Progress of the Health

and Population Sector,

2018/19
NATIONAL JOINT ANNUAL REVIEW REPORT – 2019 (2076 BS)

Government of Nepal
Ministry of Health and Population
Kathmandu
December 2019
 

Page 0
 
Table of Contents
Abbreviations ................................................................................................................................................ ii 
Executive Summary ...................................................................................................................................... vi 
1.  Introduction .......................................................................................................................................... 1 
1.1 Background ......................................................................................................................................... 1 
1.2 Status of Aide Memoire ...................................................................................................................... 2 
2.  NHSS Result Framework ....................................................................................................................... 5 
2.1 Background ......................................................................................................................................... 5 
2.2 Overview of the Progress .................................................................................................................... 5 
2.3  NHSS Mid‐Term Review ................................................................................................................ 4 
2.4  Regular Programme Reviews ........................................................................................................ 6 
2.5  Equity Analysis of Key Health Indicators ....................................................................................... 7 
3.  NHSS Outcome‐wise Progress Status ................................................................................................. 12 
3.1 Outcome 1: Rebuild and Strengthen Health Systems: Infrastructure, Human Resources for Health, 
Procurement, and Supply Chain Management ....................................................................................... 12 
Outcome 1a Infrastructure ..................................................................................................................... 12 
Outcome 1.b Human Resources for Health ............................................................................................ 17 
Outcome 1.c Procurement and Supply Chain Management .................................................................. 18 
3.2 Outcome 2: Improved Quality of Care at Point‐of‐delivery .............................................................. 28 
3.3 Outcome 3: Equitable Distribution and Utilisation of Health Services ............................................. 30 
3.4 Outcome 4: Strengthened Decentralised Planning and Budgeting .................................................. 32 
3.5 Outcome 5: Improved Sector Management and Governance .......................................................... 38 
3.6 Outcome 6: Improved Sustainability of Healthcare Financing ......................................................... 42 
3.7 Outcome 7: Improved Healthy Lifestyles and Environment ............................................................. 44 
3.8 Outcome 8: Strengthened Management of Public Health Emergencies .......................................... 47 
3.9  Outcome 9: Improved Availability and Use of Evidence in Decision Making Processes at All 
Levels  49 
Annexes ....................................................................................................................................................... 55 
References .................................................................................................................................................. 78 

 
 
Abbreviations

AA Anaesthetic Assistant
AMR Anti-Microbial Resistance
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
APP Annual Procurement Plan
ART Anti-Retroviral Treatment
AWPB Annual Work Planning and Budget
BCG Bacilli Calmette- Guerin (Vaccine)
BHCS Basic Health Care Services
BMI Body Mass Index
BOR Bid Opening Report
BPKIHS B.P. Koirala Institute of Health Sciences
BS Bikram Sambat
CAPP Consolidated Annual Procurement Plan
CAPP-MC Consolidated Annual Procurement Plan Monitoring Committee
CBS Central Bureau of Statistics
CEONC Comprehensive Emergency Obstetric and Neonatal Care
CHD Child Health Division
CHE Current Health Expenditure
CHU Community Health Unit
CMS Contract Management System
CMU Contract Management Unit
CPR Contraceptive Prevalence Rate
CS Caesarean Section
CSD Curative Services Division
CTEVT Council for Technical Education and Vocational Training
DC Delivery Care
DFID Department for International Development
DG Director General
DHO District Health Office
DLI Disbursement Linked Indicators
DoA Department of Ayurveda
DoHS Department of Health Services
DPHO District Public Health Office
DPT-HepB-Hib Diphtheria Pertussis Tetanus - Hepatitis B and Hemophilus influenza type b (Vaccine)
DRR Disaster Risk Reduction
DUDBC Department of Urban Development and Building Construction
EDCD Epidemiology and Disease Control Division
EML Essential Medicine List
EDP External Development Partners
e-GP Electronic Government Procurement
e-LMIS Electronic Logistics Management Information System
F-CAPP Federal Consolidated Annual Procurement Plan
FCHV Female Community Health Volunteer
FED Free Essential Drugs
FHD Family Health Division
FMIS Financial Management Information System
FMR Financial Management Report

 
 
FP Family Planning
FY Financial Year
GBV Gender Based Violence
GDP Gross Domestic Product
GESI Gender Equality and Social Inclusion
GoN Government of Nepal
HEDMU Health Emergency and Disaster Management Unit
HEOC Health Emergency Operation Centre
HFOMC Health Facility Operation and Management Committee
HFS Health Financing Strategy
HIIS Health Infrastructure Information System
HMIS Health Management Information System
HP Health Post
HRH Human Resources for Health
HURIC Human Resource Information Centre
ICB International Competitive Bidding
ICT Information and Communication Technology
IEC Information, Education and Communication
IHIDP Integrated Health Infrastructure Development Project
IHME Institute for Health Metrics and Evaluation
IMAM Integrated Management of Acute Malnutrition
IMNCI Integrated Management of Newborn and Childhood Illness
IMS Inventory Management System
IoM Institute of Medicine
IP Implementation Plan
JAR Joint Annual Review
JCM Joint Consultative Meetings
JICA Japan International Corporation Agency
KAHS Karnali Academy of Health Science
KfW German Development Bank
KOICA Korean International Cooperation Agency
LCD Leprosy Control Division
LG Local Government
LMBIS Line Ministry Budgetary Information System
LMD Logistics Management Division
LMIS Logistics Management Information System
LNOB Leaving No-One Behind
MD Doctor of medicine
MDGP Master's Degree in General Practice
M&E Monitoring and Evaluation
mhGAP Mental Health Gap Action Programme
MMR Maternal Mortality Ratio
MoF Ministry of Finance
MoFAGA Ministry of Federal Affairs and General Administration
MoHP Ministry of Health and Population
MPP Master Procurement Plan
MR Measles and Rubella (Vaccine)
MS Master of Surgery
MTR Mid-Term Review
NA Not Available
NAMS National Academy of Medical Sciences

 
 
NCB National Competitive Bidding
NCD Non-Communicable Diseases
NDHS Nepal Demographic and Health Survey
NHIDS National Health Infrastructure Development Standards
NHFS Nepal Health Facility Survey
NHP National Health Policy, 2019
NHRC Nepal Health Research Council
NHSS Nepal Health Sector Strategy (2015-2020)
NHSSP Nepal Health Sector Support Programme
NHSPSF Nepal Health Sector Procurement Strategic Framework
NHTC National Health Training Centre
NLSS Nepal Living Standards Survey
NMC Nepal Medical Council
NMICS Nepal Multiple Indicator Cluster Survey
NNC Nepal Nursing Council
NNMSS Nepal National Micronutrient Status Survey
NPR Nepalese Rupees
NSSD Nursing and Social Security Division
O&M Organisation and Management
OAG Office of the Auditor General
OC Outcome
OCMC One Stop Crisis Management Centres
OOPE Out of Pocket Expenditure
OP Output
OPMCM Office of the Prime Minister and Council of Ministers
ORS Oral Rehydration Solution
OT Operation Theatre
PAS Procurement Audit System
PBO Public Bid Opening
PCAS Procurement Compliance Audit System
PCL Proficiency Certificate Level
PEN Package of Essential Non-Communicable Diseases
PFM Public Financial Management
PG Provincial Government
PHCC Primary Health Care Centre
PHCRD Primary Health Care Revitalisation Division
PHD Provincial Health Directorate
PHS Public Health Service
PHLMC Provincial Health Logistics Management Centre
PIP Procurement Improvement Plan
PNC Postnatal Care
PPA Public Procurement Authority
PPFM Procurement and Public Financial Management
PPICD Policy, Planning and International Cooperation Division
PPMO Public Procurement Monitoring Office
PPR Public Procurement Regulations
PRA Procurement Risk Analysis
PSCM Procurement and Supply Chain Management
PTSD Post-Traumatic Stress Disorder
QAP Quality Assurance Plan
QSRD Quality, Standards and Regulation Division

 
 
RDQA Routine Data Quality Assessment
RF Results Framework
RMP Risk Mitigation Plan
RRT Rapid Response Team
RTA Road Traffic Accident
SBA Skilled Birth Attendant
SBD Standard Bid Document
SC Steering Committee
SCM Supply Chain Management
SD Standard Deviation
SDG Sustainable Development Goals
SHI Social Health Insurance
SNG Sub-National Governments
SOP Standard Operating Procedures
SSU Social Service Units
SWAp Sector-Wide Approach
TABUCS Transaction Accounting and Budget Control System
TB Tuberculosis
ToR Terms of Reference
ToT Training of Trainers
TSB Technical Specification Bank
TWG Technical Working Group
U5 Under five years old
UHC Universal Health Coverage
USAID United States Agency for International Development
USD United States Dollar
VfM Value for Money
WHO World Health Organization
YLL Years Life Lost

 
 
Executive Summary

The Ministry of Health and Population (MoHP) developed the Nepal Health Sector Strategy
(NHSS) in 2015 to guide the health sector for the next five years. The vision of the NHSS is “All
Nepali citizens have productive and quality lives with highest level of physical, mental, social, and
emotional health” and the mission is to “Ensure citizen’s fundamental rights to stay healthy by
utilising available resources optimally and through strategic cooperation between service
providers, service users, and other stakeholders.” It foresees nine outcomes and 26 outputs. They
are measured through 29 outcome level indicators with 56 corresponding output level indicators.
This report summarises the major progresses in the health sector in the fiscal year (FY) 2018/19,
key highlights of the activities in FY 2019/20 against the NHSS outcomes along with existing
challenges and the ways forward.

The NHSS was developed while the country was in a unitary system of governance. However, as
the country has imparted on federalism, multiple changes have been adapted in the governance
system which have implications for the implementation of the NHSS. The constitution has defined
three levels of governance and their mandates with local levels mandated to deliver the basic
health services. The management of health services in the provinces is the responsibility of
provincial governments. The development of standards and policies, management of tertiary level
hospitals, addressing outbreaks and disasters, and international cooperation remain with the
federal government. The federal government will also play a supporting role in enhancing the
capacity of local and provincial governments.

Major factors that have impact on the NHSS at the national level, in the current context, are:
 Three levels of governance: federal, provincial, and local
 Functional Assignments which define the responsibilities of the federal, provincial, and
local levels
 Distribution of financial resources across federal, provincial and local governments
 Adjustment and posting of the staff to their respective working area
 Various activities were needed to align with the new governance structure by the MoHP.

Major Achievements

MoHP carried out various activities in the FY 2018/19. The majority of the activities were continuity
of the previously carried out programmes as per the NHSS (2016-2021) while new activities and
adaptation were introduced in the annual work plan and budget process to comply as per the
federalism. As a result, various programmes and activities have been rearranged across federal,
provincial and local governments.

The major achievements of the progress in 2018/19 are summarised below:

 National Health Policy 2076 was endorsed by the Cabinet. It has 25 policy statements;
each having multiple strategies.
 The approach paper of 15th periodic plan (with chapters on health and nutrition and
population and migration) has been approved.

 
 
  Public Health Service Act and Safe Motherhood and Reproductive Health Act have been
enacted and are in action:
 Regulations related to Safe Motherhood and Reproductive Health and Health Insurance
have already been endorsed. The regulation for Public Health Services Act has been
drafted and has been shared with other relevant ministries for their inputs.
 The organisational structure in the health sector and health service delivery system has
been revised for federal, provincial and local levels and staff adjustments have taken
place. At the province level, the Ministry of Social Development, Health Directorate,
Logistics Management Office (PLMO) and Health Training Centres have been
established.
 Health Offices have been established in each of 77 districts under the Health Directorate
and previously existing District (Public) Health Offices have been dissolved.
 The Basic Health Care Package has been defined, costed and is in the process of
approval.
 The Minimum Service Standards (MSS) for various levels of Hospitals and Health Posts
are prepared and approved. Orientation to the federal and provincial hospitals has been
carried out for its roll out.
 For the establishment of the health facilities as per the national policy, standards of the
health facilities including cost sharing criteria have been prepared and approved.
 The Health Sector Gender Equality and Social Inclusion (GESI) Strategy was prepared
and submitted for the cabinet approval.
 After complementing the mapping of existing health facilities, grant amount was
transferred to respective local levels for the construction of health facilities as per
approved standards in 1200 wards having no health facilities in 2018/19 while budget is
provisioned for 1390 wards in 2019/20.
 An interaction program with provinces was carried out by the MoHP to discuss on progress
and challenges in the health sector in September 2018.
 The Gender Responsive Budgeting Guidelines in Health Sector, National Disability
Inclusive Health Service Guidelines, One-Stop Crisis Management Centre (OCMC)
Operational Guidelines, have been developed/revised and approved.
 A guideline for 'Health Sector M&E in Federal Context' has been developed.
 Pre-bid and post-bid information systems including electronic Technical Specification
Bank (TSB), electronic Logistics Management Information System (e-LMIS), Grievance
Handling and Redressal Mechanism (GHRM) and e-CAPP modules have been prepared,
updated and being implemented.
 As per the agreement in 2018 NAR, the concept of transforming PIP into an umbrella
strategic document on procurement and supply chain management is being progressed
by drafting the Nepal Health Sector Public Procurement Strategic Framework
(NHSPPSF). Similarly, Nepal Health Sector Financial Management Strategic Framework
has been drafted to guide the financial management procedures.
 Two Standard Operating Procedures (SOPs) for procurement and electronic Government
Procurement (e-GP) have been endorsed and disseminated and its implementation
continues across three levels of governments.
 Standardization of procurement process through new standard bid documents (SBD) and
e-GP-II implementation in the bidding process is now enhanced and implemented. This

 
 
 Electronic Bidding System executed as electronic government procurement (e-GP) in FY
2018/19 is increased at the highest level 98% of CAPP value comparing 83% in FY
2017/18.
 Audit queries against total audit amount has been reduced from 7.01% (in FY 2016/17) to
4.77% (in 2017/18).
 Trachoma elimination achieved and certified by the World Health Organisation (WHO).
 Nepal has been able to control rubella and congenital rubella syndrome (CRS) by
achieving more than 95% reduction in rubella incidence between 2008 and 2017 with
international standard surveillance which was certified by SEA Regional commission.

Key highlights of the achievements in 2019/20 (until November) are summarised below:
 Nepal has been declared "Open Defecation Free" country.
 The programme implementation guideline for FY 2019/20 (for the programme of provincial
and local level) was prepared and made public through the MoHP website.
 Approximately 2.3 million people have enrolled in health insurance scheme which is being
implemented in 49 districts and 471 Local levels.
 The market analysis of pharmaceutical products has been designed and survey completed
as of October 2019.
 Federal level CAPP prepared and endorsed in FY 2018/19 and the implementation
progress is being monitored by PFM Committee of MoHP and CAPP Monitoring
Committee of DoHS. Online preparation of the federal CAPP (e-CAPP) has been initiated
from 2018/19 and e-CAPP for 2019/20 captures 97% of the total procurement budget of
the MoHP.
 Internal Control Guidelines were updated and are incorporated into the TABUCS platform.
 The process of updating FMIP has been started. It is now updated as financial
management strategic framework. Timely submission of Financial Management Report
(FMR) in every trimester. The DLIs are included in the FMR templates.
 Independent review of internal audit has been completed. The findings of the report has
been presented in the PFM committee meeting.
 The new chart of account and new OAG formats are updated in TABUCS.
 Provincial review of health sector has been conducted in five provinces while Karnali
Province and Province 2 plan to hold reviews in the month of Mangsir 2076.
 MoHP secured funding from the Global Environment Facility to implement the project
entitled Building Resilience of Health Systems in Asian Least Developed Countries to
Climate Change.
 The number of districts with OCMCs has reached to fifty-four.
 Total of thirty-five Social Service Units (SSUs) have been established in referral hospitals.
 Geriatric health services are available in twelve referral hospitals.
 Health Emergency Operations Centres (HEOC) have been established in three provinces
functional; and its establishment in remaining provinces is in pipeline.
 Annual report on population for the FY 2018/19 has been produced highlighting major
progresses in the sub-sector

 
 
 1. Introduction

1.1 Background
The Nepal Health Sector Strategy (NHSS) was developed in 2015 to outline the key priorities that
should guide the health sector over a five year period. NHSS aims to progressively expand both
health packages and services, while at the same time ensuring the quality of care being delivered,
making services affordable, and covering the population in need – in particular the vulnerable and
poorest in Nepal society.

The focus of the NHSS is on universal health coverage

and have four strategic areas: equitable access, quality
health services, health systems reform, and a multi-
sectoral approach. These four areas are delivered
through nine outcomes and 28 outputs. In accordance
with the NHSS, the Ministry of Health and Population
(MoHP) has developed an Implementation Plan which
provides a broad list of interventions to be implemented in the five-year period.

A Joint Annual Review (JAR) has been held every year since 2004 in accordance to the Nepal
Health Sector Strategy: An Agenda for Reform (2004). The JAR is jointly organised by the MoHP
and the External Development Partners (EDPs) to review the annual progress and harmonise
support in the health and population sector. At the JAR meeting, the achievements of the last
fiscal year are reviewed and major action points are identified for the coming fiscal year. During
the JAR, support from external development partners are also discussed. An “aide memoire”, is
agreed at the end of the JAR which summarises strategic action points to be prioritised in the next
year. The JAR and National Annual Review, which used to happen separately in the past, were
organised as a single combined event in 2018. FY 2018/191 is the third implementation year of
the NHSS (2015-2020) for which National Joint Annual Review (NJAR) is being organized as a
combined event during 4-6 December, 2019.

This report focuses on overall progress in the health sector and is intended to contribute to
informed discussion and decision making in the annual National Joint Annual Review. The report
is organised in terms of the outcomes, outputs and interventions as defined in the NHSS and its
Implementation Plan (IP) and measures progress towards achieving the stated goals and
objectives. Major achievements made during FY 2018/19, highlights of FY 2019/20, existing
challenges, and the ways forward are captured in this report. The report also presents progress
made against NHSS indicators as defined in the results framework. The progress on the policy
and programme for the FY 2018/19 is presented in Annex 1 and the progress in Disbursement
Linked Indicators is in Annex 2.

Nepal is experiencing a transition towards federalism. Various laws have been enacted impacting
on the health sector. Restructuring is still ongoing to comply with the spirit of the Constitution. The
following overarching actions have been taken towards the implementation of federalism:
                                                            
1 Mapping between Nepali Calendar Years and Gregorian Years for last five years is provided in annex11.

 
 
  Organizational restructuring of the health sector and its overall governance is now
complete.
 The adjustment of staff to better fit the new organisational structure is almost complete,
although there are some challenges that remain in the posting of some staff which MoHP
is addressing.
 Four different types of grants and revenue transfer mechanisms have been used to
distribute financial resources to federal, provincial and local levels as per the constitution.
Provinces have channelled equalisation and conditional grants to local levels.
 Provincial Annual Reviews of the health sector for FY 2018/19 have been conducted in
five provinces while Province 2 and Karnali Provinces have planned to carry out their
reviews in the month of Mangshir, 2076.

Nepal has embraced international commitments towards meeting the Sustainable Development
Goals (SDG) and Universal Health Coverage (UHC) and is continuing to expedite activities. Under
the leadership of the National Planning Commission, the cost implications of the SDGs and an
accompanying financing strategy has been developed in order to meet Nepal's SDG targets.

1.2 Status of Aide Memoire

The National Joint Annual Review (NJAR) of FY 2017/18 was held in 17-19 December 2018 in
Kathmandu. The third day of the NJAR was a business meeting between Ministry of Health and
Population and External Development Partners. The meeting concluded with the development of
an Aide Memoire which identified certain strategic areas to be prioritised in the next FY and was
jointly signed by the Secretary of MoHP and the Chairperson of EDPs Forum. Following table
shows the progress made towards on the action points of the Aide Memoire.
Table 1: Progress on the Action Points of the 2018 Aide Memoire
Agreed Actions Current Status
Annual Review Organise three days Joint Annual MoHP and EDPs have jointly agreed to hold the
Review (JAR): two days for progress JAR in the first week of December 2019 (two days
review, followed by one day discussion to for progress review, followed by one day
agree on priorities and business meeting discussion to agree on priorities and business
to draft the aide -memoire. Next JAR on meeting).
third week of November 2019.
Digitalize All 753 local governments, 7 provincial  100% of local governments have reported on
recording and governments and federal government HMIS information
reporting for health report on HMIS and start the scale up of  eLMIS has been implemented in 57 public
information electronic Logistics Management entities
management in Information System (eLMIS)
federal context. At least one health facility in each EHR has been initiated in:
province introduces electronic health  Sudur Paschim Province: Doti and Bayalpata
record system (EHR) Hospitals
 Karnali Province: Salyan and Dailekh
hospitals
 Province 5: Gulmi, Rapti Academy
 Gandaki Province: Dhaulagiri and Baglung
hospitals
 Province 3: Nuwakot hospital, Dolakha
Charikot hospital,

 
 
  Province 2: Gajendra Narayan Singh Hospital
 Province 1: Mechi, Ilam, Pachthar, Dhankuta,
Bhojpur, Taplejun hospitals
 Federal Hospitals: Maternity Hospital, Patan
Hospital, Police Hospital, Army Hospital
Ensure budget in next Annual Workplan  MoHP and DoHS have allocated budget in
and Budget (AWPB) AWPB 2019/20 for EHR
Public Financial Improve public financial management  MoHP has revised and endorsed Internal
Management Control Guidelines on the basis of FCGO's
"Internal Control System Directives, 2019"
 MoHP has drafted Public Financial
Management Strategic Framework (PFMSF).
 TABUCS system has been updated in the
context of Government Finance Statistics
Manual (GFSM) 2014.
 Chart of Activities have been incorporated in
the TABUCS Platform
Quarterly release of hospital grant to be MoHP is in internal consultation to link the hospital
linked with HMIS and TABUCS reporting grants with overall performance status of the
hospitals including progress in MSS
Ministerial Development Action In FY 2018/19, three MDAC were held, the latest
Committee (MDAC) to review the one on 28th November 2019. Progress on
hospital performance based on HMIS hospitals' performance and the OAG performance
and TABUCS reporting and the grant audit were discussed in the MDAC.
provided
Update financial management MoHP has developed a draft Nepal Health Sector
improvement plan (FMIP) and Public Procurement Strategic Framework
Procurement Improvement Plan (PIP) in (NHSPFSF) and Nepal Health Sector Financial
the federal context Management Strategic Framework (NHSFMSF).

Endorsement of Basic Health Care MoHP has processed for the endorsement of
Services (BHCS) package by end of April package by incorporating it into the public health
2019 services regulations.
Basic Health Care Services (BHCS) Costing of the package has been conducted.
package costed by May 2019
Mid-year Review Conduct joint mid-year review by March Completed in May 2019
2019
Human Endorse the HRH strategy by July 2019 HRH Strategy was drafted in 2018 and is being
Resources for revised to comply with the Federal context. Expert
Health group meeting are also being conducted. A wider
consultation is planned to further refine the draft
strategy.
Endorse the HRH registry (database Draft of the HRH registry database template has
template) by July 2019. been prepared.
Update HRH database in HRH strategy Data from all professional councils are being
and share its status in the next health collected and summary data are included in this
sector annual review report.

Develop and Conduct an assessment of procurement  Draft report has been prepared and shared for
implement and supply chain management of drugs the feedback.
strategic and health commodities in federal  Preliminary findings of the assessment are
framework for context and present the findings in next included in this report.
health sector JAR
procurement and
supply

 
 
 Health Facility Commission Health Facility Survey -  Health Facility Survey Process has been
Survey Finalize tools and identify the initiated including the formation of Technical
implementing agency by end of 2019 Advisory Group and Technical Working Group
 Consultation with respective divisions and
centres is in progress to define the scope and
finalize the tools
 The process for the selection of the local
implementation partner is in progress. Local
partner contracted by December 2019
Health Financing Develop health financing strategy  Landscape analysis conducted and
integrating different social protection roundtable discussions held.
schemes, capturing sub-national  Policy notes are expected to be produced by
investment in health February 2020.
Minimum Service All central hospitals implement and  MSS developed for all levels of hospitals and
Standards report on Minimum Service Standards health posts and endorsed; MSS for specialty
(MSS) hospitals is being developed
 MSS implementation guideline prepared and
implementation is in progress
 Resources persons to implement MSS trained
for primary, secondary and tertiary hospitals
Quality of drugs Develop plan to establish drug quality BSL3 biological lab was planned to establish on
testing laboratory the 3rd floor but was dropped due to the DUDBC
report which raised concern on the inadequacy of
the space.
Develop and implement drug quality Developed drug quality monitoring tools:
monitoring tools to drug inspectors “Handbook for Drug Inspectors”
Ayurveda and Develop health promotion package Health promotion activities conducted at different
Alternative considering Ayurveda principles. levels linking with yoga/ayurveda e.g. Nagarik
Medicine Aarogya Program/Swasthya Jiwan Program at
district level and healthy lifestyle and yoga at
schools

 
 
 2. NHSS Result Framework

2.1 Background

The NHSS Results Framework defines major health sector indicators and targets in accordance
with the NHSS goal and outcomes. The Results Framework has 10 goal level indicators, 29
outcome level indicators and 56 output level indicators. Progress against each indicator of the
NHSS Results Framework is available on the MoHP website (www.nhssrf.mohp.gov.np). This
section of the report highlights progress in the 10 goal level indicators and selected outcome level
and output level indicators.

2.2 Overview of the Progress

Improvement in overall health outcomes has been observed over last two decades (Table 2.1).
The maternal mortality ratio (MMR) (pregnancy-related mortality ratio) of 539 per 100,000 live
births in 1996 has declined to 239 in 20162 and recent 2019 estimates indicate a level of 186 per
100,000 live births. Under-five mortality rate has declined from 118 per 1,000 live births in 1996
to 39 per 1,000 live births in 2016. Similarly, neonatal mortality rate has declined from 50 per
1,000 live births in 1996 to 21 per 1,000 live births in 2016. Overall, the nutritional status of children
(stunting) has improved. The percentage of children under five years who are stunted (% below -
2SD3) has declined from 41% in 2011 to 36% in 2016.

