Health System
Management
Campus Presentation
Group A2
MBBS 4th year
Maharajgunj Medical Campus, IOM-TU
1
Introduction of group members
Group B2
Roll No:
1. Sameep Sapkota ( GR )
1891
2. Divya Pokhrel
1858
3.Madhur Bhattarai
1868
4. Pratima Sharma
1876
5. Ranjeet Ghimire
1886
6. Srijana k. Yadav
1903
7. Subodh Adhikari
1905
8.Vipul Sinha
1909
2
Field Sites and Activities
S.N
HSM Field Sites
Duration
Tasks Performed
1
Amppipal Hospital
Day 1 to Day 21
1. Hospital Profile
2. Municipal Profile
3. Critical analysis on OPD
Services
2
Trishuli Hospital
Day 22 to Day 42
Five-year plan on Uplifting
Mental Health of people of
Bidur Municipality
3
Hetauda Hospital
Day 43 to Day 63
Epidemiological study on
Pneumonia
3
Objective
General objective
▪ To acquire essential knowledge and skills on management of federal, provincial, and
local level health services in private and public sectors.
4
Objective
Specific objective
▪ To prepare municipal health system profile, including organisation profile,
health workforce, health programs, etc
▪ To analyze the prevalence and epidemiological trend of health problem
▪ To critically analyze the health system management (HSM) and produce
alternative solutions
▪ To prepare 5-year plan to address a particular problem
▪ To prepare a report for submission to local stakeholder and department of
community medicine.
5
Study Design
•
Methodology
sa
•
Descriptive
Cross sectional
Study
Hospital Records
Review
Study Area
• Amppipal Hospital
(Gorkha)
• Trishuli Hospital
(Nuwakot)
• Hetauda Hospital
(Hetauda)
6
Study Population
Data Management
▪ For the epidemiological study, the study population were all the patients
admitted at Hetauda Hospital due to Pneumonia
▪ For 5 year plan on Mental Health Status of Bidur Municipality, the study
population were the OPD patients at Trishuli Hospital.
7
Study Data
sa
Primary data
Secondary data
Qualitative
data
from interview with
stakeholders
and
focal persons.
Quantitative
data
from
hospital
records of last three
years
8
Tools and Techniques used for Municipal Profile and Municipal Health Profile
Technique
Tools
Source of Information
Key informant
interview
Interview guidelines
∙
∙
∙
∙
Record review
Record review format
Amppipal hospital records, Records
Municipality , HMIS database 078/079
Literature review
Literature review format
Palungtar Municipality annual report 078/079, Finance
report of Palungtar Municipality
, DoHS Annual reports 74/75, 76/77 and 78/79
Observation
Observation checklists
∙
Health coordinator, Health section,
Health Office, Palungtar Municipality
Administrative In-charge, Palungtar municipality
Officer, Finance section, Palungtar Municipality
at
Palungtar
Palungtar Municipality
9
Tools and Techniques used for Hospital Profile
Technique
Tools
Source of Information
Key informant interview
Interview guidelines
Medical superintendent, hospital manager, medical
record supervisor, medical officers, store keepers,
nurses, radiographers, emergency room in-charge,
department in-charges, other hospital staffs
Observation
Observation checklists
Amppipal Hospital premises
Record review
Record review format
Hospital In-patient Records ,
Amppipal Hospital Annual Report, Logistics register
Literature review
Literature review format
Minimum Service Standards, MoHP
10
Tools and Techniques for Critical Analysis
Techniques
Tools
Sources of Information
Key Informant Interviews
Interview guidelines
Hospital In-Charge, Medical Officers,
ANMs, AHWs at Hetauda hospital
Literature Review
Literature review format
Government website, Guideline for
establishment and upgrade of health
institution
Data Review
Data Review Format
HMIS Report registers
Observation
Observation Checklist
The hospital premises
11
Tools and Techniques for Epidemiological Study
Technique
Tools
Source of information
Record review
Record review format
Outpatient records of Trishuli Hospital
Key Informant Interview
Semi-structured Interview
guidelines
Hospital incharge, Medical Officers
Literature review
Literature review format
Class notes, Standard textbooks, HMIS
Reports of the past three fiscal years, DoHS
Annual Report
12
Tools and Techniques for Five Year Plan
S.N.
1.
Activities
Prioritization of topic
Technique
•
•
2.
Situation analysis
•
•
Tools
Secondary Data
Review
Key informant
interviews
Data review format
Interview guidelines
Interview with
Stakeholders
Secondary data
review
•
Sources
•
•
•
•
•
Interview
guidelines
Data review
formats
•
•
HMIS Records from Health Office
(2078/079)
DoHS Annual Report (2077/78)
Records from Health Section,
Key informants
− Health coordinator, Health section,
Medical superintendent Amppipal
Hospital
Key informants
− Health coordinator, Health Section,
Medical superintendent
− Health Office, Records from Health
Office, (2078/079)
Records from Health Section,
13
3.
Stakeholder analysis •
Interview
with •
stakeholders
Interview
guidelines
4.
Problem analysis
•
Key
informant •
interview
Interview
guidelines
− Health coordinator, Health
section,
− Health Office
5.
Objective and target •
setting
Key
informant •
interview
Interview
guidelines
− Health coordinator, Health
section, Health Office
6.
