1 Local Innovation for Better Outcomes for Neonates (LIBON) Project PLAN Nepal Child Survival Project XXII Sunsari, Parsa, and Bara Districts in Nepal Final Evaluation Report 30th September 2007 to 29th September 2011 Cooperative Agreement No. GHN-A-00-07-0006-00 2 Report Prepared By Mahesh K. Maskey – Lead Evaluator, Final Evaluation Team Bhagawan Das Shrestha – Field Program Manager – LIBON Dipak Dahal - Monitoring and Evaluation Officer – LIBON Sher Bahadur Rana – Health Coordinator – Plan Nepal Harpreet Anand – Program Manager -- Plan USA Submitted: December 23, 2011 Plan International USA HARPREET ANAND, PROGRAM MANAGER, FIELD PROGRAM SUPPORT Plan International USA, Inc. 1730 Rhode Island Avenue, NW, Suite 1100 Washington, DC 20036 Tel. (202) 223-8325 harpreet.anand@planusa.org Plan International NEPAL BHAGWAN DAS SHRESTHA, FIELD PROGRAM MANAGER Plan International NEPAL Shree Durbar, Pulchowk-3 P. O. Box: 8980 COUNTRY, ZIP CODE: 44700 Tel. + 977 1 5535 560 extensión 135 bhagawan_das.shrestha@plan-international.org i ACRONYMS and ABBREVIATIONS AHW Auxiliary Health Worker ANC Antenatal Care ANM Auxiliary Nurse Midwife BCC Behavior Change Communication BPP Birth Preparedness Package CB-IMCI Community-based Integrated Management of Childhood Illness CB-NCP Community-based Neonatal Care Program CBO Community-based Organization CDK Clean Delivery Kit CDP Community Drug Program CHD Child Health Division (MoHP) CHW Community Health Worker CHX Chlorhexidine CS Child Survival CSHGP Child Survival and Health Grants Program CSSA Child Survival Sustainability Assessment CSTS+ Child Survival Technical Support + DAG Disadvantaged Group DDC District Development Committee DHO District Public Health Office DHS Demographic and Health Survey DIP Detailed Implementation Plan DPHO District Public Health Office DTOT District Training of Trainers EDP External Development Partner FCHV Female Community Health Volunteer FE Final Evaluation FGD Focus Group Discussions FHD Family Health Division (MoHP) FP Family Planning HA Health Assistant HF Health Facility HFMC Health Facility Management Committee HMIS Health Management Information System HQ Headquarters HP Health Post IEC Information, Education, Communication IDI In-Depth Discussions IMCI Integrated Management of Childhood Illness IOM Institute of Medicine KPC Knowledge, Practice and Coverage LBW Low Birth Weight LIBON Local Innovation for Better Outcomes for Neonates LQAS Lot Quality Assurance Sampling (statistical method) ii MCHW Maternal and Child Health Worker MDG Millenium Development Goal M&E Monitoring and Evaluation MG Mothers Group MINI Morang Innovative Neonatal Intervention MNC Maternal Neonatal (or Newborn) Care MNCH Maternal, Neonatal and Child Health MoHP Ministry of Health and Population MOU Memorandum of Understanding MTOT Master Training of Trainers NFHP National Family Health Program NGO Non-governmental Organization NHEICC National Health Education and Information Communication Center NHSP-IH Nepal Health Sector Programme – Implementation Plan NNH Neonatal Health NNM Neonatal Mortality PHC/ORC Primary Health Care / Outreach Clinic ORS Oral Rehydration Solution ORT Oral Rehydration Therapy PHC Primary Health Center PNC Postnatal Care PSBI Possible Severe Bacterial Infection PVO Private Voluntary Organization PWG Pregnant Women’s Group RCSD Resource Center for Sustainable Development (Sunsari NGO Partner) RHC Reproductive Health Committee RHCC Reproductive Health Coordination Committee RHFA Rapid Health Facility Assessment SA Supervision Area SBA Skilled Birth Attendance/Attendant SHP Sub Health Post SLC School Leaving Certificate SM Safe Motherhood STD Sexually Transmitted Disease TBA Traditional Birth Attendant TRM Technical Reference Material TT Tetanus Toxoid UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VDC Village Development Committee VHW Village Health Worker WHO World Health Organization WRA Women of Reproductive Age iii Acknowledgement We express our deep gratitude to PLAN Nepal and PLAN USA for entrusting us the task of final evaluation of Local Innovation for Better Outcomes for Neonates (LIBON) project in Sunsari, Parsa, and Bara Districts of Nepal. In particular, the support of Mr. Donal Keane, Plan Country Director, and Mr. Subhakar Baidya, Plan Program Support Manger is highly appreciated. Our special thanks to Dr. Bal Krishna Subedi, Chief, Policy and Planning Division, MOHP, Nepal, Mr. Parashuram Shrestha, Chief CB-IMCI, Child Health Division, and Dr. Shilu Aryal, Chief, Safe Motherhood Unit, Family Health Division who contributed their experience and expert opinion in the Final Evaluation sharing workshop. We also want to acknowledge the active participation in the FGDs and IDIs by Ms. Naramaya Limbu, Aid Development Program Management Specialist, USAID, Nepal, and Ms. Mangala Manandhar, Senior Public Health Officer, Family Health Division, DoHS, MOHP Nepal during their field visits. We at the same time gratefully acknowledge the kind support, enthusiasm and active participation of all the government staffs and staffs of Plan offices in the district and sub￾district level the district health and public health officers, health facility in-charge, and FCHVs of Wards visited all have shown high motivation and enthusiasm in ensuring data quality of the final evaluation field visit. Finally, we are indebted to the pregnant women, members of mothers groups, the mothers-in￾law, and husbands who participated in the FGDs and IDIs and provided valuable information to the final evaluation team. The collection of qualitative data and triangulation of quantitative data would not have been possible without their cooperation. iv Table of Contents ACRONYMS AND ABBREVIATIONS ....................................................................................... i PART A. EXECUTIVE SUMMARY ...........................................................................................v PART B. INTRODUCTION – PROJECT OVERVIEW .............................................................. 1 PART C. EVALUATION ASSESSMENT METHODOLOGY ................................................... 8 PART D. DATA QUALITY AND USE ......................................................................................12 PART E. PRESENTATION OF PROJECT RESULTS ...............................................................13 PART F. DISCUSSION OF RESULTS .......................................................................................20 PART G. DISCUSSION OF SUSTAINABILITY OUTCOMES ETC .......................................25 PART H. CONCLUSIONS AND RECOMMENDATIONS .......................................................28 PART I. ANNEXES .................................................................................. attached as separate files Annex 1: Results Highlight – Evidence Building ............................................................................. Annex 2: List of Publications and Presentations Related to the Project ........................................... Annex 3: Project Management Evaluation ....................................................................................... Annex 4: Workplan Table ................................................................................................................. Annex 5: Rapid CATCH Table* ....................................................................................................... Annex 6: Final KPC Report .............................................................................................................. Annex 7: CHW Training Matrix ....................................................................................................... Annex 8: Evaluation Team Members and their Titles ...................................................................... Annex 9: Evaluation Assessment methodology ............................................................................... Annex 10: List of persons interviewed and contacted during Final Evaluation ............................... Annex 11: Final operations research report on Chlorhexidine on umbilicus stump ......................... Annex 12: Special reports ................................................................................................................. Annex 13: Project Data Form ........................................................................................................... Annex 14: Annex 14: Grantee Plans to Address Final Evaluation Findings ................................... Annex 15: Grantee Response to Final Evaluation Findings ............................................................. Annex 16: Social Mapping Mat ........................................................................................................ Annex 17: Mother’s Card ................................................................................................................. Annex 18: Govt. of Nepal CB-NCP Final Evaluation Report .......................................................... v A. Executive Summary The Local Innovation for Better Outcomes for Neonates (LIBON) project (2007-2011) of PLAN Nepal is designed to assist the Ministry of Health and Population (MoHP) in reducing neonatal mortality in three districts of lowland Terai region of Nepal. In Sunsari and Parsa, the LIBON project primarily assists the Community-Based Newborn Care Program (CB-NCP) run by the Government of Nepal. In Parsa, an additional Chlorhexidine (CHX) component for prevention of neonatal sepsis was included. Bara does not have CB-NCP or CHX component, so it serves as a learning site for understanding the sustainability issues of child survival programs. The overall goal of the project is to reduce the burden of neonatal mortality in Nepal, which will be reached through the achievement of the following result-oriented objectives: Result 1: Increased Access to Neonatal Health services in Sunsari and Parsa Result 2: Increased Demand for Neonatal Health services in Sunsari and Parsa Result 3: Increased Quality of Neonatal Health services in Sunsari and Parsa Result 4: Strengthened support for Neonatal Mortality reduction in Nepal Several strategies have been adopted by LIBON to achieve the result-oriented objectives, including community-based service delivery to increase ACCESS, and social inclusion to increase EQUITY to meet Result 1; community mobilization to increase DEMAND to meet Result 2; Health systems strengthening to increase QUALITY to meet Result 3; and Stakeholder sharing and collaboration to increase SUPPORT to meet Result 4. The central feature of the LIBON project is to support the maternal and child health activities of the Government, particularly the CB-NCP program, through the Pregnant Women’s Group (PWG) approach. The PWGs are a socially cohesive group of pregnant women operating in a small localized community such as a Ward. These groups meet periodically to discuss issues related to pregnancy and birth, develop birth preparedness plans, and monitor their own pregnancy using a social mapping mat. The PWG is facilitated and supported by Female Community Health Volunteers (FCHVs), and constitutes a sub-group of the larger Mothers groups (MG) of which the FCHV is the member secretary. The LIBON project supports all seven major components of CB-NCP program in Sunsari and Parsa, namely: (1) behavior change communication; (2) promotion of institutional delivery and clean delivery practices for home deliveries; (3) postnatal care; (4) community case management of pneumonia/Possible Severe Bacterial Infection (PSBI); (5) care of low birth weight (LBW) newborns (<2,500 grams); (6) prevention and management of hypothermia; and (7) recognition of asphyxia with initial stimulation and resuscitation of the newborn baby. Training, self-learning tools and necessary equipment form the major components of support. The project was implemented in strong partnership with the District Public Health Offices (DPHO) and various levels of health institutions, with an inbuilt mechanism of bottom-up monitoring. The data generated is further triangulated with qualitative data at the end of the project, obtained through focus group discussions and in-depth interviews conducted with vi PWGs, FCHVs, Mothers-in-Law, Husbands, and the Health post In-charge and District (Public) Health Officer in the three districts. The Technical Intervention components of the project covers a population estimated to be over 900,000 in the three districts; the expected pregnancies per year in three districts were reported as 21,990 in Sunsari, 15,521 in Parsa, and 17,465 in Bara, as per Health Management Information System (HMIS) Section for FY 2011. The overall rapid CATCH indicators improved in the end-line survey. The children aged 0-23 months whose births were