Table 2.1: Progress in major health indicators

Year
Indicator
1996 2001 2006 2011 2016
Maternal Mortality Ratio (per 539 NA 281 NA 259
100,000 live birth) (NHSS RF4 G1)
Under-five child mortality rate (per 118 91 61 54 39
1,000 live births) (NHSS RF G2)
Neonatal mortality rate (per 1,000 50 39 33 33 21
live births) (NHSS RF G3)
Children stunted (%) (NHSS RF G5) 48 51 49 41 36
Fully immunized children (%) (NHSS 43 66 83 87 78
RF OC3.2)
Institutional delivery (%) (NHSS RF 8 9 18 35 57
OC3.3)
Demand satisfied for family planning 47 59 66 64 69
(%) (NHSS RF OC 3.4)
*MMR has been measured using pregnancy related deaths except in 2016 NA- not available
Source: Data for 1996 from Nepal Family Health Survey (NFHS), 2001-2016 NDHS

                                                            
2
The NDHS measures maternal mortality every ten years. NFHS 1996 and NDHS 2006 measured only pregnancy-
related maternal deaths per 100,000 live births for the seven-year period before the survey whereas NDHS 2016
also estimated the maternal mortality ratio (239 per 100,000 live births). Figures in the table are of pregnancy
related deaths.
3 Standard Deviation
4 Results Framework

 
 
There has been a large improvement in the proportion of women delivering at a health facility,
increasing from 8% in 1996 to 57% in 2016. The percentage of demand satisfied for family
planning among currently married women has increased from 64% in 2011 to 69% in 2016. The
percentage of children aged 12-23 months who had received all eight basic vaccinations had
increased from 47% in 1996 to 87% in 2011 but this has decreased to 78% in 2016. Although
there has generally been progress across many of the indicators, inequalities persist by
geographic location and socio-economic groups.

The UHC service coverage index for Nepal was estimated to be 52% in 2010 and has increased
to 59% in 2019. In 2019, 10.7% of people spent more than 10% of their household's total
expenditure on health care and access to essential medicines is 72%. Table 2.2 shows progress
against the ten NHSS goal level indicators with achievements in 2019 against the 2020 targets.

Table 2.2: Progress against the NHSS Results Framework goal level indicators
Baseline Achievement 2020
Code Indicators
Data Year Source 2019 Source Target
Estimates
Maternal mortality ratio (per
G1 190 2013 WHO 186 2017 (WHO, 125
100,000 live births) 2019)
Under five mortality rate (per 1,000
G2 38 2014 NMICS5 39 NDHS 2016 28
live births)
Neonatal mortality rate (per 1,000
G3 23 2014 NMICS 21 NDHS 2016 17.5
live births)
Total fertility rate (births per 1,000
G4 2.3 2014 NMICS 2.3 NDHS 2016 2.1
women aged 15–19 years)
% of children under-5 years who
G5 37.4 2014 NMICS 35.8 NDHS 2016 31
are stunted
% of women aged 15-49 years with
G6 18.2 2011 NMICS 17.3 NDHS 2016 12
body mass index less than 18.5
Nepal
Lives lost due to road traffic Nepal
G7 34 2013 9.5 Police, 17
accidents per 100,000 population Police 2075/76
Nepal
Nepal
G8 Suicide rate per 100,000 population 16.5 2014 19 Police, 14.5
Police 2019
Disability adjusted life years lost Nepal
due to communicable, maternal BoD, Burden of 6,738,95
G9 8,319,695 2013 9,015,320
and neonatal, non-communicable IHME6 Disease, 3
diseases, and injuries 2017
G1 Incidence of impoverishment due to Reduce
NA 2011 NLSS7 NA
0 out-of-pocket expenditure in health by 20%

Road Traffic Accidents (RTA)

Road traffic accidents (RTA) are the leading killer of children and young adults worldwide and
more than half of global traffic deaths are among pedestrians, cyclists and motorcyclists8. With

                                                            
5 Nepal Multiple Indicator Cluster Survey
6 Institute for Health Metrics and Evaluation
7 Nepal Living Standards Survey, Central Bureau of Statistics
8
World Health Organisation, Global Status Report on Road Safety. 2018

 
 
the increase in urbanization, the expansion of the road network and the rapid rise in the number
of vehicles, road traffic accidents in Nepal increasing.

In Nepal road accidents with human injuries are reported to Nepal Police. An analysis of RTA
cases reported to Nepal Police over the last 10 years shows that the number of RTA deaths has
doubled from 1,356 in 2066/67 to 2,789 in 2075/76 (Figure 2.1). This data implies that an
estimated eight people die and 40 people get injured from RTA every day in Nepal and the RTA
mortality rate is 9.5 per 100,000 population (Table 2.3) 9.

Figure 2.1: Trend of RTA Deaths and Injuries in Nepal

5000
4130 4701 4182 4250 4144 4376
4500 4018 4054
3986
4000 3516
3500
2789
3000 2384 2541
2500 2004 2006
1734 1837 1787
2000 1689
1356
1500 FY 2075/76 (2018/19)
1000 RTA Deaths per day: 8
RTA Injured cases per day: 40
500
0
2066/67 2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74 2074/75 2075/76

Deaths Major injuries

Reducing RTA needs multi-sectoral engagement and the MoHP is collaborating with the Nepal
Police and the Road Department in order to increase coordination. Currently there is one National
Trauma Centre in Kathmandu and MoHP plans to establish at least one trauma centre near the
major highway of each Province.

Suicide
Suicide is a growing public health concern both globally and nationally and is often linked with
mental health disorders, conflicts and life crisis situations. According to data from the Nepal
Police, suicide almost increased by two folds in the last decade reaching a total of 5,754 suicide
cases in 2018/19 (Figure 2.2). This data indicates that 16 people commit suicide every day and
the suicide mortality rate is 19 per 100,000 population. Globally, the suicide is the second leading
cause of death among the 15-29 year old age group10.

                                                            
9
World Health Organisation, Global Status Report on Road Safety (2018) has estimated RTI mortality ratio per
1,000 to be 15.9.
10
https://www.who.int/news-room/fact-sheets/detail/suicide

 
 
Figure 2.2: Trend in Suicide Related Deaths
7000
Suicide per day (2075/76) 16
5754
6000 5404 5317
5120
4680
5000 4332
3977 3974
3699
4000 3309
3061
3000
2000
1000
0
2065/66 2066/67 2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74 2074/75 2075/76

Suicides in Nepal follow a similar pattern with forty percent of the suicides occurring in the 19-35
year old age group. The second highest proportion is 36-50 year age group (Figure 2.3).

Figure 2.3: Suicide Rate by Age group, 2075/76 (2018/19)

5%

9%
16%

40%
30%

Below 18 years 19 ‐ 35 years 36 ‐ 50 years

51 ‐ 69 years Above 70 years

Table 2.3 show progress against NHSS outcome level indicators and 4 of the 10 indicators are
on-track or have been achieved. Three indicators do not have data for this reporting year and the
OC 4.1 indicator is no longer relevant in the federal context. There are a number of indicators that
seem relevant in the federal context and are presented below in Table 2.4.

 
 
Table 2.3: Progress against NHSS Results Framework Selected Outcome Level Indicators
Baseline Achievement 2020/21
Code Indicators 2018/1
Data Year Source Source Target
9
OC 1.4 % of health facilities with no
70 2013/14 LMIS 1.5 Survey Report11 95
stock out of tracer drugs
OC 2.1 % of health facilities meeting
Information not
minimum standards of quality 0.7 2015 NHFS -- 90
available
of care at point of delivery
OC 3.1 % of children fully immunized 70 2015/16 HMIS 68 HMIS 2018/19 >90
OC 3.3 % of institutional delivery 55 2015/16 HMIS 61 HMIS 2018/19 70
OC 4.1 % of MoHP’s [district] budget 39.6% 5%
Budget Budget Analysis
disbursed as block grant na 2015 budget increme
analysis 2017/18
to SNG nt
OC 5.1 Budget absorption rate (% Budget Analysis
75.1 2013/14 FMR 80.4 95
expenditure of budget) 2018/19
OC 6.1 Government health
Budget Budget Analysis
expenditure as percentage of 1.4 2013/14 1.9 2
analysis 2018/19
GDP
OC 7.1 Prevalence of diarrheal Population
12 2014 NMICS na
diseases among children based data not
10
under five years (%) available.
(422) (2015/16) (HMIS) (385)
(HMIS)
OC 8.1 Case fatality rate per 1000 Disaster
reported cases due to public 7.0 2013 Surveillance na DSS 2018/19 na
health emergencies System (DSS)
OC 9.2 Children below one year
whose births are registered 32.8 2014 BMICS 56 CRVS/MoFAGA 41
(%)

Table 2.4: NHSS RF indicators that need reconsideration in the federal context
Code Indicator
OC4.1 % of MoHP's district budget disbursed as block grant
OC4.2 Proportion of district development fund (DDF) allocated for health
OP4.1.1 Number of districts (DHO & DPHO) submitting DDC approved annual plan to DoHS on specified time
by development region
OP4.1.3 % of flexible budget provided to districts (DPHO/DHO) in total district programme budget
OP5.4.1 % of districts with functional District Health Coordination Committee
OP6.1.3 % of districts receiving budget based on identified needs and output criteria
OP8.1.1 Number of districts having health emergency response plan
OP9.1.2 Number of districts with functional integrated disease surveillance system

Progress on Tracer Indicators by Programme

Table 2.5 presents progress on tracer indicators from different programmes across three years
and by the seven provinces using HMIS data.

                                                            
11 Preliminary findings of the survey on factors contributing to the stock out of the essential medicines in government
facilities in Nepal in 2019 which captured data from 275 health facilities out of 21 districts of seven provinces.

 
 
Table 2.5: Tracer indicators for different programmes, 2016-2019 and achievement by province
National
Programme Indicators National level FY 2075/76 (2018/19) by Province
Target
2073/74 2074/75 2075/76 Sudur
(2016/17) (2017/18) (2018/19)
1 2 3 Gandaki 5 Karnali
Paschim
2020 2030

Number of health facilities

Public hospitals 123 125 125 18 13 33 15 20 12 14
PHCCs 200 198 198 40 32 43 24 30 13 16
HPs 3808 3808 3808 648 745 640 491 570 336 378
Non-public facilities 1715 1822 2122 138 175 1402 107 180 73 47
Total 5846 5953 6253 844 965 2118 637 800 434 455
Reporting status by type of facilities (%)
Public facilities 96.8 95 98.68 99.5 99.9 95.2 96.87 100 100 100 100 100
Public hospitals 93 96 89 100 97 68 91 99 100 99 100 100
PHCCs 98 98 99.2 100 100 97 98.9 100 100 100 100 100
HPs 100 98 99.5 99.5 100 98.7 98.6 100 100 100 100 100
Non-public facilities 47 49 36.59 51 29 31.98 69.65 35.82 91 57 100 100
FCHVs 90 72 74.2 79.7 85.7 50.4 82.9 81.2 87 84.8 100 100
Immunization status (%)
BCG coverage 91 92 90.9 86.8 107.2 81.1 71.8 98 101.5 84.4
DPT-HepB-Hib3 coverage 86 82 86.4 83 105.3 71.4 74.1 90.3 99.3 82.2
MR2 coverage (12-23 months) 57 66 72.8 75.3 70.6 60.1 76.7 84.3 78 74.6
Fully Immunized children* 73 70 67.9 71.2 71.4 54.4 61.2 74.2 79.2 71.3 90 95
Dropout rate DPT-Hep B-Hib 1 vs 3 coverage 4.7 7.4 4.3 2.9 7.9 3.2 2 4 2.5 2.7 0 0
Pregnant women who received TD2 and TD2+ 64 73 64.3 59.2 83.4 48 51.6 72.5 69.2 63
Nutrition status (%)
Children aged 0-11 months registered for growth
85 84 84.4 78.3 77.6 69.1 92.4 100 117.2 86 100 100
monitoring
Underweight children among new GM visits (0-11m) 3.5 3.6 2.9 1.7 4.2 2.1 0.9 3 4.7 3.9
Children aged 12-23 months registered for growth
54 56 56.7 48.5 58.7 44.1 69.4 63.6 79.3 57.8 100 100
monitoring
Underweight children among new GM visits (12-23m) 5.7 5.7 4.5 2.9 5.6 1.8 1.5 5.4 8.5 7.2
Pregnant women who received 180 tablets of Iron 44 45 50.6 38.9 56.5 29.7 62.2 60.7 61 68.1
Postpartum mothers who received vitamin A supplements 72 66 64.5 57.1 91.2 41.2 46 65.4 97.8 67.7

CB-IMNCI status
Incidence of pneumonia among children U5 years (per
66 54 82.7 116.3 65.3 55 57.6 76.4 158.4 110
1000)
% of children U5 years with Pneumonia treated with
156 165 136.1 128 203 111 145.3 127.3 120.1 113.6
antibiotics
Incidence of diarrhea per 1,000 under five years children 400 385 375.2 350.7 347.2 240.4 268 404.3 682.9 624.7

 
 
 National
Programme Indicators National level FY 2075/76 (2018/19) by Province
Target
2073/74 2074/75 2075/76 Sudur
(2016/17) (2017/18) (2018/19)
1 2 3 Gandaki 5 Karnali
Paschim
2020 2030

Number of health facilities

% of children under 5 with diarrhea treated with ORS and
92 95 95.5 89.5 102.3 92.6 97.3 94.4 99 93.9 100 100
zinc
Safe motherhood (%)

Pregnant women who attended first ANC visit (any time) 102 103 110.2 113.7 117.8 105.7 108.2 110.2 127.1 89.8
Pregnant women who attended four ANC visits as per
53 50 56.2 61.4 41.4 50.8 70.4 64.5 61.8 57.9 70 90
protocol*
Institutional deliveries * 55 54 63.2 62 52.7 61.5 47.8 78.8 73.2 71 70 90
Deliveries conducted by skilled birth attendant* 52 52 59.6 61 50.5 60.6 47 73.3 59.4 61.4 70 90
Mothers who had three PNC check-ups as per protocol* 19 16 16.4 8.7 15.2 13.5 13.1 19.3 24.1 31.4 50 90
Family planning
CPR-unadjusted* 43.6 40.6 40.9 41.9 48.8 33.7 35.4 44.2 37.1 39.5 56 60
CPR (Adjusted) n/a 40.0 38.9 40.0 45.7 32.0 33.8 42.8 35.1 38.1
Female Community Health Volunteers (FCHV)
Number of FCHVs 49101 48172 50166 8990 7536 9004 5709 8795 4072 6060
% of mothers' group meeting held 86 98 95.2 92 94.8 94.7 93.2 99.1 94.2 97.7 100 100
Malaria
% of plasmodia falciparum (PF) among Malaria Positive
13.1 7.1 5.4 26.3 16.7 30.8 17.2 4.6 0.42 3.1
case
Tuberculosis
Case notification rate (all forms of TB)/100,000 pop. 111 109 102.9 94.8 95.1 113.2 92.2 117.6 84.3 106.1
Treatment success rate 91 87 85.7 87.2 81 84.8 94.1 89.1 91.6 78.9
Leprosy
New case detection rate (NCDR) per 100,000 population 11 11 10.9 8.6 23.7 4.5 2.5 13.8 4.4 7.6
HIV/AIDS and STI
Number of new positive cases 1781 2013 2360 183 226 1065 196 417 37 236
Curative services
% of population utilizing outpatient (OPD) services 72 73.6 78 75.8 58 84.7 106 80.6 91.9 72.1
Average length of stay at hospital 3 4 3.7 3.1 1.5 4.1 3.5 5.2 2.9 2.5
Note: *NHSS RF and/or SDG indicators

 
 
Immunization: There is a declining trend in full immunization coverage nationally from 73% in 2073/74
(2016/17) to 68% in 2074/75 (2017/18). Coverage was lowest in Province 3 (55%) and highest in Karnali
Province (80%). BCG coverage is at 91% at the national level with highest coverage (100%) in Karnali
Province and the lowest coverage (72%) in Gandaki province. The coverage of DPT-HepB-Hib3 has
improved to 86.4% at the national level with highest rates in Karnali province at 99.3% and lowest in
Gandaki province at 72%. The dropout rate has decreased to 4.3% at the national level with highest
dropout rate in Province 2 (7.9%).

Nutrition: The number of children ages 0-11 months being registered for growth monitoring has
stabilised around 85% and was highest in Karnali province at 117.2%12 and lowest in Province 3 at 69%.
Under-weight children (12-23 months) among new growth monitoring visits has fallen to 2.9% but is still
high in Karnali Province (4.7%). Only half of pregnant women are receiving 180 iron tables has increased
(50.6%) with highest levels in Sudur Paschim Province at 68% and the lowest rate reported in Province
3 at 29.7%.

CB-IMNCI: Karnali Province reported the highest incidence of pneumonia among children under five,
which is substantially higher than the incidence reported by Province 3 which had the lowest incidence
among all provinces. The highest percentage of children under five with diarrhoea treated with oral
rehydration solution and zinc was found to be in Province 2 at 102.3% while the lowest rate was in
Province 1 at 90%.

Safe motherhood: The percentage of pregnant women who attended four antenatal care (ANC) visits
as per protocol has increased at the national level from 50% to 56%. Similarly, institutional deliveries has
increased from 45% to 63%. Four ANC was lowest in Province 2 (41%) and institutional delivery lowest
in Gandaki Province (48%). It was highest in Sudur Paschim Province at 31.4% and lowest in Province
1 at 8.7%. At the national level the target is to reach 50% coverage by 2020 and 90% coverage by 2030.

Family planning and FCHVs: The contraceptive prevalence rate (CPR) has decreased from 43% to
41% at the national level over the past three years. It was highest in Province 2 at 49% and lowest in
Gandaki Province at 34%. The number of FCHVs have increased in recent years and the proportion of
FCHVs holding mothers groups is 95%.

Malaria, Tuberculosis, Leprosy, HIV/AIDs: The percentage of PF among malaria positive cases has
declined (at 5.4%) at the national level while highest was in Province 3 at 41%. The new case detection
rate of leprosy per 100,000 populations has decreased marginally at the national level (11%) while it was
highest in Province 2 (24%). The detection of new HIV positive case has increased over the past 2 years
with the highest number found in Province 3.

HMIS reporting status: In general more public health facilities are reporting to HMIS. Reporting from
non-public facilities remains low.

Health facilities should enter monthly service statistics in the national HMIS database by the 15th day of
the following month. Figure 2.4 shows that reporting is lowest in Ashwin 2075 (Sept/Oct, 2017) (16%)
and highest in Ashadh 2076 (Jun/Jul, 2019) (63%). The percentage of health facilities reporting late was
higher in the earlier months of the fiscal year. About 11 percent of the health facilities sent HMIS data

                                                            
12
Percentages larger than one hundred is the result of estimated target population (denominator) being smaller than the
number of cases (numerator)
                                    
                                                                        3 
 

 
  

electronically while 68% facilities reported through parent organization, the local level or the (provincial)
health office. Up to 21% of health facilities did not report to HMIS in 2018/19.

Figure 2.4: Monthly HMIS Reporting Status, 2018/19

2.3 NHSS Mid-Term Review

Context
The Mid-Term Review (MTR) of the NHSS was carried out in 2018/19 by a group of independent
consultants under the guidance of the Technical Working Group (TWG) formed by the Ministry. The
review assessed the relevance, efficiency, effectiveness of NHSS in relation to health sector priorities
using the following tools: Critical Pathway Analysis (CPA); Political Economy Analysis (PEA) at the
Provincial and Local levels; a Critical Capacity Analysis (CCA) and a Social and Environmental Impact
Assessment (SEIA).

Major Findings
Major findings are organised according to the NHSS outcomes and are summarised below.
Outcomes Progress Gaps and Priorities
1. Rebuild and Strengthen Nepal Health Infrastructure Development Institutional structure and functions of in
Health Systems: Standards (developed); Human federal context to be further clarified;
Infrastructure, Human resources for health strategic roadmap Levels of absenteeism of health care
Resources for Health, (being prepared); and Standard bidding providers to be addressed; Delays in
Procurement, & Supply documents for health sector procurement procurement to be addressed
Chain Management (drafted)
2. Improved Quality of National Public Health Act and Safe Roles between quality governance
Care at point of delivery Motherhood and Reproductive Health structures and various autonomous entities
Rights Act (prepared); Health Institution to be clarified; Practice of analysing routine
Quality Assurance Authority Act data to measure quality of care to be
(prepared); National action plan for Anti- institutionalized; Reporting linkages
microbial resistance and the Drug Policy between different levels of government
2074 (drafted) structures to be strengthened

  4 
 

 
  

Outcomes Progress Gaps and Priorities

3. Equitable Distribution Health care utilization among the poorest Legal framework for the basic health
and Utilisation of Health quintile increased (e.g. c-section rate); service package to be approved; Service
Services Access to health facilities improved (e.g. provision in remote areas to be expanded;
time to reach a facility for institutional Alignment between health insurance and
deliveries reduced; Basic healthcare free health care program to be
package (drafted); National Strategy on strengthened; Neglected health problems
Reaching the Unreached (endorsed); (e.g. disability, mental health services,
Remote Area Guidelines for IMNCI adolescent sexual reproductive health) to
(endorsed); Ten Year Action Plan on be highlighted; A strategy for health equity
Disability Prevention and rehabilitation based on the local context to be
2073-2083 (endorsed) strengthened
4. Strengthened Capacity on planning and budgeting Planning and budgeting practice as per
Decentralized Planning functions (enhanced); Budget and new institutional structure to be reviewed
and Budgeting planning guidelines (developed), Budget and updated; Conditional grants need to
planning as per Local government cover the priority programmatic needs;
operation act (implemented); Planning Evidence based planning and budgeting in
and budgeting based on the federal all three levels of government to be
structure (practiced) strengthened
5. Sector Management Many health sector guidelines Accountability of Local levels to province to
and Governance (developed); Roles of Provinces and be clarified and strengthened; Motivation of
Local Levels being further defined and health care providers to be maintained,
clarified through practice and Enabling all facilities to provide basic
communications health care services; Model
legislature/regulatory framework for
Province & Local level to be developed and
practiced; Private sector regulatory
framework to be institutionalized; One
Health Strategy (among MoHP, Agriculture
and Livestock Development & Forests and
Environment) to be formalized and
strengthened
6. Improved Sustainability Government health expenditure Expediting expenditure on health to
of Healthcare Financing (increased); Per capita health spending achieve universal access to primary care
(increased); Health insurance program services; Strategies to reduce out-of-pocket
(expanded) expenditure to be strengthened; Health
financing strategy (to be developed), Health
insurance program to be strengthened, with
focus to poor and to improve annual
renewal.
7. Improved healthy PEN protocol (endorsed and piloted); Multi-Sectoral coordination and
lifestyle and environment Mental health policy (revised); Health collaboration to be strengthened; Multi-
National Adaptation Plan (H-NAP) on Sectoral Action Plan for the Prevention and
climate change (endorsed) Control of Non-Communicable Diseases to
be developed and implemented; Mental
health issues to be prioritized by all levels;
Services provision on non-communicable
diseases to be expanded; Social
mobilization and behaviour change
communication to improve health lifestyle
to be strengthened
8. Strengthened National protocol and operational Guidelines development and allocation of
Management of Public guidelines for emergency situation resources for health emergencies to be
Health Emergencies (developed); Partnership with non- prioritized; Institutionalization of progress
government sector and sectorial agencies made; Capacity building and mobilization
for emergency management of human resources to address impact of
(established); Implementation of NAPA health emergencies
framework for climate change induced
disaster (developed)

  5 
 

 
  

Outcomes Progress Gaps and Priorities

9. Improved Availability National e-health strategy (developed); e-health initiative at all levels to be
and Use of Evidence in DHIS 2 platform for HMIS reporting standardized, developed and
Decision Making (updated and functional); Unified coding institutionalized; Central data repository to
Processes at All Levels system and web-based health facility be operationalized; Effective
registry (developed); Grievance implementation of the guidelines and tools
management system (established); at all levels of government to be promoted.
Multiple analytical studies (e.g. NHA-
2018, NHFS-2015, NMSS-2016, NDHS-
2016 and Steps survey for NCDs)
conducted; A guideline and tools for
health sector review at all government
levels (developed).

Key recommendations of the MTR

 A legislative/regulatory framework covering accountabilities of all governments need to be
strengthened and greater focus put on dissemination and awareness raising of these frameworks;
roles and responsibilities across all levels of government.
 Multi-sectoral coordination among line ministries should to be strengthened and multi-sectoral
platforms for lower tiers of government need to be established.
 To ensure equitable distribution of funding, resource-based formulas need to be developed.
 Continuous increases in annual government health expenditure are needed to ensure an adequate
flow of funds to health services delivered at all levels of government.
 Expansion of services to deliver equitable services, capacity building of providers for quality of care
and ensuring proper recording, reporting and use of data for programmatic use should be further
strengthened.
 Improved availability and use of health sector data is needed for all levels. Tailored planning tools
with process support are needed to promote bottom up approaches and evidence-based planning
and budgeting.
 Further training and capacity development is needed to make budgeting and management systems
effective.
 MoHP could consider appropriate models to optimise resource use and ensure specialist services
reach all levels.
 MoHP should plan next health sector strategy in a federal context and the federal strategy should
serve as the umbrella one for provincial strategic plan and the development should be driven from
the local to provincial to federal level.

2.4 Regular Programme Reviews

The MoHP used to organize National Annual Reviews and JAR as two separate events. In the past two
years these events have been combined as a National Joint Annual Review (NJAR). The key objectives
of the NJAR have been:
 Jointly review the annual progress of Nepal Health Sector Strategy (2015/16 – 2020/2021) and
ensure all stakeholders develop a shared understanding of progress in the sector;
 Identify the strategic priority areas that need to be addressed to strengthen health system in the
changing context;
 Agree on the strategic actions to be included in the next year's Annual Work Plan and Budget
(AWPB).
  6 
 

 
  

2.5 Equity Analysis of Key Health Indicators

The neonatal mortality rate (NMR) declined from 33 deaths per 1,000 live births to 21 deaths and the
under-5 mortality rate declined from 58 per 1000 live births to 39 deaths from 2011 to 2016 with large
provincial variations. Province 4 has the lowest rates both for NMR and under-5 mortality rate at 15 and
27 per 1000 LB respectively, while Province 7 has the highest rates of 41 and 69 deaths per 1000 LB
respectively. Province 7 fares well in other health status of children including nutrition status, diarrheal
and fever prevalence, and health service utilisation compares to national level, and thus it is important to
identify reasons for high mortality in this Province.