Logical Framework
Matrix preparation
7.
Budget Planning and •
estimation
•
Group
Discussion
•
Key
informant •
interview
Logical
Framework
Matrix
Interview
guidelines
•
•
•
Stakeholders
− Health coordinator, Health
section, Medical superintendent,
Amppipal Hospital
− Health Office Representatives of
NGOs/INGOs
Members of Health section
Health Office
− Finance officer,
− Health coordinator, Health
section,
14
Municipality Profile of Palungtar
Municipality
15
Municipality - Geography
Province
District
Gandaki
Gorkha
No. of wards
10
158.62 sq. km
Area
Estimated total population 37748
Number of households
Major caste
9455
Chhetri
Literacy rate
Major occupation
69.2 %
Agriculture
16
Municipality - Organogram
Municipal Assembly
Municipality office
Mayor
17
MUNICIPAL HEALTH PROFILE
18
Municipal Health System
Modern Health Care System
Government Health
System
Indigenous Health Care System
Private Health
System
Supporting System
NGO
Traditional Faith
Healers
Ayurveda
Hospital- 1
INGO
Health Section of
Municipality
Health Posts- 7
Private Hospital- 1
Urban Health Centers- 4
Government Hospital - 1
Birthing Centers- 1
FCHVs- 72
Outreach Clinics
19
Study Framework: IPO Model
Internal environment
INPUTS
PROCESS
∙Infrastructures
∙Human resources
∙Budget
∙Information
∙Logistics
∙Training
∙Planning
∙Staffing
∙Recording and reporting
∙Budgeting
∙Supervision and monitoring
OUTPUT
∙Coverage
∙Service utilization
∙Morbidity and mortality
Feedback
-
External Environment
Political stability
Climate and geography
20
Input
Infrastructures
• 2 rooms has been allocated for the health section in the municipality
• One room is used for the logistics storage and another is used for the
official purpose.
• Some peripheral health institutions have their own building and some are
using the rented building.
21
Human Resources
Public health officer
Hospital Nursing Inspector
Public Health Inspector staff
Office assistance
Health Assistant
Sr. AHW
Two AHW
Two ANM
One office Assistant
Health section of the
municipality-4
One Sr. AHW
One ANM
UHCs - 2
Health
posts- 7
22
Budget
• Source of budget
- Federal Government
- Municipality office itself
• In F.Y. 2078/79 the municipality allocated 8 crore for health at
local level.
23
Information
24
Logistic Management System of
DOHS
Logistics:
Regional storage under provincial
government
Municipality
Health section of municipality
Peripheral health institutions
Fig: Pull System
Fig: Push System
25
PROCES
S
Implementation by the municipality health division
Discussion in the municipality assembly and approval of
the stakeholders
Preparing, analyzing and finalizing the plan
• Planning
Health division of the municipality
Plans proposed by the peripheral health institutions
Discussion of community health problems in health posts
and health units and related stakeholders
26
Recording and Reporting
Recording and Reporting : HMIS AND LMIS guidelines.
27
COORDINATION
Coordination
Vertical Coordination
Federal and
provincial level
Health section of municipality
Horizontal Coordination
Line
Sections in
Offices of
Municipal
Executives
Health section
of municipality
NGOs/
INGOs
HPs/ UHCs/
BHSCs
FCHVs,
EPI clinics
PHC- ORCs
28
Supervision and Monitoring
• Health Section of Municipality:
Municipal health section of Palungtar Municipality adopts two ways of monitoring
and supervision:
- Integrated supervision
- Program specific supervision
• Supervision methods:
- Indirect: by analyzing records and reports (quantitative) and providing feedback.
- Direct: by observing the performance of health workers (qualitative) while on job
(How the program is executed, Are the staffs on time or not? etc.)
29
Output
National Immunization
program.
CHILD HEALTH
PROGRAMS
Community Based Integrated
management of neonatal and
childhood illness(CBIMNCI).
Nutrition program
30
Comparison of immunization coverage
of municipality in the FY 2077/78 with
national coverage of 2077/78
Immunization Status
100
90
80
70
60
50
40
30
20
10
0
91
88
77
87
80
87
82
8284
8082
8282
8587
8385
7980
91
84
95
82
78
65
81
60
55
Municipal 2077/78
Fig.: Comparison of immunization coverage
National 2077/78
31
CB-IMNCI Program
120
100
80
60
CB-IMNCI
Program
40
20
0
Diarrhea cases under 5 year children
2076/77
source: DHIS-2,Palungtar Municipality
Pneumonia cases under 5 year children
2077/78
2078/79
Fig.: CB-IMNCI Program
32
S.N.