attended by skilled personnel increased by 36 percent (Sunsari) and 34 percent (Parsa), a post-natal visit from an appropriate trained health worker within three days after birth also increased by 35.4 percent (Sunsari) and 34 percent (Parsa). Likewise, diarrhea cases in the last two weeks who received Oral Rehydration Solution (ORS) and/or recommended home fluids increased by 48.2 percent (Sunsari) and 39 percent (Parsa) and appropriate care seeking for pneumonia increased by 46 percent (Sunsari) while it decreased in Parsa by five percent. In Parsa where CHX piloting had been carried out, 82.7 percent of newborns had Chlorhexidine application in the umbilical stump at the end of the project compared to none during baseline. The qualitative data also reveals an improvement in health seeking behavior and a reduction in maternal and neonatal health problems since the beginning of the project. This was the response from all the different target groups interviewed. This is also consistent with the quantitative data obtained during final evaluation not only of Sunsari and Parsa but also of Bara district. In Bara, the PWGs that started in 2003 are still running with impressive accomplishments in maternal and child health, despite facing problems during the years of political unrest in Nepal. The achieved results at the final evaluation are indicative of the project’s successful implementation. LIBON’s progress is attributed to many factors that include effective implementation of CB-NCP activities with innovative initiatives such as the PWGs facilitated by FCHVs; strong MOHP partnerships; intensive training and orientation programs; health education sessions on Maternal and Newborn Health (MNH) services at Village Development Committee (VDC) level; public commitments by pregnant women, their mothers-in-law and husbands (decision makers), service providers (health workers and FCHVs) who aid utilization of maternal and newborn health care practices; strong local support from VDCs and other stakeholders, community expansion of birthing centers; and regular review meetings. The fact that this project could continue amidst a most turbulent period of political transition in Nepal point to the merit of the design of the program as well as the determined efforts in implementation. The government policy for recruiting ANMs and health workers locally appears to be the single most important cause for the availability of skilled birth care and expansion of birthing centers, undertaken through community support. Social recognition awards to FCHVs, ANMs, and other key staff based on performance is an important factor in keeping their motivation high. Refresher training of all categories of health workers and an expansion of physical facilities for birthing centers was the expressed demand in all the districts, both in the VDCs that were running birthing centers and those where the communities were aspiring to open them on their own initiative. vii Recommendations  New and Refresher Training for health staff, including FCHVs  Incentives/motivation for FCHVs, ANMs, and other key health staff  Improve delivery of supplies to the community level  Targeted BCC for decision-makers  Respond to demand for birthing centers at the VDC level  Continue support and proper execution of incentive schemes for pregnant mothers and FCHVs  Scale-up PWG approach to all districts  Incorporate PWG model within CB-NCP program  Introduce CHX as a component of PSBI prevention  Replicate the effectiveness of group commitments as a strategy in other MNH programs Table 1: Summary of Major Project Accomplishments Goal - To Sustainably Reduce Neonatal Mortality in Nepal Result 1:Increased access to neonatal health services in Sunsari and Parsa Project Inputs Activities Outputs Outcomes  CBNCP program  Pregnant Women Group approach  MTOT &TOT on CBNCP  Cascade training: MOHP & FCHV  Supply of newborn care medical tools like color coded weighing scale, mucus extractor and bag and mask  PWG formation focusing on disadvantaged groups  Behavioral mapping of utilization of maternal newborn health services by using social map on mat (can be used by an illiterate woman too)  Increased knowledge and skills of management of newborn care at community and health facility  Increased knowledge on danger signs during the pregnancy, at birth, after delivery and newborns  Increased skilled delivery care.  Increased first check by skilled provider - by district  Increased care seeking for critical neonate care  Increased treatment of neonatal infections Result 2:Increased demand for neonatal health services in Sunsari and Parsa viii Project Inputs Activities Outputs Outcomes  PWG approach initiated to disadvantaged groups  Mass health education followed by public commitments  Orientation to district and VDCs stakeholders in PWG  Training on PWG to FCHVs and formation of PWG  Health education on danger signs of pregnancy, at birth after birth and newborn by behavioral mapping mat  Mass health education followed by public commitments on utilization of maternal and newborn health services by decision makers (husbands and mothers-in-law), service providers and pregnant women in a group  Local FM radio broadcasting on dangers sing of newborn and essential newborn cares  260 PWGs and 123 PWGs formed in Sunsari and Parsa district respectively. There are 2,912 members (64% illiterates, 25% Dalit, 38% tribal (janjati) and 2% Muslim)  835 mass health education sessions reaching 11,871 target groups in three districts (25% Dalit, 30% Janjati and 18% Muslim)  Increased ante natal and post natal checkup including newborns  Increased institutional delivery  Increased iron and folic acid tablet consumption Result 3:Increased quality of neonatal health services in Sunsari and Parsa Project Inputs Activities Outputs Outcomes  Baseline, midterm and end line survey by LQAS and Child Survival sustainability  Data collection and analysis of data by sub district wise (Ilaka) and indicators wise. Planning by districts to increased  The action plans prepared and implemented by district health offices  All most all the target of the project (as of DIP) were met or even surpassed in the ix assessment  Follow up after CBNCP training and onsite coaching  Quarterly review HMIS data substandard indicators and Ilakas.  The knowledge and skills of health workers and FCHV on the newborn care and management was assessed and gave on site coaching  288 health workers and 169 FCHVs were onsite coached on newborn care and newborn sick management  Increased monitoring & adjustments based on data end line survey  Result 4:Strengthened support for neonatal mortality reduction in Nepal Project Inputs Activities Outputs Outcomes  Dissemination of best practices of LIBON  Chlorhexidine (CHX) operational research  PWG approach was shared to all regions of Nepal, Nepal Perinatal society, APHA 2011 and GHC 2009  Training on CHX to all health workers and FCHVs in Parsa  Supply of CHX to pregnant women through PWGs and health facility and birthing centers and district hospital  Shared the finding of the CHX ops research to national level  Coverage is highabout 82.7% of newborns in Parsa District had CHX applied to their umbilicusbut compliance (the application of an entire tube of CHX all at once within two hours of cutting the cord) is lower, at 66.4%. Women who belong to PWGs are 1.3 times more likely to apply CHX correctly  Pregnant women group is incorporated in CBNCP program in Sunsari and Parsa  CHX application around the newborn umbilicus stump to be approved as part of the National program in Nepal  CHX drug is also included in Nepal's essential drug list to be supplied by GoN 1 B. Introduction - Overview of the Project Structure and Implementation (i) Project Goals, Objectives and Strategies The Local Innovation for Better Outcome for Neonates (LIBON) project (2007-2011) implemented by Plan Nepal was designed to assist the Ministry of Health and Population (MoHP) in reducing neonatal mortality and meeting the Millennium Development Goal 4 by promoting safe motherhood practices and applying simple low cost approaches to newborn care. The project was implemented in Sunsari, Parsa and Bara districts located in the Terai region of Nepal. These districts are characterized by low socio-economic status, limited access to health services, frequent political unrest, and a substantial population of marginalized, Dalit, and minority ethnic groups. In Sunsari and Parsa, the LIBON project primarily supported the Community-Based Newborn Care Program (CB-NCP) of the Government of Nepal. In addition to CB-NCP, the project in Parsa included an additional component for Chlorhexidine (CHX) application on the umbilical stump for preventing neonatal sepsis. Bara served as a learning site after handover to the MOHP, and was being monitored as a learning site for understanding the sustainability issues for child survival programs; the CB-NCP program was not implemented in Bara district. The overall goal of the project was to reduce the burden of neonatal mortality in Nepal which was divided into three impact-oriented and innovative sub-goals: Sub-Goal 1: To reduce neonatal mortality in the districts of Sunsari and Parsa through the application of an integrated, community-based package of interventions and service delivery strategies. Sub-Goal 2: To promote social inclusion and a fact-based decision making process for the planning and resource allocation of district-based child, maternal, and neonatal programs. Sub-Goal 3: To assist the MOHP and other constituencies in the preparation and use of knowledge, policy, and investment products that will accelerate the reduction of neonatal mortality. These goals were reached through the achievement of following result oriented objectives:  Result 1: Increased Access to Neonatal Health services in Sunsari and Parsa  Result 2: Increased Demand for Neonatal Health services in Sunsari and Parsa  Result 3: Increased Quality of Neonatal Health services in Sunsari and Parsa  Result 4: Strengthened support for Neonatal Mortality reduction in Nepal Several strategies were adopted by the LIBON project to achieve these results, including community-based service delivery to increase ACCESS and social inclusion to increase EQUITY to meet Result 1; community mobilization to increase DEMAND to meet Result 2; 2 health systems strengthening to increase QUALITY to meet Result 3; and stakeholder sharing and collaboration to increase SUPPORT to meet Result 4. The central feature of the LIBON project was its support of maternal and child health activities of the Government, particularly to the CB-NCP program through Pregnant Women’s Group (PWG), a socially cohesive group of pregnant women operating in a small localized community which serves as a political and administrative unit such as the Ward. These groups meet periodically to discuss issues related to pregnancy and birth, birth preparedness plans, and to implement a self-monitoring mechanism of their health seeking behavior using the social mapping mat (see Annex 16 for visuals of the mat). The PWG is facilitated and supported by Female Community Health Volunteers (FCHVs), and constitutes a sub-group of a larger mothers group of which the FCHV is the member secretary. This approach evolved over many years of experience (1998-2006) in implementing USAID-funded child survival (CS) programs by Plan Nepal, and particularly from lessons learned during the second CS program (2001-2006) in Bara, as the program made concerted effort to reach the unreached. In the two districts where the CB-NCP program was instituted, LIBON project’s main activities were focused on supporting the CB-NCP program which also included the provision of Co-Trim tablets from FCHVs and Gentamycin injection from Village Health Worker (VHW) for the early management of Possible Severe Bacterial Infection of newborns. The LIBON project supported all the following seven major components of CB-NCP program: 1. Behavior change communication; 2. Promotion of institutional delivery and clean delivery practices in case of home deliveries; 3. Postnatal care; 4. Community case management of pneumonia/Possible Severe Bacterial Infection; 5. Care of low birth weight (LBW) newborns (<2,500 grams); 6. Prevention and management of hypothermia; and 7. Recognition of asphyxia with initial stimulation and resuscitation of newborn baby. The LIBON project was implemented in partnership with the District Public Health Office (DPHO), Health Posts and Sub-health Posts, with an inbuilt mechanism for bottom up monitoring. LIBON also partnered with non-governmental organization (NGOs) and community based organizations (CBOs). Monthly maternal and child health related data reviews at the sub health post, at Village Development Committee (VDC) level, and at the health post at the Ilaka level were conducted along with quarterly reviews at the district level. These regular reviews were supplemented by baseline, mid-term and end-line surveys using Lot Quality Assurance Sampling (LQAS) to ensure quality of quantitative data. The quantitative data was further triangulated with qualitative data at the end of the project, obtained through focus group discussion and in-depth interviews conducted with PWGs, FCHVs, Mothers-in-Law, Husbands, Health Post In-charge and DPHO Officers in the three districts. The final evaluation report was prepared taking into account both quantitative and qualitative data and a review of the several relevant documents. 