attachment ii to no. 76-3 report of the situation analysis...
TRANSCRIPT
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Attachment II to .alaria Control PAR Serial No. 76-3
Report of the Situation Analysis
Tearr, - 1976 of the
Nepal Malaria Eradication Organization
Jan-..ary - febru.:u-y 1976
A. ~. n 86:('01'011C(I C
'0 ont61"l .~OOUl 1658 NS
Kathmandu, Nepal
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TABLE OF CONTENTS
I. Introduction
:u. Current Status of the NMEO Program
IIT.
IV.
v.
A.
D.
C.
D.
E.
F.
Gcmeral
Erldemiolob'Y
Man.qgeri
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ANNEX
I
II
III
IV
'7
VI
VII
VIII
IX
x
XII
Xln
V-'T "' .L.
~,V
XVI
XVII
XVIII
LX
GRAPH
1
2
3
TABLE OF ANt'lEXES
Organizational Chart .... ... Positive Malaria Cases ~ Far Western Region
Positive Malaria Cas~s - Western Regi~
Positive M-ilaria Cases - Central Region .... Positive l1alaria Cases - Eastern Region .0. ~dical Treatment Time Lag
Affected Villages
r~borat~ry Perform~.ce 0
ii
iii
iv
v
vi
vii
v1i1
SUJll.T'Iar'Y" of Administratioo - Western Regien 1.x
Summary of Adminintration - Far Western Regirm x:11
Summary of Adm1nistr.:ttion - Central and Eastern xv Region
Spraying Operations 1975
Fopulatiol1 protected by sprayillg 1975
Focal spraying 1974 and 1975 .... Integrated Districts MOnthly Surveillance
Fbdical T "catment and Ca:58 Investigation Time lag in Integrated Districts
L1.boratnrr l'erf~ce - Bara District
L1.b~r~to~1 Perf~ce - Parsa District
C03t Estimates Spraying Operations in the Zastern Hills
..
..
....
...
xix
Jed
xxiii
xxiv
xxv
xxvii
Kaski District Surveillance monthly pcsiti vus J'...cv11i
Rqra District ~rveillance monthly p~itives xxix
farHa Di;trict Surveillance monthly positives xxx
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I. Introdtlctie~
Nepal Malarin Eradication Organizati~1
Report ~f the Situation Analysis - 1976
A. !PI) Nepal M3.1aria E!oadicati~ BeaN (MIill) :in H. l.3 __ -ih mee-i:1ng held
en 7 ec-wber 1975 u.eterm:med 'ihat a .it.ation Analy-.is of the Nepal
Ma1Tr:i .. a l::radicatien ~rganizc:rUon (NMEJ) be held during thQ i'Sriec;,
~rul'.w.ary to rnid-Febrt1a.rr, 197". The Siwation hlal,.-siB was la"ber
scheduled by the Chairman, HEB '\0 ae held dmng "\.he ~ried frll!ffi
Jcmuary 26 - Februarr 17, 1976. ThQ MEB reqtleuted the assisi,an6:c
of the World Henl~h erganization (WHO) and "\'he U~S. Aggn~T for
International Development (A~) to p~ticipate wi\h HMG officerJ
in this Sltu~tion Analysis. These assisting agen~ies agreed with the
request and a8signed personnel. 'l'he Chief Officer of the NMEO was t",
S.:.I~C f.S Ch~irman for the 1976 S:ltuation Analysis.
B. The Tenns of RefoJ'ence provided for this Situation Analysis are as
follow"8 :
1. T,., evaluate the present ei->idemi{tJ.Ggical s;t tua tililil concerning
malaria In the ceuntry.
2. To 7,ry to find "ut re3.S'-"Tl." f!3I' difficultieg in Irv;ter and timely
8X&'Y'..ltion ~f scheduled activities in MEJi.
3. To rec~mmend ways and mean~ to rectify the;e difficulties.
~. T" study ,-:'.uu,civif'c r8g:lrding the pr"rer type of activities in
the eastern hills now under .full NMEO activities.
5. To b ring ad any pt1iat/pdn1.s which mRy have faJ"-reagfrl..ngr~
em the ov'croll efficiency of the program,.
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The MEB, recognizing the importance of proper managerial
pract1 ,~e5 within the NNEO, requested that more emphasis be placed
during this analysis en thiJ aspect beth at NIOO National Headlluartera
3nd in Regional field areas.
00 The mElllberR of the Situation AnalY'lis - 197. are ~ followsl
l.. f.T K.H. DiXit, Chief Officer, NMEO
2.. Dr Y.N. Sharma" Halaria Consultant, NMEO
3. Dr H .. tJ. Uprety, Ministry of Health, HMG
~. Dr G.l1. Sakya, Epidemiologist, N?1m
5. Dr F.F. Beales, l,tlO/Thailand
6. Mr A. Davidson, USAID/Washington
7. Mr L. '!'. Gowper, USAIDtdashington
8. Dr A.Q. B. Rnhman, HHO - Nepal
9. Dr A. V. Kondras:lin, WHO - Nepal
10. Mr S. Tarkojosopurc, 'I/HO - Nepal
The memb(~!'0 of the Situ3.tion Analysis were divided into three
work teams to u'lrr"y out the T~;rm.'3 of Reference in the field areaB ..
1. I
(RBr;iC)ll'~l UfficUI3 jn EirgtUlj and Biratnagar)
2. Te3Jll ~.,.
.J.. ... Dr H.N. Jpr\;~y, Dr G.l1. Snk;n, YlI' A. Davidson
3. Team III Dr K .. ,\. frixlt, IJr; ,.'1. lCenciraah:1n, Mr L.T. Owper
(HDg::i..On.'ll Ofnc(' in !JUpc1.1G
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Page 3.
D. The wcrk activities af the Situatton Analysis Teams in additim t.
review and analysis .f the four Regional ~fices and related
~lected District and Unit Offices during the perled 28 January
9 February als" included one day of review jn the Matern Hillr
on February 12 studying the problem of' malaria incidence in hill
areas where spraying has buen c:lrrled out for a nur. 7>er of years ..
Hill aJ'!?as visiter were Okhaldhlmga, Rumjatar, Khotang and Bhojpur.
The Tea;,l visi tin~! t.he inter,rClt cd di stricts was a} so requested to
pre:::ent its vioH on the rresent h'vd of development of these areas
in regards to malaria controL The Tea.m presented its report to the
Chairman, Nepal Nalaria r..radic c tion Board on February 17 J 1976.
II. Current Status of the NMN rrogr~~
A. Gener.'l.l
The Ikpal flJ3.1ario. Eradication Org:ll.ization (NMEO) is a natilal.
health activity, c~vering Lhe assigned nalaria areas of the country.
The Organization is under t.l18 3uth01'i ty of the Nepal Malaria
Eradlcatior. Board (NEB). The N,~ tior:al Headquarters of the NMEO is
located in Kathmandu and h:iCl under its juri:3dictior.. fo'ln'" Regiooal
Officeo (Bir~tn~g~r, Birgunj, Bhair~awa, Nepalganj), 3- District
Offices, 156 U'1it or:'ic88 rtnd fJ27 Localities. The Organizat:!.on
hilS l.pproximatcly 3 :;00 employees with special temporary personnel
hi!'ed dUj'in~ spra)' cycles.
The prcs~~nt lJopulati on sttltus ~f the pro~ in 1975 ia as
1'0110'.-1s:
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Fage h.
The present populat~.on stptus of the program in 1975 is as
follows:
Activities
Sprllyi.i1g and Surveillance
Surveil~ance
T~tal
Population
2 8)0 186
2 329 124
5 15, 31ft
TherE is also 1.5 million ~opulatian in integr~ted districts
:in the malarious areas for which NHEO is responsible for the
provisien ,=,1' specific imported items.. The total po}rulatian :in
Ncp..1.1 ::8ceiving malaria ServiC(~3 :1.s apprC'vimately }067 nrlllicno
A Tahle of' Orp,anizaticn 1s 9.ttr1.ched (Ann.,x )
During the period 19?2-71[ a steady incI'lJ9.se in malaria incidence
has been obSCrVl-'L .:.n Nop:1l. In 1975 it appeared that a le'W81ing of
the incidnncc occurred in tot'll munbers, but the reasons for this
lev(~linf! must be reviewed caref'llly as large areas hRa :incomplete
Rurveill.:mce. Previous E.:ituiltion analysis/evaluation reports 1974
and 1975 on this rise, together wi th the recommendations of these
r!!ports havt~ b(~en considerl~d by tltl: t;r-,nal Malaria Eradication Boord
ann a nei" !'itr::.tq:y has been d(;\T~lored for the .cf-~duction of malaria
tn suitabl; control lev816. The basi~ technical objectives of the
plannc:d progr:.un is to lower the ineidL:1lc;e of malaria tv apprax:1ma~ly
,.r-J 0aS(-:S p.:r million popY.lati~ O'IH the next five years. Je1nt ~grcc:mcnt:3 bc.;tween HMO and AID, \'1110 and UNDl" will enable HMG to receive
required progr
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malaria l F1an af Oper-ati ons) 1s nOl. re!!.d~t far HID far::::ll appr.vnl.
The fi.rst majar ('('(leI'S fer drup.s, sprayers and insecticides have
been placed and are beginning to be mabilized. Considerable
attention is ueine given in the Praject FormuJn tion l"lan to. improve
the mallngerial :md administr:ltive .1D[.:ctS af the pragram in ternlS
of full ut iliza ti on of manpower, ord.::...r ly an d timely receipt of
supplies and the :tvaibbility of adeqUOlte funds at tho time ref!,uired.
In ordGI' far V,r~ progr.:lm to mav\;) forward on n planned basis farmal
HMG nppravnl of thu Project Farmulntion Plan is required.
ThE: jlroblems fac:l1l1!, the NMSO C.1Il be categorized into. three
main areas - TfCchn1cal, Uperntional
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of L'1 Li:t,l'Glting the malaria orp;anization intu the bashl health
services in siX Districts of Nepal are outl.ine d in Part II-5
of this report.