1
2
Nutrition
Program
3
4
Indicator
% of children aged 0-23 months registered
for Growth Monitoring (New)
Average number of visits among children
aged 0-23 months registered for growth
monitoringᵃ
% of children aged 0-23 months registered
for Growth Monitoring (New) who were
underweight
% of children aged 0-6 months registered for
Growth Monitoring (New) who were
exclusively breastfed for the first 6 month
source: DHIS-2,Palungtar Municipality
Fiscal Year
2076/77
2077/7
8
3.6
4.7
3.6
94
102
122
1.9
1.9
3
87
81
95
Fig: Nutrition Programs in Palungtar Municipality
2078/7
89
33
Safe Motherhood
program
FAMILY HEALTH
PROGRAMS
Family planning program
Female Community Health
Volunteers Program
Peripheral Health
Centers- Outreach
Clinics
34
Safe Motherhood program
70
60
50
40
30
Safe
Motherhood
Program
20
10
0
National (2077/78) Gandaki Province
(2077/78)
Paungtar
Municipality
(2076/77)
percentage of women who had 4 ANC check up as per protocal
percentage of women who had 3 PNC check up
Paungtar
Municipality
(2077/78)
Palungtar
Municipality
(2078/79)
Percentage of institutional deliveries
Fig.: Safe Motherhood program
35
Trend of family planning users in last three years
Family
Planning
Program
Prevelance of Contraceptive Devices
45
40
37
39
35
30
25
20
15,6
16,5
17,9
15
10
5
0
Palungtar Municipality
2076/77
National
2077/78
2078/79
Fig.: Trend of family planning users in last three years
36
OUTPUT
Tuberculosis Control
Program
Leprosy Control Program
DISEASE
CONTROL
PROGRAMS
HIV/AIDS and STDs control
Program
Malaria Control Program
COVID-19 Related Program
37
Indicators of TB programme in last three consecutive years
30
Tuberculosis
Control
Programme
Number of cases
25
24
24
20
20
15
10
5
5
2
1
0
2076/77
2077/78
Year
New cases
2078/79
Relapse Cases
Fig.: TB related Indicators in last 3 years
38
COVID- 19 RELATED INDICATORS
COVID-19
CONTROL
PROGRAMME
S.N.
INDICATORS
DATA
1.
Total COVID cases
4634
2.
Total COVID deaths
25
3.
Total PCR tests
6913
4.
Active cases
0
Fig.: COVID – 19 related Indicators
39
Hospital Profile : Amppipal Hospital
40
Amppipal Hospital Profile
• Established: 2025 BS as a 15 bedded hospital
• Location: Ward No.3,Amppipal, Gorka district, Gandaki province
• Area: 39 Ropani
• Catchment Area: Gorkha,Lamjung, Tanahu
• Patient: 1214 admitted per year, 2077/78
41
Staffing pattern of Amppipal Hospital
SN
1
DESIGNATION CATEGORY
Consultant Doctor
QUANTITY
2
2
Medical Officer
3
3
Nurse
11
4
HAs
3
5
Paramedics
7
6
Administration
4
7
Supporting Staffs
25
Total staffs
55
42
Hospital Management
Consists of Hospital Management Committee under which is Internal Management Committee
The IMC consists of
• Hospital Administrative Officer
• Asst. Hospital Administrative Officer
• Head of Departments
• Concerned Staffs from all departments
The HDC is an 11 member committee compromising of
• Mayor- Chairperson
• Ward Chairperson- 5
• Elected from civil society – 4 (at least one woman)
• Medical Superintendent – 1
43
Amppipal Hospital Organogram
Fig: Amppipal Hospital Chart
44
Input, Process And Output
• Input: Infrastructure, Human resources, Finance, Logistics
• Process: Planning, organization, staffing, coordinating, recording and
reporting, budgeting, supervision and monitoring
• Output: Health services and Service utilisation
45
Study Framework: IPO Model
Internal environment
INPUTS
PROCESS
∙Infrastructures
∙Human resources
∙Budget
∙Information
∙Logistics
∙Training
∙Planning
∙Staffing
∙Recording and reporting
∙Budgeting
∙Supervision and monitoring
OUTPUT
∙Coverage
∙Service utilization
∙Morbidity and mortality
Feedback
-
External Environment
Political stability
Climate and geography
46
Infrastructure
• 4 building (1 OPD, 1 emergency, 1 administrative, 1 ward building )
• 2 Ambulances and 46 running beds ( 15 sanctioned )
Human Resources
• Total 55 staff
• 2 senior doctors, 3 Medical officers and 39 others
47
Finances
Finances
Income
Expenditure
I.
•
•
•
•
Internal:
• Inpatient income
• Outpatient income
• Health Insurance Claim Payment
• Charity
•
II. External:
• Nepalmed Nepal
• Nepalmed Germany
• UMN Endowment fund Interest
• Government Donation
• Municipality Donation
•
•
•
•
Salary
Patient and patient related cares
Capital Investment
Quarter and Hospital constructions
and renovation
Training and Human Resource
Development
Staff Health Insurance
Travel and Transportation
Electricity/ Fuel/ Telephone/ Internet
Administrative Expenses
48
Logistics
• Logistic types a. Medicine
b. Non medicine (gloves, surgical supplies etc)
• Major medicinal supply is from local government.
