (86%), oral polio vaccine 3 (86%), which were all more than the previous year. The measles rubella second dose was introduced in 2072/73 and had the lowest coverage (57%) however it is more than previous year. C. Nutrition The national nutrition programme is 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 contributed to the country's socioeconomic development. There is high level commitment to improving the nutritional status especially of women and of young children. Nutrition is a globally recognized development agenda. Since the year 2000, several global movements have advocated nutrition for development. The Scaling-Up-Nutrition (SUN) initiative calls for multi-sectoral action for improved nutrition during the first 1,000 days of life. The Government of Nepal as an early member of SUN adopted the Multi-sector Nutrition Plan (MSNP) in 2012 to reduce chronic nutrition. The UN General Assembly declared the 2016–2025 period as the Decade of Action on Nutrition. Aligning with the MSNP and current global initiatives, CHD – nutrition section has developed strategies and plans for improving maternal infant and young child nutrition assisted by experts from the Nutrition Technical Committee. Moreover, as recommended by the Nepal Nutrition Assessment and Gap Analysis (NAGA) and guided by MSNP, in 2012–2013 MoH conducted an Organization and Management Survey towards establishing a National Nutrition Centre for implementing MSNP in the health sector. Recently, MSNP-2 has been approved for 2075/76 – 2079/80. In 2073/74 an average of 3 growth monitoring visit was carried out by 0-23 month's children at national level which is slightly decreased as of previous year. Sixty three percent children aged 0-23 months were registered for growth monitoring which is six percent more than 2072/73 and twenty- five percent of 0-6 months infants registered for growth monitoring who were exclusively breastfed for their first six months which is 6.65 percent less than 072/073. D. ntegrated 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. It is an integrated package of 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 fiscal year 2073/74, 25,742 newborns cases (aged 0-28 days) were registered and treated at health facilities and PHC/ORCs of whom 12,295 were treated for local bacterial infections and 3,713 for possible Severe Bacterial Infections (PSBI). In the same year, 31,098 infants (29-59 day old) were treated at health facilities and PHC/ORCs of whom 2,765 were treated for PSBI. At the national level 1.0 percent 0-59 day old (among expected number of live births) suffered from PSBI. And 58.4 percent of all PSBI cases were treated with a complete dose of gentamycin. In 2073/74, 1,184,120 cases of Diarrhoea were reported of which 0.44 percent suffered from severe dehydration (increased from 0.2 percent the previous year). The national incidence of diarrhoea per 1,000 under-5 year olds decreased from 422/1,000 in 2072/73 to 400/1000 in FY 2073/74. In FY 2073/74, a total of 1,810,722 ARI cases were registered, out of which 10.5% were categorized as pneumonia cases and 0.29% were severe pneumonia cases. The incidence of pneumonia (both pneumonia and severe pneumonia at HF and PHC/ORC) at national level was 64 per 1000 under five children as compared to 147 per 1,000 under-five children in the previous fiscal year (FY 2072/73). E. C. FAMILY HEALTH Family planning In order to provide the reproductive population with options to limit or space births, various modern contraceptive methods are made available under the national health services delivery system. Family planning services are provided through different health institutions at various levels through static clinics as well as mobile outreach services. The Contraceptive Prevalence Rate (CPR) is one of the main indicators for monitoring and evaluating the National Family Planning Program. The contraceptive prevalence rate (CPR) for modern family planning method is 44% at national level in fiscal year 2073/74. There has been a one percentage point increase in modern CPR at national level in FY 2073/74 than in FY 2072/73. There is wide variation in CPR at the province level with lowest 35% in Province 4 and highest 49% in Province 2 ii DoHS, Annual Report 2073/74 (2016/17) Executive Summary Safe motherhood During FY 2073/74, the national level ANC 4th visit (as per protocol) as percentage of expected pregnancy has been increased to 52%. Similarly, the institutional delivery has slightly been increases to 57% in FY 2073/74 as compare to 55% in FY 2072/73. Percentage of mothers who received first postnatal care at the health facility among expected live births has also slightly decreased to 51% in FY 2073/74 from 57% of FY 2072/73. During FY 2073/74, a total of 96417 CAC service has been provided, out of which, 44% women had received medical abortion service. While about 70% women had received post abortion family planning services. Contribution of Long Acting FP service out of total post abortion FP is appeared to be only about 16% (a 2% point increase in FY 2073/74 than in FY 2072/73. Female community health volunteers The major role of the Female Community Health Volunteers (FCHVs) is promotion of safe motherhood, child health, family planning, and other community based health services to promote health and healthy behavior of mothers and community people with support from health workers and health facilities. At present there are 