The .... e are no detailed d8scriptioos of Nepal in this .r:eport~
in terms of gene r;tl geography" background inforna tion in rebarcis
to ec.)nomic, poll tical or socicll structure" ani other generalized
infornation. These pointe, arc ad8qua tsly covered in previous
reports of Situation Analysis or EvulBtion T63Jl1B in p9.st years
or b)r nthcr reports readily aV!1ila blc in Nepal. There is also
no attempt in this report to n.ccl)unt the historical develor:ment
or operations of the NMEO as this descript,ian is well documented
in tht HMG Situatic~ Analysi~ Rpports of 1974 and 1975.
B~. Epidemiology
., J... The epidemiolopical St1tUS of malaria in 1975 can be :teilealed
from the folluwin~ t~hle. The epidemiolo~cal data of 1'73
and 1~'(4 artj als 0 gi.. v']n in thE: t,"ble in order to see 'the
current status in its p~rspectiv8:
SrI> Y B A R S No. ItGm 1973 1974 197~
1. Tot11 hpulation 12 046 4.10 12 300 000 12 550 ~ 2. Pop'.1l3.tion Covered 6 3u? 9211 !) ('84 075** 5 15~ O~
by NHE(? 3. l'opul;: tlon in 342 007 1 )174 ~54 1 531 615
Integrntul ~J'l~a.s It. Popula.t1on in Att..'\ck + 1 "73 h42 2 202 5~5 2 787 032
R~vert(;d Attack areas 5. Popu11t:l.on in Ccnsoli- 5 375 31C 2 881 551 2 372 0:!4
d
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'Sr" 'No.
ft.
8.
9.
10.
Item
No. of Slides Cul10cted in Integrated artJ.J.s
No. of Positives in Intep:rat~.'d
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Sr. No.
A. Ba.rll B. Parsa C. Ra.utnhnt Do Siraha E. Saptari F. Y.aski
22. Total Positi ves A. N.M.E.O arpas B. Intogr~t~~ areas
23. A.P.I. A. N. M. E. O. area B. Integrated areas
YEll 1973
8479 R479
1.33 1.33
Page 8.
R S
1974 1975
1.~7 0.25 * 2.09 2.86 * 0.9 0.19 * 0.09 0.003* 0.08 0.03 * 0.7 0.46
14 647 13.507
1140
1.6 2 06 0.49
11 856 10 942
914
0.73 1.59 0.52
---_.----_. __ .- - ... -- ._-------------* *
** Population excludin~ integration areas
*'H
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2 .~egionwise Epidemiological Data
2.1 Far Western Regi on
The Annual Parasite Incidence in 1975 was 1.1 per thousand
in 1975 compare~ with 0.94 in 1974. The slide collection
through Mass Blood SurvE1YS has remained at the same level
as in 1974, but the number of positi yes cletected has
decreased by 4.6%. ~. ~ is the predominant species
constituting more than 9t% of the total positives in the
regian. The proportion of untraced rases has a~st
uoubled (~.5% in 1975 compared with 8.3% in 1974) due to
the movement of population workinc for the Road Project.
The number of relapse cases recorded is low (Annex II).
~.2 Weotem Region
The Annual Blood Examination Rate has increased every year
for the last three years 16.82, 19.3 and 20.99 in 1973,
1974 and 1975 respectively, while the API has decreased
(Annex III). The redllction of the case incidence has
occurred m~inl y in the Kapilvastu District where all
anti-malaria measures were strengthened and larviciding
and a weekly survei11.:mce mechanism were implemented in
FJaluhawa Unit in 1~)75. The caSes of ~.falcj.parum
constituted 5.7% of the total, although the n.mbor of
imported cases from abroad has slightly increaied.
2.3 Cerriral Region
The API in 1975 in this Region has remained almost at the
same level as in 19'(. (0.,8 and 1.37 rerpective1y). The
propori.ion of Mas. Blood Sur\-ey slides io rather high (33.7%)
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though the number of p08itives detected by MIS is only
8.1% of the total positives. The nwnbol of .!:.falciparum
cases has dacreased whilst the importation of cases from
abrt.1Ud has remajned a~ th~: same level. The number of
. ~ relapsBs':in the region continuf.'s to bE: rather h
high (14.9%) due to the inadequate treatment especially
in M9.kwanpur ctistri ct (Annex IV).
2.4 Eastern Regi~
The API has slightly increased from 1.77 in 1974 to
1. 79 in 1975. The imported ~.falciparum cases have come
from I\ssam awl other states of Inni~, where strains of
res istnnt E. faldlXlrum are prevalent.. T1.e number of
~. ~ relapses recorded have also increased due to the
Game reasons as mentioned above (Annex V).
3. Radical Treatment TilID L:..g
The time la~ uetween case detection and treatment in 1975
continues to be the srune as in previous years. Chly 39.1% of
the totnl cases were tr8ated within one week. The percentage
of patients treated by Halaria Field Workers (MFW) is very high,
42.8% in the Western Region Md 28.4% in the Easten. Region
(Annex VI) ..
4. Malaria Foci in NHFX") HerioTls
The n1Jl7lbf'r of affectrJd villMes (43.5% of total villages) is
hif,h in the 81stern Re~ion but the number of positive villages
with only indip;enous cases (24.1% of total villages) is not so
high when compl1l'ed wi th thr~ Far Western Region (96.7% of total
villages). It appears that the high number of affected
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Page lL
\,9.J: villages in the Eastern Region is due to imported cases
(Annex VII).
The epidemiological si tualiion in the Frtr Western Region is
characterized by ~ncreasinr, numbers of foci every year with
lecal transmisRion. On the contrary, Westr~:rn and Central
Regions have decreasinr numbers of foci with local transmission
and increasinr numbers of imported cases. Tne number of COlTDllon
vi Hages with indigenous casps i!1 1973-74 and 1974-75 have
increa~ed in all Hep,ions especially in the Central Reeion.
It means that antimlaria measures taken are not adequate and
timely.
5. Lab0ratory Performance
During 1975 the output of laboratory technicians was not up to
eXfK:ctations in all Regions. This was mainly due to the 10ft.
days cc.'~mcctcd with leave, As a result, ~nding slides wer.,
rather high especially in the Far Western and vlestern Region)
('fJ1eX VIII).
6. F.Iltomology
In view ()f the chnnr,inr- cpirlemir.lor;icai situation whereby
high numbers of cases have been reported from the plain Ter~l,
the entom()loF~j c-11 pror,ram has been concent.rating its efforts
on these casel>, as recommended by the provious Situation Analysis
Teo.m. Work is in prop,r(:ss in the forested Terni urea to study
the role of i1..annularis in the r..ransnlission of IT.alaria. So far
there is no evidence thcJ.t this 3pecies :i..s a vector in the
i'onsU:!c Terai.
!.annularis, 'Which has been prcved entomologically as n vector
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Page l! ..
in the plain t~rai Rreao of Lumbini Anchal, is highly resistant
to nIJ:' and Dieldrin. Therefore: change of insecticides to
malathion has been recommC'nded. Since July 1975, the entomological
wcrk has been decentralized by provi0ing entomological teams
t') each Region whilst the National Headquarters Entomological
Section provideo technical guidance.
C. Managerial Problems at National Headquarters and Regional Levels
The Malaria Eradication Board at its 134th Board Meeting recognized
the impo.riaT'lc of the Hanagerial asp8~ts of t}le NMEO campaign and
has accordint:ly l'e4.ucsted t.hat in Uis rearls Situation Analysis
carriod out from January r:6 - Febru.'lry 17, emphasis be placed on
management. In pursuing tha~ objective, at least one memb~r of each
of the field teams was given primary responsibility for lookw.g into
managemor.t problelTlB and procodures in those Regions he was to visit.
To aSSUl'e consistency of approach and relevancy of supporting data
it was decided "'",0 examine the areas of Reporting, T.'iscal Operations,
Supply, Transport and Personnel Management, utilizing uniform
types of data and quostionnaires. However, t.hese basic points
could be expander] or supplemented to cover any aspect of management
that loTas -::onsirlered rf'levant to the prol3ram.
ThE: combinGd teams visited four regions, 17 districts ami
8 unitH in their respective areas. The Eastern Hills were not
covered for administrative purpu~0S. Since the field aspects of
th.:: prog:t:llIl1 'Hcre entered inunediately after arrival, Headquarters
operations were not anblyzed in depth and in most cases only those
heaciqunrter~ operu.Gions that immecliatel,f affect the fie~d are
referred to.
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Page 13.
In general, the situati0n analysis teams found the basic
NMEO organization intact and viable. Its major organizational
problems result from some confusion as to the long range
management effects of integration (treated in anot':er section
C'f this rep0.i.-t) and the present status of the new regionalization
concept which is now beine implemented. In the latter case the
team found that there is no complete clarity an the roles of
the Regional 'ffices ill relt.tion to the District Offices and
tho relationship of beth these organizational units to
Headquarters. Is the Regional Ofnce to be primarily a
coorrlinat:inf~ unit 01' a supervising tmti? ;..t supervisory,
what o~erations does it supervise? Is it (the Regional Office)
in the line of commanrl between District and Headquarters?
These and other orr,anizational questions need to be carefully
considered, orr;anized, and documented so that ench of the
administrati va units involved has a clear organization frame
for its program responsibilities. When decisions have been
made ccncerning thest::: authorities, it is essential that the
fcnctions, responsibilities and relationships be carefully
de"ia:'lcd in wri"iten in~tNction6 ,aild .. regulations whioh should
beo'JIl8 ~art of a rlanual of iYrganiza"iion. The Mmual should
be conslianUy updat.c:i to rcfle:c\. current. administrative decisions
and used as a basic reference and instr~ction~ document.
The present Manual has not been revised since 1963.
The other major threat to management continuity of the
NMEO is the disproportionately large turn over of key
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?age 110
personnel at top and middle management levels. In the past,
two years approximately 99 senior, and middle level employees
have been transferr~r resigned posi tioni. 'J.'his is reflected
in the unc~rtainty in exorcisins managem~mt responsibili t.ies t.Jy
some of the new incumbents of Senior Officer positions. The
change~ at the top have in turn affected the 1 owe l' positions
where promotions and transfers have resulted in new employees
l.m~lertaking duties for which they are not trained and with which
they are not familiar.