• Remaining supply through procurement
• Separate rooms for storage
• Cold Chain is maintained
• FEFO( First Expiry First Out) system is applied for medicine
• Expired logistics disposed by burning
49
Process
Process
• Planning done by the Hospital Management Committee
• Discuss, analyze problems, and formulate solutions,make necessary modification in
plans and policies
• Staffs recruited by Provincial government, and hospital management committee
• Recording in HMIS tools and reporting done every month to the Health division of
Palungtar Municipality via DHIS 2
• Daily supervision done by medical superintendent and hospital manager
• Communicates
with
provincial
government
and
Palungtar
Municipality,
also
collaborates with other hospitals
50
Output
Preventive services
Curative services
• Maternal and Child • OPD for general
Health
patients
• Emergency
1. ANC service
services
2. Delivery
• In Patient
services
Department
3. PNC services
Services(IPD)
4. Immunization • Normal delivery
• Family Planning
and cesarean
Services
section
• Minor Surgical
Procedures
Diagnostic services
Others
•
•
•
•
•
•
•
•
•
Lab services
X-Ray services
POCUS services
ECG services
Health Insurance
Physiotherapy
Ambulance
Pharmacy
DOTS Services
51
Status of Performance indicators
Indicators (per Year)
2076/77
2077/78
2078/79
Total OPD visits
22043
20661
24345
Total Admission
1078
1087
1214
Plaster Cast
177
169
172
Minor surgery
669
832
776
Major Surgery
46
81
123
52
Critical Analysis on OPD services of Amppipal Hospital
53
Objectives
General objective
• To critically analyze the outpatient Department in Amppipal Hospital and critically
review the findings.
Specific Objectives:
• To evaluate the status of infrastructure, human resources, service Delivery, budgeting
and finance and monitoring and evaluation for OPD in Amppipal Hospital.
• To identify the problems and constraints concerning the OPD service in the Hospital.
54
Prioritization Table for Critical Analysis
Problem
Human
Resources
OPD service
Recording and reporting
Waste management
Magnitude of Problem
2
3
1
4
Feasibility
3
4
4
3
Availability of Data
3
3
3
2
Need for study
3
3
1
3
Cost Effectiveness
4
4
2
2
Total
15
17
11
14
Rank
2
1
4
3
55
Rationale
• OPD Service is one of the most important services provided by any hospital.
• Amppipal Hospital is the referral center for PHCs and HPs in local area.
• Quality of OPD service is directly responsible for the patient flow of the hospital.
• The introduction of health insurance system in Amppipal Hospital has brought
strong impact to patient flow in the OPD.
• The Amppipal hospital has regular OPD with in-house doctors.
• The hospital has been providing transportation services for OPD seekers.
56
SWOT Analysis
57
Physical Infrastructure
Strength
Weakness
• Earthquake resistant building.
• 3 general OPDs, 1 separate dental OPD, 1 Eye OPD.
• Separate room for screening the vitals before
proceeding to OPD.
• Well-furnished and lighted room.
• Pharmacy, Labs, and all other services under one roof.
• Disabled friendly hospital
• No separate medical and
surgical OPD.
• No separate
gynecological OPD
Opportunity
Threat
• OPD rooms can be divided into medical and surgical
• Poor road network.
OPD.
• Location of hospital is far
• Radiological facilities can be updated and improvised to
from tertiary center for
minimize the referral
referral
58
Budgeting and finance
Strength
Weakness
• Continuous source of revenue of the
hospital from patient fees, donations,
health insurance, etc.
• Provision of insurance in the district
which provides allowance upto NRS
1,00,000 per year per family of upto 5
members
• Inadequate recording and reporting
causing inappropriate allocation of
budget for different services
Opportunity
Threat
• Coordination with government and
NGOs/INGOs
• Lack of financial support from the
government
59
Human resource
Strength
Weakness
• Well trained physician with both medical and • Failure to fill the vacant posts
surgical skills
• Increased load on the staffs as they
• Well trained ANM
have to manage all outdoor, indoor,
• Well trained CMA in Dental and ophthalmic
emergency as well as OT patients.
OPD
• Adequate and efficient supporting staffs
Opportunity
Threat
• The staffs should be regularly trained on
• Reluctance of doctors and staffs to work
recent advancement and protocols in the
in the hospital due to its location in the
healthcare.
rural part
• GoN should fill the sanctioned posts as soon • Private institutions providing higher
as possible
incentives for health workers
60
Service Delivery
Strength
Weakness
• Screening of the vitals before proceeding to
OPD.
• Three general OPD, dental OPD, eye OPD,
ANC OPD, physiotherapy services.
• USG, X-ray, ECG facility and laboratory
services to support OPD.
• Provision of health insurance
• All the wide range of cases has to be dealt by
limited number of doctors and staffs.
Opportunity
Threat
• Post for the specialized doctors can be
sanctioned by GoN.
• Improvise OPD support facilities to minimize
referral.
• Suggestion box can be kept outside OPD
• Budget to upgrade the services.
• Geographical boundaries
61
Recording and Reporting
Strength
Weakness
• Record keeping is done according to HMIS • Frequent change in the record keeper
• Reporting done to DPHO
• Detail recording about follow-up patients
done
• Opportunity
• Threat
• A staff can be assigned who would be
responsible to coordinate the information
flow between Indoor Department and
Statistics division of Hospital for record
keeping
• Inadequate opportunity for training on
record keeping and reporting from
government
62
Health Insurance
Strength
Weakness
 Prevents emergency and unprepared financial
burden due to health issues
 Even poor people can afford health care when
required
 A small investment can cover a huge
expenditure of the entire family
 Patient can afford expensive medicines,
surgeries or investigations
 Insurance premium can be collected at home
 Increase in health seeking behaviour
 Doesn’t cover all surgeries or implants
 Sometimes it doesn’t cover expenses of
entire family which might exceed the limited
amount allowed
 Two month activation process is slow
 Selection of primary center can sometimes
be difficult
• Opportunity
• Threat
 Registration can be made faster
 Provision of more than one primary center
 Addition of more services and implants
 Increase in unwanted hospital visits
 Doesn’t cover all the hospitals
63
Epidemiological Study on Pneumonia
At Hetauda Hospital
64
Rationale of selection of topic
•
Pneumonia is the leading infectious cause of death among children under-5
in Nepal.