3 (ii) Health Care Delivery System of Nepal Nepal’s health care delivery system reaches the community through a constellation of government health institutions, mid-level health workers and female community health volunteers. At the central level, the Ministry of Health and Population is mainly engaged in policy formulation, planning, and monitoring and evaluation. The Department of Health Services is responsible for execution of these policies and implementation of the plan. Currently Nepal is divided into five administrative regions and there are five regional directorates in each of these regions. These regional directorates carry the task of coordination and monitoring of health activities in the districts of the region. There are 75 districts in Nepal and each has either a District Health Office (DHO) or a District Public Health Office (DPHO) which serves as a nodal point for integrated district health system. Each district is further divided into electoral constituencies, each having a Primary Health Center (PHC) with a Physician as In-charge, several Ilakas each having a Health Post (HP) with a Health Assistant as In-charge, and many Village Development Committees (VDCs) with a Sub￾health Post (SHP) and an Auxiliary Health Worker (AHW) as In-charge. The VDCs are divided into 9 wards, each having one (or more based on population) FCHVs who engages in health promotion activities particularly related to maternal and child health. The FCHVs are the member secretary of the Mothers Groups (MG) in the Ward, which hold regular monthly meetings and discuss issues related to health. The PWGs initiated by the child survival program of Plan Nepal form one sub- group of this larger MGs. The FCHVs are supported and supervised by the staffs of Sub-health post such as VHW and Maternal and Child Health Worker (MCHW), who report to them every month about their record keeping. The SHP, HP and PHC also have a mobile arm, the Primary Health Care/Out Reach Clinic (PHC/ORC), which takes primary health care services to the neighborhoods of the 2 or 3 wards at a time every week covering the entire VDC in one month. Many of the pregnancy related checkups and safe motherhood activities are conducted through this outreach clinic. The LIBON project operated in all these levels – coordination with Ministry of Health and Population, Department of Health Services and Regional Health Directorates support to D(P)HO and health institutions at various levels, and FCHV and PWG at the community level. Training and orientation was the major component of support that was provided not only to health professionals and FCHVs, but also to various sectors related to health. Supplies of the equipment and other logistic needs, support to the infrastructure development for birthing centers were also other important areas of support. The population of the three districts together represents approximately five percent of the total population of Nepal. (iii) Trends in Nepal’s progress toward meeting MDGs related to Maternal and Child Health Over the past two decades, Nepal has taken initiatives that have achieved substantial reduction in child and maternal mortality ensuring its progress in meeting MDG-4, and keeping it on track for MDG-5. It has also significantly improved equity of access to health services, particularly that of marginalized castes and ethnic groups, and beginning to reduce the extreme disparities between population of different socio-economic gradient. (NHSP-IP). 4 The goals, result-oriented objectives, strategies and interventions of the LIBON project were consistent with the policies, plans, programs and strategies of the MoHP to reduce child and maternal mortality rate as proposed in the Three Year Interim Plan (2007/8-2009/10), and NHSP-II (2010-2015). Table 2 (below) shows the targets and progress achieved to meet MDG 4 and 5 by the end of 2015. This national context of progress and targets are helpful in understanding the achievement of LIBON districts as they provide a basis for comparison with the national average. The table below demonstrates that for the year 2006, some of the achievement in both maternal and child MDG indicators exceeded the target set for that period. Table 2: Nepal’s Progress towards Millenium Development Goals (MDG) 4 and 5 Indicator Achievement 2006 DHS 2011 2015 1990 1996 2001 Achievement Target (NHSP IP-I, 2007) Achievement Target (MDG report 2010) MDG 4 - Child Health Infant Mortality Rate (IMR) 108 79 64 48 45 46 34 Under-5 mortality rate(Per 1000 live births (UMR) 162 118 91 61 72 54 54 Proportion of one year olds immunized against measles 42 57 71 85 N/A 87.7 90 MDG 5 - Maternal Health Maternal mortality ratio (per 100,000 live births) 850 539 415 281 380 Not available 213 Percentage of deliveries attended by health care providers (doctors/nurse, midwife) 7 9 11 20 18 36 60 Contraceptive prevalence rate (percent) 24 29 39 44.2 N/A 43.2 67 Source: DHS reports and NHSP IP I (iv)Project Location Sunsari district lies in eastern Nepal and Parsa district in the central region, together they constitute a population of over 1.2 million. Bara district also lies in central region with a population of 623,350. Sunsari is recognized as having a more and better trained sub-District level health staff; younger and better-educated FCHVs and more birthing facilities. In addition, in Sunsari the LIBON program was complemented by a full Plan Nepal Core program’s set of health interventions, including CB-IMCI and HIV services. Even in the difficult period, the MOHP and LIBON staff were able to work within a slightly better security situation than in the other two LIBON 5 supported districts. All these factors and the CB-NCP trainings and initial package of supplies to FCHVs and health facilities have contributed to Sunsari’s high performance. In Parsa, the staff is less trained at the sub-District level, and the district has fewer birthing facilities. Unlike Sunsari, the LIBON program in Parsa was not complemented by the full Plan Nepal Core program’s set of health interventions including CB-IMCI and HIV services. The Chlorhexidine program was implemented in this district only, with impressive success. Bara district borders with Parsa, and the two districts share many geographical and cultural similarities. However, Bara is much more rural and underdeveloped compared to Parsa in terms of all the development indicators. It did not have either the CB-NCP or CHX programs, therefore the LIBON project in Bara had limited components. The FCHVs do not receive performance-based incentives provided by the CB-NCP program. Of the three districts, the security situation in Bara was the most severe in affecting MOHP staff where turnover was as much as six times in the period of 18 months before MTE. The situation has improved but the transfer of staff members continues to be a problem. The LIBON project initiated PWG formation in Sunsari in July 2008, almost a year earlier than the implementation of government run CB-NCP (April 2009). There are 260 active PWGs in EOP with a total of 2055 pregnant women members, 23 Birthing Centers and two Emergency Obstetric Care (EmOC) venues in Sunsari. In Parsa the LIBON project started one year later than Sunsari but had the CHX program. There were 123 active PWGs in Parsa in September 2011 with a total of 857 pregnant women members. In these two districts, there are a total of 383 pregnant women groups comprised of 2912 members, among them 64 percent were illiterate, 65 percent were categorized as disadvantaged, and out of that 25 percent were Dalit/Untouchable; 38 percent were Janajati; and 2 percent were Muslims. Parsa has one sub regional hospital and one government hospital to support CB-NCP program. Government is continuing CB-IMCI program in this district. In Bara district, child survival projects were introduced in 1997 and the district completed two such CS projects (1997-2001; 2001-2006). The LIBON project started in 2007. Bara was a learning lab for sustainability issues since CB-NCP was not introduced here unlike Parsa and Sunsari and hence the LIBON project’s activities were also limited. In FY 2012, CB-NCP is being introduced in Bara by the government. The only ongoing activities in Bara between 2007 6 and 2010 were the maintenance of the PWGs and follow-up child survival activities. In these three districts the total direct beneficiaries are 643,161 (Table 3). Table 3: Population characteristics, health status and health service utilization in LIBON districts DISTRICT Total Population Population aged 0-11 months Pop. aged 12-23 months Pop. aged 24-59 months Women of reproductive age (15-49 years) Annual no. of exp. pregnancies % of live births reported as smaller than avg. by mothers % male population literate % female population literate No. of Village Devpt .Committees No. of municipalities No. of sub-districts SUNSARI 733,919 18,837 19,286 56,785 139,344 27,869 18 71 50 49 3 12 PARSA 580,572 15,697 16,617 49,533 110,422 20,742 14 55 28 82 1 12 BARA 652,286 17,680 18,616 55,291 125,053 23,538 14 55 29 98 1 15 TOTAL 1,966,777 52,214 54,519 161,609 374,819 72,149 229 5 39 Source: Plan, 2006; DHS, 2001 and projected for 2007/08 (v) Project Design The LIBON project team included: 2 Program Unit Managers, 2 District Coordinators, 3 Assistant District Coordinators, 1 Monitoring and Evaluation officer, 9 Facilitators, 1 Administrative & Finance assistant, 2 Office Assistants and 1 support staff. A Project Coordinator and Health Coordinator from the central level provided technical backstopping and management of the project at the country office level. A US-based Program Manager provided technical and programmatic support from Plan International USA in Washington DC. LIBON worked in close collaboration with several key partners such as MOHP, USAID, Tribhuvan University Institute of Medicine (TUIOM) for project implementation, sharing of information, feedback, and to conduct training sessions. In order to reach the community and mobilize local stakeholders for the improvement of maternal and child health, the project developed strong supportive mechanisms with MOHP’s 7 CB-NCP program. Training and orientation to government health and related sectors was the major support for capacity building and effective implementation at the district level. These activities constitute the seven components of CB-NCP which are monitored through ten core indicators (Table 4), with a built-in incentive system for FCHV. The safe motherhood program also provides incentives to pregnant women themselves (Table 5). Table 4: Technical Intervention Components and Core Indicators CB-NCP Elements CB-IMCI Elements Neonatal Infection CB-NCP indicator  BCC: Pregnant Women’s Group, self-monitoring pregnant women, facilitated by Female Community Health Volunteers (FCHV), mother’s cards, public commitments by decision￾makers (mothers-in-law) and service providers  Promote institutional delivery and clean delivery practices in case of home delivery  Postnatal care (home visits by FCHVs on 1st, 3rd, 7th and 29th days after delivery)  Community case management of Pneumonia/PSBI at community and health institutions  Identification and management of LBW babies at community and health institutions  Prevention and management of hypothermia at community and health institutions  Recognition of asphyxia; initial stimulation and resuscitation of newborn babies at community and health institutions  Tetanus toxoid to mother  Iron supplements during pregnancy  Skilled Birth Attendance  Hand washing and CDKs during delivery  Place newborn with mother; immediate BF  Drying and delayed newborn bathing  Four ANC visits by skilled staff  Post-partum vitamin A to mother  Knowledge of newborn danger signs  Immediate referral of newborns with danger signs  Albendazole to mother for deworming  Vitamin A during gestation for night blindness  LBW care: kangaroo care, immediate BF  CHX use on umbilicus for both home and health institutional deliveries  Community￾Based PSBI diagnosis, referral and treatment (cotrimoxazole by FCHV followed by gentamycin at an MOHP facility)  Percentage of VLBW/LBW babies among all live births weighed by FCHV  Percentage of newborn receiving care on 2-3 days after delivery  Percentage of newborn receiving care on 4-7 days after delivery  Number of neonatal deaths reported by FCHV  Percentage of newborn recorded by FCHVs with PSBI  Percentage of young infants (0-2 months) with PSBI seen by VHW who completed the full course of Gentamycin  Percentage of women whose home birth was attended by skilled Birth Attendant  Percentage of home deliveries where FCHV attended to the newborn.  