The short range and current management problems of NMEO
continue to be in these areas of manap:emcmt noted in previous
reports. In some cases such as transportation, the situation
has further doteriorated and the arrival of new vehicles will
no~ ameliorate the worst situations. Training, supplr
manaeemCTl"T:., ,mCe and fiscal problems and personnel manaeement
eontlnue "':,r) hamper tt3chnical operations, but are sUBceptible
to correctioI'. by bett'~r m.:maEement. These problema are treated
in some detail ~n thiH report. Where possible, manaeement
solutions ar0 propoaect. In a few cases only changes in basic
law ani! practice wil:'" ch::U-.ge tho situation o
1.. Reporting
The team r(:view of repJl'tinr time laps8s between despatch
an:} T' ccei}:>t of communi~ations showE:;d extreme variation.
Time between Rer-ional a:rices and Headquarters, depending
on distance and means ri: transportation, as studied particularly
sinCe very often key imtl'uctions were involved. The
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Page 15.
conclusions reached were that in the Central and Eastern
Rog1
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!tags 16.
0-6 ]}9.ys 7-10 Days 11 +Days Comments
Western (actual numbers)
Reg. Office 4h 40 12 From Hea.dquarters
Kapi::.vnstu 20 22 1.4
Nawalparasi IAI 33 17 10
Nawalparasi t}1 r 11 19 10 + 3 over 13 days 1 over 90 days
There 1s some quest! on as to whethur tlJ.ese time lapses al"3
justified. It would seem not. The nature of the correspondence
should dictate its method of despatch - telegraphic, air or
courier. Even in those cases where urgency is not essential, a
correspondence control both by initiating affice am receiving
offices requiring ackno~ledgellBl!t of receipt after a stated
period of dc>..ys sh()uld be installed.
Correspondeilcc should be clas~1fied according to urgency,
anc. a system established for e~ch category.
2. BUOf::et and F1sct!1 Opt-!raticms
The teams' examination of budRet and fiscal problems centered
primarily in the field. Where field ot=erations reflected
headquarters decisions, the headquarters function was
tl1alyzed. This section will examine these main fiscal
areas:
1. Budget Formll].a ti on
2~ Expendit~re Patterns and Allotment Schedules
3. TA/DA h. The Auctit Ftnx!tion
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Page 17.
2.1 Budget Formuh.tion
The budp,et procedure in Nepal theoretically require~ the
budget to be built from the bottom up, That is, the
operational and program units in the field determines
needs, formulate the local plan and have their requirements
incorporated in the larger program budget, subject of
course, to executive decision at the national level. In
practice it appears that RBgions and Districts are not
ablE: or do not make the initial budget plan. The planning
is done centrally based on Headquarters! estimates of
field needs. The budget is then sent to L~e various units
in the field for review with little time for change~
In s::nne cases the budget allocation is unrealistio, and
difficult to adjust after the fact.
It w::luld seem more in keepinf, with planning from the
bottom to the top for sufficient tiI:le and consideratiqn
to be F.i ven to field estimate in makinv. up the budget
before final approval by headquarter~. This would serve
two purposes. First, a more realistic plan ... based on
local conditior.s - would result. Secondly, the peopll3
who execute too operation would have a ser.se of participa-
tion in planning their own programs. The ~udget should
follow the plrm. of action ann the Regionf3 and Districts
know best how the plan affects their owr. areac.
2.2 Expenditure Pattern and Allotment Schedules
In beneral, the team 10ur.d that expenditures were on
schedule and that in the past year the greater proportion
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Page 18.
of the allotments were spE'nt,. In the Far West 84-97% of
the funds were spent. No problem existed in either the
Central or Eastern Region on total expenditures. In the
Western Region combined budget of the Regi~ and
Rupandehi District made it difficult to plan the rea::ective
expenditure for Region and District. Next year separate
allot;,lent8 will be issued.
Although a satisfactory annual expenditure pattern waB
shown, complaints were numerous ~oncerning the method
of quarterly allotments.
In the Central and Eastern Re~ons visited in the third
week cf the 3rd quarter, not a single region or district
had received its third quarter allotment. A few Districts
had been told that mop-ey was in t he bank but could not
be dr8wn. Similar cumplainto in the Westel'll Regia:r.
were heard. No complaintg "Iere JJi3.de in 1.'1e Far West.
The team is cC the opinion that the effect of late
allotments can fue corrected. The Headquarters fiscal
office could make the allotm:lnts inunediately after
receivin~ notification of availability of funds from
the Treasury, or if there appears to be an unuqual dela1
HJ;?adquarters could flotify the Regions and D1.stricts
by televraph that there would be some delay. Thls would
relieve the anxieties of delayed wagl3 and bill paj'Illents.
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Page 1',
A more serious administrative problem is the delay in 4th quarter
allotments so th~t it becomes impossible to spend the money before
the end of the fiscal year even though bi)ls may be outstanding.
T'lhile, "the I.ational budget E'-ystem /?'.ves little chance to correct this
situation, some consideration should be given to making larger
allotments in the third q.l arter :n'lCi reduce 4th quarter allotments.
This "'ould not change the annual budget, but would allow greater
flexibili ty in 4th quarter operations.
The team also heard compla:i nts on the ril!idi ty of the budget
expenditure pattern. It apDears th'lt even though the law all:Ns
SC:;'.8 flex:i bility in transfer of funds betl-leen codes (except for personrlel)
the headquarters fiscal office reQ,l ire th:~t even the smallest transfer
of money from one code to another in thf! field must be approved
an:! cleared (;oj he:loQ.l art r5 b:!fore permission is given. This often
take~ [lome tirle. Field units are irritated Hhen, for instance, they
lack Rs .2GO for forms and stationery, but have a surplus of funds
in another code and can do nothiI1JS about it wjthout a long delay in
"eceiving headquarters I ~rmission.
It is the oplnion of the team that within the Fiscal Laws of HID
a dela!~a tinn of authority to transfer a lim:" ted amr,lInt of Money
from ona ccx:le to another (except persormel) could re gi ven to the field,
which \'lould -':,he r. notify headquarters to make the npl')ropriate
change in tne fiscal records.
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Page 20.
The most seriouo fi.nancial problem encountered by tile tec:m Has the
problem of the wage!,; of sprayre::m and daily workers. I1alaria workers
do not receive Travel Allowance. other government emplvyees receive
mileage allQvTClnces. In some Districts competi ti ve allowance for both
other government workers and private enployees is much higher than
that of rralaria workers. This 10'Vl allowance for malaria field workers
has resulted in frequent turnover and has interrupted the effectivene3s
and continuity of the program. At his level of educaticn, the sprayrr.an
can \-lork jn factories, ar:rictlU1Jrc and road labor and receive hip-her pay.
The problem is fairly widespread pspf'cially in the Eastern Region anc
Hest('rn Rer:ion, "here recrui t!TI~nt. is h(')comi nr rli fficult .
The ~;~jEO should propose to the tropr.r HMG authorities or,
if possible, under its own authority, in~reasc wlges on 0 selective
hasis in those arenn where the present a.J..::'o\-lance for maLU'ia workers
makt; them non-competitive .'lith other work. l'hese wage differentials
,!ould be based on area cunditions ::nd need n0t be Ln a national basis.
2.3 TA/Dlt
Th
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Page 21.
.. , .'1'1
sufficient to cover claims. In at lea3t 2 Districts (NawalparaLJi
rAt and t8 1) only 77% of la.t year's budget was spent for
TA/DA. A/:,ain the solution to this problem appears to be to
r,rant the Regional and District Offict'Js more participation
in the planning of TA/DA and greater flexibility in utilizing
c..ther fun.Js as discussed above.
2..4 Audit
All audits of the internal aOOi tor appear to have been performe.1
on time durinp the past year. The external audi t for last
year han not been completed in a few ~istr.icts. The financial
audits are actually perfQrmed in NMEO Headquarters rather
than in the field. The fieln units send their accounts and
sUFportinr- papers to Headquarters. If changes are made they
are often made without conferrine wi th the originating field
unit. As a rule there is no report directly to the field
a5 the result of the audit unless there are flagrant errors
or vil)l3.tions. The J.udit docS not generally review
acmrlnistrative probl(ms but confines its work to fiscal
oper.:t ti ons
A recent trend in mrulagemen~ has been the establishment of
a "Management Audit" to review management activities and
problems anel to advise th c operating heads of offices or
field units on how to corrdct such problems. !t is not a
secret nr surprise allrlit but rather serves as an arr} tp th~
supervisor in performinp bis manap:ement responsibiUt1ef1
The function of internal manasement audit can either be
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Page ~.
combined wit.h .f'i..scal audit or be established sos a separate
unit at National Headquarters.
The NMEe could very well add the function of management audit
either to the present duties of the financial auditor who
would requi.i.'e additional training in management functi ons
or a minimum of two management specialists could be added
to the staff of the Senior Adminis t,rati ve Officer who is
soon to be appointed.
3. Supply Managemont
The team founn that in the field of ~up~ly management some of
the greatest weaknessos in the ~rorram occur.
There are a number uf aspects of supply managememt which should
be discussed and for purposes of clarity the subject will be
treated under four sub headings: Procurement, storage, inventor,y
control and B'IlPl)ly management training.
3.1 Procurement
In the National Mala ric. Eradication Program procurement is
of twc types. Importation and local purchases. Procurenl;)nt
from abroad, based on the schedule of required dates for
use ::-,f cr)mmodities, in the program and the lead time required
for shipment is usually handled by HMG anrJ the donor within a prt:.sc:,ihed schedule of months when the commodities must be ordered
agencies /to arrive on time. It :i.s o~:ecterJ that funds will
be roleasen on time hy the contributing a~encies to meet
the schedule. Local ~urchases are made from budget
lllrJtments under the apprl.1pria te heading of the NHEO
aCC01lnts. Money for local purchase and other operations
are disbursed to the Regh,ns and Districts and funds in
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Page 23.
turn are disbursed from districts to units by the District
Accountant. It was found that in some cases procurement was
made locally at much greater cost than would orderin~ from
abroad. It was done only '\o]hen urgently required or in the
case of spare parts. To avoid costly local procurements, it
should be emphasized in the program that all needs for
imported conunodities be planned in advance and made part of
the regular WHO Or UNDP procurement requirement. Perhaps
one reason that local procurement is r8sorted to in
emergencies is the long time lag in some instances for
procuring: supplies from N. Hq.. It must be stated here that
in general, the team heard few complaints of long time lags"
but the records show that the delays in the Far West Region
frcm Regiun to District ranged up to cO days. The fact that the Regional concept i~ still not fully implemented also
a'Jcounts for delay. The District and .tho Region often have
trouble in distinguishing where distribution of commodities
is to come from - the Repion or NHq. (except drugs where
procurement is centralized).