51,470 FCHVs (47,328 FCHVs at rural/VDC level and 4,142 at urban/municipality level) actively working all over the country. FCHVs contributed significantly in the distribution of oral contraceptive Pills, Condoms and Oral Rehydration Solution (ORS) packets and counseling and referring to mothers in the health facilities for the service utilization. FCHVs have distributed a total of 9983370 packets of Condom in FY 2073/74. Service statistics also show that more than one half of the diarrhoea and ARI cases were treated by FCHVs. Primary health care outreach clinics Based on the local needs PHC/ORCs are conducted every month at fixed locations of the VDC on specific dates and time. The clinics are conducted within half an hour's walking distance for the population residing in that area. Primary health care outreach clinics (PHC/ORC) extend basic health care services to the community level. Total number of clinics expected to run in a year 159,764 (13,314 PHC/ORC Clinics x 12 times). However, only 83% clinics were conducted in FY 2073/74. On an average 19 clients were served per clinic during the fiscal year 2073/74 and it was slightly increased compared to FY 2072/73 (16%). Adolescent sexual and reproductive health The National ASRH program has been gradually scaled up to 70 of the 75 districts covering 1134 health facilities till the end of current fiscal year 2073/74. Different development partners such as UNFPA, UNICEF, WHO, Save the Children, Ipas, ADRA Nepal and MSI Nepal at national and sub- national level supported to Family Health Division (FHD) for scaling up and strengthening ASRH services in the health facilities in order to make those health facilities as adolescent friendly service sites. The remaining five districts (Manang, Mustang, Dolpa, Rasuwa and Sindhupalchowk) will be covered in the running FY 2074/75. Demography and reproductive health research Planning, monitoring and evaluation of reproductive health (RH) activities are the key functions of Program, Budget and Demography Section. This section conducts periodic and ad hoc studies and also coordinates reproductive health related research and studies carried out by other organizations in Nepal. In addition to the development of annual program and Budget, target population setting, and guideline/ documents, implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR) was a major activity conducted in FY 2073/74 through Demography Section. A total of 1076 persons including health facility personnel and district stakeholders were trained in MPDSR during FY 2073/74. Furthermore, all FCHVs of Baitadi had also received MPDSR orientation. DoHS, Annual Report 2073/74 (2016/17) iii Executive Summary As per government commitment to count every maternal deaths, community-level MPDSR has been expanded in 6 districts by the end of FY 2073/74 and Ministry of Health has planned to gradually expand this to all 75 districts. In addition, facility-based MPDSR has already started in 42 hospitals in FY 2073/74. F. D. DISEASE CONTROL Malaria Nepal has surpassed the Millennium Development Goal 6 by reducing malaria morbidity and mortality rates by more than 50% in 2010 as compared to 2000. Therefore, Government of Nepal has set a vision of Malaria free Nepal in 2025. Current National Malaria Strategic Plan (NMSP) 2014- 2025 was developed based on the epidemiology of malaria derived from 2012 micro-stratification, The aim of NMSP is to attain “Malaria Free Nepal by 2026”. Total positive cases of malaria slightly increased to last fiscal year from 991 in FY 2072/73 to 1128 in 2073/74 where 492 cases are indigenous cases and 636 are imported casesdue to active surveillance. The proportion of P. falciparum infections is decreasing trend and reached 13.1 % in current FY2073/74 as compared to the previous year, however still the proportion is high which may be due to high number of imported P. falciparum cases.The trend of indigenous pf malaria cases are decreasing while imported cases of pf are in increasing trend. The trend of clinically suspected malaria case, slide positivity rate, pf and pv malaria cases also decreasing year by year, mainly due to increased coverage of RDT, microscopic laboratory service at peripheral level, high coverage of LLINs in endemic districts and increased socio-economic status of community people. Kala-azar Kala-azar is a major public health problem in 18 districts of Nepal and to eliminate Kala azar in Nepal set goal to improving the health status of vulnerable groups and at risk populations living in kala-azar endemic areas of Nepal by eliminating kala-azar so that it is no longer a public health problem. The incidence of kala-azar at national and district level has been less than 1/10,000 population since 2013. The trend of KA cases has been decreasing significantly for the last several years. In FY 2073/2074, total 225 native cases and 6 foreign cases were reported. 157 cases were reported from programme district while other cases were from other nonprogrammer district. The case fatality rate was 0.3 percent in 2073/2074. Lymphatic filariasis Lymphatic Filariasis (LF) is a public health problem in Nepal. The goal of national Lymphatic Filariasis programme is the people of Nepal no longer suffer from lymphatic filariasis. As of 2073/74, MDA has been stopped (phased out) in 31 districts, post-MDA surveillance initiated in 20 districts and morbidity management partially initiated in all endemic districts. All endemic districts will complete the recommended six rounds of MDA by 2018. The LF elimination programme has also indirectly contributed to strengthening of health system through trainings and capacity building activities. The transmission assessment survey in 31 districts in 2016 found that the prevalence of infection had significantly reduced. Since 2003 more than 100 million doses of lymphatic filariasis drugs have been administrated to at-risk population. 