Percentage of mother whose newborn was kept skin to skin contact to her immediately after birth where FCHV attended to the newborn  Percentage of mother who breast feed their newborn within 1 hour where FCHV attended to the newborn Table 5: FCHVs’ incentive in CB-NCP program and PW/PN Mothers incentive in Safer Motherhood Program FCHVs (CB-NCP) PW / PN (Safer motherhood) Performance based incentive of NRs 200 - 400 to FCHVs per delivery cases for their presence at birth in home, weighing the newborn, 1st, 3rd and 7th days post natal home visit and finally to close form on 29th days. If institutional delivery need to immediate visit at home as well as 3rd and 7th days home visit and closed form on 29th days. 4 times ANC visit by pregnant women getting NRs 400 and transportation cost during delivery getting NRs 500 in Terai region 8 The USAID Mission/Nepal provided technical oversight to the LIBON project through monthly meetings. Throughout the study period it actively promoted coordination among the partners and stakeholders. The mission’s negotiations with the MOHP supported an active PVO role in the roll out of the CB-NCP, enhancing Plan’s capacity for quality program management. Save the Children (US), CARE Nepal, Helen Keller International, UNICEF and the Nepal Family Health Project (NFHP) II were among the INGOs/PVOs collaborating partners. Monthly meetings, sharing of technical resources and exchange of feedback across the various partners implementing CB-NCP and similar projects played an important role in the successful implementation of LIBON project. Tribhuvan University Institute of Medicine (TUIOM) actively collaborated with LIBON on LQAS training and data collection. This partnership created capacity among TUIOM faculty and students apart from providing LIBON the data in three intervals. Plan USA’s strong technical backstopping and program support was an integral part of the program strategy that provided technical resources, skills development on program as well as finance, monitoring and operations research support to LIBON staff. C. Evaluation Assessment Methodology and Limitations The final evaluation adopted a comprehensive approach by collecting both quantitative and qualitative data The project consistently employed the standard approach of Lot Quality Assurance Sampling (LQAS) for quantitative data collection for the baseline, mid-term and end￾line surveys to assist in mid-term and final evaluation. The availability of the quantitative data using the same sampling method in three points in time provided valuable information for trend analysis of different indicators. The qualitative data used both focus group discussion with target groups and in-depth interviews of key informants. The methods of data collection and their limitations are described here in brief and in detail in Annex 9. (i) Quantitative Data: Lot Quality Assurance Sampling (LQAS) The quantitative survey findings document and update the current levels of knowledge, practice and coverage of pregnant women and mothers of newborns about birth preparedness, safe motherhood and newborn care. Such periodic monitoring helps the program manager to identify better or lesser performing areas and plan accordingly to get better results. It also helps in monitoring and evaluating the progress of the public health intervention. For the purpose of data collection, the three districts were divided into existing DHOs/DPHO Supervision Areas (SAs) - Ilakas (including the municipalities' slums) to measure the achievements and performance results against indicators based on the decision rules. Parsa district was divided into 13 Supervision Areas (12 Ilakas of Parsa DPHO and 1 municipality), Sunsari into 15 SAs (12 Ilakas of Sunsari DHO and 3 municipalities) based on Ilakas of DDCs and DHO/DPHO Supervision Area and Bara district into 7 SAs based on CS-XVII Project final evaluation Supervision Area. A sample size of 19 study subjects with the required characteristics was selected per SA. The number was so decided because if a smaller number was taken then the 9 alpha and beta error would be greater than 10 percent. On the other hand, taking more subjects than 19 would have increased time and cost but not necessarily reduced the margin of error. In assessing coverage, all the samples taken from each Supervisory Area were aggregated in order to obtain a large enough sample size to estimate the proportion in each population subgroup. Total sample size for Bara is 133 mothers (19 households x 7 Supervisor Areas=133), for Parsa, 247 mothers (19 households x 13 Supervisory Areas = 247) and for Sunsari, 285 mothers (19 households x 15 Supervisory Areas = 285). By utilizing coverage benchmark or the baseline threshold for an indicator as a predetermined level of coverage, LQAS applied decision rules as to whether an individual or an intervention area reached the average coverage benchmark/threshold or was above or below it. Limitations of the Sampling - LQAS, though a useful tool in measuring progress of project implementation, provides only aggregate estimates of the districts and quantifies process indicators. (ii) Qualitative Data Review of key documents, Focus group discussion (FGD) and In-depth interview (IDI) A team of final evaluators comprising of district LIBON project staffs, Plan USA, USAID Nepal, Care Nepal, Family Health Division, Regional Health Directorate, District Public Health offices, community and external consultant collected the qualitative data by visiting the three districts (Table 6). The following steps were taken for collection of the qualitative data. The main objective of the data collection was to triangulate the findings of quantitative survey with the observation and inputs from the beneficiaries, key informants and service providers in the project districts.  Review of key documents  Team planning meeting with key project staff 10  Development of tools for FGD and IDI for key target groups, informant and stakeholders.  Debriefing and feedback on tools from Country Management Team (CMT)  Field work for data collection – 3 districts (Sunsari, Parsa and Bara)  Preparation debriefing presentation (including quantitative and qualitative information) to national stakeholders  Drafting and finalization of report Before the FE team held a meeting to plan field visit and develop tools to gather qualitative data, several documents were carefully reviewed by the final evaluation team such as USAID guidelines for Final Evaluation, Detail Implementation Plan (DIP), Final LQAS and CSSA report, Mid-term Evaluation Report, Plan Nepal Annual reports, Chlorhexidine (CHX) Report. The VDC and wards were selected to have as much variation as possible in terms of presence and absence of birthing center, PWG, CB-NCP, CHX application. (See the matrix below). The final evaluation team selected two VDCs per district: one that had a birthing center and another that did not. Within these two categories, the team also visited three VDCs with PWG groups and one that did not have a PWG. Among them, two VDCs had a CHX program and other two did not include a CHX program. All the selected VDCs for the qualitative evaluation are middle-range VDCs (i.e. neither high nor low performing). All together 6 FGD and 5 IDI were conducted in each of the districts with six different target groups and key informants: two each for PWG/MG (FGD), Mothers-in-law (FGD), Husband (FGD), FCHV (IDI), Health facility in-charge (IDI), and one each for DHO/DPHO(IDI). It is a common practice in Nepal that the decision about pregnancy care and child birth is taken by the mothers-in-law or husband rather than the woman herself; in order to gain the perspectives of these decision makers, the final 11 evaluation team interviewed both these groups. The evaluation team was divided into five sub￾groups for data collection. For consistency purposes the team leader/facilitator of sub groups remained the same. Informed verbal consent prior to initiating each IDI/FGD was taken. The field visit was completed in 9 days from 10-18 September, 2011. Three days were spent per district, first half of each day for field visit and data collection; second half of the day for debriefing between team members and data quality check. The findings were shared in a final evaluation sharing workshop. Table 6: Field Data Collection Visit Dates Activities / District Sunsari – DHO Parsa – DPHO Bara – DHO Visited Date 10 – 12 Sep 13 – 15 Sep 16 – 18 Sep VDC Chimdi and Sonapur Madhuwan Mathaul and Bindabasini Chhatapipara and Karaiya FGD PWG/MG Mothers-in-law /Husband PWG/MG Mothers-in-law Husband PWG/MG Mothers-in-law Husband IDI FCHV Health facility in-charge FCHV Health facility in-charge FCHV Health facility in-charge IDI DHO DPHO DHO Limitations of the Method – During the first VDC visit in Sunsari, the final evaluation team attempted to interview the mothers-in-law and husbands within one FGD group. This was immediately recognized as problematic since the husbands in the group were not comfortable speaking up in front of the women. Moving forward, the FGD for the decision makers was separated into two (one for the mothers-in-law and the other for husbands) allowing for greater male involvement in the FGD process. Furthermore, due to time and resource constraints, not all variations seen in the matrix were captured in the characteristics of the communities interviewed. Lastly, local language presented a partial barrier which was overcome with the help of interpreters. The evaluation tools were developed centrally and revised in the field, especially after the initial VDC visit which was used as a pre-testing site. 12 D. Data Quality and Use (i) Data Processes Overview LIBON project followed the CB-NCP monitoring guidelines developed collaboratively by all implementing partners in its two CB-NCP Districts of Parsa and Sunsari. It also conducted two additional data quality checks: survey and CSSA data collection at baseline, midterm and end of project. However, HMIS data was used to evaluate the LIBON project only in CSSA tools. Since the LIBON project uses only CB-NCP forms, survey and CSSA, and internal quality control mechanisms (e.g., management and financial reviews) to assess its progress; assessment of HMIS data in terms of CB-NCP is not done in mid-term or final evaluation. However, LIBON staff were actively involved in various monthly reviews of HMIS data with their MOHP counterparts for service quality control as part of the District-level capacity building and system strengthening. This collaborative monitoring and quality control efforts that LIBON staff conducted with their MOHP counterparts was intended to assure quality access to services. LIBON and MOHP Staff at each level (SHP; HP/ORC; Ilaka; District) reviewed HMIS indicators to monitor progress against targets, understand the constraints at the facility levels, and support the development of action plans to remedy any shortcomings. The LIBON project employed the LQAS sampling methodology and trained IOM faculty and students and MOHP staffs. After each round of surveys, data was processed by an external consultant and then discussed extensively in a workshop with all implementing partners to evaluate progress, identify challenges, and develop further action plan. In final evaluation qualitative data were collected for triangulation and validation of the findings obtained from quantitative data. Because of adequate sample size, precision error below 10 percent and strict protocol observed during data collection, analysis, monitoring and review meetings, the quantitative data overall appears to be of high quality. The qualitative data obtained in final evaluation is supportive of the findings of quantitative data. (ii) CB-NCP monitoring system A major strength of the CB-NCP monitoring system is that it collects census data of pregnant women and the services and behaviors they engage in at the household and community levels. This is invaluable information for the successful implementation of a community-based maternal and neonatal survival program in a country where roughly 65percent of the women still deliver at home. The act of counting pregnant women in their community has been an empowering process: women see it as important and worthy of attention. This positive attitude is reinforced by the self-monitoring technique used in the PWG: monitoring themselves in front of their peers has proved a powerful mechanism for data quality and BCC adherence. Making a collective effort in birth preparedness planning has increased their social cohesiveness, reduced the social distance between different castes and ethnic groups and empowered them to become more assertive about their right to health. 