•
Pneumonia was consistently found to be one of the most common diseases
RATIONA
LE
three fiscal years in Hetauda Hospital.
in Hetauda while analyzing the hospital records.
•
•
Pneumonia was one of the leading cause of morbidity and mortality for last
Mortality and morbidity due to Pneumonia can largely be prevented if
managed promptly and adequately.
65
Trend of Pneumonia Cases of Hetauda Hospital
300
250
Pneumonia cases
250
200
180
150
100
85
50
0
2076/2077
180
Cases
2077/2078
85
2078/2079
250
Year
Fig.: Trends of Pneumonia cases in Hetauda Hospital in last 3 years 66
Source: Hetauda Hospital
Comparison of Pneumonia cases with total inpatient admission
Time Based Distribution of COPD
800
699
686
700
600
500
400
300
200
244
250
180
85
100
0
Year 2076/77
Year 2077/78
Total number ofPneumonia cases
Year 2078/79
Total Inpatient Admission
Fig.: Comparison of Pneumonia cases with total inpatient admission
67
Percentage of Pneumonia cases among total inpatient cases
40,00%
35,00%
30,00%
34,84%
35,77%
Year 2077/78
Year 2078/79
26,24%
25,00%
20,00%
15,00%
10,00%
5,00%
0,00%
Year 2076/77
Fig.: Percentage of Pneumonia cases among total inpatient cases in last three years in Hetauda Hospital
68
Sex wise distribution of pneumonia
43,69%
female
male
56,31%
Fig.: Sex wise distribution of pneumonia cases in Hetauda Hospital
Source: Hetauda Hospital
70
Trend of Pneumonia cases sex wise
160
140
Pneumonia Cases
120
100
80
60
40
20
0
2076/2077
Source: Hetauda Hospital
2077/2078
Year
Female
Male
2078/2079
Fig.: Trend of Pneumonia cases in Hetauda Hospital Sex wise
71
3,17%
4,76%
3,77%
Age wise distribution of
11,71%
Pneumonia Cases
76,59%
<5
Source: Hetauda Hospital
5 to 20
20 to 40
40 to 60
>60
Fig.: Age wise distribution of Pneumonia cases in Hetauda Hospital
72
Trend of distribution of Pneumonia in different age group
180
166
Number of Pneumonia cases
160
140
139
120
100
81
80
60
36
40
22
20
9
8
2
1
0
2076/2077
2
5 to 20
20 to 40
12
16
0
2077/2078
year
<5
Source: Hetauda Hospital
1
9
40 to 60
2078/2079
>60
73
Fig.: Trend of distribution of Pneumonia cases age wise in Hetauda Hospital
Month wise distribution of cases in last 3 years
100
91
Number of Pneumonia Cases
90
80
79
70
60
50
40
40
30
20
50
48
39
33
33
27
35
23
17
10
0
Source: Hetauda Hospital Fig.: Month wise distribution of Pneumonia cases in Hetauda Hospital
74
Comparison of Pneumonia on under 5 children at different levels
30000
Total number of under 5 pneumonia
cases
25491
25000
19351
20000
15728
15000
11958
10000
5000
139
0
81
Hetauda Hospital
Bagmati Province
Year 2076/77
National
Year 2077/78
Fig.: Comparison of Pneumonia on under 5 children at different levels
75
Fig.: Child deaths from Pneumonia by risk factors, Nepal 2019
76
Fig.: Deaths from Pneumonia in elderly people by risk factors, Nepal 2019
77
5 Year Action Plan on Uplifting The Mental Health
Status of People of Bidur Municipality
78
Situation Analysis
• Mental health policy exists in Nepal, having been adopted in 1997, but
implementation of the policy framework has yet to begin.
• In common with other LMICs, the budget allocated for mental health is
minimal.
• Mental health services are concentrated in the big cities, with 0.22
psychiatrists and 0.06 psychologists per 100,000 population.
(Luitel et al, 2015)
79
Source: Rai Y, Gurung D, Gautam K. Insight and challenges: mental health services in Nepal.
BJPsych Int. 2021 May;18(2):E5.