Women from Provinces 2 and 6 had lowest timely antenatal first visit, four antenatal visits, which is the
current protocol, and institutional delivery among all seven provinces. Coverage and compliance to 90
days Iron Folic acid also is lowest in Province 2 while prevalence of anaemia among married women of
reproductive age is highest in Province 2.

While improvement in service utilization was observed during the last few years, HMIS data from 2017/18
shows a decline in service use (e.g. ANC 4 and institutional delivery) especially in some Provinces. It is
not yet clear whether the decline is due to declining functionality of service sites or due to incomplete
reporting.

Of the total 31,020 estimated people living with HIV in Nepal about 53% (16,428 persons) received ART
from 74 ART sites in 59 districts in 2017/18. Of the 330,460 people tested for HIV at 175 sites; 2,101
were tested positive. It is estimated that approximate 8% of people living with HIV are co-infected with
TB. Fifty four percent of newly diagnosed TB patients were tested for HIV, as per the 2018 TB report. At
the time of TB diagnosis 9,634 persons knew their HIV status (positive). This has increased from 6,307
in 2016/17. The number of TB patients under treatment with ART is 214 in 2017/18 which was 227 in
2015/16.

Equity gap between the 10 high performing districts and the 10 low performing districts
This section analyses the average equity gap across three indicators (contraceptive prevalence rate; %
of institutional delivery; and % of children with pneumonia treated with antibiotics)13 from 2016/17 to
2018/19) using HMIS data. The green (ten high performing districts) and yellow colours (ten low
performing districts) used in the tables and figures reflect the values related to performance with green
reflecting good performance. .
The difference between the high and low performing districts has been declining over the past 3 years
for CPR and the treatment with antibiotics of U5 children with pneumonia but in the past year has
increased for institutional delivery. At the national level, the CPR has marginally from 40% in 2017/18 to
40.9% in 2018/19. The CPR in the high performing districts reflects the national trend. CPR in the poor
performing districts has more or less stabilised over the past 3 years. The proportion of women giving
birth in a health facility has increased nationally from 54.6% in 2016/17 to 63.2% in 2018/19. Institutional
delivery in the top ten performing districts and in the 10 poorest performing districts has also increased.

                                                            
13
Contraceptive prevalence rate; % of institutional delivery; and % of children with pneumonia treated with antibiotics are
the DLI indicators.
  7 
 

 
  

However, the gap between the average of the best performing districts and the poor performing districts
has increased.
Table 2.6: Equity Gap between the 10 high performing and the 10 low performing districts

FY 2016/17 FY 2017/18 FY 2018/19

districts (%)

districts (%)

districts (%)

districts (%)

districts (%)
Average of

Average of

Average of

Average of

Average of

Average of
Difference

Difference

Difference
bottom 10

bottom 10

bottom 10
Indicators

districts
top 10

top 10

top 10
(%)

(%)

(%)
Contraceptive
29.1 26.1
Prevalence 59.6 26.1 33.5 53.8 24.7 52.5 26.4
[13.1] [10.5]
Rate (%)
Institutional 69.6 74.6
88.0 18.4 69.7 88.7 19.1 95.6 20.9
Delivery (%) [0.1] [7.2]
U5 children
with
38.4 29.9
pneumonia 56.1 14.6 41.5 48.2 9.8 38.2 8.3
[7.6] [22.1]
treated with
antibiotics (%)

In the case of treatment of pneumonia with antibiotics, nationally 32% of U5 were treated in 2016/17,
falling to 19% of cases in 2018/19. This national pattern of declining treatment over time is reflected in
both the top 10 performing districts and the 10 poor performing districts. However, the difference between
the performance of the top and bottom districts has fallen.
The following text looks at the top 10 and bottom 10 performing districts in more detail.
Contraceptive prevalence rate: The 10 low CPR districts have changed a bit over the past 3 years.
Udayapur, Arghakhanchi, Mugu
and Rukum West have remained
in the 10 poorest performing
districts over the 3 year period.
Likewise, the districts that have
continued to have high CPR
include Morang, Saptari, Parsa,
Rasuwa, and Manang.

Institutional delivery: There are

four districts (Illam, Bhaktapur,
Mustang and Nawalparasi East)
who remained in the bottom 10
performing districts over the 3
years. Two of the poor performing districts (Chitwan, Humla) moved from the bottom 10 performing

  8 
 

 
  

districts to the top 10 performing districts. Parsa, Lalitpur, Kaski, Palpa, Rupandehi, Banke and Surkhet
have all remained in the top 10 performing districts over the 3 year period.

Pneumonia cases treated with

antibiotics: Three of the bottom ten
performing districts remained in the
bottom 10 over the past 3 years
(Surkhet, Kailali, Kaski). Out of the top
ten performing districts in 2016/17, four
districts were able to maintain this
status until 2018/19 (Rautahat, Dolpa,
Mugu, Humla). Even among the top
performing districts there is a decline in
the proportion of pneumonia cases
treated with antibiotics over the past 3
years with some districts really falling.

Effect of Distance on the Use of Institutional Delivery

The hill and mountainous terrains of Nepal present an imposing geographical barrier to the use of health
facilities and has a significant influence on women’s uptake of institutional delivery care [2]. An analysis
of the NDHS 2016 data and
geolocation of the birthing facilities as
recorded in the HMIS database reveals
that about one fifth (19%) of the Nepal
population live 5 Km or more from the
nearest health facility with delivery
services and more than half (52%)
within 2-4 Km (Figure 2.5). Institutional
delivery rate is 57.4% in Nepal and is
28% higher among who are living in
less than 2 Km (64%) in comparison
with living at 5 Km or more (50%)
distance. Ten percent of the population
are living at 5 Km or more distance
from a health facility with birthing
services in the mountain and hills and
26% are living at 5 Km or more distance in the Terai. The institutional delivery rate is 128% higher among
who are living in less than 2 Km in the mountain/hills but only 9% difference in the institutional delivery
rate between less than 2 Km and 5 Km or more distance in Terai.

  9 
 

 
  

Figure 2.5: Geographical Distribution and Institutional Delivery

70 64 66 62
56 58 57
60 56 54
52 50 48
50

40 34
29 29
30 25 26
19
20
10
10

0
% distribution of % institutional % distribution of % institutional % distribution of % institutional
sample delivery sample delivery sample delivery
population population population
Nepal Mountain/Hill Terai

<2 KM 2‐4 KM 5 KM +

Source: Further analysis of HMIS and DHS data.

Figure 2.6 demonstrates that distance to the nearest birthing facilities is inversely associated with
institutional delivery. The probability of institutional delivery is 26% less likely among women who are
living within 2-4Km distance and 43% less likely among women who are living 5Km or more distance in
comparison with those living less than 2Km distance.
Figure 2.6: Association between distance from a health facility and institutional delivery

<2 Km (ref) 2-4 KM 5 KM and more

1.4 1.31
1.23
1.2 0.88
0.82
1 0.82 0.83
0.74 0.72 0.73 0.70 0.56
0.8 0.67
0.57 0.61 0.56
0.6 0.49
0.37 0.34
0.4 0.22 0.25
0.16
0.2 0.06 0.07
0.00
0
Poor No-poor M/H Terai P1 P2 P3 GP P5 KP SP
Nepal Wealth status Ecological zone Provinces

Source: Further analysis of HMIS and DHS data.

The poorest women who are living 5 Km or more distance from the health facility are 63% less likely to
deliver at a health facility and yet there was no association between distance from the health facility and
institutional delivery for non-poor women. Availability of health facility with delivery services close-by to
women living in the hills and mountains is a strong factor in determining whether women will use the
services. Women who are living at 5 Km or more distance are 84% less likely to deliver at health facility
as compared with the women living at less than 2 Km distance to the birthing facility. Distance to a health
facility is also inversely associated with institutional delivery in Terai however the magnitude of the
probability is comparatively less than in the mountain/hills. Similar patterns are seen across the
  10 
 

 
  

Provinces; in province 3, Gandaki and Karnali Province the probability of institutional delivery decreases
with an increase in the distance to the health facility and there is no association between distance and
institutional delivery in Province 1 and 2.
Utilisation of ANC and Delivery services at different level of health facilities
HMIS recorded that 125 hospitals, 187 PHCCs, 2,174 HPs, 25 UHCs and 77 CHUs had reported at least
one institutional delivery in 2018/19. We know that some health facilities are under-utilised and others
are over-crowded. Using 2018/19 HMIS data, Figure 2.7 presents the ratio of first ANC visit to institutional
deliveries at different levels of health facility. ANC is higher in lower level health facilities compared to
delivery services whereas the opposite is true in higher level health facilities. This indicates that lower
levels health facilities are bypassed by women for delivery services. In Sankhuwasabha, for example,
40% of women who had their first ANC at a health post used the health post for child birth. Whereas the
hospital received 220% more women for delivery services than for first ANC.

Figure 2.7: Ratio of ANC to Delivery Services by Health Facility Type, 2018/19

2.5
2.2

2.0 1.9

1.5 1.4
1.2 1.3 1.3

1.0 0.8
0.7 0.6
0.5 0.6
0.4 0.4 0.5
0.5 0.4

0.0
Taplejung Sankhuwasabha Terhathum Surkhet Kanchanpur

Hospital PHCC HP

Source: Further analysis of HMIS data.

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3. NHSS Outcome-wise Progress Status

3.1 Outcome 1: Rebuild and Strengthen Health Systems: Infrastructure, Human

Resources for Health, Procurement, and Supply Chain Management

Three key components as defined under outcome 1 of the NHSS for achieving efficient and effective
service delivery include health infrastructure, human resources for health, and procurement and supply
chain management. This section highlights progress made in these areas, and the progress in building
back better after the destruction of the 2015 earthquake.

Outcome 1a Infrastructure
Background
The MoHP continues to improve the health facility network across the country, guided by the NHSS
requirement to build earthquake resilient infrastructure, adopt upgraded standards, and improve practices
in regular maintenance and inventory management. The MoHP has been working in coordination with
provincial and local governments to promote good practices and to ensure a harmonized approach to
health related infrastructure. It has continued to use information from the Health Infrastructure Information
System (HIIS) to encourage a rational and efficient health infrastructure network at sub-national level
while at the same time supporting the GoN’s goal to Leave No One Behind (LNOB) by locating health
facilities in areas that cover ethnically and geographically marginalised communities. As per the policy of
GoN, Basic Health Care Centres are being established in all the wards where there is not health facility
yet. Sub-national government have been orientated and encouraged to implement maintenance and
management plans for health infrastructure, to continue their effectiveness and extend the life-span.

Major progress
Significant progress has been made in the fiscal year 2018/19 and to date. Major achievements are
summarised below under different thematic areas.

Nepal Health Infrastructure Development Standards (NHIDS) 2074 (2017) and Integrated Health
Infrastructure Development Programme (IHIDP)
 The MOHP has orientated provincial and local governments in Karnali, Gandaki, Province 3 and
Province 2 on the NHIDS and IHIDP categorisation of health facilities. These are proving to be
effective frameworks to guide implementation, supporting facilities development shown in Table 3.1.1
below.

Table 3.1.1: Sub-national Health Facility development guided by NHIDS and IHIDP
Province Health Facility Development
Province 2 Design of Ramraja Prasad Singh Academy of Health Sciences in Saptari (previously
Sagarmatha Zonal Hospital)
Design of Provincial Medical Store
Province 3 Primary Hospital programme in Bagmati, Bharatpur, Bhimphedi, Chauri Deurali, Gajuri, Gauri
Shankar, Indrawati, Jiri, Jugal, Kailash, Khanikhola, Lalitpur, Mandandeupur, Netrawati,
Panchpokhari Thanpal, Phikkal, Rubyvalley, and Tarkeshwor municipalities.
Primary Hospital at Budhanlikantha
Kanti Children Hospital Operation Theatre and Surgical Ward
Gandaki Design of Provincial Medical Store
Province 5 Design of Secondary Hospital at Bhim
Karnali Primary Hospital at Dailekh, Dolpa, Dullu, Humla, Jajarkot, Kalikot, Mugu, Mehelkuna,
Rukum and Salyan.
Secondary Hospital at Surkhet

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Design of Provincial Medical Store

Health facility reconstruction post 2015 Earthquake

 At the end October 2019, 367 activities related to reconstruction have been completed (93%
achievement against a target of 394 activities), while 27 are not yet complete or are in the planning
stage. A summary of progress is presented in Table 3.1.2 below.

Table 3.1.2: Repair and Reconstruction activities with External Development Partners
Districts Total Status Type of Construction Semi-
number Complete Ongoing Planning Permanent Prefab Repair/ Permanent
of Retrofitting & Shelter
Activities

Bhaktapur 5 4 - 1 2 3 - -
Dhading 55 52 1 2 4 38 13 -
Dolakha 45 43 1 1 2 36 5 2
Gorkha 57 56 1 - 2 37 3 15
Kathmandu 7 6 - 1 5 2 - -
Kavre 40 36 3 1 9 30 1 -
Lalitpur 9 8 - 1 2 7 - -
Makwanpur 12 9 3 - 4 8 - -
Nuwakot 48 47 1 - 1 42 1 4
Okhaldhunga 9 7 - 2 2 7 - -
Ramechhap 17 16 1 - 2 13 - 2
Rasuwa 18 17 1 - 1 13 3 1
Sindhuli 4 - 4 - 4 - - -
Sindhupalchowk 62 60 2 - 3 31 6 22
Solukhumbu 6 6 - - - 6 - -
Total 394 367 18 9 43 273 32 46
Note: Solukhumbu belongs to the category of Earthquake Medium Affected District but many health facilities
were damaged

Establishing health facility in all wards:

 As per the government policy of establishing health facility at ward level, budget was provided for
1200 wards in 2018/19 while budget is provisioned for 1390 wards in 2019/20; Establishment of
such health facilities is being done on cost sharing basis.

The GoN also has in place a set of bilateral arrangements with external development partners for health
facility reconstruction. Progress is set out in Table 3.1.3 below.

Table 3.1.3: Progress under Agreements with Bilateral Agencies

Agency Works description Progress
JICA Bir Hospital, Kathmandu Construction complete and handed over.

Paropakar Maternity and Construction complete and handed over.

Women’s Hospital, Kathmandu

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KOICA Nuwakot District Hospital 70 % of total works completed, including structural and
finishing works. Medical gas supply, false ceiling and
landscape-related works are being carried out.

Prefab structures at 10 health All 10 prefab health posts have been constructed and handed
posts over.
KFW Reconstruction of Rasuwa, Reconstruction work in Dolakha, Gorkha and Ramechhap
Dolakha, Gorkha, and district hospitals is ongoing. Rasuwa hospital is in planning
Ramechhap district hospitals stage.
CHINA Chautara and Manang hospitals Chautara Hospital reconstruction work is ongoing.
Reconstruction work at Manang Hospital is in planning stage.

Regular construction programme for health facilities

The MOHP collaborates with the DUDBC as its delivery agent in the construction, extension and
refurbishment of health facilities. Since the year 2015/16, there has been a general improvement in the
number of projects completed, while the number of ‘sick’ projects (projects that have been stalled or
halted, for example due to technical or contractual problems) has decreased. As shown in Table 3.1.4
below, MOHP authorised DUDBC to implement 746 projects in 2018/19. Of these projects 228 have been
completed and the contractors fully paid, while 107 projects are complete but there are payments
outstanding. There are 386 live projects carried over from previous years, and new 29 projects
commissioned in 2018 /19. A total of 23 projects were either dropped or terminated over the same period.

Table 3.1.4: Progress status of ongoing health infrastructure construction works as of end 2019
Description Ongoing (Carried over from Works planned in
previous years) before 2018/19 fiscal year 2018/19
Work Completed but full payment pending 107 -
Work Completed and full payment made to contractor 228 -
Work up to Finishing, Electrification, Sanitation 193 -
Work up to RCC in Fourth Floor/Roofing - -
Work up to RCC in Third Floor/Roofing - -
Work up to RCC in Second Floor/Roofing 47 -
Work up to RCC in First Floor/Roofing 40 -
Work up to Sill Level/Wall of Third Floor 2 -
Work up to Sill Level/Wall of Second Floor 34 -
Work up to Sill Level/Wall of First Floor 28 -
Work up to Foundation/DPC Level 23 1
Work Ordered 5 3
Tender Called 5 3
Design & Cost Estimate 9 22
Projects Dropped 14 -
Projects Terminated 9 -
Total 746 29
Total Ongoing and New Projects 545
Note: Projects terminated: Projects which have been contracted then ended due to unresolvable issues. Projects dropped: Projects originally
planned but had to be withdrawn as they were later found to be unfeasible.

Health Infrastructure Information System (HIIS)

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 A detailed infrastructure and Minimum Service Standards assessment at 503 health facilities in the
seven Learning Lab Districts (Bhaktapur, Dadeldhura, Humla, Kapilbastu, Kaski, Siraha and Sunsari).
 Support to the DUDBC to plan the health facility construction programme for the Annual Work Plan
and Budget (AWPB), including the identification of Primary Health Care Centres (PHCCs) with
potential for upgrading to Primary Hospital level.
 Assessment of over 2,400 wards and identification of priority wards for health facilities.

Development of health infrastructure policy and standards

Disaster Risk Reduction
 The MoHP’s Health Emergency and Disaster Management Unit (HEDMU) developed comprehensive
training guidelines on health sector disaster preparedness and response planning.
 The MoHP trialled a survey tool which assesses the level of disaster preparedness and response
planning at health facilities

Capacity Enhancement
Over the period October 2018 to November 2019, the MOHP conducted nine capacity enhancement
events on health infrastructure, involving a total of 413 participants. See Table 3.1.5 below for details.

Table 3.1.5: Health Infrastructure Capacity Enhancement Events October 2018 – November 2019
Capacity Enhancement Event No of
Participants
Information Session Retrofitting designs Bhaktapur 43
Karnali Province: Orientation on Health Infrastructure Development 38
Manthali Municipality: Orientation on Health Infrastructure Development 24
Province 3: Orientation on Health Infrastructure Development 45
Province 2: Orientations on Health Infrastructure Development 202
Skills for Retrofitting in Masonry Buildings 17
Health Infrastructure Policy Development Training 20
In-service Training for Health Infrastructure specialists 16
Orientation on Retrofitting for Contractors 8
Total Participants 413

Impact assessments on Policy Development and Technical Skills training were conducted in April and
May 2019. A series of detailed training modules and manuals under the health infrastructure capacity
enhancement programme is nearing completion.

Retrofitting of Bhaktapur Hospital and Western Regional Hospital Pokhara

The retrofitting of the Western Regional Hospital in Pokhara (WRH) and the Bhaktapur Hospital is a
flagship activity in the MoHP health infrastructure programme. As well as strengthening and rehabilitating
health infrastructure at two significant hospitals, this activity will provide replicable experience that can
be applied to health facilities across the country. It implements a four-fold integrated approach, involving:

 Seismic retrofitting (structural and non-structural elements, as well as rehabilitation of relevant

functional service areas)
 Construction of a temporary multi-purpose decanting facility
 Decanting transfer of hospital services and patients
 A ‘Green’ retrofitting package to maximise environmental benefits and improve sustainability
(including implementation of a Zero Waste site policy, potential adaptive re-use of the decant facility,
improved water management and energy efficiency).

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This is a patient-centred construction process, involving close cooperation with the DUDBC Health
Buildings Division and Federal Project Implementation Units in Pokhara and Bhaktapur. Progress is set
out in Table 3.1.6 below.

Table 3.1.6: Retrofitting Bhaktapur Hospital and Western Regional Hospital Pokhara
Activity Progress
Design complete, and tender awarded. Construction work underway.
WRH Decanting Block
Anticipated completion date February 2020.
Design complete, and tender award due November 2019. Anticipated
Bhaktapur Decanting Block
completion date March 2020.
Design complete, and tender to be awarded.
WRH Main Retrofitting Works
Anticipated completion date November 2021.
Design complete, and tender to be awarded.
Bhaktapur Main Retrofitting Works
Anticipated completion date November 2021.
WRH Decanting Services tender Tender documents are being prepared
Bhaktapur Decanting Services tender Tender documents are being prepared
WRH ‘Green’ Retrofitting Package The work is completed by November 2021
Bhaktapur ‘Green’ Retrofitting Package The work is completed by November 2021

International Monitoring & Verification

The structural designs at Bhaktapur and WRH Pokhara Hospitals were reviewed in November 2018 by
an independent international team commissioned by DFID Nepal. The review found that seismic safety
had been upheld, and that structural, functional and green retrofitting, and services systems factors, had
been appropriately addressed in the designs. Independent monitoring will take place in November 2019
and at regular periods in 2020.

Gender Equality and Social Inclusion (GESI) in Health Infrastructure

Gender Equality and Social Inclusion (GESI) aspects are included in the hospital retrofitting tender
documents and have also formed regular sessions in health infrastructure training and orientation events.
Contractors and on-site workforce have been briefed on GESI requirements.

Challenges
The health infrastructure sector has seen major progress since October 2018 in terms of quantity, quality
and geographical coverage of health facilities. However, there are significant challenges remaining:
 Although organisational restructuring under federalism is now largely complete, there are still large
numbers of vacancies in sub-national professional positions needed for good quality health facility
development.
 Provincial and local governments have received funds from the centre for operational and capital
expenditure on health infrastructure. However, weak absorptive capacity is a real challenge, and
comprises a shortage of ready-to-implement projects, procurement delays, weak institutional
arrangements, and scarcity of skilled staff.
 Evidence-based decision making requires robust and comprehensive data and analysis. While there
is detailed information on the type and condition of health infrastructure for selected districts, there
are significant gaps in coverage elsewhere, which hampers planning and implementation.

Way Forward
Following activities are planned for the continued improvement of health infrastructure planning,
development and maintenance:
 Continuing to work closely with DUDBC, provincial and local governments to improve planning and
decision-making. This will support the development of a rational inter-connected hierarchy of health
facilities across the country. There will be continued orientation and support for adoption of NHIDS,
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IHIDP, DRR and other relevant infrastructure-related policies and standards at sub-national level,
involving close engagement and information sessions with provincial and local governments
 Establishment of the health facilities has been planned and budgeted in the wards where there are
no health facilities.
 Continuing investment in capacity enhancement for improving technical skills at federal and sub-
national level, targeting managerial and technical staff.
 Carrying out infrastructure risk analysis, with the development and incorporation of a multi-hazard
resilience perspective.
 Implementing the flagship Retrofitting Project at WRH Pokhara and Bhaktapur Hospital, ensuring that
effective and efficient patient-centred construction takes place, and that lessons are disseminated as
the project progresses.
 Strengthening evidence-based decision making through improved HIIS data and analysis and wider
geographical coverage.

Outcome 1.b Human Resources for Health

Background
The NHSS recognises that a key component of quality health services relies on strengthening the
production, deployment, and retention of skilled human resources. This NHSS outcome will be delivered
through the following outputs: improved availability of human resources at all levels with a focus on rural
retention and enrolment and improved medical and public health education and competency. As a result
of restructuring of health governance, the staff adjustment is progressing. Of the total 31,591 permanent
employees in the MoHP, approximately 4,000 positions are vacant.
Major Progress

 Draft of the HRH strategy was further refined to comply with the federal context.
 Adjustment of about 27,500 MoHP staff as per the Staff Adjustment Act (2074) by October 2019
 Provincial Health Training Centres have been established in all seven provinces
 Nursing & Social Security Division (NSSD) is developing guidance to place the midwives
 NSSD developed a MoU to contract to the hospitals under a Federal system
 Specialist Doctors sent in a batch to provincial governments for appropriate placement.
 Workload Indicators and Staffing Norms (WISN) training was organised and MoHP has
identified health facilities and cadres to work on workload indicators.
 Developed deployment procedures to deploy 189 specialists (MD/MS, MDGP and others) who
will graduate this year from NAMS, Institute of Medicine (IoM) and B.P. Koirala Institute of
Health (BPKIH)
Challenges

 Local Governments (LG) are responsible to recruit staff on a contractual basis, but there are no
standard guidelines which are crucial to ensure the quality.
 The data about HRH from professional councils is yet to be completed.
 HRH projections, gaps and needs are not yet complete as per the new structure.
 There is a mismatch of HRH production and actual needs in particular for Pharmacists, Nurses,
family planning service providers, ENT specialists etc.
 Lack of HRH in new areas such as Hospital Management.
 Very few public hospitals feel they should provide 24 hour services

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 Partnerships with academic health institutions to support HRH needs have not yet yielded
positive results due to the lack of clarity on roles and responsibilities.
Way Forward

 Strengthen partnerships with public and private academic health institutions to address the HRH
needs.
 Strengthen the HRH unit in the MoHP.
 Implement appropriate deployment of specialists as per the need identified by the referral
hospitals.
 Endorse the updated HRH Strategic Roadmap.
 Revise in-service training programmes focused at actual need of the health facilities under
various levels of governments.

Outcome 1.c Procurement and Supply Chain Management

Background

Procurement and Supply chain are interdependent activities which affects the quality of health services.
The MoHP realises the importance of strengthening the procurement and supply chain cycle through the
development, endorsement, and implementation of the Procurement Improvement Plan (PIP, 2017-
2022). However, MoHP is in the processing of developing Nepal Health Sector Public Procurement
Strategic Framework (NHSPPSF) for the health sector. This framework will provide strategic policy
guidelines for all spheres of health governance. Under this comprehensive plan, MoHP is implementing
following five reforms:

(i) Pre-bid information system strengthening such as, Market Analysis, TSB and LMIS
improvements;
(ii) Efficient procurement and logistics planning along with APP, MPP and CAPP consolidation;
(iii) Standardization of procurement and logistics management process by executing e-GP system
with health friendly SBDs and e-LMIS;
(iv) Enhancing contract management and capacity building program at all spheres of health
governance; and
(v) Strengthening Post-bid evaluation system of procurement and supply chain, like Risk
Analysis, Procurement Compliance System, Quality Assurance Plan, etc.