13 (iii)Neonatal Death Records With the new CB-NCP PNC, any neonatal deaths that occur in a facility go into that facility’s records and are submitted to the CB-NCP pilot M&E system which is then linked to Neonatal Health Information System (NHIS) data base. These neonatal deaths are discussed with other CB- NCP outcomes at the SHP level on a monthly basis, and any neonatal deaths recorded are discussed again at the monthly Ilaka Review Meetings. Such information is still inadequate for comparison and trend analysis since the records are available only from the last year. However, this practice may prove a major step in community based surveillance system of monitoring reduction in neonatal deaths. (iv)Qualitative Data During the final evaluation the field validation exercise to explore the qualitative side of the quantitative indicators proved an invaluable source of information in understanding the “why” and “how,” about the progress made and formulating recommendations. Experience of final evaluation field experience and also of MTR is suggestive that while qualitative issues are drawn from field staff experience and discussed verbally in monthly review meetings and reflected in action plans, the project did not employ a formal qualitative monitoring mechanism which could have been vital in turning all this data into useful decision-making information during the life of the project. E. Presentation of Project Results (i) Qualitative results Analysis of qualitative data is presented in the sections that follow, highlighting key observations, areas for improvement, and sustainability of the program. Issues common to Sunsari and Parsa districts are first described, followed by key observations in individual districts; the observation on Bara is described separately. Field visits by VDC resulted in specific observations and characteristics which are expressed in the flow chart of the matrix in Annex 6. These characteristics are summarized in the table below. Table 7: Field Observations during VDC visits, by district, conducted during FE Sunsari District Sonapur – Sub health post Chimdi – Sub health post  Community supported birthing center  Government supported birthing center  Marginalized “Dalit” community  Muslim community  Musahar ward has pregnant women group  Muslim ward has pregnant women group  CB-NCP program  CB-NCP program  No Chlorhexidine (CHX)  No Chlorhexidine (CHX) 14 Parsa district Madhuwan Mathaol – Sub health post Bindabasini – Sub health post  Community supported birthing center  No birthing center  Mixed community  Marginalized community  No pregnant women group  Pregnant women group  CB-NCP program  CB-NCP program  Chlorhexidine  Chlorhexidine Bara district Chhatapipara – Sub health post Karaiya – Sub health post  No birthing center nearby (closest is 15 minute drive)  No birthing center nearby (closest in Birgunj or Kalaiya)  Mixed community  Mixed community  Pregnant women group  Pregnant women group  No CB-NCP  No CB-NCP  No CHX  No CHX (ii) Quantitative findings Quantitative data is presented by categorizing it according to the four expected results: 1. Increased Access to Neonatal Health services in Sunsari and Parsa, 2. Increased Demand for Neonatal Health services in Sunsari and Parsa 3. Increased Quality of Neonatal Health services in Sunsari and Parsa; and 4. Strengthened support for Neonatal Mortality reduction in Nepal. Detailed monitoring and evaluation matrices obtained from quantitative data, for each district, are included in Annex 6. In this section, some selected indicators are highlighted through bar graphs below. The survey data utilized 0-5 month’s old children for project core indicators denominator, and Rapid CATCH indicators utilize mothers with 0-23 month old children for denominator. The quantitative data show that the project exceeded the set targets for most of the indicators. For instance, the comparison of baseline and end line data in Sunsari reveals the increase in women knowing two dangers signs during delivery went from 17.2 percent to 82.1 percent, far exceeding the set target of 45 percent for this indicator; similarly, in Parsa knowledge of at least two danger signs post delivery increased from 27.5 percent to 96.8 percent, exceeding the target of 40 percent for this target. The graphs that follow present more such findings. In Bara district, child survival projects were introduced in 1997. Bara completed two such CS projects (1997-2001; 2001-2006). The LIBON project started from 2007 therefore the comparison of quantitative data is between the end-line data of CS project (2006) with end-line 15 data of LIBON project (2011). There was political unrest in Bara district after 2006 and Plan Nepal had halted all the activities for more one years in Bara. Thus some indicators decreased in Bara during the MTE but it was maintained or increased in the end line survey. Sunsari District 16 17 Parsa District 18 19 Bara District Although the end-line data for Bara, the control site, implies poor program performance when compared to baseline, it should be noted that this area office experienced problems during political unrest and had to stop functioning, as reflected in the extremely low coverage numbers in MTE; it is still a credit to the program that since mid-term data collection in 2009, the coverage numbers have steadily increased, as seen in final evaluation numbers. 20 F. Discussion of Results (i) Contribution towards Objectives Increased Access to Neonatal Health (NNH) Services in Sunsari and Parsa – the first objective seems to be well substantiated by both the quantitative and qualitative data. As the graphs above demonstrate, the achievements exceeded the set targets and increased significantly from the baseline status. PWGs have served as a critical entry point for the target groups and beneficiaries to increase access to health education and maternal and newborn health (MNH) care services facilitated by FCHVs, particularly for the marginalized population. Increased availability of trained personnel, increased awareness of beneficiaries at community level and proximity of birthing center in the community appear to have a synergistic effect on increased institutional delivery. Another crucial factor for availability of SBAs/ANM in the birthing centers is the Government’s existing policy that allows HFOMC and VDC to hire required health personnel at community level with their own resources. Incentives paid to FCHVs and pregnant women for institutional delivery have also contributed immensely for increase in institutional delivery. Increased Demand for NNH Services in Sunsari and Parsa - the second objective of the project also increased a great deal in terms of demand for capacity building and services (refresher training on CB-NCP), for expansion of PWGs to other wards/VDCs in the district, and for SBA training by ANM/newcomers/other health staff. Demand for expansion of birthing centers in sub-health post has increased tremendously. Increased Quality of NNH Services in Sunsari and Parsa – the third objective was achieved through massive training and orientation programs, a referral system, and refresher trainings. Prompt supply of a CB-NCP kit with essential equipment (color coded thermometer and weighing scale, mucus extractor and resuscitation bag and mask), regular supplies of CB-NCP materials such as reporting and recording format, mother’s cards, and sensitization of local health care provider for better care and observation of patient rights, especially of marginalized communities all contributed to this increase in quality. Strengthened Support for NNM Reduction in Nepal – the fourth objective was primarily achieved through coordination with different MNH stakeholders described in the section above (overview of the project), social recognition of FCHV and pregnant mothers based on performance, and better supervision and monitoring as per CB-NCP guidelines. The Action Plan developed with other stakeholders also contributed in strengthening support for NNM reduction. (ii) Contextual Factors The project period was a turbulent period of political transition in Nepal. The historical people’s movement of 2006 replaced the Constitutional Monarchy with a Democratic Republic, and the seven-party alliance that led the movement was in the government for a period of two years. The election of constituent assembly was held in 2008 in which the former rebels emerged as the largest party and led the new government. The transition from Monarchy to Republic was conflict ridden, and the “Madhesh” movement in Terai region of low land Nepal erupted at this 21 time. The interim constitution was amended several times to accommodate demands of the new situation. The government was short lived and had to resign over a row with the Army Chief. The fluid situation of the transition period further escalated in 2009; thereafter, began to normalize. Frequent turnover and many vacant posts during the leadership transition in the government became a norm, including in the MOHP. For a period, the security situation in Terai deteriorated and the government workers avoided going there because of insecurity. Bara and Parsa districts were relatively more affected than Sunsari. In spite of adverse situation, LIBON continued to work at the local and district levels in the three districts in the Terai with socially and economically disadvantaged groups. Even when MOHP infrastructure was limited and in poor condition, the MOHP facility staff continued their commitment to reducing maternal and neonatal mortality, positively acknowledging the contribution of the LIBON project supported trainings in enhancing their technical skills in CB￾NCP and other MCH related activities (MTE, 2009). They also mentioned that LIBON’s ongoing supportive supervision helped to keep the focus on services, health behavior changes needed and other efforts for measurable results. In the final evaluation, when the situation had normalized for about two years, they expressed similar sentiments in all the districts. (iii)Pregnant Women’s Groups The FGDs among PWG members conducted during the final evaluation in all the districts demonstrated high recall rates of CB￾NCP package components and key interventions, and reported good relations and services with providers of all levels, from FCHVs, ANMs and VHWs, and facilities (ORCs, SHPs/HPs and PHCs). The PWs were aware of the Kangaroo care method (skin to skin contact) of protecting newborns from hypothermia. The women regularly monitored their own health seeking behaviors through monthly meetings and social mapping mat used during PWG meetings. By sticking colorful tikas (tiny adhesive stickers) for each activity (ANC, iron tablet intake, PNC, tetanus vaccinations, etc.), even the illiterate women were able to follow the time schedule to ensure a healthy pregnancy term. The PWG members also did not hesitate to complain against a particular health staff in front of his superiors for his rude/unfriendly behavior. To have witnessed such expression from the women in a Muslim community during the FE team field visit is evidence that PWG is empowering women in Sunsari. Similar complaints were also heard in Parsa from health staffs and FCHVs. The PWGs in Bara, which started in 2003, appear to have contributed to making larger mothers groups more active as it empowers pregnant women and create a healthy competition among the peer pregnant women for positive behavior change, on utilization of maternal and child health care services. 