80
Proportion of Major Psychiatric Illness in Bidur Municipality
0,34%
Substance use, including
alcohol use disorder
1,02%
Bipolar affective disorder
0,39%
0,11%
0,61%
3,99%
Dementia
Depressive disorders
Anxiety disorders
Psychotic disorder, including
schizophrenia
Fig: Proportion of Major Psychiatric Illness in Bidur Municipality
Source: HMIS of Trishuli Hospital last 1.5 years
81
Comparison of Indicators at different levels from Shrawan 2078 to Ashad 2079
5,00%
4,50%
4,40%
4,30%
4,16%
4,00%
3,50%
3,00%
2,49%
2,50%
2,20%
2,00%
1,50%
1,00%
1,00%
0,66%
0,50%
0,43%
0,29%
0,10%
0,22%
0,10%
0,06%0,05%
0,00%
Prevalence of
any mental
disorder
Substance use, Bipolar affective
including alcohol
disorder
use disorder
Dementia
Bidur Municipality
Source: HMIS of Trishuli Hospital last 1.5 years
Depressive
disorders
Anxiety disorders
Psychotic
disorder,
including
schizophrenia
National
Fig.: Comparison of Indicators at different levels from Shrawan 2078 to Ashad822079
Proportion of Major Psychiatric Illness in Bidur Municipality in last 1.5 Years
4,50%
4,00%
3,50%
3,00%
2,50%
2,00%
1,50%
1,00%
0,50%
0,00%
Prevalence of any Substance use,
mental disorder including alcohol
use disorder
Shrawan 2078 to Poush 2078
Source: HMIS of Trishuli Hospital last 1.5 years
Bipolar affective
disorder
Dementia
Magh 2078 to Asar 2078
Depressive
disorders
Anxiety disorders
Shrawan 2079 to Poush 2079
Fig.: Proportion of Major Psychiatric Illness in Bidur Municipality in last 1.5 Years83
Suicide Rate
Suicide mortality per 100000 population
35,0
30,3
30,0
25,0
27,8
24,32
23,1
23,23
21,36
20,0
15,0
10,0
5,0
0,0
Nuwakot District
Nepal
2076/2077
23,1
21,36
2077/2078
30,3
24,32
Nuwakot District
Source: District Police Office, Nuwakot
2078/2079
27,8
23,23
Nepal
Fig.: Trends of Suicide rate in Bidur Municipality
84
Number of cases
Age wise distributions of Suicide Attempts in Bidur Municipality
10 TO 20
20 TO 30
30 TO 4O
50 TO 60
> 6O
Age Group
Fig.: Age wise distributions of Suicide Attempts in Bidur Municipality
Source: SUICIDE CASE MANAGE IN TRISHULI HOSPITAL : N=
85
Rationale of selection of topic
• Global burning issue of health
• Lack of enough programs related to mental health from Municipality and
Hospital level
RATIONA
LE
• Lack of standardized mental health training for PHC workers.
• The prevalence of any mental disorder in Bidur municipality is much less than
that at national level may be due to lack of enough data record keeping
• The suicide mortality rate in Bidur municipality is higher than national suicidal
mortality rate.
86
Target
Reduction of
prevalence of mental
health disorders by
10% each year
Reduction of
prevalence of suicide
rate by 10% each year
Increase in out reach
clinic services ( 5
times per year)
Increase of mental
health coverage by
50%
Increase the treatment
coverage by 10%
87
Stakeholder Analysis for mental health program
High influence


High importance 

Municipality office
Health Office
Health Institutions
Political Leaders
 FCHVs
Low importance  Local Media
 Academic Institutions
Low influence
 Private Health
Institutions
 Affected patients
 Other municipality
offices
 Other stakeholders
88
Problem
ANALYSIS
89
High burden of deteriorating Mental Health
Causes
Health Facility related
Shortage of funding.
.
No psychiatric services
up to secondary level
health centre.
Human resource related
Inadequate training
Inadequate Manpower
Urban-centred with
0.22 psychiatrists and
0.06 psychologists per
1 lakh population
Patient and community related
Abuse and ill-mental Health



Widespread discrimination and
stigma against mental health

No separate inpatient
care for children with
mental illness
Delay health care
seeking behavior
Non adherence to
treatment.
Domestic violence
Sexual abuse, esp.
women
Child abuse

Mentally ill are
avoided, coerced and
segregated.
Abused even during the
course of treatment
.
Cultural
stereotypes: Coercion
and the Man-up attitude

Alternate health
seeking behaviour
‘man-up’ ‘don’t act childish’
‘such is the life’ ‘just face it’ etc.
are the frequent form of
90
On Patient
-
-
On Family
decreased QoL
Vulnerability to abuse,
low quality care,
human right violations
Lower productivity
and poverty,
educational difficulty
-
decreased economic
output
Stress and burden
emotional upheaval
limitations
On society
-
-
Effects
-
Increased burden on
national economy and
impeding international
public health efforts.
Homelessness,
unemployment, poverty
Mortality, under
treatment
Disability costs, physical
health problems
High burden of deteriorating Mental Health
91
92
Goals
 To reduce distress, disability and premature mortality associated with mental
health problems across age group.
 To enhance understanding of mental health.
 To develop, introduce and monitor a range of mental health initiatives to
support individuals and families through preventive interventions, primary and
secondary service provision, referral and rehabilitation.
93
Objectives
 To provide universal access to mental health care.
 To establish a comprehensive approach which involves individuals from
mentally healthy population, those at risk, those with minor psychiatric
morbidity and those with severe mental illnesses.
 To develop a coordinated and easily accessible system of mental health care,
support, treatment, counselling and follow-up of mental illness and related
disorders at the primary health care level.
 To enhance the understanding of mental health in the community and
promote de-stigmatization and desegregation.
94
Objectives
 To reduce the risk and incidence of suicide and attempted suicide.
 To ensure appropriate medical, vocational, social and psychological
rehabilitation of the affected person.
 To deliver high quality and professional mental health care at a standard set
by MoHP.
 To develop basic counselling skills among health care providers and
community health volunteers in primary and secondary care including
psychotherapy and behavioral therapy.