Procurement Management Reform

The procurement management in the health sector consists of preparing, executing and monitoring of
the Procurement Improvement Plan (PIP), the Technical Specification Bank (TSB), Logistics
Management Information System (LMIS), Inventory Management System (IMS), Annual Procurement
Plan (APP), Master Procurement Plan (MPP), the Consolidated Annual Procurement Plan (CAPP) and
their effective implementation to ensure their timely delivery and the distribution of medical goods and
equipment. Since FY 2014/15, MoHP continues to monitor and evaluate the implementation of the
compilation and consolidation of APPs through its departments.
Table 3.1c.1: CAPP Budget, Plan and Actuals (in NPR Million)

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% of CAPP
Total Procurement CAPP CAPP plan value on
Fiscal Years
Budget Budget Plan Actuals Procurement
Budget

2014/15 33517.1 1410.85 1405.37 513.22 99.61

2015/16 36729.5 2159.01 2102.33 1321.01 97.37

2016/17 39122.3 4125.19 2899.23 1723.91 70.28

2017/18 24420.2 2728.55 2156.34 1606.18 79.03

2018/19* 34082.2 6300.00 5944.83 5590.29 94.36

2019/20** 42670.8 5590.78 5433.48 0 97.19

* Figures since this FY are figures of federal PEs. **Planned figures.

Source: Various Years Fiscal Statements of DoHS, MoHP and CAPP Plans. Figures of FY 2019/20 are taken from the output of e-CAPP
module of TABUCS retrieved from http://tabucs.gov.np/new.

The CAPP was introduced in 2017/18 and only covered 79% of the procurement in the health sector. In
2018/19, a Federal CAAP (F-CAAP) was introduced and in 2019/20 around 97% of procurement budget
is planned to be processed through online F-CAPP procedures. CAPP execution has been improving in
recent years (Table 3.1c.1). Table 3.1c.2 shows F-CAAP procurement management according to
different MoHP departments.

Table 3.1c.2: Federal CAPP Budget, Plan and Actuals of FY 2018/19 (in NPR Million)

% of % of CAPP
Total CAPP CAPP Value
Budget FY Procurement Value Plan on Actual on
Description 2018/19 Budget CAPP Plan Actuals PB CAPP Plan

MoHP & Federal Hospitals 16704.7 1350.0 1231.57 1551.99 91.23 126.02

DoHS & Programs 8161.5 3000.0 2987.16 2738.06 99.57 91.66

DoDA & Programs 167.6 80.0 79.00 46.94 98.75 59.42

DoAA & Programs 165.8 12.0 11.59 18.49 96.58 159.53

Board & Academies 8882.7 1858.0 1635.51 1234.81 88.03 75.50

Total 34082.3 6300.0 5944.83 5590.29 94.36 94.04

% of Total Budget 18.48 17.44 16.40

Source: Federal Budget and procurement Budget taken from Red Book, 2018/19; F-CAPP, 2018/19 and CAPP Status, 2018/19 taken from NPC
Form No.2.

F-CAPP Execution
FY 2018/19 was the first year of federal level CAPP execution. Out of NPR 34.08 billion allocated, federal
procurement budgets were NPR 6.3 billion (18% of total budget), under which NPR 5.94 billion (99% of
federal procurement budget) was planned in the F-CAPP and executed over this year. The absorption
capacity on procurement was about 16% in FY 2018/19. Out of 30 PEs, 28 PEs (93%) participated in F-
CAPP planning process by using manual and offline method of F-CAPP preparation at that time.

Table 3.1c.3: Federal CAPP Actuals by Procurement Type FY 2018/19 (in NPR Million)

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CAPP
Value Civil Medical Consulting Other
Description Actuals Works Goods Services Services
MoHP & Central Hospitals 1551.99 539.46 1003.13 2.50 2.70
DoHS & Programmes 2738.06 75.85 2212.83 80.95 368.43
DoDA & Programmes 46.94 4.57 42.37 0 0
DoAA & Programmes 18.49 2.32 9.00 4.52 2.65
Board & Academies 1234.81 978.24 221.45 28.74 6.39
Total 5590.29 1600.44 3488.78 116.71 380.17
% of CAPP Value 94.04 28.63 62.41 2.09 6.80
Source: CAPP Status, 2018/19 taken from NPC Form No.2 of Physical Progress Report & CAPP Monitoring Report of MoHP

As against of the F-CAPP value of NPR 5.94 billion a sum of NPR 5.59 billion (94% of F-CAPP value)
have been absorbed as of procurement expenditure in FY 2018/19. The expenditure includes the
procurement categories of civil works (28.6%), medical goods (62.4%), consulting services (2%) and
other services (6.8%). EDPs observation on the implementation of F-CAPP shows CAPP procedures as
an updated management tool was effectively applied in procurement management of MoHP. (September
2019; A Report on Biannual Assessment of CAPP Implementation Process for FY 2018/19; DFID). This
co-monitoring study also indicates a notable improvement in procurement management reform practices
of MoHP in recent couple of years.

Functional Status of Equipment in Hospitals: As a regular monitoring of the functional status of the
equipment, Management Division has maintained the functional status of the equipment that are under
the scope of the DoHS. The functional status of sixteen different intermediate equipment in 94 hospitals
(mostly provincial level), disaggregated by province, is presented in Table 3.1.c.4 below. In overall, 82.3
percent equipment were found to be functional (range: 51.8% - 92.2%). The lowest functional status was
of the ventilator (51.8%) which is used in intensive care while the highest functional status of the dental
X-ray (92.2%). Variation in the functional status across provinces is relatively low; the highest and the
lowest functional status was respectively in Sudur Paschim Province (92.6) and Province 1 (76.9%).

Table 3.1c.4: Functional Status of Equipment in Hospitals: by Equipment Type and Province

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Number of Equipment by Provinces Total
SN Name of Equipment Sudur  Total  Functional 
1 2 3 Gandaki 5 Karnali
Description Paschim (No.) (%)
Tota l 83 68 134 97 119 59 71 631
1 Vital Sign Monitor
Functiona l 65 57 107 82 90 47 70 518 82.1
Tota l   95 47 51 54 69 70 51 437
2 Oxygen concentrator
Functiona l 78 41 46 42 61 58 51 377 86.3
Tota l   60 69 54 50 74 36 54 397
3 Warmer, infant
Functiona l 51 60 49 38 55 31 53 337 84.9
Tota l   48 30 30 57 53 36 40 294
4 Microscope, binocular
Functiona l 35 24 27 54 51 36 38 265 90.1
Tota l   57 25 42 43 46 35 29 277
5 Electrocardiograph (ECG)
Functiona l 37 19 34 36 39 29 25 219 79.1
Tota l   38 16 29 27 49 26 28 213
6 Analyser, biochemistry
Functiona l 25 13 26 16 43 23 26 172 80.8
Tota l   34 15 24 26 35 23 23 180
7 USG Machine
Functiona l 25 10 22 20 31 19 20 147 81.7
Tota l   30 20 25 29 33 12 12 161
8 Phototherapy unit
Functiona l 27 14 25 27 30 12 11 146 90.7
Tota l   34 13 18 20 30 21 21 157
9 Electrosurgical unit
Functiona l 29 11 17 20 28 18 20 143 91.1
Tota l   28 15 15 23 18 13 16 128
10 Incubator, laboratory
Functiona l 19 10 12 13 15 10 15 94 73.4
Tota l   11 9 13 9 16 5 11 74
11 Anaesthesia apparatus
Functiona l 6 7 11 6 13 4 9 56 75.7
Tota l   3 2 6 9 8 5 4 37
12 Defibrillator
Functiona l 2 1 5 8 6 5 3 30 81.1
Tota l   5 7 5 8 8 5 1 39
13 Endoscopy
Functiona l 3 6 4 6 8 3 1 31 79.5
Tota l   5 6 14 17 25 9 9 85
14 Ventilator, intensive care
Functiona l 5 5 5 8 8 7 6 44 51.8
Tota l   12 5 9 7 8 5 5 51
15 X‐Ray, dental
Functiona l 11 5 9 5 8 4 5 47 92.2
Tota l   33 25 29 29 38 26 29 209
16 X‐Ray 
Functiona l 25 13 24 23 25 17 21 148 70.8
Total Tota l   576 372 498 505 629 386 404       3,370
Functiona l  (No.) 443 296 423 404 511 323 374       2,774 82.3
Functional (%) 76.9 79.6 84.9 80.0 81.2 83.7 92.6 82.3
Source: Management Division, Department of Health Services.

e-CAPP nitiation: In FY 2018/19 monitoring of F-CAPP had some shortfalls, due to it being offline which
led to limited participation. A new online e-CAPP module under TABUCS has been piloted and an
orientation and initial training to MoHP officials was conducted in FY 2018/19. FY 2019/20 is the second
year of federal level CAPP execution and first year of online data entry into the e-CAPP module of
TABUCS at federal level.

The FY 2019/20 national budget allocated NPR 42.67 billion to the federal health budget and the federal
procurement budget is NPR 5.59 billion (13% of the overall health budget), under which NPR 5.43 billion
(97% of procurement budget) was planned as online F-CAPP and shall be executed over this year. DoHS
and Programs have a lead role of 47% of CAPP Plan as against of procurement budget, Board and
Academies have 33% and MoHP and central Hospitals have 19%. Full coverage of PEs under MoHP
(47) has incorporated into the system in online basis.

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Figure 3.1c.1: Federal e-CAPP Plan in FY 2019/20 (in NPR Million)

Major Progress

In the fiscal year FY 2017/18 to 2018/19, the MoHP has made impressive progress in improving the
performance of procurement management. The following targets have been achieved:

 Procurement Improvement Plan: Procurement Improvement Plan (PIP, 2017-21) has been
prepared and endorsed by MoHP; the formation of a nine member CAPP monitoring committee
(CAPP-MC) under the chairmanship of the Director General (DG) of the DoHS, and the
endorsement of the terms of reference (ToR) of the CAPP-MC in FY 2017/18. Since then,
trimester monitoring meetings have been held each year. Eight consecutive CAPP monitoring
meetings up to FY 2018/19 have been held.
 Federal Procurement Planning and Consolidation: The departmental CAPP up to FY 2017/18
has been made within the specified timeframe in DoHS along with its divisions. Whereas, Federal
level CAPP was initiated and executed in FY 2018/19 for the first time. Online CAPP under
TABUCS was designed and piloted in 2018/19 and an orientation training provided for MoHP and
DoHS officials.
 Nepal Health Sector Public Procurement Strategic Framework (NHSPPSF): The NHSPPSF
has been prepared as a strategic document for both procurement and supply chain management
which is expected to replace the PIP upon its endorsement.
 Technical Specification Bank: The codification of 108 drugs and 1,089 equipment was
uploaded in the TSB in FY 2017/18 and 121 drugs and 1,109 equipment in FY 2018/19. The TSB
was restructured and uploaded in the DoHS website in FY 2017/18 and is available for all
stakeholders. In 2017/18 more than 300 system users were registered and in FY 2018/19 this has
increased to more than 700 users and more than 17,000 TS downloads.
 Procurement Process Standardizations: In FY 2017/18 83% of bids were processed using the
electronic government procurement (eGP-II) system and in FY 2018/19 this increased to 98%. In
FY 2017/18 Standard Bidding Documents (SBDs) for health sector procurement (3 SBDs

  22 
 

 
  

including a Framework Agreement) were drafted and sent for approval to Public Procurement
Monitoring Office (PPMO) and several follow up discussions meeting were held in FY 2018/19.
 Two SOPs on procurement management and eGP operation for SNGs levels were prepared,
endorsed and were in use in FY 2017/18. 119 Procurement Clinics were held in FY 2017/18 and
205 in FY 2018/19 including 19 provincial level clinics along with other regular support activities
of different division and centers.
 Capacity Enhancement: Two eGP trainings in procurement were conducted at the central level;
four provincial/local level trainings in procurement were conducted in FY 2017/18; Training
session plans were developed for SNGs in procurement management in 2017/18 and in FY
2018/19 SNGs training on Forecasting and Quantification (7), Procurement Planning (7), eGP
operation (7) have taken place in 3 Provinces. The Logistic and Procurement Management
Training Manual was reviewed in FY 2018/19.
 Procurement Modality: MoHP is using open, competitive, and transparent modality of bidding.
The open bid method is most commonly used method in the PEs for the procurement of drugs,
medical equipment, hospital devices, contraceptives, cold chain equipment, insecticides, and
health infrastructure facilities. It indicates towards openness, transparency, and competition in
procurement and increasing VfM.
 Bid Evaluation and Approval: The standard time taken for a bid evaluation and approval is 120
days as per PPA/PPR. All procurement of drugs and equipment were within this legal timeframe.
In DoHS, all ICB bids are evaluated within the period of 90 days of time and all NCB bids are
evaluated within the period of 35 days.
 ICT Usage in Grievance Handling: In FY 2017/18 a concept paper on ICT based Grievance
handling and Redressal was endorsed by DoHS on behalf of the MoHP and system software was
developed, approved and executed in FY 2018/19. The Grievance Handling Mechanism software
which is installed in MD/DoHS reported more than 37 grievances handled by the system in FY
2018/19.
 Committee Monitoring: MoHP has formed a Public Financial Management (PFM) committee
with the PPMD chief as chair and endorsed a TOR to monitor financial management in
procurement and supply chain management. In 2017/18 MoHP formed a CAPP Monitoring
Committee (CMC) under the leadership of Director General of the DoHS and endorsed its TOR
to monitor overall matters of procurement and supply chain management. Under these two broad
central level committees, DoHS has formed and expanded their various technical committees
since FY 2017/18. In FY 2018/19 PFM committee started to monitor the function of CAPP-MC on
behalf of MoHP.

B. Supply Chain Management Reform

Supply chain management (SCM) in the health sector consists of preparing, operating and monitoring
logistics needs in the Procurement Improvement Plan (PIP) using the Logistics Management Information
System (LMIS), electronic Logistics Management Information System (eLMIS) and the Inventory
Management System (IMS). It involves warehouse development and management and transportation to
ensure the timely distribution of medical goods and equipment. Under this comprehensive system the
DoHS/MoHP is implementing the following reform packages on logistics and supply chain management:

(i) Enhancing Strategy and Planning with effective M&E functions;

(ii) Improving Forecasting and Quantifications techniques;
(iii) Standardization of warehousing and inventory management;
(iv) Enhancing Management Information System practices through e-LMIS; and
(v) Promoting Capacity Development Programs in all forms of governments.
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LMIS collects data from 77 districts and data was entered into the LMIS system on a quarterly basis. To
date, 71 out of 77 districts were reporting information in this way. In 2016/17 eLMIS was introduced and
in 2017/18, 22 district (5 districts off-line and 17 districts on-line) are piloting the system.

In FY 2018/19, eLMIS was implemented at 6 central stores, 2 PMS, 22 HO stores (Province 5 & 6), 4
LGs and 23 HFs of Bardiya and Surkhet. As a result, >90% LMIS reporting rate in province 5 , > 80% in
Karnali Pradesh (eLMIS implemented provinces) has been achieved. Data from all health facilities is
reported quarterly and made available nationally in the form of dashboard and reports through use of
eLMIS software. Work is in progress to make LMIS data entry at the SNGs level and capacity is being
built starting from the health directorate, and logistics management centres at the province, and health
offices at the district, municipality health section at the local level (LGs). So far, 371 LGs has been trained
on eLMIS data entry. Likewise, eLMIS implementation in remaining PHLMCs, hospitals, health offices,
and LGs is also in planning.

Major Progress

In the FY 2017/18 and 2018/19, the MoHP and DoHS has made good progress in improving the
performance of logistics management. The following targets have been achieved:

 Roll out of the eLMIS: In the FY 2018/19, the MD/DoHS carried out some of the training activities
in an integrated manner. IHMIS section of MD/DoHS conducted one-day eLMIS training for LGs
health coordinators, sub-coordinators as well as storekeepers in all provinces in succession with
training on DHIS2. 371 LGs were trained on how to enter data into eLMIS but
username/passwords are not yet available to these trained LGs and until the last fiscal year, LMIS
reports were collected and entered at the central level. eLMIS has been implemented in 57 sites
including:
o 2 central stores
o 4 central sub-stores
o 2 Provincial Health Logistics Management Center (Butwal and Nepalgunj)
o 22 districts in Province 5 and 6
o 4 Local Governments and 23 health facilities in Bardiya and Surkhet districts.

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 eLMIS rollout assessments: Management Division assessed eLMIS operational sites in

December 2018 using a formal assessment tool. In FY 2018/19, assessments were conducted at
eLMIS operational sites, including all levels of the supply chain (i.e. CMS, PMS, district, LGs and
SDPs) and covering all types of eLMIS modules (i.e. online, offline and mobile modules of eLMIS).
 eLMIS Phase II preparation and configuration: For eLMIS Phase II implementation, a formal
request was sent to USAID in November 2018 by MD/DoHS to scale-up eLMIS throughout the
country including all 753 LGs. USAID/GHSC-PSM developed an eLMIS scale-up plan to rollout
eLMIS transactional module to 5 PMS and 55 districts stores and reporting module to 753 LGs.
As per this plan, required username and password has been made ready for distribution. To
support the eLMIS scale-up, a local vendor has been selected in FY 2018/19 to rollout eLMIS.
Additionally, all requirements for scale-up including site readiness assessment are already in
place.
 Ensure master data management and interoperability within NHSS: The Management
Division has developed a shared dashboard which includes key indicators such as HFs reporting
percentage and growth patterns, expiring/expired commodity situations country-wide, and stock
availability status. They are regularly reviewed by concerned authorities for appropriate decisions
based on the data. The analysis reports were regularly circulated to the districts and relevant
stakeholders to resolve any identified issues.
 Forecasting and Quantification: DoHS uses LMIS data for forecasting and quantification of
drugs. Historical consumption data, alongside data on morbidity, demographics and program
considerations are used to predict the annual procurement need. Basically, LMIS software
provides national, province and local level requirements of drugs as the basis for health
commodity procurement planning and delivery schedules practices commonly used.
 Review of LMIS reporting system: With new Federal structures in place, it was unclear how
information across the supply chain levels will be handled and as a result it created a gap in the
LMIS reporting rate. The GHSC-PSM has focused its TA on these areas which resulted in an
improvement in LMIS reporting rate. The reporting rate for FY18 quarter 4 was only 30% whereas
the reporting rate for FY19 quarter 4 has increased more than two-fold to 68%. The quarterly
average reporting rate of FY18 was 65% whereas in FY19, it increased to 78%.
 National supply chain policies at all levels: The Management Division organized a consultative
meeting with high level province MoSD officials to discuss health commodities specification,
FASP, procurement, LMIS and human resources. This activity was followed through interaction
with PHD and PHLMC Directors, LG officials.
 Capacity Building and Technical Support to LGs: A critical mass of people at LG has been
developed. Comprehensive training on procurement and supply chain management was
conducted, participants certified and viber groups created for exchanging know-how and success
stories.
 Ensure commodity security through Pipeline Reporting and Monitoring: Drug status pipeline
report of FY 2017/18 and 2018/19 is produced through LMIS software and monitored with EDPs
representatives and MD/DoHS. Stock status of 37 drugs is monitored on a quarterly basis, out of
121 FEDs included in TSB. The requirement for medical equipment and the status of available
equipment is not monitored through the system yet.
 Enhancing warehouse and inventory management: In FY 2018/19, 500 posters promoting
basic warehouse good storage practices were distributed and a catalogue of health commodities
developed to support better practices in stores. The Epidemiology and Disease Control Division
(EDCD) store physical stock count is complete and the EDCD store now part of eLMIS alongside
five Divisions and Centres, two province stores, 22 district stores, four LGs and 23 HFs. A draft
warehouse management guidelines has been developed and is under review. MD has sent racks,
material handling and safety equipment to five PMSs.
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 Data governance & online IMS support: USAID/GHSC-PSM will reconciling eLMIS master data
against the health facility code issued by the new Health Registry. Online IMS support is
performing optimally through Intellisoft. As per the new regulatory requirements on Ma.La.Pa
forms, Intellisoft team has developed and incorporated those changes on the Online IMS and
made available for the users for their daily operations.
 Monitoring and Evaluation: The country M&E plan was updated in FY 2018/19 to reflect
organizational changes arising from the new federal structure. Minor changes were made to
indicators based on the learning from the project. In FY 2018/19 two new KPIs related to eLMIS:
order fill rate and lead time were reported in the quarterly report. Regular follow up with the supply
chain pharmacists recruited by MoHP took place throughout the year. They were provided
coaching and mentoring through visit, phone calls and email communication.

Challenges

 Weak system linkages between TABUCS, eAWPB, eTSB, eLMIS and eCAPP in preparing
procurement proceedings and pre-bid information.
 The existing LMIS/e-LMIS is not comprehensive enough to inform the quantification and
forecasting of drugs to cover all SNGs and federal requirements.
 Absence of health specific SBDs in eGP system is hampering the procurement of medicine in all
levels of government.
 Delays in the evaluation of procurement systems due to the lack of post-bid information activities
such as Procurement Compliance Audit System [PCAS], Quality Assurance Plan [QAP], Risk
Mitigation Plan [RMP] and Contract Management System [CMS]
 Warehousing facilities in the medical stores do not have enough staff and or space for the
adoption of good warehousing practices.
 There is a lack of skilled staff across all levels of Government who can carry out eGP, eCAPP,
eTSB, eLMIS and Information Management System (IMS) and institutional memory has
weakened due to the rapid transfers of staff involved in procurement and supply chain systems.
Similarly, Capacity Building of Bidders and Suppliers is another issue to resolve immediately in
the SNGs level.
 Weak contract management capacity and practices have caused issues relating to liquidated
damages charges, variations, extension of time, and non-timely delivery of drugs.
 Ensuring the continuous availability of the free drugs at respective levels remains to be a
challenges. A recently conducted survey has recently been carried out which reveals low level of
availability of drugs at health facilities (Annex 9).

Way Forward

 Specific provisions for the procurement of drugs are required in the PPA/PPR. This will lead health
friendly procurement practices in the health sector. The amendments on PPA/PPR shall also
focus on Framework Agreements, Commodity Contracts and G-2-G Arrangements for health
sector use.
 Focus on PFM and CAPP-MC to strengthen its monitoring functions to reduce audit observations
in procurement. ICT based monitoring functions should be initiated.
 PPMO needs to develop and endorse standard operating procedures (SOP) for the quantification,
forecasting, procurement and the disposal of expired drugs at SNGs level.
 Pre-bid information and planning systems should be strengthened including market analysis, cost
analysis, sourcing analysis and risk analysis in procurement and supply chain management.

  26 
 

 
  

 Enhance the use eGP, eLMIS, eCAPP; and incorporate health sector friendly SBDs into the eGP
system. Institutionalization of Procurement Clinic function for troubleshooting and technical
support in SNGs levels procurement. The Learning Lab (LL) approach which is currently being
implemented could be strengthened as a focal hub for SNGs level technical support.
 Ensure Quality Assurance Plan (QAP) including Pre-Shipment Inspection (PSI) of drugs in federal
level and Post-delivery Inspection (PDI) of drugs at SNGs level.
 Strengthen strategic planning skills, data driven planning and decision making at various Supply
Chain management levels; Capacity building, Quantification & Supply Planning, forecast
accuracy, stock status analysis, Provincial Task Force developed and capacitated.
 Design competency-based in-service training, supportive supervision, and mentorship program,
to improve SCM performance at provinces, District and local level.

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3.2 Outcome 2: Improved Quality of Care at Point-of-delivery

Background
Improving the quality of care at the point-of-delivery is a priority for NHSS and is delivered under three
outputs:

 Quality health services delivered as per standards and protocols

 Quality assurance system strengthened
 Improved infection prevention and health care waste management

Progress has been made in the first output by establishing minimum service standards for health posts
and primary, secondary, and tertiary level hospitals. Both the NHSS and the 2019 National Health Policy
prioritise quality of care and strongly advocate that regulations to accredit health institutions and quality
assurance mechanisms should be endorsed and implemented for allopathic and ayurvedic medicines,
supplies, lab services and medical equipment.

Major Progress in FY 2018/19

 Various divisions of DoHS/MoHP are revising and developing new protocols and guidelines, to
align with the new Federal organogram.
 The Public Health Service Act 2018 was enacted.
 The Public Health Service Act 2018 outlines the institutional arrangements for accreditation. A
Health Institution Quality Assurance Authority Act was drafted to establish an autonomous body
for accreditation of private (including NGO) health institutions and Quality Assurance Guidelines
have been prepared.
 A draft of the standards for accreditation of Provincial Laboratories is prepared.
 Public Health Service Regulations have been drafted and are in the process of approval.
 The guidelines to establish and upgrade hospitals have been developed by QSRD.
 MoHP has started to develop a National Health Care Quality Improvement Strategy.
 The Basic Health Care Services (BHCS) package has been defined and costed and in the
process of consultation before proceeding for endorsement.
 Draft standard treatment protocols and draft operational guidelines for the BHCS package have
been prepared by CSD/DoHS.
 MoHP/QSRD has developed Minimum Service Standard (MSS) for all levels of health facilities
from health post to tertiary hospitals and have drafted MSS implementation guidelines.
Provincial officials were provided training on the MSS (and training of trainers) to implement the
MSS at federal and provincial hospitals. Details of the MSS approach is presented in Annex 5.
 Other standards and guidelines that have been prepared include: draft of the hospital risk
management standard; draft of referral guidelines; standards for reproductive health and
protocols for various level of health workers.
 The National Action Plan for Anti-Microbial Resistance (AMR) is being finalised. Tools for
implementing AMR stewardship at hospitals was piloted in four hospitals.
 On-going support from NHTC to services providers included: follow-up enhancement (FEP) to
SBA (40), MLP (74), and OTTM (6). Since 2016/17, 150 SBA nurses were trained as clinical
mentors and in 2018/19 they provided on-site clinical mentoring to 1088 service providers. 45
service providers who received more than one mentoring sessions over a two year period
demonstrate an increase in three decision making skills (from 58% to 73%) and four practical
skills (from 51% to 70%).