22 (iv)Positive impact of the Government’s CB-NCP Program on LIBON’s efforts The “mother’s card” (referred to as “Jeewan Suraksha Action Card”) has educated mothers about the Birth Preparedness Package (BPP) and danger signs. The card is used by Government in all (75) districts of Nepal. The card is an A4 size pictorial card that is green in color on one side and red in color on the other side. On the green side are the illustrations of antenatal care, birth preparedness plan, post natal care and neonatal care; the red side has illustrations of danger signs during the pregnancy, at birth, after delivery and for neonates (Annex 17). LIBON project used the mother’s cards for self-education and monitoring of the pregnant mothers through the facilitation by FCHVs in the PWG/MG monthly meeting and also in BPP health education programs to the decision makers (mothers-in-law and husbands). It is followed by a public commitment, by pregnant women, decision makers and service providers and FCHVs, to carry out these activities in their own lives. For example pregnant women say “I will do 4 ANC checkups”, mothers-in-law say “I will send my daughters-in-law four times for ANC checkup”, and health workers say “I will provide four times ANC checkup”. The card is distributed to each pregnant woman to be hanged in their room as a reminder. Pregnant women bring the card in the monthly PWG meeting. The card is very useful material for health education and as a reminder of the activities to be carried out. It can be used by illiterate pregnant women too. Moreover, the increase in institutional deliveries has increased demand for Safe Birth Attendants (SBAs) and birthing centers at the VDC and district level. The proximity of the birthing center to the VDC has a positive impact on the number of institutional deliveries in these areas. VDCs increased support in staffing has been reported as a major factor in promoting community initiated birthing center. In terms of strengthening health systems, the VDCs in general are increasing their support for FCHVs and recruiting of ANMs in health posts. Such initiatives were facilitated by the government policy of allowing Health Facility Management Committee to hire required health professionals by their own resources. (v) Positive behavior change as a result of CB-NCP and PWGs The response from all the focus groups and key informants were emphatic in asserting tremendous improvement in the following pregnancy and new born related KPC: ANC and PNC visits; Iron consumption; TT immunization; Recognition of danger signs; BPP mass campaign; Asphyxia management; Institutional delivery; KAP of key decision-makers (specifically, mothers-in-law) in encouraging pregnant women to attend PWGs and improved nutrition during pregnancy/ post-partum period. Overall, the qualitative data suggests that there was an improvement in health seeking behavior reduction in maternal and neonatal health problems since the beginning of the project; this 23 impression is consistent with the quantitative data obtained during final evaluation not only of Sunsari and Parsa but also of Bara district (Annex 6). In addition to these observations in Sunsari, the active participation of the women during the group discussions presented as one indication of the role PWGs have played in empowering them and raising their consciousness of their health rights. They were openly critical about behavior of some health staffs in front of the health authorities. Here, larger mothers groups are very supportive providing them financial loans for birth preparedness. The social behavior mat is an effective self-monitoring mechanism for pregnant women to take charge of their own health throughout their pregnancy and during the post-partum period, particularly among the marginalized populations. In Parsa, the social distance between marginalized groups and higher classes had noticeably reduced due, as it appears, to PWGs. While the PWG meetings used to be held in segregated groups in the initial periods, the meetings are held now mixing closely together. The women from higher social classes are now coming to the local health facilities (in the past, they preferred private clinics/hospitals). Use of CHX was reported to be near universal. In the past, women applied Dettol, (unidentified) powder, oil, turmeric, etc. on the umbilicus. This accords well with the CHX coverage (79 percent) reported by the quantitative data. (vi)Health volunteers: FCHVs During in-depth interviews with FCHVs in Sunsari and Parsa, it was found that they had been trained by the CB-NCP program. They were regularly conducting monthly mothers group / pregnant women group meeting in their community. During the meeting disadvantaged pregnant women, postnatal women and mothers-in-law and adolescent girls also participated. In the meeting they discussed about CB-NCP: especially sign and symptoms of infection of newborn and its management as well as nutrition, proper breastfeeding etc. After the CB-NCP program implementation, there was an increase in institutional delivery. Now initial management of low￾birth weight babies and birth asphyxia is taking place in the community itself. The FCHVs were regularly visiting and supporting women who delivered at home and in case of institutional delivery, jointly visiting with pregnant women to the birthing center. They also made three post natal home visits on 1st, 3rd, and 7th day and weighing newborn baby and finally on 29th day for closing the form. Overall, they were motivated to provide services for saving the lives of women and newborns. Now community people have more trust and they seek FCHVs’ advice and suggestions more frequently. The interviewees also reported that the CB-NCP and BPP health education mass campaign program is increasing the awareness through active participation and mobilization of pregnant women and decision makers. Both groups learn about danger signs during pregnancy, delivery, postnatal and newborn as well as EP, FP, pneumonia, CDD, nutrition and regular check-up of postnatal and newborn baby. They have demanded refresher training for health workers and FCHVs on CBNCP, required regular supplies, ambulance service, expansion of birthing center, exposure visit to exchange learning and sharing, some essentials such as umbrella, torch light and bi-cycles. 24 (vii) Decision Makers Mothers-in-law and Husbands are the decision makers for the pregnant women and decide whether they should go or not to go for antenatal checkup, birth at health institution and post natal check-ups of mother and newborns. During the mid-term evaluation, most of the mothers-in-law reported that they make the final decision on whether or not their daughters-in-law should have ANC checkup and institutional delivery in health facilities as well as post natal check including that of newborns. Thus, mothers-in-law are the gatekeepers who have a decisive role on whether their daughters-in-law utilize maternal and newborn health services. As per the LIBON MTE recommendation, the health education on ANC, natal care, post natal care and newborn care for pregnant women was expanded to decision makers followed by their public commitments. The FE found that the mothers-in-law are regularly attending PWG/MG meetings, are making public commitments for BP plan and are encouraging their daughters-in-law to seek proper care during pregnancy, delivery and post natal period. The husbands said that they now allow their wives to attend PWGs to learn about maternal and newborn health. They felt that the orientation about CB-NCP and safe motherhood should be given to all who are responsible for taking care of pregnant women. They had observed when home delivery was common, many neonates died. They also pointed out that the behavior of pregnant women has changed. They are visiting clinics for antenatal checkups, consuming iron tablets during pregnancy and after delivery, mothers go to FHCV after delivery for postnatal care and most of the children's births take place in birthing centers. Many of the husbands learn about BPP through their wives after coming back from mother’s group communication sessions. During a final evaluation field visit a husband even fetched a mother’s card to present to the evaluators. Many of the husbands were aware of what to do when there is bleeding and abdominal pain, and willing to take their wives to specialized centers such as Narayani Sub-regional Hospital, Birgunj in case of Parsa District. However, they were not aware whether FCHV visited to delivered women after delivery since usually they are usually outside home for the work either in factory or other labor works. In Parsa they were aware of the need to apply chlorhexidine after delivery on the umbilical stump of the newborn. (viii) DPHO and Health Facility In-charge The D(P)HO staff in all three districts said that the maternal and newborn health status improved after LIBON project. The ANC, PNC and institutional deliveries all increased. The staff gained the new knowledge and skills of newborn cares. The use of pregnant women group behavioral mapping and mother’s cards use is good and needs to be replicated in all wards of districts. The BPP health education for pregnant women and mothers-in-law and father decision makers followed by public commitments is effective. The services provided by the health care facilities constitute supply side services. The CB-NCP supplies and the essential medicines were regularly available in health institution/birthing center in both Sunsari and Parsa. The FCHVs were also getting their incentives in Sunsari, but in Parsa the FCHVs were not getting the actual amount of money. Sunsari possessed some model ANMs 25 who came from MCHW background but got the training of an ANM and then SBA training and were available to the service of community any time of need. The MOHP staff, working closely with LIBON staff, has raised awareness levels by health promotions and Outreach Clinics in all the districts which in turn is credited with the increases in facility deliveries. (ix)Quality Assurance For assuring quality of service LIBON project had initiated joint DPHO/LIBON monthly review meetings at the Ilaka level to support facility staff and FCHVs in acquiring additional skills and receive direct supportive supervision by D(P)HO and LIBON staff in all the three districts. (x) Challenges The unavailability, or high cost of transport when available, appears to be the most serious limitations for institutional delivery. Many women reported sudden labor pain and so have less time to reach to the birthing center. Also the difficulty in recalling the expected date of delivery is not accurate, thus increasing uncertainty regarding the time of delivery. Additionally, the high level of staff turnover within the District MOHP continued to be a vexing problem in all the three districts. The DHO who accompanied the FE team in the field was recently posted, both in Sunsari and Parsa but both were highly motivated to bring a positive change in the district. The need for refresher training was mentioned by all respondents as a need for expansion and for the critical sustainability component. G. Discussion of Sustainability, Scale-Up, Equity, Global Learning Contributions (i) Progress towards Sustainable Outcomes Sustainability in primary health care projects is a contribution to development of conditions enabling individuals, communities, and local organizations to express their potential, improve local functionality, develop mutual relationships of support and accountability, decrease dependency on insecure resources (financial, human, technical, informational), in order for local stakeholders to negotiate their respective roles in the pursuit of health, wellbeing and development beyond project intervention (CSSA FE report p.97) The LIBON project is an outcome of Child Survival Project that have been expanded and scaled up 1995 onward, addressing sustainable issues involved in the project implementation, carrying services to marginalized children, mothers and communities of Nepal in open social laboratories with joint collaboration of various relevant actors, stakeholders and communities. The shift was from “project thinking” to “development thinking”. The tool to measure sustainability of the project from this perspective- the CSSA dashboard - was developed in the Sustainability initiative study in 2000. CSSA is measured as an aggregate of several indexes such as Health 26 Outcome, Health Services, Organizational Capacity Index, Organizational viability index, Community Capacity Index, Environmental Index. The changes in these indexes show that in Sunsari there was a steady progress from the baseline of 2008, which became more noticeable in the post-MTE period. The CSSA workshop done in August 2011 suggest highly encouraging trends: Health outcome index increased to 58 percent from 45 percent; Health services index 81 percent from 57 percent; Organizational capacity index 60 percent from 45 percent; Community Capacity index 80 percent from 40 percent; Environmental Index 54 percent from 35 percent. The component number 4 organization viability index only slightly increased to 47 percent from 43 percent (see Annex 6). These assessments suggest that while other indicators are making good progress, in Sunsari, the need is to focus more on organizational viability. In Parsa there was not much change from the baseline of 2008 to MTE of 2010, except for the indices of Organizational viability and Health services. In