2172 hydrocele surgeries have been performed in year 2073/074. Dengue Dengue, a mosquito-borne disease emerged in Nepal in since 2005. The goal of national Dengue control program is to reduce the morbidity and mortality due to dengue fever, dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS).The number of reported dengue cases has decreased significantly since 2010 but cases of dengue were increased in 2073/74 fiscal year. The majority of iv DoHS, Annual Report 2073/74 (2016/17) G. Executive Summary cases have been reported from Chitwan, Jhapa and Rupandehi with more than 46 percent of 2073/74 cases from Chitwan. Total 1527 cases reported from 42 districts. Zoonoses Nepal has dual burden of disease and zoonotic diseases of epidemic, endemic and pandemic potentials are major public health concerns. Globally more than 300 Zoonotic diseases are identified among which about 60 have been identified in Nepal as emerging and re-emerging diseases. No Nepalese dies of rabies or poisonous snake bites due to the unavailability of anti-rabies vaccine (ARV) or anti-snake venom serum or timely health care services and to prevent, control and manage epidemic and outbreak of zoonoses is the goal of zoonoses program. Around 30,000 cases in pets and more than 100 human rabies cases occur each year with the highest risk are in the Terai. During the FY 2073/74, 39,744 dog and other animal bites cases has been reported including 8 deaths throughout the Nepal and 6121 cases of Snake bite has been reported. 33 deaths due to snake bite has been reported this year. Leprosy During the reporting year 2073/74, a total number of 3215 new leprosy cases were detected and put under Multi Drug Therapy (MDT). 2626 cases were under treatment and receiving MDT at the end of the fiscal year. Registered prevalence rate of 0.92 cases per 10,000 population at national level was reported this year which is below the cut-off point of below 1 case per 10,000 population as per the standard set by WHO. 87 (2.71%) new leprosy cases of Grade 2 Disability (G2D), 220 (6.84%) new child leprosy cases and 1361 (42.33%) new female leprosy cases were recorded. The increasing trend of registered prevalence rate after the elimination in 2009 is a serious concern for leprosy control programme hence early and active case detection activities need to be amplified and records/reports of local health facility level needs to be verified and validated. Leprosy Control Division, Disability Focal Unit had recently endorsed Policy, Strategy and 10 Years Action Plan on Disability Management (Prevention, Treatment and Rehabilitation). The unit is coordinating with DPOs and related organization for the disability prevention and rehabilitation of people with disability Tuberculosis Tuberculosis (TB) is still a major public health problem in Nepal. Directly Observed Treatment short course (DOTS) have successfully been implemented throughout the country since April 2001 and a total of 4344 DOTS treatment centers are providing TB treatment service throughout the country. In Fiscal Year 2073/74, total of 31,765 cases of TB were registered. Among them, 54.63% were pulmonary bacteriologically confirmed (PBC). Most cases were reported among the middle-aged group with the highest among 15-24 year of age (20%). The childhood TB (new and relapse) was 5.7%. The Case Notification Rate (CNR) all forms was 111 per 100,000 population. The Midwest Region hold highest case (CNR 128) followed by central region (CNR 123), far western region (CNR 109), western region(CNR 106) and eastern region (CNR 83). Whereas in eco-terrain, CNR was highest in Terai zones followed by hill and mountain zones with rates of 123, 104 and 61 per 100,000 populations respectively. The overall treatment success rates (all forms) of drug susceptible TB was 92.%. The treatment success rates of new and re-treatment Pulmonary Bacteriological Confirmed (PBC) was 90% compared 93 % in new Pulmonary Clinically Diagnosed (PCD) and Extra Pulmonary cases. Failure rate in new PBC was 1.2% compared to 2.2% in retreatment cases, 0.1% in new PCD cases and 0.16% in EP cases. National Tuberculosis program, Nepal was able to save 29,027 lives in FY 2073/74 nationally, but still 971 deaths were reported among general TB cases. DoHS, Annual Report 2073/74 (2016/17) v Executive Summary HIV/AIDS and STI Making up 3.6% of the total estimated people living with HIV (PLHIV) (32,735), there are about 1,197 children aged up to 14 years who are living with HIV in Nepal in 2016, while the adults aged 15 years and above account for 96.4%. Almost 75% of total estimated infections (31,539) among population aged 15-49 years. By sex, males account for two-thirds (62%) of the infections and the remaining more than one-third (38%) of infections are in females. The prevalence of HIV among 15-49 years of age group is 0.17% in 2016. Total 14,544 PLHIV are on ART treatment by the end of FY 073/74. 