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 Assessments conducted on the availability and quality of services (including waste

management); of the Provincial Hospital in Surkhet, 10 district-level hospitals in Karnali
Province and 3 referral level hospitals in Province 5.
 Tuberculosis prevalence study has been completed

Challenges
 Improving access to health services remains a major challenge in mountain and hill areas, due
to geographical barriers.
 Unclear governance and regulation structure for Quality Assurance at provincial and local level
health institutions. Overlapping roles of various MoHP/DoHS divisions on quality of care leads
to confusion.
 Weak quality assurance framework at health institutions for quality health service delivery.
 Less focus on data driven quality assurance mechanisms to improve the service delivery
 Developing key indicators in order to monitor the implementation of standards is challenging.
 Linking performance of health institutions with annual planning and budgeting.
 Large number of undetected cases of the Tuberculosis as revealed by the recent studies

Way Forward
 Finalise regulations to implement commitments in quality in the PHA.
 Finalise and endorse BHCS package and regulations/guidelines/protocols and implement
 Finalise and endorse AMR action plan and implement.
 Finalise national quality of care strategy and implementation guidelines, ensuring that planning is
based on performance of health facilities and needs. Develop and define the quality assurance
structures at all three levels of government.
 Implementation of MSS and develop a reporting and monitoring mechanism to link with annual
planning.
 Cabinet approval of the GESI Strategy and develop an implementation plan to roll out the GESI
strategy at Federal, Province and local levels.
 Develop a geriatric health care strategy and guidelines for elderly friendly services in hospitals.
 Expand the establishment of rehabilitation units and disability centres.
 Develop new and innovative rehabilitation related training courses i.e. physical and rehabilitation
medicine, occupational therapy, and mid-level health workers.
 Finalise and approve the guidelines for the establishment and upgrade of health institutions. Bring
the private hospitals under the licensing framework and develop e-licensing submission for private
health institutions.
 Strengthen legal framework for the regulation of drugs and laboratory services across each level
of government.

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3.3 Outcome 3: Equitable Distribution and Utilisation of Health Services

Background
NHSS states that the MoHP will sustain and improve the progress made towards reducing inequalities in
health outcomes through the expansion of health services focusing on the under-served, the poor, and
urban communities. The NHSS has equity as one of its four strategic approaches as part of the approach
to achieve universal health coverage. The major implications of financial, socio-cultural, geographical,
and institutional barriers are reduced access to services. Equitable access to health services means that
activities need to be developed that give priority to populations and areas who lack or have limited access
to health services. There are two outputs under this outcome which include:

• Improved access to health services, especially for unreached populations

• Strengthened health service networks including the referral system

Major Progress
 The social health insurance (SHI) programme is being implemented in 49 districts with
approximately 2.3 million members enrolled.
 450 Community Health Units are in operation across 77 districts.
 Visiting providers have been providing long acting reversible FP methods in 60 municipalities of
20 remote districts.
 Roving auxiliary nurse midwife (ANM) are providing reproductive, maternal, new-born and child
health services to un-reached groups for past two years.
 Birthing centres have been expanded in rural and remote areas by local government.
 Specialist doctors (MDGP, MD, DGO) who studied under the GoN scholarship programme have
been deployed to provinces.
 84 CEONC sites have been providing caesarean section service
 12 hospitals14 have been providing geriatric health services and in 2019/20 MoHP plans to
establish 415geriatric wards in referral hospitals.
 Social service units (SSUs) are functional in 35 hospitals and MoHP has planned for an additional
316in FY2019/20. Trainings on communication, psychosocial support, coordination and
volunteerism have been provided in 3 SSUs in hospitals.
 53,330 people received the Deprived Citizen Treatment Fund in FY 2018/19 (beneficiaries by
diseases category: Cancer-37,121, Kidney- 5,866, Heart – 6,828, Sickle cell Anaemia- 1,026,
Spinal Injury – 1547, Head Injury- 761, Parkinson -377, Alzheimer- 121.
 Disability Inclusive Health Services Guidelines and Disability Management guidelines have been
developed to support implementation of the National Policy and Plan of Action for Disability.

Challenges
 Geographical barriers need to be addressed to improve access to health facilities
 Anaesthetic assistants continue to be placed in health facilities that do not have CEONC services
and/or surgery.
 Limited population coverage under the health insurance programme.

                                                            
14Patan Hospital, Kirtipur Ayurvedic Hospital, Bharatpur Hospital, Western Regional Hospital, BPKIHS, Bheri Zonal Hospital,
Seti Zonal Hospital and Lumbini Zonal Hospital, Bir hospital, Koshi hospital, Rapti Academy of Health Sciences,
Narayani hospital
15
Mechi hospital, Janakpur hospital, Hetauda hospital and Surkhet hospital
16
Dadeldhura hospital, Gaur hospital and Tulsipur hospital
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 The procedures to access the Deprived Citizens’ Treatment Fund remain to be complicated for
the needy people to timely access the services.
 Limited availability of geriatric services and disability friendly health services and capacity of
service providers to adapt service accordingly
 Mismatch between the budget allocated for SSUs and the client load.
 Increasing Leprosy prevalence rate yet an inadequate budget for the Leprosy Control and
Disability Management Programme.
 Incorporating the disability information into the HMIS, including birth defects. Referral to higher
level facilities for reconstructive surgery is not common.
 Insufficient numbers of skilled rehabilitation professionals and of rehabilitation facilities and
equipment.

Way Forward
 Endorsement of PHS Regulations which contains BHCS package as an annex.
 Improve governance and accountability at the respective level by clear division of responsibilities
for ensuring the delivery of basic health care services.
 Ensure equitable availability and provision of basic health care services especially in rural and
remote areas through the continued expansion of services at strategic locations.
 Expand health insurance to all remaining districts and prioritise the enrolment of the poor in the
health insurance scheme.
 Harmonise the services and benefits available in the BHCS package, health insurance and other
free health care programmes (SSUs, Deprived Citizens Fund, Aama programme etc).
 Implementation of GESI Strategy, establishment of a GESI institutional mechanism and support
to province and local levels for the roll out of the GESI strategy. Support to local government in
health planning focusing on reaching un-reached and marginalized/vulnerable groups. Advocate
for health services at local council and provincial levels to display data service coverage that is
disaggregated.
 Develop new rehabilitation related training courses i.e. physical and rehabilitation medicine,
occupational therapy, and mid-level health workers. Build the capacity of health workers for early
case detection, management and community based rehabilitation. Intensify IEC activities to raise
community awareness on early diagnosis and treatment, the prevention of disability, rehabilitation
and social benefits
 Develop a geriatric health care strategy and guidelines for elderly friendly services in hospitals
 Coordination with provincial and local government and partners for the effective implementation
of the “Policy, Strategy and 10 Years Action Plan on Disability Management”. Revise the current
HMIS as per the internationally comparable data standards to include disability data
 Review the budgetary allocations for expansion of SSU, OCMC, Geriatric, Disability and Leprosy
Control Program.
 Manage and regulate home based care by developing guidelines related to home based care.

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3.4 Outcome 4: Strengthened Decentralised Planning and Budgeting

Background
The NHSS highlighted the need to focus on a decentralised approach to health sector planning and
budgeting with an aim to make the health system more accountable to the public and more responsive
to their needs. It identifies that the centre will define national priorities, establish the necessary regulatory
framework, monitor progress, and provide necessary technical and financial resources. Outcome 4 of
NHSS has one single output: “strategic planning and institutional capacity strengthened at all levels”.

NHSS had envisioned that districts will become more responsible for participatory planning, budgeting,
and implementing their respective health plans. However, with the promulgation of Constitution,
Federalism has instead provided a major impetus to decentralised planning and budgeting. Each of three
levels of governments have mandates to operationalize their policies and strategies and to develop
Annual Work Plan and Budgets (AWPB). The MoHP organisational structure and health service delivery
system has been revised for the federal, provincial and local levels and staff adjustments have taken
place. At the province level, the Ministry of Social Development, Health Directorate, Logistics
Management Office (PLMO) and Health Training Centres have been established. Health Offices have
been established in each of 77 districts under the Health Directorate and previously existing District
(Public) Health Offices have been dissolved.

As the planning and budgeting now happens in each of three levels of government, it is critical to ensure
harmonisation of the annual work planning and budgeting process across levels of government so that a
consistent and coherent plan can be developed for the overall effectiveness in the health sector. The
delivery of basic health services will be a primary responsibility of the LGs while the federal and provincial
governments have major roles in relation to setting the policy and regulatory framework, quality
assurance, financing and management of hospital services.

Major Progress
 In the fiscal year 2018/19, annual planning and budgeting function happened in each of three
levels of government from the start of the fiscal year, unlike in the FY 2017/18 when only a limited
number of local governments were operational. As per the constitution, in FY 2018/19 in addition
to the equalisation grant and conditional grant from the federal level to the provincial and local
level; special and complementary grants were also provided.
 Overall, sources of revenue for the local level included: revenue transfer and grants from the
federal and the province level as well as tax and non-tax revenue of the local governments (just
like federal and provincial governments). Similarly, sources of revenue for the provinces include
revenue transfer and grants from the federal level as well as tax and non-tax revenue of the
respective provincial governments. An overview of the various source of the revenues for three
levels of governments and fund flow mechanism are shown in Figure 8.
 Tax and non-tax raising rights of federal, provincial and local level are defined in Inter-
governmental Fiscal Management Act. As shown in Figure 3.4.1, revenues collected in the form
of value added tax and excise duty on domestic production will be accumulated in the Federal
Distributive Fund which will be distributed across federal, province and local level at the proportion
of 70:15:15. Allocation across provinces and local level are to be done as per the basis provided
by the National Natural Resources and Fiscal Commission.

Figure 3.4.1: Fiscal Transfer across Different Levels of Government

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 The equalisation grant is unconditional by nature and can be used for administrative and
developmental activities including for the health sector. The conditional grant is earmarked to
specific sectors and should be spent as per the conditions provided. In terms of volume of the
grant, conditional grant is mainly for education, health, and agriculture sectors.
 MoHP developed a consolidated implementation guideline for province and local levels to
facilitate the implementation of health programmes as provisioned through the conditional grants.
 Of the total health budget (NPR 56.4 billion), 33% was allocated for the local level, 7% allocated
for the provinces and remaining 60% was allocated for the federal entities. However, it is important
to note that additional budget was channelled to provinces and local levels to meet the budgetary
shortfall and for the establishment of the health facilities as per the National Health Policy.
 An overview of the health sector budget by the NHSS outcome is presented in in Table 3.4.1
which depicts that Outcome 2 “Improved quality of care at point of delivery” accounts for the
largest share of the budget (43%) followed by “Equitable utilisation of healthcare services” (29%)
and “rebuilt and strengthened health systems” (22%) in terms of the budgetary weight in 2018/19.

Table 3.4.1: Budget Allocation for NHSS Outcome Indicators by Federal, Provincial, and
Local Government, FY 2018/19
Amount in million NPR

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Source: FMoHP and NHSSP (2018). Budget Analysis of Ministry of Health and Population FY 2018/19. Ministry of Health
and Population and Nepal Health Sector Support Programme.

 The provision of grants and own-source revenue of the provinces and local levels has provided
an opportunity for integrated planning at the sub-national level. The volume of the equalisation
and conditional grants allocated in FY 2018/19 is depicted in Table 3.4.2. On average, local
government received 200 million NPR in budget in the form of an equalisation grant while the
volume of the conditional grant per local level was 102.7 million NPR including 20 million NPR
conditioned for the health sector.

Table 3.4.2: Summary of the Financial Equalisation and Conditional Grant Provisioned by Federal
Government, 2018/19
Amount in million NPR
Description Financial Conditional Total Grant
equalisation
Total Average (per
government unit)
Provinces Total 50,298.6 63,135.5 113,434.1 16,204.9
Local Level
Metropolitan 2,663.0 4,054.2 6,717.2 1,119.5
Sub-metropolitan 3,559.8 4,479.2 8,039.0 730.8
Municipality 38,165.4 50,175.9 88,341.3 320.1
Rural municipality 40,819.3 51,136.3 91,955.6 199.9
Local Level Total 85,207.5 109,845.6 195,053.1 259.0
Source: Compiled from MoF (Red Book) and AWPB for local level.

 Two separate guideline documents were developed for the local level and provincial level to
facilitate the implementation of the health program planned under the conditional health budget
provisioned from federal to provincial and local levels.
 For the establishment of the health facilities as per the national policy, and standards for the
establishment of the health facilities including cost sharing criteria have been prepared and
approved by MoHP.
 After completing the mapping of existing health facilities, grant amount was transferred to respective
local levels for the construction of health facilities as per approved standards in 1200 wards having
no health facilities.

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 Allocation of the health sector conditional grant to local level (18,152.7 million NPR) increased by
20% in FY 2018/19 as compared to the grant allocated in FY 2017/18.
 The revenue transfer mechanism as provisioned in the constitution has come into effect from the
FY 2018/19. As per this mechanism, funds accumulated in the federal distribution fund will be
divided to federal (70%), provinces (15%) and local levels (15%).
 Provincial governments have also allocated equalisation and conditional grants to local level in the
FY 2018/19.
 On top of the conditional and equalisation grants, NPR 20 billion was provisioned by the federal
government under complementary and special grants for FY 2018/19 to meet additional needs at
provincial and local level.
 With the support of external development partners, MoHP has channelled technical support to the
provincial and local levels. MoHP continues to implement the learning lab approach in seven local
government areas (one from each province) to closely monitor and document challenges and
successes.
 Organisational capacity assessment tool (OCAT) has been implemented in the learning sites which
has contributed to a better understanding of the status of the organisational capacity at the local
level and to be able to identifying training needs. Details about the implementation approach of
OCAT is provided in an Annex 3.

Highlights of FY 2019/20
 The volume of the equalisation and conditional grants allocated in 2019/20 is depicted in Table
3.4.3. For 2019/20, on average, NPR 284.0 million has been provisioned per local level in the form
of equalisation (NPR 119.5 million) grant and conditional grant (NPR 164.5 million).
 Similarly, per province equalisation grant and conditional grant from the federal level for 2019/20 is
NPR 7899.8 million and NPR 6363.7 million respectively. The summary of the equalisation and
conditional grants for the provinces and local levels is presented in Table 3.4.3.

Table 3.4.3: Summary of the Financial Equalisation and Conditional Grant Provisioned by Federal
Government, 2019/20

Description Financial Conditional Total Grant

equalisation
Total Average (per
government
unit)
Provinces Total 55,298.6 44,545.8 99,844.4 14,263.5

Metropolitan 3,131.2 4,620.2 7,751.4 1,291.9

Sub-metropolitan 3,484.1 4,511.1 7,995.2 726.8
Municipality 39,779.6 55,510.3 95,289.9 345.3
Rural municipality 43,552.1 59,232.5 102,784.6 223.4
Local Level Total 89,947.0 123,874.1 213,821.1 284.0
Note: Amount in million NPR.
Source: Compiled from MoF (Red Book) and AWPB for local level.

 The amount of conditional grant provisioned from federal to provincial and local level for health
has been respectively NPR 4,878.5 million NPR and NPR 21,229.7 million which comes to be per
province NPR 696.9 million and per local level NPR 28.2 million, on an average.
 On top of the conditional and equalisation grants, NPR 20 billion has been provisioned by the
federal government under the complementary and special grants for FY 2019/20 to be provided
to provinces and local levels to address additional needs at provincial and local level.
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 A comparative scenario of federal grants (equalisation and conditional grants) to select local
levels (learning lab sites) for 2018/19 and 2019/20 is presented in Table 3.4.4 which depicts that
the flow of grants is not uniform across the local levels. Pokhara Metropolitan City is the
exceptional among the selected sites to receive reduced grant under each of the equalisation and
the conditional grant in 2019/20 as compared to 2018/19. Among the selected sites, the highest
percentage increase (45.9%) in the federal grant is observed for Kharpunath Rural Municipality
which is dominated by the substantial increase in conditional grant component. This indicates that
basis for the resource allocation is being adjusted to their needs and the revenue generating
capacity which are the two major components to define the equalisation and conditional grants to
local governments.

Table 3.4.4: Overall Pattern of the Federal Grant to Selected Local Levels
Amount in million NPR
Equalisation Grant Conditional Grant Total
%
S. Chang Chang chang
N Municipality 2018/19 2019/20 e in % 2018/19 2019/20 e in % 2018/19 2019/20 e
Itahari Sub-Metropolitan
1 City 283.1 316.6 11.8 303.6 341.0 12.3 586.7 657.6 12.1
Dhangadhimai
2 Municipality 136.7 141.9 3.8 129.1 155.4 20.4 265.8 297.3 11.9
Madhyapur Thimi
3 Municipality 213.3 217.9 2.2 150.5 161.7 7.4 363.8 379.6 4.3
Pokhara Metropolitan
4 City 614.4 600.2 (2.3) 1,204.2 1,172.7 (2.6) 1,818.6 1,772.9 (2.5)
Yasodhara Rural
5 Municipality 120.8 123.2 2.0 101.4 136.2 34.3 222.2 259.4 16.7
Kharpunath Rural
6 Municipality 60.0 68.1 13.5 110.8 181.1 63.4 170.8 249.2 45.9
Ajaymeru Rural
7 Municipality 68.2 78.5 15.1 167.5 190.8 13.9 235.7 269.3 14.3
Source: Compiled and analysed based on data from Inter-governmental Fiscal Transfer, 2018 and 2019, Ministry of Finance.

Challenges
 Although the package of basic health services has been prepared, it is yet to be endorsed.
 Delay in the staff adjustment and grievance redressal process affected the management of health
functions and services delivery at respective level.
 Local Governments are often not allocated sufficient conditional budget to cover staff salaries and
demand side financing programmes as Local level information is not always up-to-date. The
MoHP is coordinating with the Ministry of Finance (MoF) to address this problems.
 Challenge lies in ensuring horizontal and vertical harmonisation in the planning and
implementation of health sector programmes across three levels of government.
 Ensuring timely implementation of the planned activities and utilisation of the allocated budget in
the current federal structure continues to be a challenge as the institutional structures are newly
formed and organisational capacity remains limited.

Way Forward
 Accelerate the process for the endorsement of the basic health care services package which is
the critical for the planning and budgeting process.
 Create a platform to enable interaction across three levels for ensuring harmonised and
coordinated planning and addressing the issues as they emerge.
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 Develop a planning framework to effective link different budget management information systems
across three levels such line ministry budgetary information system (LMBIS) and sub-national
treasury regulation system (SUTRA)
 Closely engage with provinces and local levels to monitor progress, performance and challenges
in planning and implementation.
 Continue to develop case studies, document success stories and promote cross and peer learning
approach to strengthen delivery of the health services at the local level.
 Coordinate with the National Resource and Fiscal Commission and MoF to develop a transparent
mechanism for the rational allocation of resources for the health sector for provinces and local
levels.
 Consider developing a framework for the enhancement of organisational capacity to effectively
manage the health sector functions at the respective levels.

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3.5 Outcome 5: Improved Sector Management and Governance

Background
The NHSS states that the restructuring process of the health sector will be aligned with the broader state
restructuring agenda vis-a-vis federalism. Furthermore, it recognises aid effectiveness as an important
facet of health governance through embracing the principles and priorities of the Development
Cooperation Policy, 2014, for further strengthening sector wide approach (SWAp) arrangements. There
are five outputs under this outcome as follows:

 The MoHP structure is responsive to health sector needs

 Improved governance and accountability
 Improved development cooperation and aid effectiveness
 Strengthened multi-sectoral coordination mechanisms
 Improved public financial management

Major Progress

Transition to Federalism
Along with the implementation of political and governance structure, the health sector has continued the
transition to full federalisation. Managing transition with ministerial stewardship and adequate and timely
technical and managerial guidance to the sub-national governments remained vital to the MoHP. The
sixteen bills necessary to guarantee the fundamental rights enshrined in the constitution were passed by
both Houses of the Federal Parliament. Of these two Acts, Safe Motherhood and Reproductive Health
Rights; and Public Health Service Bill, set historic landmark towards securing health as the fundamental
rights of the citizen.
With the gradual deployment of officials in line with the new structure, the MOHP has provided timely
guidance on an annual plan and budget process; rationalised the health budget under the conditional
grant; progressively institutionalised sector coordination functions; initiated the policy dialogue platform
and formed and/or revitalised technical working groups in a number of areas. Structurally, sub-national
governments require a range of competencies and skills to deliver their responsibility in health sector,
which is being addressed by the MoHP but it is a long-term investment.
Increased number of visits, including high-level officials, from federal to sub-national level and ongoing
dialogue on technical and governance matters between the federal ministry and sub-national government
has improved coordination. As part of the decentralisation process, MoHP has set up a committee to
review the federal-level organisational structure to consider downsizing. Confusion in mandates between
various levels of government, weak coordination, technical and managerial capacity constraints still limit
the ability of provincial and local governments to fulfil their new responsibilities. Systems and processes
for financial management and procurement are not yet fully established at sub-national level. Human
resource constraints (both skills set and staffing numbers) are a key challenge to quality service provision.
The MoHP is in a much weaker position to influence health financing and performance. Given the scale,
nature and complexity of the transition, the risk of discontinuities and disruption to health service delivery
is high and fiduciary risks are likely to increase, at least in the short-term.

Policies, Acts, Guidelines and Structure

 The 2019 National Health Policy has been endorsed by the GoN.

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 The approach paper of 15th periodic plan (with chapters on health and nutrition and on population
and migration including) has been endorsed by the GoN.
 The following Acts have been passed: Staff Adjustment Act, Public Health Service Act (PHS Act)
and the Safe Motherhood and Reproductive Health Act have been enacted.
 The PHS Act has broadly defined the scope of basic health services, it has provision of health system
and health service management, organ transplant, social, environmental and cultural determinants
of health and management of emergency health services among others
 The overall structure of the MoHP has been reorganised as per the federal structure under
federalism. As per the new provision, there are 3 departments, 7 centres, 22 hospitals including
academia, 8 councils and health insurance board and development committees.
 Provincial Health Directorate, Provincial Health Logistics Management Centres, Provincial Health
Training Centres and Provincial Health Offices at district level have been established.
 The revised Gender Equality and Social Inclusion Strategy (GESI) has been submitted for the
approval.
 The Gender Responsive Budget Guidelines for health sector were developed.
 The Guidelines on Leaving No One Behind Budget Markers developed and submitted for approval
 The National Guidelines on Disability Management developed and approved alongside the National
Guidelines on Disability Inclusive Health Service Guidelines.
 Under the leadership of OPMCM a five-year National Strategy and Action Plan for GBV and Gender
Empowerment is prepared.
 Health sector social accountability guidelines developed process has been initiated based on the
strategic review of Social Audit given the changed federal context.

DLI Achievements
 The target "60% of audited spending unites responding to OAG's primary audit queries within 35
days" was met with 60.99% achievement
 The target “85% of MoHP's annual spending captured by TABUCS” was met with 86%
achievement.
 The target “decrease the audit queries against audited amount” has been met: In FY 2016/17 audit,
there was 7.01% audit queries and in FY 2017/18 audit queries reduced to 4.77%.

Public Financial Management

 Internal Control Guidelines: In February 2019, the FCGO developed the "Internal Control System
Directives" and in October 2019 the Parliament passed the Financial Procedural and Accountability
Act. MOHP revised and endorsed Internal Control Guidelines on 4th July 2018.
 Public Financial Management Strategic Framework: The Financial Management Improvement Plan
(FMIP) has been updated as the Nepal Health Sector Financial Management Strategic Framework
(NHSFMSF) which is yet to be approved.
 Procurement Strategic Framework: The Procurement Improvement Plan (FMIP) has been updated
as the Nepal Health Sector Public Procurement Strategic Framework (NHSPSF) which is yet to be
approved.
 Changes in OAG’s Forms and Formats: GoN changed the financial recording and reporting forms
and formats in FY 2018/19 and MoHP is updating these forms and formats in TABUCS.
 New Chart of Accounts: GoN has applied a new chart of accounts from FY 2019/20. MoHP has
incorporated these new chart of accounts in TABUCS
 Chart of Activities: The revised chart of accounts and OAG forms have been linked with chart of
activities in TABUCS. Through these changes TABUCS can capture health sector budget and

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expenditure from all spheres of government. These technical inputs can be used by other systems
including SUTRA. The updated chart of activities now implemented in DUDBC.
 Linkage between TABUCS and LMBIS: All planned activities of LMBIS can be uploaded directly in
TABUCS and auto transfer will start.
 FMR: All FMR (3 trimesters) were submitted to EDPs on time as per the revised FMR templates.
The last and final third Financial Monitoring Report (FMR-3) for FY 2018/19, has been prepared
and submitted to EDPs on 26th September 2019.
 Audit Financial Statements: The Audit Financial Statements of FY2017/18 has been submitted to
the Office of the Auditor General (OAG) and its audit report certified by OAG on 4thJune, 2019. The
certified report forwarded to EDPs on 10thJune, 2019. This is an improvement on last year, when
the report was submitted on 27th June 2018
 Internal audit: MoHP prepared the internal audit FY 2017/18) status report on May 2019 and shared
in PFM committee meeting with EDPs. Internal audit data are recoded on TABUCS.
 Capacity enhancement: Financial management workshops were held in five regions (covering 7
provinces) to enhance capacity of the programme managers and finance officers in financial
management. 40 people were trained in TABUCS including 18 account staff of DUDBC, PIU and
cost centres.

Other activities
 With the view of gaining an in-depth understanding on health service delivery at the local level (i.e.
leadership, governance and accountability, service quality, planning and budgeting, and monitoring
of health interventions, reaching the unreached) the MoHP is implementing the ‘learning lab’
approach in seven rural/urban municipalities, one in each province.
 For measuring and improving data quality, the RDQA tool, (an online tool) is developed and is
available for health workers and managers at various levels to monitor the quality of data produced
by health facilities.
 A Health Facility Registry which captures brief information on each health facility belonging to both
the public and private (non-government sector including) sectors across the country is prepared
and uploaded on the MoHP web site. The registry features an interface that allows various
information systems to connect to it and keep their individual lists of health facilities up-to-date and
synchronized with that of MoHP. The list of facilities in the registry can be viewed from
http://nhfr.mohp.gov.np.
 The report of Nepal national micronutrient status survey is finalised and published.
 The guidelines for Health Facility Operation and Management Committee has been endorsed and
is being implemented.
 Joint Consultative Meetings (JCM) are held as planned.