 To ensure that the rights of the mentally ill must be valued, protected and
promoted.
95
Strategies
96
• Increase availability of a range of community based rehabilitation services
Universal
Access
to
Mental Health
Services
Effective
Governance
and
Accountability
for Mental
Health
• Implement programs for screening, early identification and treatment of mental health
problems.
• Build effective leadership and management systems.
• Develop relevant policies, programme, laws and regulations within relevant sectors in line
with mental health policy.
• Appropriate plans with adequate budgetary provision across sectors to allow
implementation of evidence based mental health plans and actions.
• Develop and sustain technical capacity and suitable mechanisms at municipal level to
plan, monitor and evaluate implementation of mental health policies, laws and programs.
97
Addressing
suicide and
suicidal behavior
Strengthen
Municipal strategy
oversight and
implementation
• Increase competency of healthcare providers and front liners in handling suicidal behavior
• Provide modules and Standard Operating Procedures in managing suicide and suicidal
behavior
• Improve access to appropriate care pathway for individuals with suicidal crisis.
• Implementation of mental health program through formal planning and processing at
municipality level.
• Collaboration at the municipal level to effectively deliver the NMHS
• Establish appropriate mechanism across sectors to plan, implement, and monitor interventions
that will help in implementation of national strategy.
Strengthen
preventive
intervention
and
service
delivery
resources
and
infrastructure.
• Ensure a continued supply of trained mental health workers is available to provide
services in all level
• Increase collaboration with relevant organizations and departments to ensure that staff
have necessary skills to deliver required services including referral
• Develop infrastructure to support care and treatment at the level of municipality
98
GOAL
LOGICAL
PURPOSE
FRAMEWORK
OUTPUT
ANALYSIS
ACTIVITIES
99
Narrative Summary
Objective/ Variable indicators
Means of verification
Assumption
To reduce distress,
Incidence rate
Annual report of Bidur
Co-ordination among all tiers
disability, exclusion
Prevalence rate
Muncipality
of government.
morbidity and premature
Suicide Mortality Rate
HMIS
GOAL
mortality associated with
Nepal Police annual
mental health problems
report
across age group.
PURPOSE
The illnesses get
Estimated Case Recognition Rate
Annual report of Bidur
Political support, National
recognized, reported and
Proportion of patients receiving psycho-
Muncipality
Policy support,
appropriately addressed at counseling
the primary level through
Proportion of patients receiving
promotive, preventive,
pharmacotherapy
curative and rehabilitative Hospitalization/Institutionalization Rate
Commitment of stakeholders
HMIS
100
Narrative Summary
Objective/ Variable indicators
OUTCOMES
Universal access to mental Number of human resources on each ward
health services
providing diagnostic and counseling
services
Number of health facilities providing
screening and counseling services
Effective governance and
accountability for mental
health and strengthened
municipal strategy
implementation
Dynamic preventive
intervention and service
delivery resources and
infrastructure.
Number of diagnosed cases
Number of administrative personnel with
relevant public mental health trainings
Means of verification
Assumption
Municipality health
Sufficient budget and
records
logistics are allocated to
Record register of health support the program.
facilities
Collaborated programs
continue to function
Health records
Dedication of available staffs
Annual Reports
Number of health centers (Urban health
centers, basic health service centers, health
posts) providing screening and counseling
services.
Number of health personnel trained with
screening and counseling skills
Municipality Health
Records
Sufficient infrastructure and
financing.
Personnel trained with
preventive measures.
101
Narrative Summary
Objective/ Variable indicators
Means of verification
Assumption
OUTCOMES
Promotion of mental
health and provide life
skills education
KAP of key population on importance of
mental health and coping skills
KAP surveys
The community is receptive
to Behavior Change
Communication
interventions.
Frequency of awareness campaigns
conducted.
Effective addressing of
suicide and suicidal
behavior
Strengthened mental
health preparedness and
services during
emergencies, crisis and
disaster.
Frequency of TV/Radio programs
Number of Suicide helplines
Number of OCMC centers to address
deliberate self-harm
Number of health centers facilitated with
tele-medicine/psychiatry
Number of active helplines following the
patients continuously
Frequency of training programs for
disaster/crisis preparedness for health
personnel
Hospital/Health centers
records
Helplines
Organizational records
Health/Hospital records
Availability of TV/Radio
even in the remote parts.
Availability of skilled
counselors and health
personnel
Sufficient resources allotted
during the crisis
The issue is still addressed,
not inundated by other
problems
102
S.N. Activities (Plan of action)
1
2
3
Smooth commencement and expansion of projects dedicated beforehand to mental health like
“MHgap”
Development of helpline numbers for calls and SMS services
Promoting mental health by conducting yoga, meditation programs
4
Commencement of incentive plans for patient doing regular follow up
5
6
Infographics on public vehicles and main public places
Provision of standard modules and procedures for suicide prevention and counselling
7
Development of suicide prevention centers and suicide hotline numbers for people in suicide
crisis
Establishing health institutions and rehabilitative centres dedicated to psychiatric problems
8
9
10
11
12
13
14
15
PHASE I
PHASE II PHASE III
FY 2080/81 FY 2081/82 FY 2082/83 FY
FY
2083/84 2084/85
Development of municipal data surveillance system software for monitoring mental health
during disaster
Establishing PHC centers at each ward with screening facilities for mental illnesses
Targeted training activities regarding psychiatric illnesses to health personnel at the primary care
level
Awareness and orientation program on Mental health screening, diagnosis, treatment modalities
and rehabilitation
Awareness program against the prevailing social stigmas and discrimination on mental health and
towards mentally ill patients.