The role of the Rer-ion in storing and dlabur~ing commodities
must he more clearly spelled out - optimally in the Administrative
Manual. As it is, a district can order the same item
from bnth HearJquarters and the Region ... and receive from
both of chern; fer lnstance, spray pumps. Headquarters has
records of its distribution to the field, but has no
knowledge of the field inventories. Thus it can not make
a judgement as to whether a procurement request is reasonable.
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Page 24.
As a re3ult, Hq. Supply Office sometimes cuts a procurement
order arhitra~ily on the assumption that the requesting field
unit is inflatinp- its demp.nd.
The above situation indicates that a comprehensive procurement
and distribution system be installed which would assume
balanced distribution to all field units on the basis of
n~ed. It is the opinion of the tean that the Region could
plLiY a IiItrong role in the system by maintaining a record
system of inventories in all its Districts and informing
Headquarters periodically of its supply situation. This
system would, of course, have to be supplemented by visual
inspection and checking of inventory records by the Regional
Off:Lce.
3.2 storage
In all the Regions and Districts some problems in storage
were found. In the Far West Region there was a problem of
outside storqge at Kailali and in l);mr, t.he D'1T was several
yp.!'.rs old. In t.he Central and Eastern Regions the storage
of DUT was generally poor, and in some cases DDT was
exposed to rains and westher. In the Western Region in
several districts, the physical facilities were cramped and
dirty, with somo older DDT buried under trash.
CamoqwU\ tablets were often stored in bottles intended for
other drugo, and in one instance over 2((0 tablets had been
destroyed by ratl:l (Western Region). In t.he East primaquin
tablets were diB~olored or were stuck together. A problem
frequently encountered is the hck of storage space
-
Pc..ge 2~.
(for Dm') but in 11I'05t cases lack of training of the
supply clerks accounted for storage problems. The fact
that supervisory District und Regional Personnel oid
not check these facilities may account for the continuation
of the problem.
3r3 Inventory Controls
The team noted that in many instancus the inventory
rocords did not agree with the actual supply of the
product in stogage. In the Far West most of the
inventory aheeta checked 'tiere incorrect. In the
Western Rep1 on, receip-c of druf,s in one unit 'Tltls'!not
posted until some time after receipt. In the same post
several thousand tablets of camoquin had been found
stolen after a shinment of 16000 tablets had been
rEceived. In three districts in the Western Region
the record showed a total number of spray pmnps withOll.t
no~ing tha~ almos~ 1/3 of ~hem were no~ repairable.
fther ins~ance~ of inven~or1 discrepancies were noted.
Almo:;o~ invariably two conditions existed: stock
clerks were ~ct trained in supply procedures and supervisors
did not check the rp.Go!"ds.
Again the question of the r.esponsibility of the
Region in kee',)lng posted on the inventories 01' the
DistrictlJ com"lS up. Are the Regions respOJlsible for
knowlecgt:; of all adrl'linistrative matt~rs in their areas?
-
The unanimous cunc)usi('n li1' tho team iH that training is
needed in supply mp..nageroont. Further that supervisors up to
the rank of D,O, should periodically (monthly) eheck stocks
a.."ld inventorles and initial the records. The HMO should
alSo spot check when he visits the District. It is felt
that distribution should be based on demand and should not
be automatic. Particularly in tho case of chloroquine tablets,
automatic distrihution leads tn waste.
3.4 Supply Manarerrent Training
As noted ahove, turnover in pe:rs:'nncl and lack of training
in supply management has led to widespread deficiencie; in
control anci storat~e of supplies. Good management require.
trained r:ersor.nel n.nd an efficient system. Both of these
conditiuns could bl~ fuliilled bi a t;erie. of training
programs for sUPFly clerks. The training sesson~ could be
given perinc1it.ally in Kathmandu or other Centers under
superTi;oior. of a supply expert on temporary assignment.
The problem L: probably- so wido[;Vread that consideration
m~ght be given to initia~ine a Ministry wide training
:>rogrrun.
4. Transport
Perhaps the major managorial problem in the NMEO is that of
transport. The situation hns even worsened since last July
(Project Formulation Document). In distri(.;t after district
visited by the team, transporlation deficiencies were found.
In th6 Far West H6~~ion only ~wo working vehiclef: were found
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Page 27.
and ~wo-.were- bE.1'uI1ti-repair-_ In--the Western Regon Dne ~d Rever
for supervision is on the road, two others are irreparable. No
load carrying vehicle :s available. In the East and Central Region
all types of transport were searoe and in the Regions the vehities
lacked s'[lare parts and are off the roan.
As for\.repp.ir shops and .. facilities, o:11y one region, the East..
Region he.s a .re?air facility. The other regions and districts.
are provided for by either the Headquarters repair shop for
mC'.;or repairs, or the 'periodic visits of the senior mechanicr.-
and helpers to t11e field. otherwise, repairs have to be made
where few f~cilitieo arc a~J.i12.blQ. The team lias informed that
fully manned regiunal repair shops are not now being contemplated.
The rletedoratis>n of a once excellent fleet of vehicles is
dua to a number \)f factor:., mos t of which can be traced to
manaGement deficiencies.
(1) Many of the vehicles ordered are not suited to the
road and land condition!;; of Nepal.
(2) Inadequate repair parts were ordered, often not in
time or in the quantity necessary.
(3) Inventory controls were not always ade~uate (especially
in the field) to indicate reoDdera of parts on tim~.
(4) Inadequate driver trainins in basic repairs and
preventi ve maintenance.
(5) Unavailability of even small repair part~ on the local
market.
(6) Lack of funds.
(7) The availability of mechanics to work full time on a
sustained basis.
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Page 28.
(8) PlanninG of replacement of vehicles and parts long
eno~gh in advance to prevent breakdown of transport
in ,'my PRrt of the country.
(9) HiGh price of petrol prevent~ use of many vehicles.
All of these deficiencies are correctable with the possible
ex~eption of #6 and #9.
The status of the vehicle fleet at present (February 1976)
is as follows:
6 Land Hovers are on the road and operating.
3 other Land Rovers require major o,erhauls.
1 Unimog truck is operating in the Far Wes~.
3 7rucku are available and in good contition.
However, many of these vehicles cannot be. used because :f
of high cost of petrol. There are l~ vehic~ea funded by
HMG Clvor the last 12 years which are not ope::-able. The
greatest need is for load carrying trucks and pick-~ps.
The use of fO\r-wheelod vehicles for "dumping" wou.:::l
increase the efficiency of the spray operation cons~derablY'
by rlistributing DIJI' quickly to many places that othErwise
must be reached by porters or dum?ed ia central locaiions
and then carried by porter, ".:ith all the; consequent
problems of day labor, tardy payment of wages and sometmes
unreJ iability of the labor supply. The vehicles neede~
for this type of work in rough terrain are four-wheel
drive trucks and piQk-ups.
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Page 29.
Unf nrtun,q,t ely, the vehiclus on order for load carrying which
have n0W arri veri in C3.1cutta are two-wheel riri ve l>I".azda trucks.
Eif:,ht of th em wi 11 be delivered to NMEO in the next few weeks.
It, is the C('l1sidered opinion of the team th;=tt these will be
completely ir,arlequate for "the job to he done. Money would have
heen spent more effectively if fewer trucks with four-wheel
drive had been ordered at the same cost. If the situation can
be retrieved by trade or :purchase it should be done immediately.
HUh the limite,! number of vehicles and with the tremendous
need for traruoport allover the country, it would seem appropriate
fur a new .urvoy of transport needs to be made over the entire
field ol'ganizc:ttiOT. and Headquarters, perhaps with the employment
of a UNICEF tr,:ion::l nn~ rerhaps even Districts where feasiClle.
In any case, the continuation of CI. post for Transport Advisor
is essenUal in view of the above conditions. It would be false
econorr.y to cancel the post tion at this time, as is contemplated.
5. nepair and I'Jaj ntenance
Even if all nece.sary vohicles were available, their usefulness
would depend on adequate repair and maintenance faciUtie .. and
training. At present the major facility i. at Headquarters.
While the equipment appear:. adequate, the 0UtPUt of the facili~y
ha. not c.Jme up to its potential. It was noted that lung and
frequent absences of the Seuior and I-laster Mechanics may have
detracted from the efficiency of the operation. As stated above.
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Page 30.!.
only the Eastern Region ha~ a functioninf, repair facility. Major
rep~ir jobs are broupht bac~ to Kathmandu m1 d other repairs are
taken care of by a mohile team that periodically visits the diotricts
and re~ions. Ohviously this ~as not been satisfactory.
A "new lac-k" At trans~ort needs including a five-y~r plan for
rrl)CUrement of vehicles and spare parts, repair facilities, and
training is needed. The survey suggested here would serve that
purpose. The team has noted l:hat prccurement program ha. been
planned by HMG and contriLutinv ar:encies, but feel. that a survQy
by an (?xpert team would verify and establish a comprehensive
The \erum feels strongly that even with the prenent fleetof
vehiclec ~d espedally wi ti: the acquisition of new vehicles,
it is most imI10rtant to establish a system of preveniive
~lilt8n~ce. The key to a successful maintenance program is
the driver. :::t is urged th'lt driver training and refresher
traini n~ be c,")JTI.rnenced as early as possible to include minimal
rer-lir s kil::'s for the dri v0r, and a requ iremant that vehicles
1e tested a: least once a month for all routine maintenance
requirements.