Challenges
 Ensuring the delivery of BHCS across all local levels with limited capacity of local governments for
managing devolved health functions.
 The health sector at the local level will have to compete with other sectoral priorities such as roads
and infrastructure, among others. In the absence of a clear mechanism in health for the prioritisation
and resource allocation with use of evidence at the local level, the health sector may suffer from a
lack of resources and compromise service delivery.
 Ensuring a good balance between strengthening hospitals/facility based curative services and
sustaining public health interventions at local levels. Indications at the local level show an increased
focus on curative care which can be at the cost of public health interventions.

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 Unclear engagement modality for development partners and other stakeholders such as private
sector, NGOs/CBOs, and cooperatives for the provincial and local level.
 Developing a coordination and collaboration mechanism between ministries and different tiers of
government (Federal, Provincial and Local levels) to address the complex issues that impact on
access to and use of health services by women, the poor and other excluded groups. Insufficient
training program and budget to implement TABUCS in Province level. There is not a single activities
and budget for annual maintenance cost (AMC) support to update and upgrade the TABUCS
System.
 Maintain gains made in GESI in the health sector at provincial and local levels

Way Forward
 Approval of the BHCS package and support the LGs to implement BHCS.
 Clarity on the health governance structures of all levels with clear roles and responsibilities.
 Provide technical and managerial support to government leadership and respective health
departments/units at province and local level for uninterrupted health service delivery.
 Work with Natural Resources and Fiscal Commission, MoF, and respective ministries to ensure
financial accountability and reporting of health expenditure.
 Update TABUCS in the federal context and support for its effective implementation by concerned
entities.
 Updated the Internal control guidelines in light of "Internal Control System Directives, 2019" (FCGO)
and new Financial Procedural and Accountability Act, 2019
 Finalization of Public Financial Management Strategic Framework (PFMSF) for the overall
improvement of financial management.
 Contract Management System (CMS) and Store Management System (SMS) has to be develop as
additional model of TABUCS System.
 Development of Gender Responsive Budget Guidelines and its implementation at all levels
(Federal, Provincial and Local Levels).
 Promote the use of disaggregated data (from GESI and social inclusion perspective) and evidence
during planning, programming and monitoring at provincial and local level.
 Integration of GESI concerns into all to be formulated and revised policies, strategies and action
plans.
 Implementation of GESI strategy including development of Implementation Plan and establishment
of GESI institutional mechanism at all levels after the approval.
 Implementation of Gender Responsive Budget Guidelines and its implementation at all levels
(Federal, Provincial and Local Levels).

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3.6 Outcome 6: Improved Sustainability of Healthcare Financing

Background
The National Health Policy 2019 ensures the provision of free BHCS as a fundamental right of every
citizen. The policy envisions providing access to quality health services (beyond BHCS) in an affordable
manner by ensuring financial protection in health. The policy aims to do this by gradually increasing the
state’s investment in the health sector, increasing per capita expenditure and reducing out of pocket
expenditure (OOPE) through social health protection arrangements, including targeted subsidies.
Increasing investments in the health sector and in social health protection mechanisms are the focus of
NHSS and are delivered through two outputs:

 Strengthened health financing system

 Strengthened social health protection mechanisms

Major interventions proposed under this outcome include developing and introducing a resource
allocation formula, enhancing the MoHP’s capacity on performance based resource allocation, enhancing
capacity for the institutionalisation of the National Health Accounts and the harmonisation of existing
social health protection schemes, and the implementation of health insurance.

Major Progress
 The NHSS sets a target of allocating 9% of the national budget to the health sector. Figure 9
shows that the proportion of the total government budget allocated to health has remained at 5%.
Compared to FY 2018/19, there is 0.1% increase in the health sector budget for FY2019/20. PGs
and LGs appear to have used different revenue sources to increase the allocations to the health
budget and so the actual health budget as a percentage of national budget is anticipated to rise.

Figure 3.6.1: Health budget as a percentage of the national budget

Source: Budget Analysis 2019/20

 The GoN had expanded the coverage of the health insurance programme to 49 districts and
approximately 2.3 million people have been enrolled which is around 5% of the catchment

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population in the implemented districts. The Health Insurance Act makes enrolment in health
insurance mandatory which is important to increase the enrolment levels.
 The National Health Account (NHA) reports that OOPE as percent of CHE was 63.53% in FY
2012/13 and 55.44% in FY 2015/16. This implies that OOPE as percent of CHE has gradually
been decreasing.

Challenges

 Still low level of government health spending in relation to government’s commitment to achieving
UHC and leaving no one behind.
 Out of pocket expenditure is still a dominant share of health care financing.
 Capturing health spending at all level of governments beyond the conditional grant.
 Institutionalisation of the National Health Accounts to routinely monitor health expenditure
including spending by PGs and LGs.
 A fragmented approach to the management of various social health protection schemes such as
the free health care programme, free delivery, health insurance, and so on.
 Delays in the identification of the poor hampering for the inclusion of the poor and other targeted
groups in health insurance.

Way forward

 Initiate a discussion to improve the ‘conditionality’ in conditional grants to make the conditional
grants more effective and easy to manage.
 Assess the root causes of low budget absorption and take action accordingly
 Support to PGs and LGs for increased spending in health
 Establish a mechanism to track and consolidate budget allocation and spending for health at each
level of government
 Design and develop a health financing strategy that is applicable to all levels of government
 Prioritise the enrolment of the poor segment of the population in health insurance through
government subsidy as provisioned in Health Insurance Act

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3.7 Outcome 7: Improved Healthy Lifestyles and Environment

Background
MoHP believes that creating a healthy environment and healthy lifestyle is central to the improvement of
overall health status. For this purpose, NHSS suggests innovative approaches for behavioural change
for specific behaviours like smoking, alcohol consumption, health seeking behaviour, and obesity. The
single output for this outcome is promotion of healthy behaviours and practices.

Major Progress
 Mental Health Section has been set up at EDCD as per the new organogram of MoHP. Mental
health strategy and action plan has been drafted under the leadership of EDCD
 Developed training based on the Standard Treatment Protocol for Prescribers and conducted
TOT at central level and training in 6 different provinces. Training modules for child and
adolescent mental health has started.
 An International Conference on Child and Adolescent Mental Health was organized in November
2018.
 MoHP secured funding from the Global Environment Facility to implement project entitled Building
Resilience of Health Systems in Asian Least Developed Countries to Climate Change with the
support from WHO
 MTOT on climate change and health impact conducted for officials from federal, provincial and
selected local levels (two batches)
 Nagrik Aarogya Program conducted in all provinces and local level promoting active lifestyle
through Yoga and Meditation sessions, health diet
 Implementation of the Package of essential NCDs (PEN) expanded in 30 districts
 Development of training module on mental health for adolescents has been completed
 Expansion of school health/nurse program by province 1 and 3
 Teaching module developed on Ayurveda and Yoga Education at School
 Orientation on Ayurveda and Yoga Education at School in five public schools (Kathmandu,
Bhaktapur, Rupandehi; Dhanusha)
 Guideline for the rehabilitation of helpless, persons with disability and those unclaimed by the
family developed and implemented through NGOs
 Different IEC materials disseminated on various themes such as for the prevention against
dengue, general awareness and sanitation, mental health.
 National mental health survey is ongoing. A pilot study in three districts has been completed and
preparation for the national prevalence survey has been initiated.
 Healthcare waste management guideline is being developed
 Package of essential NCDs (PEN) expanded in additional districts to cover 51 districts
 Effect of climate change in medicinal plant is planned
 Psychosocial counselling training package is in development process
 Expansion of school health/nurse program is planned for 30 additional schools
 Physiotherapy training package developed and piloting is ongoing in three districts (Dhanding,
Dolakha and Dhanusha)
 Development of training package for the occupational health safety is ongoing
 Development of training package on road traffic accident is ongoing
 Ayurveda and Yoga Education at School is being piloted in five public schools (Kathmandu,
Bhaktapur, Rupandehi; Dhanusha)

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 Mental health strategy has been drafted is in the process of consultation

 NCD related promotional health services are expected to initiate from the FY 2019/20 from
National Ayurveda and Panchakarma and Yoga Center, Budhanilkantha
 The MoHP developed a Standard Treatment Protocol for medical officers and primary health care
workers based on the revised essential drug list and Mental Health Gap Action Programme
(mhGAP) intervention guidelines.
 The National Health Training Centre developed training modules and facilitators guides for both
psychosocial interventions and detection and management of priority mental disorders using
mhGAP intervention guides.
 OCMC operation guidelines SSU Operation guidelines were revised as per the federal context in
2018/19.
 Fifty five OCMCs have been established and functional in fifty-four districts by the end of 2018/19.
6243 GBV survivors received services from OCMCs in year 2018/19. Among them, 32% of girls
were 18 years and below. Out of the total number of cases, physical and mental abuse accounted
for 57%, rape and attempted rape account for 39% and 4% of the cases were related to witchcraft,
child marriage and trafficking.
 Medico-legal Service Guidelines were approved by the Cabinet. 150 doctors in all 77 districts and
26 forensic specialists were trained to improve skills critical to GBV cases especially for rape
survivors.
 Basic GBV and psychosocial counselling training was provided to 46 staff nurses and OCMC
focal persons from 43 hospitals with OCMCs.
 GBV clinical protocol rolled out in 16 hospitals of 16 districts. Completed a training of trainers'
session entitled Health Response to GBV at 6 hospitals.
 Case study booklet developed containing the 45 GBV cases and are being distributed in the
different districts.
 Process initiated for the revision of GBV Clinical Protocol under the leadership of Nursing and
Social security Division.
 A much awaited senior citizen survey commissioned in 2014 has finally came out.
 GBV Referral Directory developed for the GBV survivors.

Challenges

 Monitoring of air quality, food quality and hygiene and water quality remains poor
 Preparedness to combat with repercussions of the climate change remains weak
 Increasing prevalence of vector borne diseases such as dengue and chikungunya
 There isn’t a “one-door” service for GBV survivors and the long-term rehabilitation of the GBV
survivors.
 Low level of awareness on GBV, mental health, and psychosocial issues at community level
 There is not yet nationally representative data on prevalence of mental health problems.

Way Forward
 Provision of public places to promote active life and fitness centers for physical activity
 Expansion of urban health promotion centers to promote healthy life styles and preventions of
lifestyle related diseases
 Development of Guideline for yoga package (Basic and Medium) and NCD-wise therapeutic yoga
package
 Institutionalise Yoga in public offices and organizations (corporate yoga)
 Strengthening and scaling-up of 12 new OCMCs in 2019/20.
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 Finalise TOT on GBV Clinical Protocol and roll out in OCMC based hospitals and periphery
 Develop online reporting system for OCMCs.
 Conduct psychosocial counselling training to staff nurses in OCMC based hospitals.
 Conduct of GBV Medico-Legal training in seven provinces covering 77 districts.
 Development and standardize psychosocial counselling training curricula.
 Incorporate NCD data management into the current HMIS training package.
 Strengthen integrated surveillance of communicable diseases and NCDs.
 Implement surveillance of road traffic accidents in coordination with concerned stakeholders.

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3.8 Outcome 8: Strengthened Management of Public Health Emergencies

Background
NHSS provides a roadmap for improved preparedness and strengthened response to public health
emergencies during humanitarian and public health emergencies. It prioritises revising protocols and
guidelines for improved health sector emergency at the central and decentralized levels along with
enhancement of institutional and human capacity for effective and timely response. The outputs of this
outcome are:

 Public health emergencies and disaster preparedness improved, and

 Strengthened response to public health emergencies

Nepal experienced a humanitarian crisis due to the devastating earthquake and its subsequent tremors
in April 2015. The health sector response to earthquake was well recognized and applauded at national
and internal level. However, the post-earthquake response nevertheless stretched the capacity of the
health sector to its limit and also exposed some limitations of the health systems and capacity especially
on emergency preparedness and disaster response. Isolated tremors not related to the 2015 earthquake
have been reported from Karnali and Sudur Paschim provinces indicating preparedness is very essential.

Besides earthquakes, disease outbreaks have been being reported. Table 3.8.1 summarizes the situation
of major diseases reported to EDCD, including an unprecedented number of dengue cases in the first
four months of the FY 2019/20. Kala-azar has been reported for the first time in the mountainous districts
(Dolpa, Humla and Mugu) of Karnali Province.

Table 3.8.1 Reported Cases of Disease

Diseases Districts affected Number of Period

reported cases
Scrub Typhus 63 1271 July 2018 – October 2019
Kala-azar 54 218 July 2018 – October 2019
Dengue 67 14662 July 2018 – October 2019
Malaria 48 1065 July 2018 – October 2019
Source: EDCD, EWARS Bulletin

Major progress in FY 2018/19

 Effective support was provided to the outbreak of dengue in Sunsari (Dharan), Kathmandu,
Chitwan and Kaski (Pokhara) and other districts of the country through search and destroy
activities and raising household awareness through the media and the mobilization of youth.
 An additional 4 hub hospitals (2 in Province 5 and 2 in Sudur Paschim Province) were established
which included setting up medical logistics warehouses and finalising contingency plans.
 Emergency Medical Deployment Teams were formed in the existing six designated hub hospitals
in the Kathmandu valley.
 A kala-azar tracking system at treatment sites is planned for the current fiscal year and has
startedin province 1.
 The EWARS system is now operational in all 77 districts and is based on the DHIS 2 platform.

The following documents were produced

 National Malaria Treatment Protocol 2019

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 National Malaria Surveillance Guidelines 2019

 National Guidelines of Prevention, Control & Management of Dengue in Nepal 2019
 A Guide to Early Warning And Reporting System (EWARS) 2019
 LLINs Distribution Report-2019
 National Guideline on Kala-azar Elimination Program 2019
 National Guidelines for Rabies Prophylaxis and Management in Nepal
 Implementation Guideline for Case Based Investigation 2019 (Revised)
 Procedure for Rehabilitation of people with Psycho-social Problems, 2019

Challenges
 Lack of clarity in the roles and responsibilities of different authorities for the management of Public
Health Emergencies.
 Funding gap to address emergency status.
 Inadequate supply of essential medicines and prepositioning of supplies at strategic locations
 Regular reviews of ‘hospital emergency response and contingency plans’ do not happen
 Gaps in coordination and communication between public and private hospitals.

Way Forward
 Continue to develop the capacity and deployment procedures of Rapid Response Teams at Local
level and in hub hospitals in order to ensure an effective first response.
 Strengthen EDCD information management and its role in coordinating support between relevant
line ministries and other stakeholders at all levels of government.
 Establish an emergency response fund at all levels of government and ensure the prepositioning
of essential lifesaving drugs/medicines and supplies in strategic locations.
 Establish HEOCs in the remaining provinces.
 Develop a comprehensive integrated multi-year national capacity building plan for the
management of emergencies and disasters.

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3.9 Outcome 9: Improved Availability and Use of Evidence in Decision Making

Processes at All Levels

Background
The NHSS focuses on increased access to and use of information through the use of ICT. It also
emphasises improved and interoperable routine information systems and prioritises surveys and
research. Similarly, it strives for improved and integrated health sector reviews at various levels that feed
into the planning process. Towards achieving universal health coverage and leaving no one behind, the
NHSS and the SDGs emphasise monitoring and reducing the equity gap in the health outcomes of
different population sub-groups. The outputs linked to the stated outcome 9 are as follows:
 Integrated information management approach practiced,
 Survey, research and studies conducted in priority areas
 Improved health sector reviews with functional linkage to planning process

Major Progress

Development of Guideline
 In line with the 2017 National eHealth Strategy, the MoHP has drafted the National eHealth Guideline
to provide a framework for standardization of eHealth systems in Nepal. The guideline defines the
necessary steps and standards to be followed during the design, implementation, monitoring and
review of eHealth systems.

Integrated information management

 With regards to the information management in the health sector, the Cabinet has decided to establish
an institutional mechanism for ensuring monthly reporting of the health facilities in the national HMIS
database by the concerned Local, Provincial and Federal Governments. Further, the mechanism is
also for ensuring regular, timely and complete reporting of other information from health facilities to
the Local Government, from Local Government to Health Offices, from Health Offices to Health
Directorates and from the Directorates to the Department of Health Services.
 ‘Health Sector M&E in Federal Context’ is the Monitoring and Evaluation (M&E) guideline for the three
levels of government and was developed last year. It has been a guiding document for provincial and
local governments to generate, use, share and report health sector data.
 The MoHP continued to prioritise developing the eHealth system so that various health information
systems are interoperable. The Health Facility Registry, a tool that keeps track of all health facilities
within the country, public and private, as well provides information on which services are offered has
been updated. The registry has an interface that allows other information systems to connect to it in
order to keep their individual lists of health facilities up-to-date and synchronized with the MoHP. The
registry can be accessed from the MoHP website.
 The MoHP continues to expand the electronic reporting of service data from health facilities. This
year 1400 public health facilities submitted HMIS monthly reports electronically. As health posts and
primary health care centres are now being managed by the local government, the MoHP is focusing
on enhancing their capacities on health information management, including the use of the DHIS2
platform and all 753 local governments reported the health facility based service statistics
electronically to the national database (HMIS). This has been a milestone for the continuous flow of
data from local governments to the national HMIS system. The HMIS e-learning modules for the
orientation of health workers, statisticians, computer operators and programme managers have been
developed and are available on the DoHS website (dohs.gov.np).

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 The web-based Routine Data Quality Assessment (RDQA) tool and the e-learning package have
been updated incorporating feedback from the users and is made available on the MoHP website
(www.rdqa.mohp.gov.np). A summary of the key findings from applying this tool is in Annex 6.
 Web-based digital dashboards have been developed to monitor major health indicators including the
NHSS Results Framework and health-related SDG indicators.

Electronic Health Records

 MoHP has drafted a guidelines for implementation of electronic health records (EHR) at health
facilities. The MoHP alongside the MoSD at the provincial level, have prioritized EHR at hospitals.
To date the following hospitals have started EHR including:

 Province 1: Mechi, Illam, Pachthar, Dhankuta, Bhojpur, Taplejung Hospitals

 Province 2: Gajendra Narayan Singh Hospital
 Province 3: Nuwakot Hospital, Dolakha Charikot Hospital
 Gandaki Province: Dhaulagiri Hospital, Pokhara Academy of Health Sciences
 Province 5: Gulmi, Rapti Academy of Health Sciences
 Karnali Province: Salyan and Dailekh Hospitals
 Sudurpaschim Province: Doti and Bayalpata Hospitals

Surveillance systems
Maternal and Perinatal Death Surveillance and Response (MPDSR)
Facility-based MPDSR has been expanded from 77 hospitals in FY 2018/19 to an additional 16 hospitals
in FY 2019/20. Community-based MDSR has been expanded from 11 districts to an additional seven
districts (Taplejung, Rautahat, Nuwakot, Myagdi, Palpa, Dailekh and Bajhang) in FY 2019/20. FWD is
updating the web-based MPDSR recording and reporting tools and planning to use a mobile application
to report deaths from the community. MoHP’s 2020 target is to have Community-based MPDSR in 20
Districts and Facility-based MPDSR in all public (110) hospitals.

Early Warning and Reporting System (EWARS)

EWARS is a hospital-based sentinel surveillance system where the sentinel sites (hospitals) send weekly
reports (including zero reports) on six epidemic prone, vector-borne, water and food borne diseases in
order to detect outbreaks. EWARS started in 1997 with 8 sentinel sites and expanded to 24 sites in 1998,
26 sites in 2002, 28 sites in 2003, 40 sites in 2008, 82 sites in 2016 and 118 sites in 2019. A total of 36
(private hospitals and medical colleges) were included as sentinel sites across Nepal in 2019. EWARS
sentinel sites are gradually reporting in the DHIS2 platform, which will contribute to building better
linkages with the HMIS.

Survey, research and studies

 MOHP is planning to conduct the second Nepal Health Facility Survey (NHFS) in FY 2019/20. The
initial consultation with supporting partners has been initiated and the sub-national level consultation
was held in Gandaki Province in May 2019. Data collection is planned for February-May 2020 and
the report is expected to be finalized in November 2020.
 Nepal Health Research Council (NHRC) has conducted a number of researches/studies in 2018/19,
the key findings are summarised below:

Non-communicable diseases risk factors STEPS survey 2019

Key findings
Tobacco users: 29% of adults 15-69 years of age

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Alcohol users: 21%

Consumption of Fruits and vegetables: Only 3% met WHO recommendation
Salt intake: 9.1 grams per day - almost twice the WHO recommendation
Physical activity: 7.1% of adults did not meet WHO recommendation
Cervical Cancer screening: 6% of women of age 30-49 had the test in the last five years
Oral Health: 90% cleaned their teeth once or more than once a day. 14% reported issues with teeth,
gum or mouth; while only 2.8% visited dentist in last 12 months
Violence and injury: 4% were involved in a road traffic incident in past 12 months
Mental Health: 66% had some or high level of work stress, 62% had general stress at home
Joint Pain: 17% (not related to injury and lasting for more than month)
Back Pain: 19% reported to have back pain in last 30 days
Headache: 15% reported to have severe headache in last 30 days
Mean BMI: 22.7 (22.6 for men and 22.8 for women), Overweight: 24% and Obese: 4%.
Raised BP: 25% (Males-30%, females-20%)
Raised fasting blood glucose or currently on medication: 6%
Raised cholesterol levels or currently on medication: 11.0%
Cardiovascular disease (CVD) risk ≥30%, or with existing CVD among 40-69 years: 3%
Health System:
 61% of 40-69 years aged had got their BP measured from a health worker at least once
 10% measured to have raised BP and/ or on treatment /medication
 21% of people measured to have raised blood glucose and/ or on medications
 Among the surveyed population only 7% are member of health insurance scheme
 40% usually go to a government facility/ provider for raised blood pressure while 35% for oral health
issues
Policy recommendations
 As the prevalence of NCD risk factors is found high, there should be effective enforcement of NCDs
risk factor prevention and control programmes
Population based study on selected Chronic disease in Nepal
Key findings
 High prevalence of non-communicable diseases (COPD: 11.7%, Diabetes: 8.5%, CKD: 6.0% and
CAD: 2.9%).
 Most of the behavioral and biological risk factors were more prevalent among men than women.
Other factors such as high LDL cholesterol, low HDL cholesterol, overweight, obesity, waist-hip ratio
and abdominal obesity were noted high especially among females.
Policy Recommendations
 Effective health promotion and chronic disease prevention program
 Effective rehabilitation programs to lessen the effect for those who are already alcohol dependent and
effective awareness and prevention programs should be started and strengthened to advocate the
risks associated
 BP screening programs should be deployed in larger numbers catering to a greater coverage.
 Special interventions need to be designed for women to help counter issues related to body mass
which have long term health implications.
Sickle Cell disorder in Bardiya Municipality of Bardiya district
Key findings
The prevalence of Sickle Cell disorder is found 11.3% among 1 to 29 years Tharu population
(Sickle cell trait 10.7% and Sickle cell diseases 0.7%)
Policy Recommendations
There is need of counselling to unmarried people for their marriage to avoid Sickle cell in their future
generation
Mapping the availability of Ayurveda and other Complementary Medicine Services Centers in
Nepal
Key findings
 Most of the Government institutions practicing T&CM in Nepal were the Ayurvedic Centers.
Acupuncture was commonly practiced in combination with Ayurveda or Naturopathy as an adjuvant

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therapy in most centers. T&CM were commonly practiced by qualified and registered doctors in their
respective system. There were also practices done by the registered assistants with diploma or
certificate degrees.
Policy Recommendations
 Create national level information of different types of T&CM practices that can be available to the
public would be useful in bringing all traditional system under single umbrella where they could be
recognized, regulated and connected with each other to deliver better impact on population health in
Nepal.
 There is a need to develop conceptual models or frameworks for each system, create definite
regulations policies, planning, and building network infrastructure required for the overall
developments of all the existing T&CM in Nepal.
 Further, there is a growing demand for complementary medicine with the burgeoning morbidity and
mortality of Non-communicable Diseases. Many patients seek complementary medicine along with
the conventional medicine for the treatment of Non-communicable Diseases. In this scenario
research on identifying the main scientific, policy, and practice issues related to CAM research and
explores and translates of validated therapies into conventional medical practice to reduce burden of
Disease due to Chronic Non-Communicable disease is very crucial.
Population based cancer registry
Key findings
 From January to May, 2018 a total of 702 cancer cases from Kathmandu Valley, 256 cancer new
cases from Siraha, Saptari, Dhanusha and Mahottari and 23 new cases from East and West Rukum
were identified
 In 702 cases from Kathmandu Valley, cancer incidence is higher among females comparing to the
males (379 Vs 323). The higher incidence is found among the age group of 70-74 years.
 In male the top leading cancer site is lungs followed by lip and oral cavity
 In females, breast followed by lungs, cervix uteri
Quality of essential medicines in public health care facilities of Nepal.
Key findings
 Out of 244 batches of 20 generic medicines collected, 37 batches were found substandard.
 Out of identified substandard medicines, 23 (62.16%) batches of medicines were supplied by
Government of Nepal and 14 (37.83%) batches of medicine samples were purchased from local
resources
 Among 62 health facilities, only 13% were found to follow the medicine storage guidelines
 Temperature and humidity records exceeded the recommended range in both health facilities and
Regional Medical Stores.
Policy Recommendations
 There should be provision to assess the quality of essential medicines supplied in health facilities.
 Stringent rules and regulations should be made along with their effective implementation to prevent
substandard/counterfeit medicines from entering into pharmaceutical supply chain.
 All the infrastructures required for storage of medicines should be established and maintained in all
Regional medical stores and health facilities.
 DDA should strengthen its resources to ensure quality of medicines that are widely being used in
pharmaceutical market of Nepal

NHRC has plan to conduct the following studies in the coming months of FY 2019/20:
 Community based Intervention for Prevention and Control of Non-Communicable Disease Risk
Factors (CIPCoN): Baseline Survey in province 2
 Community based Intervention for Prevention and Control of Non-Communicable Disease Risk
Factors (CIPCoN): End line Survey in Dhankuta and Illam Districts
 Assessing the status of Menstrual Health and Hygiene Management among adolescent girls in Nepal
 Population Based Cancer Registry in Nepal
 National Mental Health Survey, Nepal
 Nepal Clinical Trial Registry (NPCTR)
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 Burden of Diseases (BoD) study in Nepal

 Assessment of Residual Pesticide levels in commonly consumed fruits and vegetables and their
Health Risks in Kathmandu Valley
 Assessment of impacts of air pollution on human health in selected urban areas of Nepal
 Assessing effects of climate change on spatio-temporal distribution of vector-borne diseases in Nepal

NHRC has provided ethical approval for the following major studies in FY 2018/19
 Transmission Assessment Survey (TAS-II) in 12 districts of Nepal
 Factors associated with willingness to pay for Social Health Security Scheme among the residents of
Baglung Municipality
 Identifying barriers to accessibility and availability of Safe Abortion Services among young women in
Makawanpur
 Cost analysis of diagnosis and treatment of tobacco related cancer in selected hospitals of Nepal

Policy / Technical Briefs

With the objective of translating the evidence into action, policy briefs have been developing using
secondary data. The following briefs have been developed:
 Hand in hand in health care: partnership management
 Visiting service providers in family planning
 Organisational capacity assessment and its utilisation in Nepal
 Minimum Service Standards for Health Facilities
 Effect of distance to health facility on use of institutional delivery services in Nepal
 Equity gap between the 10 high performing districts and the 10 low performing districts
 Utilisation of ANC and Delivery services at different level of health facilities
MoHP is also preparing technical briefs on the following:
 Improving quality of HMIS data through web-based RDQA,
 Use of HMIS data in reviews and planning.
 Stock take of health information management and M&E in the Constitution, Acts, Regulations, Policies,
Strategies and Cabinet Decisions

Health sector reviews

 Based on the last year's feedback the MoHP prepared a guideline and tools for the health sector
review at all three levels of government. The objective was to standardise the review process at the
local and provincial level and link the review at the sub-national level with the federal level review and
planning. The guidelines and tools have been distributed and shared through the MoHP website.