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 at the current time. In 2073/74, Nepal’s hospitals, eye care centres and outreach clinics provided 3,873,340 outpatient consultations and performed 317,901 eye surgeries. Human Organ Transplant services National Transplant Center's main objectives are to strengthen and expand organ transplantation services, provide specialized services beyond transplantation along with high quality health care at a low price/free of cost and produce high level human resources by providing structured training in various aspects of services to expand the services across the country. During this reporting year a total number of 22,473 OPD services, 518 minor and 1,101 major surgeries, 132 kidney transplantation and along with two liver transplantation (which was first of its kinds in the nation) services were provided. Entomology Entomology section/entomology lab is one of the integral parts of Epidemiology and Disease Control Division. It is accountable to plan, implement, monitor & supervise all entomological activities like surveillance, risk assessment & operational research of vectors borne diseases as well other emerging and re-emerging diseases having potential of outbreak and prone to be epidemic in nature. In FY 2073/74, investigations and an entomological survey was conducted in 12 different districts of five regions of Nepal. In that survey Anopheles mosquitoes were collected. These are the common species of anopheles mosquito which were found in that survey. Epidemiology and outbreak management In Nepal communicable disease outbreak are common and occur in different district. Forty-one communicable disease outbreaks were recorded in Nepal in 2073/74, which affected 3,565 people and resulted in 29 deaths. There were major outbreaks of acute gastroenteritis and diarrhoea, cholera, leptospirosis, scrub typhus, influenza, food poisoning, mushroom poisoning and dog bite. The average case fatality rate was 0.81 percent. The Scrub Typhus outbreak had the greatest morbidity. Mushroom poisoning also had a high case fatality rate (45%). Reported water and food- borne diseases were more prevalent this year. Disaster management This collaborative programme between MoH/DoHS/EDCD and WHO-EHA has been committed to enhancing health sector emergency preparedness, disaster response and epidemiology and outbreak management capabilities in close coordination & collaboration with key players in the country. In the fiscal year 2073/74, no any such disaster event was recorded which affected the health of people. District health sector contingency planning, Rapid Response training, Emergency and disaster preparedness planning activities were carried out for disaster preparedness. vi DoHS, Annual Report 2073/74 (2016/17) Executive Summary Surveillance and research Disease surveillance and research is an integral part of Epidemiology and Disease Control Division. This section came into existence in August 12, 2013 (Shrawan 28, 2070 BS). The mission of the communicable diseases Surveillance program is to protect and improve the health of Nepalese citizens by tracking and responding to the occurrence of disease in the population across the country. In 2073/74 an additional 4 sentinel sites were trained on EWARS (District hospital Khotang, District hospital Panchthar, District hospital Manang and Bayalpata hospital, Achham) bringing the number of EWARS sentinel sites to 64. Similarly Water quality surveillance Central committee (WQSCC) meeting with stakeholder and organized water quality surveillance workshop at Arghakhanchi, Baglung and Gorkha districts. Surveillance of reportable diseases is responsible for collecting, analyzing, interpreting, and reporting information for infectious diseases. E. CURATIVE SERVICES In 2073/74, 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 this fiscal year 2073/2074, 72% of the total population received outpatients (OPD) services, 1,322,816 patients were admitted for hospital services and 1,765,764 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 2073/74 initiated a number of new training programmes including on primary trauma care management, on-the-job training for gynaecologists and obstetric fistula training. Vector Borne Disease Research & Training Vector Borne Disease Research & Training Center (VBDRTC) became semi autonomous with the effect of Development Board Act from 24th January 2000. Now the center is being governed by the Development Board. Main objective of training center is to fulfill the knowledge and management gap between vector borne disease and program to the VBD focal persons. Mostly who were not trained before or newly recruited also enhance the level of knowledge and skills of the participant pertaining to prevalent and possible vector borne diseases. VBDRTC is responsible for research and training of VBDS including Malaria, Kala-azar, Dengue, Chikungunaya, Lymphatic Filariasis, Scrub typhus and Japanese encephalitis. Health education, information and communication The National Health Education, Information and Communication Center(NHEICC) is the apex body under Ministry of Health for planning, implementing, monitoring and evaluating Nepal's health promotion, education and communication programmes including periodic surveys and research. The major achievements in 2073/74 at the central level were the development and implementation of health communication policies, strategies, development and broadcasting of health message through various