The team will not further comment on the need for Regional
repair fricilitic~, 18;wm!~ that to any rcc,:ml!ncndation of the
survey team referred to above. The same is true of whether
vehicles ;ho'uld be located onq in the ReEional Offices or also
L~ key Jistricts where transport is most eQsentiAl. The team
will, however, urge that the list of spare paxts for existing
vehicles be dispa~chcd for procurement as soon as possible.
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Page 31.
~. PerDonnel MP.nagement
Personnel m~~agement in the NMEO ha~ been characterized primarily
by the lar~o turnover in pE:rsonnel in the past two years. As a
result of integrat,ion and other changes in the Hinistry the staff
has been somewhat reduced. But reductiLn alene is not the major
change. In the senier ~d middle management positions a number
of changes have taken place which affect management stability
and efficiency. Some of the chanp,es noted are the following:
1974 - Two Deputy Chief (Medical Officers) have been
tr&nsferred to the ncpartmont of Health. Also in 1974
two l'-10's (Epidemiology) Here newly transferred to NMEO.
Two arlministrative officer::; (1 supply) were: transferred.
A Grade 3 acting accountant was transferred to the Ministry
of Health
~ Sflnior malaria a~iOi .. tants were transferred in 1974 to the
Inte~rated Health Sorvl~e~.
2 Grade 1 A.si.tant Malaria l'Jffl"ft."if were ~ran.fgrred
out of NMEO.
1975 - One Malaria Offi~er in ~harge of opera\ion.
tran.ferred to ano\her po.ition in NMEO.
One Sr. Health Educator and 2 Malaria Officers 'vere
tran~ferred to the Ministry of Health.
In the same year 2 Senior Officers resigned and one was
transferred to Pokhara (Integration Region)
Also in 1974-75 a total of 75 lower grade personnel left
the Organization as follows:
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Page 32.
48 Senior Hilaria Inspectors~
15 Senior Lab. Technici~s ) transferred )
4 Malaria Assist~nts ) )
8 Resignations )
Even if some of these posts were ref:i.l1ed, the turnover of
99 positions, ma'1Y of them senior and midnle supervisory posit-ions,
mus~ affect the continuity of management and supervision.
The Team did find tl1.!t at present most authorized positions were
filled with the exception of Regional personnel in West and F3.r West
vlhich are still considerably understaffed. The implementation
of the Hegional Organization plan is not yet complete and no
doubt these positions will gradually be occupied.
Tho Team has concluded thA.t excessive turnover in t,he cause of
many of the manflf~ement pr0blems in the field and :in the
Organizntinn as a whole. Every effort should be rrr:lde to stAbilizQ
the present st.qff tr) assure a smooth continuity of operations.
The Director of NMEO should inrlicate the consefluences of turnover
to the Hinistry of Health and Puhlic Services Commission.
The teams o~~~ed in most of the Ref-ions ann Distric:s that the
Senior Officers spent varying portions of their time in the
field. In Central and Eastern Regions it was noted that the
senior staff had a low percentage of time in the field, only
the malaria inspector:; and :;;enior malaria ins[,ctors spent a.t
least 5i% of their time in the field. In the Far Wes~ field
t~e rangQu frem 33% ~o 55%. In \he WQS~ k8-~8%. However,
'\,he 1.ime in ~he fie Id did no'\, :llwayi represen'\, adequate supervision.
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Page 33.
Only iJ" a very few cases was there any evi nence that HMOs or DOs
had checked personnel records, supply records or any other
adminifltro.t i ve data. For instance it war; noted that several senior
staff mctnl'(~r!} rf some I1istric ts Offices had been on leave at the
same tjmf: durinG thE: hei;::rht of the spraying season. This fact
had not L(:c:n noted or 'crouvht to the attention of the RMO. In
almost no case was any Cl)rrecti ve action taken.
It is 1I1d~rst::mdable that the Regional and District Officers were
more involved in tel,;hnir.~l than administrative. interests. However,
their responsibilities as sUlJervisors require them to note
adlnini"trati VG pr.:)blem .:mel put~ntial breakdcwns.
The t"mm recommends that senior fiegional and District t;rficers
receive training in supervisory management in seminars or special
cl:tsses conducted for that purpose under management personnel.
It is also recommended that all ru10[s and DOs check adminis~rative
rec,~rcls on a srot rasis when they visit the field. They should
ini tial the records they h:we reviewed.
In order to facilit.1te manaRerrent chan(l'es .and to assure continuity
of efficient practices the team urges that a Manual of Procedures
be ini~jated to reflect the pra~tices and standards required for
good admini~tratibn. The present Manual has not been revised
.in"c 19'3 and is compl~tely LlUt of date. A!;ency-wide attention
.hould be ~alled to new issuances or amendments to the
The ~~am wa~ impreD;ed with the general enthusiasm and dedication
of ~he .~a.ff of ~he Organization at all le"elg. The NMEO is a
well ~on~eiTed and well planned Organization whlch is known and
http:tec.:hnic.al
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Page 34
respected throughout the country. It is important that its
mission not deteriorate as a result of bad management and
slipshod practices. This report attempts to point out some cf
those areas that require attention.
D. Operational Accomplishments and Problems
1. Insecticide cover~
DDT was mainly used except in tr.e four localities of Baluhawa Unit
in Kapilvastu district which had :received one round of BHS. In
addition, 'ABATE' (larviciding agent) was used in two of the
above localities in the same Unit (Annex XII).
1.1 According to the plan of action for the F.Y. 1914-15, a
population of 1.9 million was to be rrotected with DDT
Rpraying during the Feb/March cycle cf 1915. However,
because of limited stocks of DDT. Selective spraying had
to be carried out very cautiously ke~ping in mind both the
DDT in stock and the epidemiolo~ical situation. A targeted
population of 165,000 was selected. But during spraying a
population of only 155,000 ~LS covered.
1.2 Similarly during the May/June spray cycle 960,000 persons were
protected out of the targeted population of 1 million
(on a selective basis) against the planned population of
2.2 million. Due to the various administrative difficulties
in some places, the spraying operation had to be started
late.
1.3 The Aug/S~pt. cycle on a very selective basis due to the
same reason was targeted to cover 1 million as against
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Page 35.
the planned 1.5 million. However, actually 423 108 persons
were protected. Ill." some places spraying started late and
had to be terminated without completion because of variouii
administrative difficulties and of time factors. During this
round a tJtal of 47 001 population in Baluhawa Unit were
prut.ected by BHC (58%) wdp at a dosage of 0.5 gm/sqm.
(Annex XIII).
1.4 Five rounds of larviciding with 'ABATE I were used between
A]')ril and Jlme 1975 in the ponds and other lftter collections
considered ideal for anopheline breeding, in localities
3 and L. of the !laluh:.lwa Unit. The whole operation was planned
,:mrl inj tially executed tmrer the tii rect Ir,tlidance and supervision
by the HHO ReF'ional Sanitary ~f_~ineer and ne~ional Entomologist.
However, the results could not be thoroughly reviewed and
analysed because of improper collection of data after the
derarture (.If the reGional WHO tgam.
2, Focal sprayinK
Due t.o insufficient Di)T, focal srJrayings had to be re:otrioted
on many o~casions. On the whole epidemiological factors determined
t.he rriori"y for such spraying. It was observed that in some
area~ selection of the houses round a focu. wa. ve~ unrealisti
Unwarr~ted del~ys have aiso been noted in carr}~ng out su.h
srernti MS in some placelJ (Annex XIV).
3. Surveillante
3.1 Throur-~hout 1975 schedulon AC n rounds were maintained.
Depending on the epidemiological situation the time interval
be~ween AC[l rcnnds was adjusted. In some of the difficult
-
areas like r.a.luhawa, Ast.trcd.na, Belatnri., Lumbini and Jhapa,
11100d slides were collected every tenth day during house
to house visitinG' In other areas, lC' was restricted to
15 days interval. The remainder of the country had monthly
visitini" vrith the exception of project areas usually dra1.nng
larp,e com;rer;aUon of labour....whre twic-e-1llonthly visiting
was r.ecessary.
There is a tendency to visit the same h~use at each visit
in some of the Units. It appeared that age and ~exwise
coverage was not uniform and special attention must be paid
to infants and children.
MI3S had to be res',ricted in a number of places, e~pecially
lihere there was a huge backlog of slides. Examination of
slides obtained throuGh Ml~ clearly indicated that-ACD needeu
to be improved.
3.2 FCD produced only 0.9% of the total slides collected during
1975 from all sources. However, the positivity rate amongst
Fe:r slides lvaS h.7%. Cooperation from all medi~al/health
services units is neede1 to improve the rate of slide
collt:ct ion.
'I'reatr.1E:nt
4.1 Drugs were readily available throughout the year for both
f-'res~ptive and radical treatment. Proper acrutinization
during issuance of drugs at all levelu could help in the
reduction ofjmisu~e. The higher initial dOBe of
k-amin0quinoline group ,.,f drugs and the use of long acting
sulpha drugs a. subceque.t recrudescence of resistant
-
~. falciparum have not been st.rictly adhered to in seme
places. DiBtr.tbution of drugs by persons entrusted with
other duties have in some places created doubt.ful situations
about relapses. 'rhe persoas employed to gi VI3 radical
treatment, should be the only persons entrusted to treat
cases, as far as possjb1e. This will not only Ansure proer
proper taking of drup.s by the patients, but also interfer
less with the t:chedu1ed activities of other personnel such
as the MFWs.
4.2 Because of the d~tection of large numbers of imported
posi ti ve cases (1082) in persons residing outside the
NMEO o~rations area i..'1 the Eastern Region, treatllEnt had
to be arranged. But with the present resources of the
NMEO, it is not possible to do so effectively. In this
connection close liaison wi.th Ministry of Health is needed.
3 Three rounds of MDA using 6&0 mgm of camoquine and 45 IfIga
of primaquine were re~ommended in the Asuraina Unit. Only
-ihe first round was given under proper supervision and t.he
resu1-i was inadequate coverage during the other two rounds.
In the resettlement area of ~h'andragarhi Unit in Jhapa
nistrict, a sin~le round of 600 rng carnoquine and 50 mgm
of pyrimethamine p.1ven during the mon,ce of September
produced very good results (116 cases de~ected between
September - Detember 1975 compared with 913 cases during
the same period in 197_).