Challenges
 Limited availability of quality data to meet the health sector data needs at local, province, and
federal levels
 Limited use of evidence based decision making at all levels
 Limited use of integrated information management leveraging the ICT at all levels to sustain the
good practices and achievements of the health sector
 Slow progress in the institutionalisation and regularisation of national health accounting.

Way Forward
 Ensure compliance of timely reporting from health facilities on monthly basis.

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 Digitize HMIS recording registers to facilitate on time reporting, improving data quality and use of
data at the point of data generation.
 Standardize the M&E orientation package for induction training to different health cadres and roll
out.
 Finalize and share eHealth Guideline and EHR guideline with stakeholders to facilitate
standardization and interoperability with the national database.
 Digitize and integrate Aayurveda Information Management System with the national database.
 Ensure functional and reliable data sources for all the NHSS and SDG indicators.
 Effective implementation of the guideline 'Health Sector M&E in Federal Context, 2075.
 Implementation of 'Health Facility Registry' at all levels.
 Develop and operationalise the central standard data repository.
 Standardise, develop, strengthen, and institutionalise e-health initiatives at all levels.
 Institutionalize and regularize of producing national health accounts.

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Annexes
Annex 1: Progress on the Health Sector Policy and Programmes as stated in Policy and
Programme of FY 2075/76

S.N. Policy and Programme statement Progress

1. Implement the behavioural ethics of health  Behavioural ethics of health workers and clinicians
workers and clinicians towards towards patients/service users were compiled from
patients/service users respective councils and uploaded in website of MoHP
 Monitoring of health workers behaviour has been done
to check whether behavioural ethics has been followed
2. Provide emergency surgery and trauma  Guideline has been prepared and the process of
management services in health facilities construction of trauma unit via Department of Urban
Development and Building Construction in health
facilities in all seven provinces nearby highway (Attariya,
Rakam Karnali, Lamahi, Kurintar, Waling, Pathalaya,
Itahari) and modern trauma center in Dhalkewar and
Dadelhura has begun
 Total number of trauma service centres will be 7
 Construction of 2 modern trauma centre has been
initiated;
3. Provision of punishment for hospital  Guideline has been prepared by the hospitals and
administrators/managers not adopting safe implementation has been done as per the hospital waste
disposal of hospital waste management guidelines
 Under clause 41 of Public Health Act 2075, there are 5
sub-clauses that are linked with sanitation and waste
management
4. Increase the use of modern communication  Health facilities registration system has been
technology in health care, make available established, registration of all health facilities has been
high-speed internet service in hospitals and completed and updated in MOHP website
health facilities and manage virtual learning  Telemedicine service is running in 30 different hospitals
and treatment through digitalization of the country, Health Management Information (HMIS)
Online reporting is being done by all 753 local levels
 205 resource materials have been updated in the MOHP
website
 Internet facilities is available in all level hospitals
5. Health insurance Program will be expanded  Health insurance program has been implemented in 456
nationwide to make accessible to all citizens local levels according to the target of this year
 Health Insurance Regulation has made provision to
gradually incorporate other health services not listed in
the basic health services into the insurance package
 Health Insurance Guideline has been approved and
endorsed by the cabinet on 4 Chaitra, 2075
6. Maternity care services will be provided  Besides the implementation in governmental facilities,
beginning from the pregnancy period to Aama Programme is being implemented in partnership
ensure better nutritional status of mother with 64 health facilities as per the target of this year.
and child. Under this, the transportation  Free new-born care program has been implemented in
allowance provided for those who visit 31 (SNCU-20, NICU-11) health facilities.
health facilities for ANC and delivery has  Guideline has been revised to provide the transportation
been doubled allowance; transportation allowance has been doubled
from current FY
 Multi-sectoral Nutrition Program is being conducted
regularly in 562 local levels as per the target for this year
7. A minimum of one health facility will be  Cost sharing criteria and health facilities establishment
established in each ward within two years standard have been prepared and approved by MOHP.
with a cost sharing approach with the local  Mapping of existing health facilities has been completed
levels and communication has been done with the Ministry of
Finance for the fiscal transfer of the required grant
amount to respective local levels for the construction of
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health facilities as per approved standards in 1200 wards

having no health facilities
8. Manage and ensure the availability of  Listed essential free drugs has been provided from 84
essential drugs provided free of cost by the district hospitals, 204 Primary Health Centres and 3809
government in all health facilities Health Posts
 The list and standards of essential free drugs has been
prepared and circular was sent to federal, provincial and
local levels
 All district hospitals have been operating their own
pharmacy
9. Begin the construction of Bir Hospital  DPR has been prepared and feasibility study is being
according to the Master Plan, establishment done for the construction of Bir Hospital’s wing at
of modernized health laboratory as a high Duwakot
technology diagnostic centre and  Koshi, Narayani, Bharatpur, Bheri and Dadeldhura
establishment of kidney treatment centre in hospitals have been strengthened to specialized
Kathmandu, and service expansion for the hospitals by the cabinet decision on Falgun 3, 2075.
treatment of sickle cell anaemia with the  The work for site selection of modernized health
help of identification and research of sickle laboratory and kidney treatment centre has been
cell anaemia prevalent in Terai region commenced by the committee.
especially in the Tharu community  The treatment for sickle cell anaemia has been started in
11 hospitals (Mahakali, Seti, Tikapur, Bheri, Rapti,
Tulsipur, Lamahi, Bardiya, Kapilvastu, Lumbini and
Parasi)
 Three researches on sickle cell anaemia have been
conducted by Nepal Health Research Council (NHRC)
and the reports have been prepared
10. To encourage for the expansion of  To be self-dependent in basic medicines by expanding
pharmaceutical production in order to be the pharmaceutical production capacity, a coordination
self-reliant in basic medicines meeting was held participated by Association of
Pharmaceutical Producers, investors, importers,
exporters, DDA, MOHP and other relevant stakeholders
 More than 50% of the medicines purchased are of
national production
11. Geriatric ward will be established in 100  Geriatric ward establishment and operation
bedded hospitals and above hospitals. implementation guideline has been approved by the
Extended health services in these hospitals Government of Nepal (Ministerial level) on Kartik 4,
will be made compulsory 2075.
 There were 8 hospitals operating geriatric ward in last
fiscal year. As per the target set for this year, the service
has been started in 4 additional hospitals making a total
of 12 hospitals where geriatric ward is available.
 A draft of Extended Health Service operation guideline
has been prepared
12. Mobile hospital service including specialized  Specialized health camp with surgical services was
services will be organized in coordination conducted in G.N.S. Sagarmatha Zonal Hospital in co-
with private medical colleges ordination with Nepal Army Hospital and in Syangja in
co-ordination with Civil Servants Wives Association.
13. Process will be accelerated to establish  As per the Government of Nepal cabinet decision,
Government run medical academy in all G.N.S. Sagarmatha Zonal Hospital in Province 2 has
seven provinces and additional institutes been upgraded to Ramraja Prasad Singh Academy of
Health Sciences
 The draft bill of Ramraja Prasad Singh Academy of
Health Sciences has been prepared
 A proposal for in-principle approval of Integrated Act for
all Health Science Academy has been submitted to the
cabinet
14. Ten Crore has been allocated for the  A bill on Bidusi Yogmaya Ayurved has been prepared by
establishment of Bidusi Yogmaya Ayurved the bill drafting committee and been forwarded to
University for research and development of

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Ayurvedic medicines and to provide Ministry of Law, Justice and Parliamentary Affairs by the
Ayurvedic education Ministry of Education, Science & Technology
15. Citizen Arogya Program will be launched to  Working procedure for Citizen Arogya Program has been
develop healthy body, positive thinking and prepared
personality through meditation and yoga.  Citizen Arogya Program has been organized in different
Arrangement for the delivery of health places of the country
service by integrating alternative treatment  The tender for the procurement of necessary equipment
methods such as Ayurvedic, Homeopathic, for the operation of Panchakarma and Yoga has been
Unani, Acupuncture, Amchi and Natural approved
medicine with allopathic treatment.  Provincial level Ayurveda research centre and hospital
has been established at Sunsari, Laukahi, Bardibas,
Gorkha and Nuwakot.
 A procedure/guideline for integrating allopathic
treatment with Ayurvedic, Homeopathic, Unani,
Acupuncture, Amchi and natural medicine treatment
methods has been prepared.
 One door service delivery is being done continuously by
heath facilities at local level
16. Smoking and drinking will be banned in all  Guideline has been prepared and implemented for the
public places and vehicles. Arrangement effective implementation of Tobacco Control Act and
would be made to streamline the production, Regulations
import, sale and distribution of alcohol and  In clause no. 39 of Public Health Act, under quality of
tobacco products consumable goods, for the quality improvement during
production, storage and distribution of consumable
goods including meat and water, it is mentioned that the
Government of Nepal can set minimum quality standard
as per the federal law
17. Rapid Response Team including specialist  For the deployment of Rapid Response Team in
will be deployed for the control and province and local levels, working procedure/ draft has
elimination of epidemic prone diseases been prepared and approved on 31 Baisakh, 2076 by the
committee meeting
 Rapid Response Team has been formed in 25 hub
hospitals
18. Provision of Air Ambulance in rural areas for  As per the working procedure prepared by the Ministry
the emergency relief of pregnant and post- of Women and Children for the operation of Air
partum women at risk Ambulance, request was made to MOHP to facilitate in
this regard and was done accordingly
19. Quality improvement of basic and  Basic Health Care package has been revised
specialized health services  Cost estimate of basic health care package has been
completed for implementation process
 A draft of treatment protocol of all diseases mentioned in
basic health care package has been prepared
 Minimum Service Standards has been prepared for the
quality improvement of health care in health facilities at
all levels
 Implementation guideline has been prepared to
implement Minimum Service Standards for the quality
improvement of health care in health facilities at all levels
 A draft of working procedure for Hospital risk/hazard
management has been prepared
 A preliminary draft document has been prepared for
improving the referral mechanism
 List of specialized services has been prepared in
Minimum Service Standard and there is provision to
provide those services from selected hospitals
 Selected specialized services are available in all central
level hospitals

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20. Ensure there is minimum of one medical  A committee coordinated by PPMD chief has been
officer in each local level formed to draft a guideline for mobilization of doctors in
local level
 The list of 251 health facilities (Primary Health Centre
and Health Posts) to be upgraded to Primary Hospital
and the working procedure has been prepared and as
per the procedure the work has been initiated by
Department of Urban Development and Building
Construction
 Feasibility study of health facilities selected by
Department of Urban Development and Building
Construction is being done
21. Treatment and rehabilitation of disable and  A working procedure for the treatment and rehabilitation
helpless psychiatric patients of disable and helpless psychiatric patients has been
prepared
 The working procedure has been sent to all health
facilities and being implemented

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Annex 2: Progress on the Disbursement Linked Indicators

DLI DLI target for year 3 Progress of
2018/19
DLR 1.2: Training on procurement or e-procurement and standard bidding Achieved
documents to provinces completed
DLR 1.4 70% of value of total contracts managed by MD done through online e- Achieved
procurement of Year 3
DLR 2.3 Annual Report on grievances received and addressed Achieved

DLR 3.3 MoHP endorses standard specifications for essential equipment to be Achieved
procured by MD

DLR For Year 3 procurement, 80% procurement of health commodities, as Achieved

3.4 specified in the list of health commodities with standard specifications
and procured by MD, is based on the use of standard specifications

DLR 4.2 Training on, and installation and operation of, eLMIS completed for all Achieved
central and provincial (including sub-provincial) medical stores of at
least two provinces; and baseline data generated for minimum stocks
of tracer health commodities
DLR HMIS/DHIS 2 training provided to all seven provinces and HMIS/DHIS Achieved
10.3 2 dashboard includes indicator measuring timely reporting from health
facilities
DLR 7.3 eAWPB used in Year 3 for planning and budget submission by MoHP Achieved
and all departments, divisions, centers, and 25% of remaining spending
units under the MoHP.
DLR 8.3 85% of MoHP spending in Year 3 captured by TABUCS Achieved

DLR 9.3 60% of spending units reporting to the MoHP respond to primary audit Achieved
queries within mandated 35 days

DLR MoHP provides orientation training to all seven provincial and a limited Achieved
11.3: number of municipal-level governments on social audit mechanism

DLI 12 Equity in essential health service utilization improved. Partially

Achieved (1 &2
Three tracer indicators will be: (1) family planning (2) safe motherhood
achieved; 2 not
and (3) sick child care - Average 10% point improvement from the
achieved)
baseline in the equity gap in each tracer indicator
DLI 13 60% of low performing districts have fully immunized VDCs Achieved

DLI 14 Infrastructure: health infrastructure better able to withstand to Achieved

earthquakes - hospital retrofitting (not needed to be verified by NHRC)

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Annex 3: Enhancing Capacity through the Implementation of Organizational Capacity

Assessment Framework

Background: As part of Nepal’s shift towards a federal system, the management of basic health care
services has been devolved to local governments. In this regard, the DFID-funded Nepal Health Sector
Support Programme (NHSSP) has been providing necessary support to the MoHP in enhancing the
capacity of these local-level entities. The first step in the process, however, was the assessment of the
organizational capacity for the management of the health sector at the municipal level using
Organizational Capacity Assessment (OCA) tool. This tool has been introduced in seven municipalities-
identified as ‘learning sites’.
OCA as a tool for self-assessment: OCAs have been implemented in other countries, including in
spheres other than health. The OCA tool is a self-assessment tool that facilitates to identify the gaps and
helps in strengthening of the health system through building and boosting organizational capacity. In line
with the World Health Organization’s health system building blocks framework, the OCA is tailored for
the local governments, which comprise of seven domains branching into three to seven sub-domains
each. Each sub-domain, then, consists of multiple benchmarks or criteria for capacity assessment.
Scores range from zero to four, where, zero represents the weakest while four represents the optimum
capacity for that particular sub-domain. Performance is subsequently measured by comparing the overall
score for all the domains against the optimum score in percentage. Based on this, capacity is categorized
as follows: if performance falls below 40%, capacity is “limited” or in “need of significant support”; if
between 40% to 70% as “some” or in “need of additional support”; and above 70% as “good” or “need to
sustain”.
A capacity development plan were also developed as part of the process, so as to address capacity gaps
over time. Furthermore, periodic capacity appraisals should be conducted in accordance with the MoHP’s
evaluation cycle.

Adaptation of the tool and its institutionalization: The National Health Training Centre (NHTC) of the
MoHP was identified as the institutional home for rolling out the OCA across the learning sites and to
other local government levels. A seminar was organised with NHTC officials for the adaptation of the
OCA concept and its implementation process and to train the facilitators for its roll out in local health
system, based on the WHO’s framework for health system building blocks.

The seven OCA workshops were conducted at six local government levels from January to July 2019.
The key participants of the workshop from the local governments were elected bodies (mayor, deputy
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mayor and ward chairs), municipality staff (administrative, IT, planning, finance and women development
officers) and health team (municipal officials and health facility in-charges). A slightly different approach
was followed in Kharpunath Rural Municipality of Humla district, Karnali, Strengthening System for Better
Health, a project supported by the United States Agency for International Development facilitated the
capacity assessment process.

Summary of findings: At the OCA workshops, participants rated their own capacity on a scale of zero
to four, based on the benchmarking criteria defined under each of 32 sub-domains under seven building
blocks of the health systems —Governance, Service Delivery, Human Resources for Health, Health
Infrastructure, Health Products, Health Information and Health Financing. The benchmarking criteria for
the assessment were defined by the participants themselves tailoring to the local context. The
assessments found different capacity score on health system components which was not dependent on
the type, size, or location of the local governments.
Based on the assessment in seven learning sites, the score ranged from 17% to 65% on Governance;
from 5% to 45% on Service Delivery; from 20% to 60% on Human Resource for Health; from 5% to 55%
on Health Infrastructure; from 25% to 85% on Health Products; from 25% to 44% on Health Information;
and from 33% to 92% on Health Financing.

The OCA revealed that the overall capacity of the local governments in managing delivery of basic
healthcare services was found to be “weak”. This was similar to the situation in Health Infrastructure as
each of seven municipalities were found to have struggled to set up infrastructure according to the
national standard. In fact, of the 58 health facilities (including health posts and primary hospitals) across
seven learning sites, a majority either did not possess their own land or had not well-constructed
structures. The findings also revealed that although local governments were equipped with reasonable
level of financial resources, management structure, and health products, weaknesses in ensuring
effective evidence-based planning and their implementation were major reasons for their weak
organisational capacity. Correspondingly, it was also observed that service delivery functions and support
services did not meet the minimum service standards.

The capacity development plans were developed based on the gaps identified via the OCA tool. They
were then discussed with the municipal team so that priorities could be set for the allocation of budgets
for the upcoming fiscal quarter/year. From the perspective of Gender Equality and Social Inclusion, focus
was on developing strategies to expand coverage and ensure access to services for the unreached
population.

Lessons learned: To enable the roll-out of the OCA beyond the learning sites and sphere of
government, the following key lessons were identified:

 The OCA was found to be an effective tool to improve the organisational capacity in the health
sector by systematic assessment of the existing capacity, enhancing accountability within the
organisation and addressing the capacity gaps.
 OCA process should be standardized by developing the User's Guide and Participants' Manual
to ensure harmonized approach and to aid facilitators and participants to facilitate its expansion
beyond learning sites.
 The mixed composition of participants was ideal for OCA workshop because the benchmarking
tools were related to decision-making, resources-mapping, planning, legal frameworks, and
regulation, the participation of elected representatives (mayor, deputy major, and ward chairs
from local government) was highly effective.

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 Local governments were found have commitment for the health sector as reflected in their
capacity development plan to increase resources for the health sector for ensuring delivery of
quality health services.
 A majority of the local governments prioritized the strengthening of the health facilities,
establishing information systems at the health facility level, and arranging logistics for improving
service delivery in accordance with MoHP standards.

Conclusion: The Organizational Capacity Assessment is a self-assessment tool that aids executives
and health planners to identify their capacity levels and the key gaps, development of action plan to
address the gaps and implementation of those plans for improving the overall capacity and decision-
making to allocate resources effectively through the local-government planning and budgeting process.
When implemented in several learning sites, the tool was found to be effective in enhancing the overall
capacity of local governments and demonstrated considerable potential for implementation during scale
up. The development of standard manual and guidelines by NHTC will provide further opportunities to
implement OCA beyond the local level.

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Annex 4: Developing Provincial Health Policy in Karnali - Balancing Aspirations and Feasibility
Nepal is transitioning from a unitary to a federal system of government. During the transition, provincial and
municipal levels of government are developing their own policies to address local contextual issues and
challenges in alignment with the federal level. In this context, the Ministry of Social Development (MoSD) of
Karnali Province initiated the formulation of the Provincial Health Policy and Health Act to strengthen the
health system and improve health outcomes within the province. Karnali Province represents one of the
hardest to reach and disadvantaged areas Nepal.
In early 2019, the MoSD prepared a draft policy in consultation with key stakeholders to ensure alignment
with federal policies and inclusion of evidence-based priorities and actions to improve health outcomes in
Karnali Province. USAID’s Strengthening Systems for Better Health Activity, along with other partners, has
been supporting the provincial government to develop their policies and systems, and has facilitated the
review and provided technical support to the MoSD during the policy finalization process.

The support of the development partners included facilitating public engagement, reviewing the draft policy
against the mandate of federal, provincial and local governments, and providing technical review based on
the policy’s appropriateness, feasibility and sustainability. Key stakeholders engaged in the series of
consultations, review and refinement of the policy draft included Dr. Senendra Raj Upreti, former Secretary
of Health and Population, Dr. Bhagawan Koirala, Chair of the Advisory Committee, other Committee
members, and senior staff from the Activity. Stakeholders who participated in consultative workshops to
draft, refine and finalize the policy included Mr. Dala Rawal, Honorable Minister for Social Development in
Karnali Province, Dr. Man Bahadur BK, Secretary of the Ministry of Social Development, Mr. Brish Shahi,
Chief of Health Service Division, Ms. Rita Bhandari Joshi, Director of the Provincial Health Directorate and
other senior staff members. The draft policy was shared and discussed with the Chief Secretary, officials
from the Ministry of Internal Affairs and Law, members from the Ministry of Finance and Planning, and level
local leaders. Together, this team reviewed the evidence, discussed options, considered issues surrounding
feasibility and appropriateness, identified the best approaches for Karnali Province, and reflected them in
the policy. Along the way, stakeholders gathered and reviewed inputs from development partners and
reference from other provinces.
Engaging a diverse group of expert stakeholders, creating an open environment to explore new ideas,
and considering the unique contextual needs of Karnali Province resulted in the development of a tailored
provincial policy, which is endorsed by the Cabinet in November 2019. Effective implementation and
periodic review can convert the policy aspirations into the practice resulting into better and sustained
health outcomes in the Province.

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Annex 5: Minimum Service Standards for Health Facilities: A tool for need-based planning to
improve the quality of health services
Background: The Government of Nepal, Ministry of Health and Population developed the Minimum
Service Standards (MSS) for all level of health facilities ranging from health post to tertiary level hospitals.
The MSS aspires to ensure the readiness of each health facilities to deliver quality health services. In the
federal context, primary hospitals and health posts have been handed over to the local government,
secondary A and B to provincial government and the tertiary and specialized hospital to federal
government. Thus, to ensure health services delivered to a high standard is the responsibilities of
respective government. The MSS helps to quantify the evidence through its scores and determines the
status of the health institutions in terms of its readiness and service availability. This provides a basis for
evidence- based planning and budgeting to ensure value for money. Previously MoHP has implemented
MSS for district level hospitals, now referred to as Secondary A and B hospitals and felt there was a need
to develop MSS for all levels of health facilities. DFID-funded NHSSP and Nick Simon Institute along with
other partners supported MoHP in developing MSS for all levels of health facilities, from health posts to
tertiary hospitals.
MSS as tool for need based planning for quality improvement: The MSS focuses on strengthening
the overall management of health facilities to improve service availability and readiness by addressing
the needs. In order to assess these, the MSS looks at governance and management, clinical service
management and support service management as the key domains. Under each domain, there are areas
which specifies the particular service which are referred to as subdomains. Each subdomain have many
criteria or standards and checklists for scoring. Those each criteria or standard has the optimum score
of 1 and if the criteria fully meets as per the standard, it is scored as 1, otherwise scored as 0. The overall
MSS score is computed by summing up with 20% weightage of Governance and Management, 60%
weightage of Clinical Service Management and remaining 20% weightage of Support Service
Management and is presented in percentage. The overall MSS score with below 50% means “very poor
and needs immediate actions” (colour coded as white), while the MSS score of 50% to less than 70% are
taken as "improving status and need specific targeted area support" (colour coded as Yellow), score of
70% to less than 85% indicates "acceptance level and needs careful specific intervention" (colour coded
as Blue) and score 85% and above indicates "optimal level of readiness and requires sustained efforts
to maintain and move towards 100%" (colour coded as Green). As an example of MSS tool for health
post, the major key subdomains have been presented in Figure 1.
Figure 1: Domains and subdomains of Minimum Service Standards for Health Posts

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Source: MSS for Health Post, Curative Service Division, DoHS, MoHP

The NHSSP supported the MoHP to conduct the baseline MSS assessment in 51 health posts and three
primary health care centres across seven local government (learning sites) during November 2018 to
July 2019. The MSS, as the self-assessment tool, was used by the health facility team to assess the
service readiness and service availability in health facility. Based on the identified gaps, action plan were
developed to improve the readiness for the improvement in quality of care and those actions points were
considered in the ward and municipal level Annual Workplan and Budget (AWPB) process.