methods and media. More over MERO BARSA 2074" Ma Swastha Mero, Desh Swastha" health promotion campaign was launched and implemented, Tobacco Control Intervention, Golden 1000 Days Communication Campaign and health information related Mobile SMS messages were delivered. DoHS, Annual Report 2073/74 (2016/17) vii Executive Summary At the district level, behavior change communication activities were conducted for preventing and controlling epidemics, broadcasted health message through local FM Radio, developed need based IEC materials and distributed to health facilities. Logistics management The main role of Logistics Management Division is to support in delivering quality health care services providing by program divisions and centers through logistics supply of essential equipments, vaccines, family planning commodities and free health drugs to all regional /district stores and health facilities. The major function of LMD is to forecast, quantify, procure, store and distribute health commodities, equipments, instruments and repairing & maintaining of the bio-medical equipments/instruments and transportation vehicles. The quarterly LMIS and monthly Web-based LMIS have facilitated evidence based logistics decision making and initiatives in annual logistics planning, quarterly national pipeline review meetings, the consensus forecasting of health commodities and the implementation of the pull system. LMD carried out Regional Procurement and Supply Chain Workshop in all regions of the country to address the problems and issues faced by the districts in procurement and supply chain management of health commodities in the region and district. LMD has form a authorized 23 members Logistics Working Group (LWG) under the chaired of LMD Director with representation of Divisions, Centers, supporting partners and other stakeholders. LWG address all issues and challenges on procurement and supply chain on health commodities and materials in center, region and district level. Health laboratory services The National Public health laboratory (NPHL) is the Nodal Institute for capacity building and for the development of 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, 22 other district level hospitals, 204 PHCCs and more than 1,500 private health institutions. In 2073/74, NPHL provided various types of routine and specialized laboratory services with more biochemistry, haematology, parasitology, immunology, virology, endocrinology, and microbiology test carried out more 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 2073/74 out of total national budget of Rs. 10,48,92,13,54,000 a sum of Rs. 40,56,30,27,000 (3.86%) was allocated for the health sector during the reporting year. Of the total health sector viii DoHS, Annual Report 2073/74 (2016/17) Executive Summary budget, Rs. 31,45,05,36,111 (77.53%) was allocated for the execution of programs under the Department of Health Services Network Health service management The Management Division is responsible for DoHS’s general management functions. The division’s major ongoing activities were institutionalizing 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, and health facility upgrading. Other activities included HMIS training for newly recruited health workers, arranging the supply of HMIS recording and reporting tools. Managed the provision of free treatment to impoverished citizens including 5,821 Cancer, 3,291 Heart disease and 5,888 Kidney free treatment services Primary health care revitalization The Primary Health Care Revitalization Division is responsible for strengthening Primary Health Care by increasing access to basic free health services especially for poor, disadvantaged and unreached population groups. Its main achievements in 2073/74 were related to increasing access to free basic health services, improving social health protection and strengthening urban health including non communicable disease services. 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: recognizing 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. 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 / 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 2073/74. G. PROGRESS OF OTHER DEPARTMENTS The Department of Drug Administration (DoA) is responsible for regulating all functions related to modern, veterinary and traditional medicines. Its 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. DoHS, Annual Report 2073/74 (2016/17) ix Executive Summary I. HEALTH CARE SOCIAL SECURITY The Social Health Security Program was initiated in April 2016 in Kailali district and in June 2016 in Baglung and Ilam districts. As such, the program was rolled out to three districts in FY 2072/73. In the FY 2073/74, the program was expanded to additional 12 districts. By the end of this year 228,113 people have been enrolled to the program. More than 63 million annual contributions have been collected. J. DEVELOPMENT PARTNER SUPPORT Development partners support the government health system through a sector-wide approach (SWAp). The SWAp now supports the implementation of the new Nepal Health Sector Strategy (NHSS, 2016–2021). The Joint Financing Arrangement (JFA) has been signed by various partners and the government. The JFA describes in detail the arrangement for partners’ financing of the NHSS. The JFA elaborates the pool funding arrangement and parallel financing mechanism as bilaterally agreed between the government and the donor partners.