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5. Laboratory Services
5.1 The central cross-checking laboratoI'Y' at NHQ was decentralized
effect.i ve August 1975. The C61tral laboratory at NHQ is to bEl
used far cross-checkin~ slirles from the regional laboratories
and far basic and refresher traininr courses far the
lab. technicians. At some of the lab~ratories visited the
slide output per lab. technician was too low (about 38 ~ 40 slides
~er day), Leave of absence was noted to be a major cause
of backlog of slides} and this could be dtcreased by properly
utilizing (by temporary transfers) the laboratory technicians.
A total of 46 laboratory te8hnicians of the central and
east8rn regions (including SMA, HA + SLT) were tested usig
six different sets of six numbered slides which were provided
by NHQ lah. Only 18 (39.13%) identified all the slides
correctly, 15 (32.6%) did very badly and have been recommended
for refresher training.
5.2 The par2.sitolor:;ical orerational ma.uaLis not being strictly
follower:1 hy the SMA/MAs of the RHQ laboratories while visiting
distrjct lahoratories.
5.3 Some micr:)~'copes need Iilaintenance or replacement. The
overnip:ht safe keepine of microscopes \-lhere electricity is
available, is not being done.
E. Integrated Areas
The ~eam visited the integrated districts of Kaiki, Bara and Parsa
and in the limited tiroo available, endeavoured to evaluate the
malaria status and to i,jentify technic al and administrative prob.i.ems
both to NMEO and the Basic Health Services. Pr'wious reports
-
"Page ;39,
outline in detl'l.il the HMG Policy Rnd achievemants regardingtbe
intcgr.-... ti.m cf the 'bnsic health services and a comprehensive
cvalua ti0n was c2rried (\ut hy a HMG/AID/lvHO team in January/February
1975. Thus the present team marie no attempt at an in c1epth study
but prefient here an overall il'lprGssioJn 'Jf the situation based upon
statistic& "lnd inf:~rmation provided dUr'inr. the visi t.
The timinfs of integration varied 1::etween Bara and Kaski distri
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Page ~.
consideration the distril.Jution and leveJ of survci1lance
activities in time and sl~ce and the coverage and level of cane
investigatiun.
The total nwnber of 98 cases detected in 1975 were found amongst
~ cunsic18r({lJly reduced nwnber of slides taken compared with
previous yo:1rs. The overall impression is that the malaria
situation hRS not improved in this d:'strict and t he situation
c(lntinues to be of major concern. It was apparent to the team
that the Il"l.sic Health S8rvices personnel responsible for the
malaria activities are ~~able to adequately cope with the
continuinl' caS0 loan. The reasons f,r t.his 2re r'rilTlA.rily
admir.istriltive interferring tTith t::ase dotpct.i'Jn, timely treatment
of cases and the implementation of remedial measures.
The actual am::mnt of allotted Ludr,e+, fer' the required level of
anti-malaria activities is insufficient particularly for TA/DA
and spraying operations. The Situation Analysis Team in 1975
visited this district and noting the risiP.[~ t.rend in malaria
caBes ann the increased A1-I, recommenc!L:d that regula!' spraying
be carried Gut in certair. areas coverin!; 36 000 population.
Hot/ever, due to an acute shortage of DDT this was not carried
out durine 1975. Supplies of DDT h'J. vo n,)w been provided to
this riistrict, but the district h'-is insufficient funds to carry
out ref!Ular or focal spraying. The team noted that the DDT was
not properly stored.
The shortage cf TA/DA funds has had the effect of reducing field
supervision v;rhich the team found to c':::lsti tute only 21% of tho
supervis0ry personnelts time. Close supervision of ~he Junior
Health Worker is essential for effective surveillance activities.
-
At the time uf the visit tu the Health Post buth
Jiux:Uary Health Workers W8ru "lbsent and the Senior Auxilary
Health Horker was umble ill cops with the activities norm11.1y
carri~d ~lUt by the AHW. Thi.s appnrently was a frequent
OCCUITt:mcu at this Health Post. This is one explanation for
the long delay in r,qciic.:ll t.rLa"t,ment and case detecti:m whioh
was noted hy the tee_me
The lahoratory is sufficiently staffed to copw with the
present level (If survei llance, to the point that the microscopists
were examin~n[; an averaFe of 30 malaria slirles per day. There
was no slide back-lo~.
SincL~ the ensct of intq"ration in this district malaria
activities h'lve teen r-.rriud uut from the three HCdlth Posts
at Dcui"lli, Pokhara and Batulcdwur. Since September 1975
three adJi tional Health Post~ In ve l,oen established at Majhthana
m.endabari 3l1d Sishawa. The team c onsidero this to be a
beneficial cleveloJ'loont which should result in improved case
detecti()n::;nd treatment.
2. Bara District
The team, accomp.:'mi'3d hy the Civil Surgeon of the Zone visited
the Thra District Health Services Office and tho Rampur Health Post.
statistics wore avaihble lJp i" and inclurlin~ October 1975. The
si tuation in the district :nay be briefly summarized as follows:
Blood Slides Positive Year Population examined cases
1973 2463n 34 114 26
In. 254 173 43 390 333 1975 261 152 26 34h 272 (10 months)
(Jan-Oct ober)
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Page 42
Detailed statistical data is presented in annexes XV and XVI. It
shoU:.d be note~ that the reduced number of cases compared with 1974
were detected in a considerab~y lower number of slides collected.
Difficulties have been encountered in coping with the case load
to be investigated. This was revealed by 2~ of the cases detected
between April 1975 and January 1976 remaining uninvestigated and
46.57% o~ case investigations being carried out 4 weeks or more after
the blood smeaT collection. StIDilarly for the same period radical
treatment was not given to 26.67% of cases detected and was delayed
by 15 days or more in 48.23% of cases. No records were available
of follow-up of positive cases, but in the previous two years
follow-up was continued beyond 6 months in only 4 cases. The
changing epidemiological pattern reflects the above difficulties
(graph 2).
The overall level of surveillance was markedly reduced during
1975 and from January to June was below the expected 1% per month.
An examination of the records at the Rampur Health Post
indicated that the total surveillance in 1975 amongst the
population served amounted to 8.65%. At this health post blood
slides were not taken from all fever cases but from suspected cases
only which averaged less than 4% of the total attendance. In 1975
the total out-patient attendance was 11,817 and a total of 357
slides were taken for nk~laria screening.
The laboratory also had difficulty in keeping pace with
slide examination, due mainly to the low dailr examination rate
by each microscopist, until the slide back-log reached more
than 2,000, whereupon the daily output per microscopist
-
went up to 87 and 123 durin~ September and October 1975
respectively (Annex XVII). Only one of the three microscopists
is engnrcd in examining specimens for TB and Leprosy and these
amount to no more than 15 specimens each per month. The Team
tested the microscopists malaria diaenostic ability and
fotU1d two of them to be quite compet.ent.
TIle adnUnistrative difficulties which have affected
the m~laria activities in this distl~Ct may be briefly
surrunarizeu as C1. coordin.:'1 tion I~ap between the NMEO and the
district regarding the February rel0ular 0pray cycle; lengthy
delays in reporting to NMEO; the lack of cross coverage
between the AHW curative and AHW preventive; +':le ruutd to
ensure that the remaining S health assistant posts are
fi) len. hy !"lers onnel c.dequa tely conversant w t th the integration
activities; unsettled, TA/DA claims for the period
April 1974 - March 1975 and a similar situation developing
with outstanding TA/DA from December 1975; late arrival
of ~unds for salaries; an1 the lack of a bUdgetary
provision for the laboratory technicians.
The -I;,eam examined the supply situation and found
it to be satisfactory, with adequate stock A of
4-aminoquinoline~.
3. Par~a D:i..s "t.ric t
The team was able to visit the Par'..Ja District HeaUh
.~rvi.e. Qffi~e a"t. Birganj and the Langadi Health Post.
'l'he Uu':l.'\ion in \hi. District is cause for more conc81'll
\han Kaski or Bara and mar be simply stated as:
-
Pa,[e 44.
Blood slides Po~itive Year Population El%amined Cal;es
1974 211 552 34 963 459
1975 212 768 20 030 499
Detailed 6~atistical nata ts presented in annexes XV and XVI
and graph 3, An extremely low level of surveillance prevailed
il1 this r1istric t throu~hout the early part of 1975, with
improvement from July onwards.
As in B.:lra the personnpl are unable to cope with the
case load fm' investigation '. and radical treatment and details
of follow '1.41; ,,,erE: net availClLle. The lq;ontJry work output
"laS much better, the mie rose opists maintaining a regular daily
DUtput resulting in a minimum of slide backlog (.hnn8X XVIII).
It vms i't}lt that this was tht) result of better supervision.
The throe l1l.1.croscor-j.sts WEre tested for their ability to
diagnose malaria parR-sites and were all found to be thoroughly
compe"t.c:nt.
Few records were avail.'lhle a~ "t.he I.angacli HeaUh Pos",.
S~atisti on blood slides examined from patients attending
the Hertlth P')st bef!:in from September 1975. In the 9 months
April to !1eeemher In5 the patient attewlance at the Health
Post amounted t.o 6396 and from September 155 blood smears
~~I-. I-,aken and 6 positives found. The surveillance coverage
of the area served hy the health post from January to December
1975 was very satisfactury, when a total of 3706 slides were
taken and 13. positives found, in a population of 26 206.
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Pae~ 45.
Radical treatm:mt and case investir-ation however, was delayed
by 15 days or more in 70.9% of cases. The administrative
difficulties encountered in this district are no different to
thoge in the other integrated areas except that at the time
of the visit the nistrict Health Servic es Office was not
officially sanctioned a nrl was opE:rating with a temporary
staffing pattern. All personnel W8re on loan.
The administrative difficulties encountered in this
district reflect the ne8ci for adequate preparation and planrmg
l.;efore effecting inteeration.