Findings of the Assessment: The overall MSS score of health facilities of learning sites ranges from
23% to 76% with average score of 45.9%. This indicates that majority of the health facilities have
poor service availability and readiness indicating the need of immediate actions to improve the
service quality. While comparing the score by domains across the heath facilities, the Governance
and Management domain was found comparatively better with 51% average score ranging from
19.5% to 77.8% across the health facilities followed by Clinical Service Management with 48%
average score that ranged from 20.3% to 77%. The Support Service Management was found to be
the poorest among the three subdomains with overall average score of 34.1% that ranged from as
low as 3.8% to 65.8% across the health facilities. The aggregate MSS score of the health facilities in
seven local level is presented in Figure 2.
Figure 2: MSS Baseline Assessment Scores in Selected Local Levels

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70%
60%
60%
51%
50% 47%
41% 41%
38%
40%
31%
30%

20%

10%

0%
Yashodhara RM Dhangadhimai M Itahari SMC Kharpunath RM Pokhara MC Ajayameru RM Madhyapur
Thimi M

The self-assessment showed gaps, primarily on the availability and readiness of the laboratory services
and support services in the heath posts. These gaps are mainly due to either non-availability of basic
equipment and human resources or the weak managerial skills. The action plan developed to address
the gaps at each health facility provided a case for investment by the local government to further improve
the service availability and readiness. The assessment scores of the MSS and the action plan were
discussed with the concerned senior officials of local government and the NHSSP support continues to
monitor the action plan and their implementation. Findings of the assessment has been instrumental to
rationalize the need of the budget and other resources and hence address the gaps through AWPB. The
implementation of the MSS at the health post level has contributed to replenish the required equipment
and supplies, improvement in the governance and management functions and gradual impact on the
quality of the health services delivered.

Conclusion and way forward: MSS, bring the standard tool, can facilitate the respective governments
to monitor the status of the health facilities and use the evidence generated through the MSS to
strengthen the quality of care. The action plans developed based on the MSS assessment also provide
evidence for the local government to advocate to the Provincial and Federal Government for
additional resources, like human resources, equipment, and overall infrastructure of the health facilities.
The MSS scores could potentially be the basis for Federal and Provincial Government to provision
performance-based grants to the respective level. MSS can gradually lead to the improved quality of care
at all level of health facilities by enhancing the readiness and availability of the services at the health
facility level.

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Annex 6: Routine Data Quality Assessment

The Routine Data Quality Assessment (RDQA) is a web-based application developed for health facilities,
programmes and administrations to self-assess the quality of HMIS data and strengthen the data
management system. The tool comprises of two domains viz., 'data verification' and 'system assessment'.
Using data from the HMIS, the tool is able to calculate quality metrics by verifying the data under the
'data verification' domain; and the five functional areas of Monitoring & Evaluation (M&E) system are
assessed under the 'system assessment' domain.
The data verification domain of the RDQA tool helps to assess if service delivery sites (health facilities)
at different levels and the national M&E are collecting, consolidating, and reporting data to measure the
selected indicator(s) accurately and on time, and to cross-check the reported results with other data
sources. For cross-checking, the data reported for selected indicators are verified against the recording
registers/forms; Register vs Tally sheet; Register vs Monthly Monitoring Sheet; Tally vs Monthly
monitoring sheet; and the Register Vs Client tracking (optional).
The system assessment component of the RDQA Tool identifies strengths and potential threats to data
quality posed by the design and implementation of the data management and reporting system at the
M&E, and Service Delivery sites at different levels. Data verifications let the users know whether there is
a problem with data quality. The system assessment component is designed to address the 'why' and
'how' so that users can take corrective actions that should then be seen by improved data verifications
during future RDQAs. System assessment has five functional areas: M&E structure, functions, and
capabilities; indicator definitions and reporting guidelines; data collection and reporting forms and tools;
data management processes; and use of data for decision making.

The RDQA tool was originally developed by United Stated Agency for International
Development/Measure Evaluation in Microsoft Excel© format as part of global efforts to combat AIDS,
malaria, and tuberculosis17. The MoHP customized the tool to suit the local context. The web-based
RDQA implementation guidelines, manual and tutorials have also been developed and published on the
MoHP website18. The MoHP is implementing Learning Labs approach in seven selected local level
municipalities – one in each province – to strengthen the local health systems so that they are more
resilient and can deliver quality health services which leaves no one behind; learn from them and
disseminate the learning to wider stakeholders; and support scale up of the good practices in the
remaining local governments. The web based RDQA system has been implemented in all public health
facilities in the seven learning lab sites. The section below presents the issues/challenges and lessons
learned from this process which will help to guide the scale up of RDQA.
Challenges
1. Registers were not uniformly maintained between the health facilities.
Case 1: definition of defaulter of family planning method was not consistently practiced. Some health
facilities categorized a client as a defaulter if the client did not visit the facility on the given (follow up)
date. While others waited for four weeks before classifying the client as a defaulter.

Case 2: definition of ‘new case’ for growth monitoring was not consistently practiced. In some
instances, the health facilities categorized the client as ‘new’ if it was the first visit; regardless of
whether growth monitoring was done at other health facilities or not. While in other cases, the client
was considered ‘new’ only if the growth monitoring was done for the first time.

                                                            
17 MEASURE Evaluation, October 2015, User Manual - Routine Data Quality Assessment Tool, MEASURE Evaluation
18 www.mohp.gov.np or www.rdqa.org
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2. Supervision and mentoring visits to the health facilities from higher level authorities are very limited.
Regular supportive supervision would provide an opportunity for the staff to clarify their confusions
regarding recording, reporting and other issues.

3. Although health facility staff have received training on e-reporting, they are unable to practice this skill
due to lack of internet connection in the health facility and their limited skills on computer operation.
Both, internet connection as well as computer skills will be necessary for them to make use of web-
based RDQA tool.

Lesson learned
1. Ensuring availability of computers, power back up and internet connectivity at the health facility
level and basic computer literacy among the health workers are pre-requisites for implementation
of e-reporting and RDQA.
2. The facilities without/inconsistent internet connection can use the MS-Excel© based RDQA tool
as this will not require internet connection to operate. The MS-Excel© based RDQA tool is
available at www.rdqa.mohp.gov.np.
3. The use of RDQA should be officially mandated in all health facilities.
4. Frequent supportive supervision visits from higher level authority is needed for routine use and
follow up of RDQA process in health facilities.

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Annex 7: Findings of the Rapid Assessment of Aama Programme

The maternity incentive scheme (MIS) was introduced in 2005 with a payment being made directly to all
women who delivered in a Government Health Facility which varied according to geography and was
meant to contribute to the transport costs of reaching a health facility. In 2006, the scheme was renamed
the Safe Delivery Incentive Programme (SDIP) and in addition to the transport incentive free delivery
care was introduced in Government health facilities in 25 districts with lowest human development index.
In 2009, the scheme was re-named the Aama Programme and the transport incentive and free delivery
care made available to all women who delivered in a certified health facility across the country.
The review of the Aama Programme indicated a rapid and statistically significant increase in births
attended by a skilled health worker after the introduction of the MIS and SDIP schemes. This trend
continued after the introduction of the Aama Programme in 2009 but not at an obviously higher rate.
Variations were seen across the geographical areas of Nepal over time but in general in the Terai and
Hills the rates of skilled birth attendance are at similar levels. Inequality in institutional delivery has fallen
across all wealth quintiles and between caste/ethnic groups. However, there is still low institutional
delivery in Mountain areas, in Province 2 and 6 and among Madhesi, Dalit, Muslim and Hill Janajati
groups. The relationship with the Aama Programme and 4 ANC is less clear as there was an upward
trend in 4ANC before the introduction of MIS/SDIP and there is now almost zero inequality in 4ANC visits.
Aama is a free Government Programme but in 2019, 50% of women paid for delivery care and only 53%
of women received the full transport incentive. The payments for delivery care are higher in private health
facilities across all types of deliveries. Private health facilities are also more likely to perform caesarean
section surgery. The number of health facilities with birthing centres (BC), basic emergency obstetric care
(BEONC) and comprehensive emergency obstetric care (CEONC) services has increased over time. A
rapid increase in BC/BEONC services was seen after the introduction of the Aama Programme in 2009.
However, there is still an unequal distribution of CEONC services which tend to be in accessible areas.
There are no private CEONC services in mountain areas.
Lower level health facilities are used for ANC but not for delivery care – women prefer to give birth in
higher level health facilities. However, if a health facility is more than 5km away poor women are less
likely to the health facility whereas distance does not have an effect on whether women in the top two
quintiles use a health facility for childbirth. The costs of accessing care in the mountain areas is still
excessive and prohibitive to women planning for birth and in accessing care. Barriers to access for
excluded groups in accessible areas can be overcome with better relationships with health facilities and
the availability of ambulances.

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Annex 8: Changing Burden of Diseases

A major achievement of the year (2019) was the publication of the Nepal Burden of Disease (NBoD) 2017
Report: the first time comprehensive, credible disease burden data for Nepal has been compiled and
published in one place. The Report tracks disease burden and risk factors since 1990.

The NBoD reveals a substantial increase in life expectancy in Nepal: females are expected to live longer
(73.3 years) than male (68.7 years) which is an increase by more than 10 years between 1990 and 2017.
However, not all these additional years gained will be healthier ones. Females are expected to live only
62 years of healthy life, with men living only 60 years of healthy life. As people live longer, however, they
tend to suffer more from the disability, ill-health and distress of older age. The NBoD reports on all these
through Disability Adjusted Life Years (DALYs), Years of Life Lost (YLLs), Years Lived with Disabilities
(YLDs), and risk factors attributing death and disability etc.

While not all these are at present included in the current Nepal Health Sector Strategy (NHSS) 2015-
2020, the NHSS does track DALYs. These are divided into three broad categories of disease conditions:
communicable, maternal, neonatal and nutritional (CMNN) diseases; non-communicable diseases
(NCDs) and Injuries. Approximately, 59% of disease burden (DALYs) in 2017 is due to NCDs, 31% due
to CMNN diseases and 10% due to Injuries. This represents a major shift in disease burden and cause
of deaths in Nepal. Out of the total of 182,751 deaths estimated in Nepal for the year 2017, NCDs are
the leading cause of death with two third (66%) of deaths due to NCDs, with an additional 9% due to
Injuries. The remaining 25% are due to CMNN diseases. In 1990 these proportions were: CMNN diseases
– 63%, NCDs – 31%, Injuries – 6%.

The Report also tracks Risk Factors for illness, disability and death. Child and Maternal Malnutrition,
Dietary Risks, Tobacco, High Systolic Blood Pressure and Air Pollution are the top five risk factors driving
death and disability in Nepal.

The growing pattern of a double burden of NCDs and CMNN diseases is becoming more and more
apparent, posing a need for the health system to accelerate its actions towards rightfully addressing the
rapidly growing burden due to NCDs and Injuries without deprioritizing interventions to maintain the gain
the country has made on reducing the burden due to CMNN diseases.

Reference: Nepal Health Research Council (NHRC), Ministry of Health and Population (MoHP) and Monitoring
Evaluation and Operational Research (MEOR). Nepal Burden of Disease 2017: A Country Report based on the
Global Burden of Disease 2017 Study. Kathmandu, Nepal: NHRC, MoHP, and MEOR; 2019.

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Annex 9: Factors Contributing to the Stock out of Essential Drugs/Commodity in Government

Health Facilities: Preliminary Findings
Background
Ministry of Health and Population, Department of Health Service, Management Division in collaboration
with the United States Agency for International Development (USAID) and HERD International (research
partner) successfully completed the study with an aim to identify factors contributing to stock-out of
essential tracer drugs in government health facilities of Nepal. The specific objectives of the study were
to:
- identify top five factors contributing to stock-out of tracer drugs/commodity,
- examine medicine prescription practices of health service providers,
- examine medicine dispensing practices at the health facilities,
- assess client’s demand for medicines and user factors that may potentially contribute to stock-out of
drugs/commodity
- explore procurement and supply chain management mechanisms of drugs and commodity in the
new federal system
The study assessed 18 tracer drugs/commodity in selected health facilities in seven provinces.

Methodology
The study used mixed-method (quantitative survey and qualitative techniques) approach. A sample of
three districts from each of the seven provinces were selected, thus a total of 21 districts across the
country were reached out. 275 public government health facilities were sampled that included all public
hospitals (district and higher-level hospitals and all 15 bedded hospitals, n=28) and all PHCCs (n=54) in
the 21 selected districts and sample of health posts (n=193) from the 21 districts. The study employed
five different tools for data collection: i) Health facility assessment tool (n=275), ii) Observation of client-
health worker interaction (n=145), iii) Exit client interviews (n=431), iv) Observation of prescription/
prescription audit (n=333), and v) Semi-structured interviews (n=53). Data collection was done from April
to June 2019.
As part of this study, an Oversight Committee was formed under the leadership of Management Division
with participation from respective divisions and external development partners as members of the
committee. The committee played crucial role in designing the study, finalizing tools, training, field
implementation and monitoring and review of study report at different stages. Ethical clearance was
obtained from the Nepal Health Research Council [Ref # 887].

Key findings
The key findings of the study are presented under the following major headings.
GENERAL SERVICE READINESS OF HEALTH FACILITIES
Among the 275 sampled health facilities, 93.8% of them had access to electricity, however, 50.4% of
them had electricity capacity to run 24/7. Twenty percent health facilities had functional landline
telephone, 42.9% health facilities had functional computer, 37.8% had internet connectivity and 44.4%
health facilities had functional refrigerators.
Store conditions of these health facilities were assessed following the WHO “Standard guideline for the
storage of essential medicines and other health commodities”.1 Out of 275 health facilities, only two health
facilities (one PHCC and one health post) followed eleven standard storage conditions (3 conditions were
not applicable for all health facilities).

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The study assessed availability of 18 tracer drugs/commodity through Logistic Management Information
System (LMIS) report and physical count of drugs/commodity on the day of visit. LMIS reports of first and
second quarter of fiscal year 2075/76 were used. Among 275 health facilities, 76.7% (211) of health
facilities had first quarter LMIS report and 69.4% (191) of health facilities had second quarter LMIS report
available. However, among health facilities that had LMIS report, complete information of all 18 tracer
drugs/commodity was in 60.2% of health facilities for first quarter and 58.1% in second quarter. Therefore,
total n for each drug varies (table 1 and 2).
STOCK STATUS OF TRACER DRUGS/COMMODITY
Among the health facilities that Table 1: Availability of the tracer drugs on the first quarter, second quarter
had record of all tracer and on the day of visit
drugs/commodity, all 18 tracer Tracer drugs/commodity 1st 2nd Day of visit
drugs/commodity (except quarter quarter
n (%) n (%) n (%)
Oxytocin, as it was assessed in
Albendazole 400mg 187 164 (89.6) 234 (85.1)
birthing centres only) were (89.0)
available in only 2.4%, 0.9% and Amoxicillin 125mg DT 139 116 (68.2) 158 (57.5)
1.5% of health facilities for first (69.8)
quarter, second quarter and on Amoxicillin 500mg 118 138 (77.1) 227 (82.5)
(58.1)
the day of data collection
Clotrimazole skin cream 25g 1% 54 (29.2) 77 (47.5) 176 (64.0)
respectively. Out of 70.5% health w/w
facilities having birthing services, Ciprofloxacin eye/ear drop 123 105 (61) 143 (52.2)
Oxytocin was available in 69.8%, (61.5)
78% and 71.6% of health Iron 60mg + Folic acid 400mcg 194 175 (96.7) 255 (92.7)
tablet (92.8)
facilities in the first quarter, Chlorhexidine gel 4% 112 88 (55.3) 172 (62.5)
second quarter and on the day of (61.2)
data collection respectively Gentamycin injection 80mg/2ml 83 (47.2) 86 (55.1) 135 (49.1)
(Table 1 and 2). Metronidazole 400mg 193 164 (92.1) 251 (91.3)
(92.3)
Oral Rehydration Solution 168 149 (81.9) 236 (85.8)
(81.2)
REASONS FOR STOCK-OUT Oxytocin injection* 90 (69.8) 85 (78) 139 (71.6)
OF ESSENTIAL TRACER Paracetamol 500mg 202 173 (96.1) 257 (93.5)
(96.2)
DRUGS/COMMODITY Paracetamol suspension 175 155 (86.6) 241 (87.6)
125mg/5ml (85.4)
Povidone Iodine Solution 193 167 (92.3) 255 (92.7)
Table 2. Percentage of health facilities with availability of tracer
(92.8)
drugs/commodity
Salbutamol 4mg on the day of visit disaggregated
117 146 level
(82) of health 233 facility
(84.7)
(57.6)
Level of health facility
Zinc Sulphate 20mg DT 159 PHC124 (70.9) Health 201 (73.1) Total
racer drugs/commodity Hospital
(76.1) C post n (%)
Isoniazide+Rifampicin+ % 103 % 81 (55.5) % 122 (44.4)
Pyrazinamide+Ethambutol (59.5) 234
Albendazole
(RHZE) 400mg 75.0 83.3 87.0
(85.1)
Vitamin A capsule 117 102 (61.1) 84 (30.5)
158
Amoxicillin 125mg DT 28.6 (57.6) 70.4 58.0
(57.5)
Condom 183 148 (82.7) 223 (81.1)
227
Amoxicillin 500mg 75.0 (87.6) 90.7 81.3
(82.5)
All 18 tracer skin
Clotrimazole drugs/commodity*
cream 3 (2.4) 1 (0.9) 4 (1.5)
176
75.0 79.6 58.0
*25g
All 1%
18 includes
w/w tracer drugs/commodity except Oxytocin as it was assessed only
(64.0)
in facilities that offer normal delivery 143
Ciprofloxacin eye/ear drop 42.9 53.7 52.8
(52.2)
Iron 60mg + Folic acid 255
82.1 96.3 93.3
400mcg tablet (92.7)

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Table 3 presents top five reasons Chlorhexidine gel 4% 172

42.9 74.1 62.2
for stock-out of tracer (62.5)
Gentamycin injection 135
drugs/commodity on the day of 80mg/2ml 50.0 68.5 43.5
(49.1)
visit disaggregated by province 251
Metronidazole 400mg 82.1 96.3 91.2
and type of health facilities, and (91.3)
hence the data might not Oral Rehydration Solution 236
75.0 88.9 86.5
(85.8)
represent as top reasons for each
139
province and for each facility Oxytocin injection* 57.1 70.4 44.0
(71.6)
type. Delay in supply of 257
Paracetamol 500mg 82.1 94.4 94.8
drugs/commodity by higher level (93.5)
was the most cited reason for Paracetamol suspension 71.4 92.6 88.6
241
125mg/5ml (87.6)
stock out at all levels of health 255
facilities in all seven provinces in Povidone Iodine Solution 82.1 100.0 92.2
(92.7)
the first quarter, second quarter Salbutamol 4mg 71.4 96.3 83.4
233
as well as on the day of visit. (84.7)
201
Other major reasons reported Zinc Sulphate 20mg DT 57.1 77.8 74.1
(73.1)
were inadequate supply of drugs Isoniazide+Rifampicin+
122
and commodity against the Pyrazinamide+Ethambutol 39.3 57.4 41.5
(44.4)
demand placed by health (RHZE)
facilities, no demand for certain Vitamin A capsule 32.1 27.8 31.1 84 (30.5)
223
drugs/commodity placed by Condom 50.0 90.7 82.9
(81.1)
health facilities as there was less All 18 tracer
7.1 1.9 0.5 4 (1.5)
or no consumption of certain drugs/commodity*
drugs, high consumption of Total (n) 28 54 193 275
* All 18 includes tracer drugs/commodity except Oxytocin injection, as it was
drugs/commodity at the health
assessed only in facilities that offer normal delivery
facilities than anticipated, near to
expiry drugs received by health facilities and PUSH system of drug supply where health facilities did not
receive drugs/commodity they requested and rather received other drugs leading to both overstock and
stock out.

Table 3: Top 5 reasons for stock out of tracer drugs/commodity on the day of visit disaggregated by
province and type of health facilities
High
Higher level Inadequate Didn't Received Tot
consumption
did not send supply against the demand near to al
than
on time demand drugs expired drugs (n)
anticipated
n % n % n % n % n %
Province
Province 1 26 66.7 14 35.9 18 46.2 2 5.1 4 10.3 39
Province 2 30 81.1 22 59.5 12 32.4 4 10.8 5 13.5 37
Province 3 25 69.4 21 58.3 16 44.4 4 11.1 4 11.1 36
Province 4 19 63.3 21 70.0 21 70.0 6 20.0 5 16.7 30
Province 5 49 98.0 35 70.0 16 32.0 13 26.0 6 12.0 50
Province 6 41 87.2 28 59.6 28 59.6 8 17.0 6 12.8 47
Province 7 30 93.8 3 9.4 6 18.8 1 3.1 5 15.6 32
Level of health
facility
Hospital 14 53.8 9 34.6 8 30.8 4 15.4 3 11.5 26
PHCC 39 73.6 28 52.8 13 24.5 8 15.1 12 22.6 53
Health post 167 87.0 107 55.7 96 50.0 26 13.5 20 10.4 192
Total (n, %) 220 81.2 144 53.1 117 43.2 38 14.0 35 12.9 271

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DRUGS PRESCRIPTION AND DISPENSING

PRACTICES, AND CLIENTS DEMAND FOR DRUGS Prescribing Standards
From prescription audit of 324 slips, only 13.9% of
prescriptions for antibiotics and 8.3% prescriptions for
We interviewed 431 exit clients or their care taker, observed other drugs met WHO prescription standard2 with
correct information on all five prescribing indicators of
145 interactions between client and health worker and dose, dosage form, mode of administration, length of
examined 333 prescription slips to understand drug treatment and time of administration.
prescription and dispensing practices of health workers and  Average number of drugs prescribed per
drug demand by clients or their caretakers. encounter was 2.85
 Percentage of encounters with at least one
Among 431 exit clients, 77.3% received a formal antibiotic prescribed was 50.9%
prescription slip from health worker, 21.6% did not receive Majority of drugs prescribed by Brand Name
prescription, and five clients received prescriptions in a In 324 prescription slips used for prescription audit,
piece of paper (all in health posts). The practice of providing altogether 925 drugs were prescribed. Only 25.6% of
prescription slips to patients was lesser in health posts these drugs were prescribed using generic name and
the trend of using generic name was similar in PHCC
(56.5%) as compared to hospitals (98.1%) and PHCCs and health post (31.4% and 30.6% respectively) and
(98.2%). Out of those clients who were prescribed drugs was much lower in hospital (14.7%).
(n=333), 57.7% received all the prescribed drugs, majority
served by health post (78.7%).
Table 4. Percentage of clients who received prescribed
drugs Expired or damaged drugs/ commodity
Level of health facility
28.9% of health facilities in the first quarter and 22.5%
Healt
of health facilities in second quarter had at least one
Received prescribed Hos PHC
h
Total of the 18 tracer drugs/commodity expired (except
drugs pital C
Post
oxytocin).
% % % n (%) Drugs/commodity above ASL (overstock)
192 38.5% of health facilities had at least one of the 18
Yes, all received 47.1 43.9 78.7
(57.7) tracer drugs/ commodity above ASL on the day of visit.
Yes, partially 106
32.7 44.9 19.7
received (31.8) Drugs/commodity below EOP
No, not received at 31.6% of health facilities had at least one of the 18
20.2 11.2 1.6 35 (10.5)
all tracer drugs/ commodity below EOP, and the
Total (n) 104 107 122 333 percentage is higher in PHCCs and health posts.

Client/caretaker demand for medicine: Information on client or caretaker demand for medicine was
obtained from exit client interviews. 10% of the 431 respondents said that they requested for additional
medicines during OPD consultations. Analgesics (37.2%), anti-helminthic (27.9%), and anti-gastritis
(20.9%) were mostly demanded medicines by 43 respondents (10%) of which 33 (76.7%) of them
received medicines they demanded. This practice of fulfilling patients demand for medicines by health
workers was found higher in health posts (82.8%) as compared to PHCCs (66.7%) and hospitals (60%).

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1
John Snow, W.H.O., Guidelines for the Storage of Essential Medicines and Other Health Commodities. 2003. Arlington, Va.: John Snow,
Inc./DELIVER, for the U.S. Agency for International Development. 2003.
2
WHO, How to investigate drug use in health facilities: selected drug indicators, action program on essential drugs (DAP). 1993

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Annex 10: Registration Status of Health Professionals in National Health Workforce

Registry, as of March 2019
Council Category Degree Number
MBBS
16,551
BDS
Nepal Medical 2,095
Medical Doctors
Council
MD
1,440
Sub-total
20,086
Registered Nurse
55,009
Nepal Nursing ANM
32,324
Council Nursing Professionals
Foreign Nurse
842
Sub-total
88,175
Allied health disciplines/Paramedics
General Medicine GM/HA
12,647
General Medicine CMA/AHW
63,935
Dental Paramedics Dental Hygienist/Assistant
1,490
LA/CMLT/BMLT/MScMLT,
Laboratory Professionals
etc 25,564
Public Health MPH & BPH
3,637
Nepal Health Health Education MHE/DHE
36
Professional Council
Laboratory CMLT/BMLT/MSc/MLT, etc
25,564
Ophthalmology Assistant/Optometry
1,032
Radiology Assistant/Technician
1,102
Physio & Rehab science Assistant/BPT/MPT etc
784
Ayurveda & alternative medicine
Homeopathy/Yoga etc
(in the past) 695
Sub-total
136,486
Nepal Pharmacy
Pharmacists Diploma/Bachelor/Masters
Council 11,017
Nepal Ayurvedic
Ayurvedic doctors & paramedics Diploma/Bachelor/Masters
Medical Council 4,022
Grand Total
259,786
Source: Ministry of Health and Population

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Annex 11: Mapping between Nepali Calendar Years and the Gregorian Years
Nepali Fiscal Year Gregorian Fiscal Year

2060/61 2003/04

2061/63 2004/05

2062/63 2005/06

2063/64 2006/07

2064/65 2007/08

2065/66 2008/09

2066/67 2009/10

2067/68 2010/11

2068/69 2011/12

2069/70 2012/13

2070/71 2013/14

2071/72 2014/15

2072/73 2015/16

2073/74 2016/17

2074/75 2017/18

2075/76 2018/19

2076/77 2019/20

2077/78 2020/21

2078/79 2021/22

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Supported by:

This material has been funded by UK aid from the UK Government; however, the views expressed
do not necessarily reflect the UK government’s official policies.

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