the final evaluation it was assessed that Health outcome index increased to 75 percent in 2011, from 54.9 percent in 2008, Health services index increased to 61 percent from 52 percent, Organizational capacity index increased to 72 percent from 47 percent and Organizational viability increased to 47 percent from 16 percent. Parsa need to give more attention to community capacity index, organizational viability index and health services index. In Bara, except for health service index, all sustainability indexes decreased in the MTE period as compared to the baseline. But in the 18 months period thereafter, all except health outcome index and organizational capacity index have improved dramatically. The health service index increased to 73 percent in 2011 from 63 percent in 2006, and the environmental index increased to 50 percent in 2011 from 32 percent. While Organizational viability and community capacity are maintained as 54 percent and 76 percent in 2011 compared to 51 percent and 67 percent. But achievement of Bara is more noticeable when FE sustainability index are compared with that of MTE, 2009 – the red line in the CSSA dashboard diagram (Annex 6) shows the fast recovery Bara made when situation normalized. Another important landmark in ensuring sustainability is the development of MNH Action Plan. The project implementation through the government health system in coordination with other stakeholders is critical to ensuring sustainability and synergy and avoids duplication of efforts. Since PWG is a low-cost intervention with simple technology that could be carried out by illiterate mothers, its potential for scaling up is well recognized by the government authorities as well. The MNH Action Plan (CSSA July-August 2011) prepared by Plan Nepal, government and other stakeholders recommends several steps for ensuring sustainability. It also quotes the July 2008 MOU between Plan and the MOHP where MOHP agreed to “maintain and sustain all interesting results” achieved by Plan in Bara (Annex 22). (ii) Contribution to Replication or Scale Up The Pregnant Women’s Group (PWG) approach was developed and refined in Plan’s previous two child survival projects in Bara and extended to Sunsari and Parsa through LIBON project. More than 75 percent of the PWGs formed in Bara are operating nearly four years after the Plan CS support stopped. PWGs are not only sustaining themselves by establishing funds to run their meetings but also becoming one compelling reason for regular Mothers groups meetings. Since 27 the PWG approach is low cost and employs simple technology for self-monitoring of good practices in pregnancy and newborn care, it is a strong candidate for incorporation in CB-NCP and scaling up in other areas. The use of Chlorhexidine on newborn umbilicus stumps to prevent infection in Parsa is one of four pilot Districts piloting CHX for the MOHP Nepal. The final evaluation of LIBON project shows that it is well accepted in Parsa. This is highly relevant as neonatal sepsis is one of the top causes of neonatal mortality in Nepal. Supplemented when necessary by anti-bacterial (Co-trim and Gentamycin injection), CHX can play a crucial role in prevention of Neonatal sepsis. The CHX program can be scaled up to other districts of Nepal by integrating other programs like CBNCP and its coverage can be increased by supplying it through government existing health system like hospitals, health facilities, birthing centers and from community health volunteers in the monthly pregnant women group meeting. The near universal acceptability of CHX appears to be due to the fact that it fitted into the prevailing culture of applying remedies on the umbilical stump. (See Annex 11). (iii) Attention to Equity Attention to equity by social inclusion was one of the five main strategies of LIBON project. From its very inception it targeted the marginalized community and gender. Dalit and other disadvantaged communities and persons in geographic areas are usually located far from health facilities with limited access of health services. The social distance also is substantial. As noted above, the PWG approach lessened the social distance among the various ethnic groups and increased social mixing and cohesiveness, thus empowering the marginalized community and minority ethnic groups. (iv)The Role of Community Health Workers FCHVs are the key link and prime mover that provide support and services to the PWG. FCHVs comprise the non-salaried volunteer cadre with responsibility of health promotion in every ward and are selected from within the Mothers Group. They are trained, supported and respected by the MOHP and the community. FCHV are not government staff: they are volunteers selected from Mothers Groups. The MOHP recently established a performance based incentive scheme in relation to CB-NCP for the FCHV. The plan is to provide stipends to reward their work in MNH care on the basis of their job performance. To supervise and support the FCHV, there is one MCHW (now called ANM) and one VHW (now AHW) in each health facility: they provide support and supervision to the FCHVs. Over the years FCHV have gradually assumed greater importance in community health approach becoming its mainstay. And they are going to remain as the foundation on which the health care structures are built. The MOHP and all the stakeholders working in the field of MNH recognize the importance of the FCHV, so their continued support after the project end is likely. With the expansion of government and community supported birthing centers, the importance of ANMs with Skilled Birth Attendant training has attained great importance and prestige in the 28 eyes of local people. The SBA policy aims to train at least 7000 SBAs by the end of 2015. However this number may increase as the communities are demanding more SBA training to expand birthing centers at their own initiative. (v) Contributions to Global Learning CHX is well accepted for its ease of application and minimal side effects. The project as yet cannot evaluate how much reduction happened in neonatal sepsis/PSBI due to its application since it was implemented for just one year and we have no baseline information on PSBI. Studies have shown that immediately cleansing a neonate’s umbilicus with 4% chlorhexidine (CHX, or kawach in the vernacular) reduces the rate of infection and, in consequence, of neonatal mortality by about 23%. Qualitative interviews with health staff/FCHVs and records of neonatal deaths suggest that neonatal infection might have decreased. Where CHX application is being implemented it is desirable to have a baseline of incidence of neonatal infection. The Pregnant Women’s Group model is a strong candidate for contribution to global learning and adaptation since every community has and will have pregnant women in need of ANC and care of the newborn. However, in those countries where the decision makers are still mothers-in￾law or husbands, ensuring their involvement is crucial for participation of their daughters-in law/wives in the PWG. (vi) Dissemination and Information Use The PWG approach was documented as a best practice and shared at national and international levels. The PWG video in English and Nepali was produced in 2009 and also by Plan Head Quarter in 2010. The web link of the video is http://plan-international.org/where-we￾work/asia/nepal/what-we-do/our-successes/saving-babies-lives. The PWG approach was selected for a panel presentation during the GHC 2009 Annual Conference in a panel entitled “Better Beginnings: Improving Neonatal Outcomes, and for the panel hosted by ICRW at the 2010 Women Deliver Conference in Washington DC. An article describing this approach was published in the journal of Indian Council of Medical Research (Maskey et. al, Jan 2011). H. CONCLUSIONS AND RECOMMENDATIONS The LIBON project achieved significant success over the 4-year implementation period amidst a turbulent period of political transition in Nepal. Numerous factors, prominent among them being the following, contributed to the success of this project:  Effective implementation of CB-NCP activities using the PWG model;  Active participation of FCHVs in facilitating PWG meetings;  Strong MOHP partnerships;  An intensive training and orientation program;  Strong local support by some VDCs and other stakeholders;  Community expansion of birthing centers; and 29  Regular review meetings. Presented below are programmatic, technical, and policy level recommendations for future action: New and Refresher Training for health staff, including FCHVs: During the qualitative final evaluation process, respondents highlighted the need for the expansion of CB-NCP training for municipality FCHVs and newcomers (local hires from VDC, health workers, lab technicians, and new FCHVs). In addition to new trainings, a need for refresher trainings on CB-NCP for all staff, including FCHVs was also highlighted as the current situation only allows for refresher trainings to a limited and random ten percent of FCHVs Incentives/motivation for FCHVs, ANMs, and other key health staff: The positive role of social recognition awards as incentives to motivate FCHVs, ANMs, and other key health staff was an important finding during the final evaluation process. The in-depth interview process with FCHVs demonstrated that the Government of Nepal’s incentive scheme for FCHVs served as a motivator for existing staff. As demonstrated during the Sunsari visits, ensuring the Performance Based Incentive (PBI) of NRs 200-400 for FCHVs for PNC home visits would keep the morale of local volunteers high. Continued incentive schemes combined with increased supervision and support from higher levels such as the district, regional, and central levels would ensure proper assessment of performance based incentive and awards. Improved delivery of supplies to the community level: There is a need for greater coordination in distribution of key tools from the DHO down to the health posts and FCHVs. This was noted especially in terms of the supply of mother’s cards for PWs through the government health system via the FCHVs. Targeted BCC for decision-makers: During the FGDs with the mothers-in-law, it was found that not all mothers-in law in the community send their daughters-in law for PWG meetings, even though the trend is improving. Also, male involvement was limited during pregnancy and many men consider pregnancy and child bearing as a domain limited only to women. Increasing male involvement may need further focus in future programming. Respond to demand for birthing centers at the VDC level: The need for a local birthing center at the VDC level was expressed in all three districts. The demand was especially acute in VDCs where there was no nearby birthing center and the distance to the closest hospital was great. Continued support and proper execution of incentive schemes for pregnant mothers and FCHVs be ensured: In Parsa, an additional issue of improvement was ensuring the incentive for ANC check-up during pregnancy for mothers (NRs 400). Scale-up PWG approach: Throughout the final evaluation process, it was clear that the PWG model served as a mechanism through which many of the CB-NCP interventions reached the communities. Scaling up this approach to improve safe motherhood and new born care practices in non-PWG districts and particularly among marginalized communities would serve as an effective and low-cost intervention. 