Development of curriculum regarding mental health program at the school level.
16
Publication and broadcasting of information on mental health on radio, TV, newspaper, social
media
Celebration of World Mental Health day and mental health awareness week
17
18
Supervision and monitoring on mental health program
Publication of annual report on mental health program
103
Plan of Action
and Budget
104
S.No. Activities
Total budget (5 years)
A.
Universal access to mental health services
1.
Health institutions availability up to primary level 2 lakh
with mental health service and rehabilitation
facilities
Trainings to health professionals for early
10 lakh
screening of mental health problem
2.
3.
4.
Development of instant helpline number to health 1 Lakh
institutions
Incentives on regular follow up to the health
1 lakh
institutions
105
S.No.
Activities
Total budget (5 years)
B.
Promotion of mental health and provision of
life skills education
17 lakh
C.
Strengthen municipal strategy oversight and
implementation
Addressing suicide and suicidal behavior
56 Thousand
Strengthen mental health preparedness and
services for emergencies, crisis and disaster
Monitoring and evaluation
10 lakh
Total( including miscellaneous)
50.56 Lakh
D.
E.
F.
5 Lakh
4 Lakh
106
Year wise Budget Allocation
14,00
12,64
Budget in Lakh
12,00
10,62
10,00
10,11
10,36
2081/208
2
10,11
2082/208
3
10,36
9,35
8,00
6,00
4,00
2,00
0,00
2079/208
0
Budget in Lakh
12,64
2080/208
1
10,62
2083/208
4
9,35
107
Financing
With a total budget of around 50.56 lakhs, we have made a 5 year plan on
Mental health program with sources as follows:
1.Unconditional grant from health section of municipality- 4 lakh each year
for 5 years
2.Training sessions, awareness programs, yoga and meditation programs
and via the help of NGOs and INGOs such as TPO (Transcultural
Psychosocial organization), Koshish Nepal -4 lakh each year for 5 years
3.Budget provided by the province after the submission of 5 year plan
proposal- 10 lakh 56 thousand
108
109
IMPACT/TARGET
INDICATORS
OUTPUT
PROCESS
o Number of health
centres facilitated with
telemedicine
/psychiatry.
o Number of human resources
on each ward providing
diagnostic and counseling
services.
o Number of health facilities
providing screening and
counseling services.
o Number of psychiatry
patient registered at
municipality.
o Prevalence of any
mental disorder and
substance abuse
o Suicide mortality
rate
110
Supervising Team
consists of :
Mayor of the
municipality
Health coordinator of
Bidur municipality
Hospital Incharge of
Trishuli Hospital
Health post incharges
Health related
experts(Psychiatrist)
Civil citizen
111
Learning Reflections
We learnt
• about current health system management of Nepal.
• our responsibility as a health care provider in peripheral health institutions.
• to identify & prioritize problems, find solutions & provide recommendations.
• the importance of peripheral health institutions & workers in promoting
national health.
• skills for critical analysis, five-year plan & epidemiological study.
• about various initiatives like outreach program, OCMC.
• to interact with stakeholders and local authorities.
• the importance of group dynamics, time management and communication.
112
• To reconsider the OPD Registration fee of
the hospital
Recommendations
to Amppipal
Hospital
• To act for the fulfillment of the vacant posts
under government services
• To extend superspeciality services in
various departments
• To manage an information desk for the
patients about the services available
• To pressurize the concerned authority to
improve the accessibility to the hospital
113
• More human resource could be hired in the
Recommendations
to Palungtar
Municipality
health section, on contract basis if
necessary.
• The roles and responsibilities of peripheral
health institutions should be clearly defined.
114
• Greater attention to maintaining health
Recommendations
to Trishuli
Hospital
records
• More human resource could be hired in the
health section, on contract basis if
necessary.
• Opportunities for collaboration should be
explored
115
• Digital
Recommendations
to Hetauda
Hospital
record
keeping
and
proper
reporting system is essential
• Conducting awareness program related to
pneumonia
by
involving
multiple
stakeholders.
• The record book needs to be revised to
ensure the adequacy of data and it should
be managed accordingly.
116
• Practice sessions, especially for budgeting
Recommendations
to Department of
Community
Medicine
• Incorporation of Minimum Service Standards
in the orientation sessions
• In addition to physical supervision,
designated regular 2-3 online monitoring and
supervision meetings can help solve
pertinent issues experienced in the field
• Feasibility on accommodation should be
managed better
117
Photo Gallery
118
With respected Dr. Pawan Agrawal of amppipal Hospital
119
With our respected faculties at Palungtar Municipality during first
supervision
120
Fig: Birthing Center at Palungtar
Municipality
Fig: Amppipal Health Post
121
Trishuli Hospital, Nuwakot
122
Presentation on 5 Year On Uplifting Health of Bidur Municipality
123
After Presentation on 5 Year On Uplifting Health of Bidur Municipality
124
After Presentation on Epidemiological Study of Pneumonia
At Hetauda Hospital
125
Letters of Appreciations
126
Thank You!!
127