4. Conclusions
'The epidemiological picture in the three integrated districts
is depicted in graphs 1, 2 and 3. The situation should not
be interpreted only in terms of positive caoes foune, ag
this i~ dependent upon the number of p3tients screened, whioh
in 1975 was lOWEr than in previous years. These graphs
indicate that in 1975 transmission commeneed ea~ly in the
season indicating the presence of a sizeable reservcir of
untreated p~rasite carriers. Intensive case detection, timely
radical treatment ann case follow up throurhout the year, and
especially during the non-transmission season (October - February)
would produce the epidemiological picture seen in 197.3 ir.
Bara district. That is to say late onset of transmi~sion,
and a short, sharp transmission period. The present picture
therefore is cau~e for confiiderable conc~rn during 1jhis year
and prompt remedial measures are essential.
The team is fully aware that the problems revealed during
-
this evaluation nre well known and th~t efforts are beinr. rrade
to overcome them. However, the mahria situation in these areas
is such that the inter:r9.t.ed services cannot adequately contain
the dis8ase. In some localities it has reached the criteria
(lIPI ~ 0.5 %0) for the reintroductiun of r8gular spray rounds,
in keeping with the NMEO efforts in the rest of the country~
It is very apparent thut the Basic Health Services is unable
to carry out the required remedial measur8S of focal spraying
and rcn:ular sprayin!; through lack of aciequate budgetary provision,
personnel ~d transportation. S~milarly the NNEO at the
present. time, is
-
cases are either not being investigated prompt:.y or not at all.
Laboratory serviaes need to re maintained at a very lrlgh level
of efficiency with adequate superTision.
Numerous administrative difficultie. involving budge~,
Bupplie. and I)ersonnel exist, and require urgent attention,
The key man in the integrated areas is the Civil Surgeon and
persons fillinr such a post should be devoid of clinical
responsibilities to ensure adequate field supervision of the
integrated operaticns, and more time devoted to the administrative
diff~clllties of' such nn operation. It ia through the Civil Surr,eon
:hat the NMEO can maintain improved coorn.ination at the
operational level to the advantaf"e of the Basic Health Services
and NMEO.
Careful and r;radual phJ.std inteGration of a. complex
vertir.al programme like malaria offers the bes~ pros:p3c~ for
success. The basic oreanization needs to be establi.hed,
staffed, adequately budgeted ir.Glud~g a ~0ntingency plan,
and functiGning, bgfare the pro[;ramme begin. to be phaDed
in. Ctherwise economic gains alrc.:tdy achieved may well be
10s"8 J3efare inteGration a high level vf p9.6si ve case de'ic;lc'Uon
c auld be devol eJIX'd by th (: s ~reening cf all fevtff cases
attending outpatient clini.d at :he various heaHh institution
and Health Posts.
The] ahol"1.tory caplcility can also be develo:p3d to a high
deF-rAe of efficiency. Case invpstigation, radical treatment
and finally house visitinr, can be built on top of this in an
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oPage 48. 0
orderly fashion, with the appropriate expansion of the
Health Servicea,
In the six districts already integrated containment
and eventual reduction of the disease incidence c?~ now best
be hrouf!,ht about by sharing the responsibilities for the
malqria activities between the NMEO anc the Bafic Health
Services :in a joint ecoorrlinated effort. However, it must be
emphasi~ed thnt appropriate and adequate funding muet be
provided a~ a pr~ority to both NMEO and the Basic Health Services
to enable their respective activities to be effectively carried
out.
The team anticipates that the future integration of NMEO
districtu into the Basic Health Services 'will be carried out
gradually ~nd effectively along the lines developed in the
1975 Prcj ect Fonnulation for l3asic Health Services.
F. The FEstern Hills
This area of Ne~~l presents a special problem and in accordance
\Olith the Terms of Reference the tC'3JTl visited the eastern hill
mal"lria district offices of Okhaldhunra, Khotang (fliktel) and B
!Jhojpur} nnd the malari.a Unit II of Okhalr:lh'Jnga at Rumjatar.
In this arE.J. the popul:ltion rellides on top of and along the sides
of the hills, ann farms the land in the valleys. Some families
have tHO honses, Glle on the hill and the other in the valley. There
is .onsidr-:rabJ (; movemen":. of t.his population to the N .E .. Indian Stat)s
for farmint; (1 - 2 ye3.!'g), tea planting (1 - 2 years) or wood cutting
(6 mop. ... h.). eorne\i.mes a leader will take a group of male villagers
to work outside the countr)", but generally farmers take the entire family.
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Page 491~
The malaria Bi tullticm h both Okhaldhunga and Khotang-- iB--very
similar, in that it is doubtful whether any transmission is occ\l.l:"rlng
at all. Very few cases are bein~ classified as indigenous. From
60 to 70% of all cases are imported from outside Nepal, ma5nly Assam
and Nagalano. Of these imnorted cases more than 50% are ~.falciplrum
and during 1975 in Khotanf, 39 recrudescent cases were reported which
rt:sponded to tre2.tment with sulphadoxine and primaquine. In addition
m,')re tha:t1 70% of the imported cases reside outside of the operational
area. These cases aru usually detect8d when they report sick to
the malaria unit within the operational area, at winch time a blood
smear is tc?ken and presumptive treatment given. rhe patient then
returns tu his hCll8 ann if t.he blood smoar is subsequently found
to be posi ti ve then r3di.cal treatment \lecomes a problem.. Attempts
,g,re made to trace the pCitj,ent. If md when the patient is found,
radical treatment usually consists of the first dose only and the
patient carries hack home the remaining four days treatment.
Somo positive cases are referred from the check-post on the
eastern horder at Kakarvita, in which case attempts are made to
trace those parasite carriers even if they reside outside the
operatio~al arpa. In Okhaldhunga during 1975 a little more than
20% of the non-indigenous ~ases remained 1,lIltraced, and ill Khotang
6% in ~he same year.
The situation in Llhojp-.r is identical J.n every respect to that
in the o~her \WO di:;l,rt"t.s wi th one important difference.
Transmissiun is defini.tely occurring. TJuring 1975 10% of all
cases were indi~enous. However, these came mainly from two
localities in Unit I Dingla, and one locality in Unit III Dinglapu
Transmission is centred around the Arun river valley,
-
The team was aware of a lack of entomological data for this
area. The receptivity is not precisely known. Latest entomological
infOI'JTlation appears to pertain to a study more than 5 years ago
in Kiri village of Khotan~ district, when ~.nuviatiliB was recorded
The team felt that entomological information was neede~ in order
to make a BOu''1d judgement as to the effects of, and the need for,
residual spraying.
From the brief study of the districts visited the team had the
impression that in a significant portion of the operational area
there is Ii ttle or no transmission, whilst in the remainder
transmissicn is occurring but in pockets associated with specific
eco] ogical candi tiona conduci vo to vector breeding. Furthermore,
the villae;es are ~enerally not compact" the houses bein~ widel):
scattered over the hill side.
A l:lreakdO"m of cGm~rati vt:) costs of spraying in the terai and
the eastern hills ~ex XIX) indicated that the costs are more
than trebled for operations in the hills. In addition, due to the
difficul t terrain" alld scattered hOUl~es, the quality of spraying
and supervislon cannot be guaranteed. It therefore beccmes of
sifJ11ficilll"t importance to determin8 the precisE:::J situation .' _ :7._'
e.xisti:1f, in localitie:: at present covered by spraying operations
and to adjust these operationa accor.-dingly. Focal spraying is
proba'.ly logistlcally more ci.ifficul t than an organized regular
spray cycle since adequate superrision is virtually impoosible,
and there is an i~evitable time lag in distributing the supplieB
and equir,ment..
http:proba'.ly
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l'age 51
Many of the imported. ccses-are entering through the Kalmruta
border ch~ck-post where it is estimated that 52 to 55% of cases
found are ~. falciparurn, and as can be seen from the statistics
below, 8.3% of these persons checked are parasite carriers:
Blood Smears Positives Slides positivity Year examined found rate
1972 2 193 28 1.2%
1973 7 018 455 6.4%
1974 10 490 632 6.f1'/o
1975 l327l 1 066 8.3%
Effective control at this post would offer some protection
to the population from ~. falc ip a rum , reduce the chances of a
4-aminoquinoline resistant strain of ~. falciparurn becoming
established in the country and reduce the vulnerability in the
eastern hills. Careful consideration should therefore be given
to three possibilties:
1. That ~ediate blood examinations be conducted at the
check-post and appropriate on the spot radical treatment
be given to all positive cases found, using a single dose
radical treatment in the case of ~. falciparum.
2. That a single dose presumptive or radical treatment be
given to all persons from whom blood smears are taken.
3. That a single dose presumptive or radical treatment be
given only to suspected positive cases, based upon history
of fever.
The first alternative is difficult because migrants arrive in
large groups, the second is very expensive, and the third is less
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Page 52
expensive but IDay not be as effective. These considerations
should be balanced against th.; fact thllt these migrants are
often unable to provide an exact address, many never arrive at
the locality originally indicated and they invariably stop
overnight on their way to the eastern hille. Thus many parasite
carriers are probauly lost within the country, and precisely to
what extent warrants careful study.
III. Review of Present Program Policy and Planning
A. PolicY"
Support for a nntional malaria program is based primarily
on tee broad based r.a"cional health objectives of reducing
morbidi ty and mortality so as to facil:""tate the economic and
social development of Nera1. This objective has its origin in
b0th national and hC'aUh sector priori"~y planning areas.
The basic fou~dations of the HMG FIfth Development Plan
(FY 1976 - FY 1980) outline three basic principles to follow in
developing this national development pJan. These principles are
1. To maximize n'1tione 1 output for the general welfare
2. To muximize utilizotion o~ the labor force
3. To create regional balancr~ and greater inter-regional
exchanges, thereby encournging national unity.
The planned malaria activities of the NMEO meet all three
of these over-nIl national objectives by: (1) increasing improve
working conditions for Agriculture development in fOl~erly
malarious areas; (2) maintaining a healthy work force to produce
crops and materials required by the nation; and (3) allowing the
-
malarious regionD of t.he I;ountry to take their rightful plaCE; in
the regional development schellU::Jl of the country.
In reviewing the priority concerns of the t1iniatry of Health
for the Fifth Development Plo.n there emerges four principles areas:
1. Contr')l or eradication of malaria, smallpox, tuberculosis
and lorrcmy 0
2. Family p:anning, nutrition and related matters,
3. Environme:1tal Health and water supply.
h. General Health Services.
The activities of the NHEO relate directly to the health
policy concerns (;1' the I>linistry of Health in meetine their
priority objectives.
The Nl"I;al Halaria Eradica ti011 Lloard (MEB) ws con~idered
the pre:oent maln.rJa situation through evalw. tiona reports and
fleld uhoervations. The o'iljectives of the HE~3 and the NMFD are
nl)W focused G[, the control of malaria to a level where it is no
lon,~er a public health problem and to facilitate the orderly
;levelopment cf basic health services in Nepal.
In ~uantifiecl technical terms the objecti vesaail for the
interruption of the risinr~ endcnriaity of malaria and the reduction
of its 'lnoicience to 0.5 Arumal Pare1site Incirlence (API) based
on an API calcub.t(;r1 from all the reported casc::-o minus the imported
case:: from ~l)1os.d. For Nepal Country-wide, the 0,5 API standard
translates to an incidence level where the annual number of detected
case:. under a stabilized surveillance mechanism should not exceed
J COO cases and with an adequate response mecwnism in p1:1. ce
to effecitvely handle this level of jncidence.
-
The Situat~on Analysj sTeam - JYi6 believes the palicy ta~c
f(,r :Jllrr,ortir.g the malaria contrul Cictivities is in accord w;:.th ":loth
national [lLci he:lltb development objectives. There are clear and.
clircct l:i.rH' (ut-l'ut V((LU80 to the activiU.es of the NHEO which
in r;,-'1'":2.. TL,' 'l't:iln lJcli8v(~s that it :ls extremely important that
pl'oj)t;r, planrkd {lnd :o.de'-lU~lte S11ppt'rt. be given to the NMEO in order
that tld.s ()rt~ani a.tien can meet its responslbill ty in the atta:1nment
of nat-lOin] olJj (~ctl vus. 'l'be Tc:m. WlS impl'l-!ss eri with the detcrminatioT'.
of' the i-1alad a Era(~icati0n noard to SU~)port a national malaria
effort. Tilt: rtLfficult d!:cL, ions :-rw.de L,v the- HE l"1o.1.rrl. to revE:n .
al'ea~1 tel ~)I'rCl?-hf:: aGtjv:t~il~S aI'(: irlriicat.ion:.> of the concern of the
ME ;lu'lr'rj fer a ~~,)und prof'ram ba~1ud on technLcal n8eds ..
Plannlng
The f)1jEC iu guided in its over-all program direction by the
Flilll of Opt::nt~i.uns which is Jet3.ilcd each :rear through annual
Plans ,1 f:.. ction" wring the pc:riud of Jmu~-..l.,.. 1975, a revisod
PrGj-Jct Furmulation Papl::r (Plan of OperA.tiC1t~) was prepared by
thL! HHG with thu [lBSistrillCt of MIO. The draft :.If this Project
FOrlrN.l'ttion Paper is Lef...,re the G(.mceIT.eJ (jfflciald in the Health
Hinist1J ;u:l i~~ r'}Cl.dy f'Jr pr('!ll!ntTLiun tu oth(:r ap)::roving
lJ.uth;'riti8[,.. Thi8 ?rojt:ct F'~rrnul;:-,tion Pap"r wan approved in
I_,rinc.;i;:,lc l
-
Page 55.
plf the
Plan of Acti0n with the targets in the operational portions of
http:Fi,,rmulat.io
-
Page> 56.
the F-la~. The oper~1,joll'j".J a.~cJJfl!,liflbmtJnts and problems of'1975
are provided in jJ3.rt. lJ-h c,r thb ne~ort awl are not repes.ted here.
Th::' late arrival of iW3 ecticide was the reason given for the
p:Jor c,'veraf;
-
i.e. ~i':.lministr'ltive, t'~llt()m'_)lt:,[,y, iJar;;wit!)1.oVY, ope::rations, The
Team abc felt that pant rc:c,}mrwmdaLi ons ,)f External Heview (Jr
Situut:im all,:,lYDi(3 Teams HC:l'C: :H.::inl" us.:::d hy the NHEO and the
pro,:ram wat: ",l~o~rvinf! and aclaptinc many cf the changes previGualy
rc~','Jnm0n,it-d. 1!r:\,,8ver J it is felt by the Team that more national
c:valuatic![J d'f\,rt (;hould lie made b;{ the NMEO .. .:i th more inter-related
evalu[, tiGn ;~cti vi tius ,,.nth c.;tht:!' Ministry of Hoal th personnel.
The 'h;;lJn h:l~ nc,tc:d 11 f!r 'I.'int impro':.~'ment in this intra-I1inistry
c".r,::i.n,'lt:i,n be:tHeen the int'.:f:rltc'(; health Rel'v:ic(.:s and malaria
rtnd it i[; hurc-d that tl::i.o c"'}r:!iwlti-'Jn will c(ntinue to imprc)ve
d,nc in cr'm;ult:lti(:n ...,itl, t::'J i-!inif,try 0f Ikalth and the NMEO
1"":-tlc1l11rly 1.n tlH' f](;lcci,i.on "r dist.r:icts to be intcgr'lted, time
In [~llmrr,ar'r, tr,c pelicy ~',':!.f,t~ for tho mmo apT_'L:ar(;d to the
Team t,_, ~:,,) in acccrd wjth both ;)ll.t..:i.onal and H(;altb fvlinistry planning.
'T'l!c 'fe2:n
-
1. Thr~ '~'.;:1rr, rcc:-;mmend~ th!1t the troj8ct Formulation Paper for
malaria l;i; i'ln:llizc-] .:tnd approved hy the concE:rned HMG
.)fficc'rt!
2. 'l'he final upprov.:ll ,.1' this docur,;cnt by hiRher HM'G authorities
roquire that the contribltions of the various assistinG
aCE:l1cics be carefully c(lcr~1irJ.3. ted in orde:r that these funds
rr,;vlrle timely and .:td('~-ilwte assistance support. The Team
rocommencis tll'l t. this a,~ Lhn b t~ carried out as promptly ao
pussiblu t.o avoid Clnr time la[;3 in t. he planned program
.3. The Team supports t.he 1975/76 NHEO {-'lan (If Action target
()i' pI'\lvid:'nl~ ~1 St:?l1~cr J\dC1inist r:ltivc Officer and an 8J
-
revised manual and re gul,tj ons refle:ctinv, current administrative
requirements.
6. Traininr: f'-f aclministr3.:iv8 i-'ersc,nne:l is 11adl)r needed. The findings
of the ~ituati.:n hnalysis Tfams in t hr:: riel r ] indicated th'lt well
0v,:r the tJO'':: )f th
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10% frem onr; code to another fer the Dls trict (except
Dcrsc.nnel) !icc.r:~ll:t'l.rt er~ ~;')l:l~l 1-(: infe rn:('~ after thl;! fact . '
12. ;l srstun,' "n8.I1Ll"'e!1l(mt a\~dit" shl)uld be initiated, This
in Hc;:iGn, lli::;tric t, ell' Unit pcriodicall:r (twice a yenr) ,
ThL! Nanal;\JTncnt .specialist HOule. relJort his findinG to the
Rcf_:icnal or District offices and advise propP!' action. 'l'h
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15. In the Far West Dist.ric:t of Dan~-neokhuri the area cover:d
by the Tllstrict off'lc(. is too l"rr~e for propAr manar-em8nt.
Thl:: Tealn rf'comrnenri:; th t a sut,-rJist.rict 'Afico Lo estahlished
at Ghoraha to c ovn' the area il1 the Deokhuri Valley ami, P10re
importantly, the !-i.R.N. Ito ad Project as this project is causing
malaria problems for th~ 0ntire area.
16. SUFerv:i.sion frarr, thE: inkrme:liatE: level shauLl be strE:n~thened
by revising thp existini; Travel a"::l lJaily ~\}_lCW-mCC8.
17. The lo~t m./1'1As of the
re gi un.:l1 1a L ora to rie s
4.. Takin,:: intv cor.sikr.'lti'Jn the approved general str.!ltegy'
of the pro ;:'7am two r:.,unds of spraying may be cJnsidered
in all common positive villages in formerly hypoendemic area.
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5. Ha;;s iJrut' i,:lr.'..inistraUon UWh) ill the C(JI'II'lrJn positive
Survqr [;'11 ~l'S an'! 1.0\01 J)~;s:itivit.y rates, it is rtJ8urrunenrk:d that
t () t hc' ::hil'lren ' ... r:i i, J. '~'r \.; it h ou t. fevi"' r e:3 p:' (~i :llly i.r1 th ()
S(:)'.i us 1)'.
i) th0~c villares wJth a level of tfhnsmissirnl
precisoly l.,.h(~re transmbsion js occurring
(inside or ,-;utsirle thE; villaf~e);
http:regul.ar
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Page 63
. . , ~1, the preci::;e transmission seaDon;
ill) the le vel of existinl: surveillance acti vitie.
Clnct ;
iV) the receptivity existin,' in l,hp rerlaining vlllaP'8s
~f the srrnyed 10cality, bas8~ upon simple
considerations of the: ccolo:~ic3.1 ccmditions suitable
to support the orincipal vect'::-r and/or the
demonstrated presence of the v8ct:)r.
The outcome of '~hi~ rf~cJr.;n:endatilJn should be selecti vo
re~ul.U' sprayinG Cit an appropric.te time relative '10 the
known transmission [-,,,,riorj only in thl)se villagos with
an API I!,rc:ate-:- 1;h:m ur qual to 0.5/1'J00, and in those
assistClnce over no less than OLe (r. +,ire year, in
selocted 'rillarcs where transmi ssion is c;ontin'Cling '\.0
determine}
i)
i , 1,
the precise anopheline f?Una'i
the vectorial ca):'d.c-l ty of the pr.i.ncipal,
secondary ann sus pt~cteci vcc+.ors j
iii) the soasonal variation of tho vectorial
cap3.citic:s (,f ,he \'ectors stuJies;
iT) ~he 10 vel of vt1ctodal ca;:l.ci ty Oissociated
wi t