30 Incorporation of the PWG model within CB-NCP: A potentially effective means of scaling up PWGs would be to introduce PWGs as part of CB-NCP; doing so would ensure the maintenance and sustainability of the health outcomes to-date. Introduction of CHX as a component of PSBI prevention: The CHX operational research in Parsa was the CHX application on umbilical stump be made a component of prevention of PSBI along with Co-trim and Gentamycin injection, by integrating it with CB-NCP Replicating the effectiveness of group commitments as a strategy in other MNH programs: The health education sessions on MNH services at VDC level followed by group commitments by pregnant women, their mothers-in-law and husbands (decision makers), service providers (health workers and FCHVs) should be replicated to other maternal and newborn health program for better results on utilization the maternal and newborn health care practices. Annex 1 Nepal LIBON Project - Results Highlight Annex 1: Nepal LIBON Project Results Highlight—Evidence Building  Innovative ideas: “Application of chlorhexidine (CHX) on and around newborn’s umbilicus stumps” Current neonatal mortality rate of 33 per 1000 live births in Nepal translates to around 23,000 neonatal deaths per annum. Home delivery is widely prevalent in Nepal since only 36 percent of babies are delivered by a doctor or nurse/midwife, and 28 percent are delivered at health facilities. Therefore, umbilical care in hygienic conditions at home is very rare resulting contribution of high neonatal death. Studies have shown that immediate cleansing of umbilical cord with 4 per cent Chlorhexidine (CHX) reduces the cord infection and reduces neonatal mortality by about 23 per cent. Plan Nepal with endorsement by government made an operation research in Parsa district after validating efficacy of Chlorhexidine lotion versus aqueous solution. All health workers and female community volunteers were trained and oriented on application Chlorhexidine in the umbilical stump with training package of community based newborn care program. The achievement on application of CHX on umbilical stump was very successful after nearly two years of the project introduction while survey was made on July 2011 with final evaluation of LIBON project among 494 recently delivered women (RDW). The major findings were very remarkable. Ninety eight per cent RDW in this district were immunized against tetanus toxoid vaccine. Seventy eight per cent of RDW had taken iron/folic acid tablets and more than 60 per cent of the RDW delivered by skilled provider (doctor or nurse or HA or AHW or ANM). Eighty eight percent persons washed their hand before touching of newborns and 94.4% washed their hands before application of CHX. About 97% of the SBA/caretakers applied full tube of CHX in the umbilical stump. About 82.7 per cent RDW reported to have their newborns’ umbilical cord cut with safe instruments of Clean Delivery Kit (CDK). (Please see the detail report on annex 11)  Promising practice: “Publicly group commitments on utilisation of maternal and newborn care services by pregnant women, decision makers and service providers” LIBON project added a most promising practice in its project area is health education sessions on Birth Preparedness Package and public commitment of decision makers (mother in laws and husbands), service providers and volunteers though it is of very short span. Following an recommendation from LIBON’s Mid-Term Evaluation (MTE) to involve decision makers in PWG health education sessions, the D(P)HOs of Sunsari and Parsa Districts and Plan Nepal disseminated key CB-NCP messages to PWG member husbands and mothers-in-law. The sessions were conducted by MoHP staff (either a District Health Officer, Supervisor, Sub/Health Post or Primary Health Care staff), and sessions were followed by commitment by PWG members, their husbands, mothers-in-law and FCHVs to follow Birth Preparedness Plan (BPP) guidelines developed by government Family Health Division. The program was started from July 2010 (Y3 Q4). At the end of the project 11,877 PWs took participation in this campaign in three districts (Sunsari, Parsa and Bara). Overall, of them 23% were from Dalit; 38% Janjati; and 17% from minority like Muslim and 22% from others. The project used mother's action card in very exemplary way developed by government Family Health Division. As a result, service utilization from pregnant women and mothers increased tremendously in very short period. Government and other supporting agency can use this card taking lessons learned from this project although its documentation is very limited. Annex 1 Nepal LIBON Project - Results Highlight  Best practice: “Pregnant Women’s Groups (PWG) approach for self monitoring of the utilization of maternal newborn care services even by illiterate women to reduce maternal and newborn deaths” Endemic discrimination by certain cultural groups like so called higher castes still exists in Nepal. Hiding pregnancy status of women within the family and at community due the social stigma is another cause which has become a major threat to the life of pregnant women from danger sign during that period. To ensure equitable access to services, LIBON formed PWGs where there are less coverage and in areas (wards) where there are relatively disadvantaged and marginalized community within the districts. One of the most important and successful approach of the project is the use of innovative PWGs followed approach of previous child survival projects. It is not so complicated but simple and very effective behavioural change communication sessions among pregnant women members using social and behavioural mapping for their healthy behaviour at community level even in extreme poverty situation. Each PWG comprises 7-15 pregnant women (averaging 8) living within 10 minutes walk of one another in the same village. They meet once a month to discuss on pregnancy, what the danger signs are, how to prepare for delivery and newborn care. The map is updated during monthly meetings and becomes an accountability tool for pregnant women, mother-in-laws and husbands in this group. LIBON Project yielded two new promising practices. The first is equitable outreach to marginalized groups. The second relates to explanations for high levels of PWG sustainability. Till now, 8313 pregnant women have been involved in 1253 PWGs in Plan Nepal working districts (Sunsari, Rautahat, Bara, Parsa, Makawanpur, Banke and Bardiya) of which 63% are from disadvantaged groups (14% Dalit (so called “untouchables”), 27% are Janajati (a deprived group) and 22% are Muslim (a minority religion) and 37% other castes. PWG approach including CB-NCP will be sustainable at community level if it is aligned with local health governance program. The PWG has been documented as a best practice and shared at national and international levels. The PWG approach was selected for a panel presentation during the GHC 2009 Annual Conference in a panel entitled “Better Beginnings: Improving Neonatal Outcomes.” The Web link is http://www.globalhealth.org/conference_2009/presentations/d5_shrestha.pdf Annex 2 Nepal LIBON Project – Publications and Presentation list Annex 2: List of Publications and Presentations Related to the Project Year and Month Title/ Topic Nov 1, 2011 Presented “Peer support groups and community volunteers improve newborn care in rural community, Nepal,” at the 2011 Annual Meeting of the American Public Health Association (APHA), Washington, DC, USA January 2011 Published article on Indian J Med Res 133, January 2011, pp 64-69 “Field test results of the motherhood method to measure maternal mortality” May 27- May 31, 2009 Presented the article on Pregnant women group participation and reduction of neonatal and maternal mortality rates in 36th Annual International Conference on Global Health, Omni Shoreham Hotel, Washington, DC, USA 2009 (Nov) Published article on “Pregnant Women’s Groups and the Impact on Newborn's Mortalities in Bara District, Nepal” NEPHA (Nepal Public Health Association) Newsletter, Volume #1 , Issue # 2, Pg 8, November 2009 2009 (Nov) Published and presented the article on “Pregnant Women’s Groups and the Impact on Newborn's Mortalities in Bara District, Nepal” in the Souvenir of Peri￾natal Society of Nepal (PESON) 2009 (Jun) Published article on Plan Nepal Khabar "Reducing neonatal and infant mortality through women’s participation", Kathmandu, Nepal. 2009 (April) Published article on Plan Nepal Khabar "Empowerment of pregnant women’s group", Kathmandu, Nepal. 2008 (May) A report on "Child Survival Sustainability Assessment (CSSA) Framework Report May 2008, Sunsari, Nepal", Kathmandu, Nepal. 2008 (Feb) A report on "Rapid Health Facility Assessment (R-HFA) Report Feb 2008, Sunsari, Nepal", Kathmandu, Nepal. 2008 (January) A report on "Lot Quality Assurance Sampling (LQAS) Report January 2008, Sunari and Parsa, Nepal", Kathmandu, Nepal 2008 (January) Local Innovation for Better Outcomes for Neonates (LIBON) brochure Annex 3 Nepal LIBON Project – Project Management Evaluation Annex 3: Nepal LIBON Project – Project Management Evaluation The external evaluator chose not to address project management issues as a separate annex since all issues related to project implementation (as identified during the final evaluation) were addressed in the main report. Annex 4 Nepal LIBON Project - Workplan Annex 4: Nepal LIBON Project Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 Start-up and Administration: Hire and train LIBON Staff √ √ √ HRM, PC Completed Purchase equipment √ √ √ Admin, PC Completed MOUs with IOM, NFHP and MoHP √ √ CD, PC, HC Completed Execution of MOUs with DDC and DHO √ √ PUM, PC, DLC, HPC, Asst DLC, Completed Preparation of DIP √ √ CMT, PC, HPC, USNO Completed DIP sharing with USAID – USA √ HC, PC, USNO Completed Prepare and sign formal agreements with partners (NGO/CBO/DHO/IO M) to implement the LIBON program in Sunsari, Parsa and Bara districts √ √ √ √ √ CD, PUM, HC, PC, HPC, DLC, Asst DLC Completed DIP revision and resubmission √ √ Completed Design and preparation of modules on Community Based Newborn Care Package (CB-NCP) jointly Child Health Division (CHD), MoHP √ √ √ √ HC, PC Completed Annex 4 Nepal LIBON Project - Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 Master Training of Trainers (MTOT) on CB-NCP (5 persons each from Sunsari and Parsa) in Kathmandu organized by CHD √ √ √ HC, PC Completed District Training of Trainers (DTOT) on CB-NCP in Sunsari and Parsa districts (Ilaka In charge and DHO staff) √ √ √ √ PC, HPC, DLC, Asst DLC Completed Training on CB-NCP at Ilaka (sub-district) level in Sunsari and Parsa districts √ √ √ √ √ √ PC, HPC, DLC, Asst DLC Completed Training on CB-NCP at Sub-health post level in Sunsari and Parsa districts √ √ HPC, DLC, Asst DLC Completed Formation of pregnant women group (PWG) linking with local health facility in Sunsari and Parsa districts and strengthening of existing PWG in Bara district √ √ √ √ √ √ √ √ √ √ √ √ √ HPC, DLC, Asst DLC 260 PWGs and 123 PWGs formed in Sunsari and Parsa district respectivel y. 82% PWG has followed up and functional out of 430 in Bara. Pilot Emergency Referral system in one Ilaka √ √ √ HC, PC, DLC, Asst DLC Not completed Annex 4 Nepal LIBON Project - Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 Train FCHVs on CB￾NCP of interventions in Sunsari and Parsa districts √ √ √ √ √ √ √ HPC, DLC, Asst DLC 1070 FCHVs trained from Fifty Seven batches in Sunsari and 792 FCHVs trained from Forty Four batches in Parsa. FCHV level training on CB-NCP has been completed in Sunsari and in Parsa districts. Dissemination of CB￾NCP message to community (mother) groups by FCHVs through using BCC methods and materials in Sunsari and Parsa districts √ √ √ √ √ √ √ √ √ √ √ HPC, DLC, Asst DLC Completed Support on BCC (flip chart, key ring with message) material of CB-NCP to FCHVs in Sunsari and Parsa districts √ √ √ √ √ √ PC, HPC, DLC, Asst DLC Provided during CB￾NCP training Mass media (radio) BCC messages √ √ √ √ √ √ √ √ √ √ Completed Annex 4 Nepal LIBON Project - Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 FCHV participate in monthly monitoring and decision making meeting at the village level in Sunsari and Parsa districts √ √ √ √ √ √ √ √ √ √ √ √ √ √ HPC, DLC, Asst DLC Completed Support implementation of CB-NCP of service (Supportive supervision and monitoring) in Sunsari and Parsa districts √ √ √ √ √ √ √ √ √ √ √ HC, PC Completed Review meeting on CB-NCP at VDC, district , region and national level √ √ √ √ √ √ PC, HPC, DLC, Asst DLC Completed Monthly review meeting in Ilaka (sub￾health post and Ilaka in-charges) and district (DHO staff and Ilaka in-charges) level in Sunsari, Parsa and Bara districts √ √ √ √ √ √ √ √ √ √ √ √ √ √ HPC, DLC, Asst DLC Completed Training in application of LQAS and CSSA for MoHP, IOM, and District level stakeholders in Sunsari, Parsa and Bara districts √ √ √ √ √ √ √ √ √ HC, PC, M&EO, HPC, DLC, Asst DLC Completed Annex 4 Nepal LIBON Project - Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 KPC survey application using LQAS in Sunsari, Parsa and Bara districts √ √ √ √ √ √ √ √ √ PC, M&EO, HPC, DLC, Asst DLC LQAS data is used for program monitoring and planning by Plan Nepal and D(P)HOs RHCCs prepare annual strategic and operational plans in Sunsari, Parsa and Bara districts √ √ √ √ PC, HPC, DLC, Asst DLC Completed Quarterly meeting of RHCCs in Sunsari, Parsa and Bara districts √ √ √ √ √ √ √ √ √ √ √ √ √ PC, HPC, DLC, Asst DLC Completed Publication on Neonatal health in Nepal (in coordination with CARE) √ √ √ √ HC, PC Completed Coordination and sharing meeting with USAID, NFHP, Care, MIRA and others INGOs working on neonatal program √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ HC, PC Completed Meeting with District stakeholders in Sunsari, Parsa in regard to municipality approach for community mobilization √ √ √ PC, LDC, Asst LDC Completed Bi-annually steering committee meeting √ √ √ √ √ √ √ CD, HC, PC SC met only twice in Year 1, and 2, Annex 4 Nepal LIBON Project - Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 LIBON staff participate in the neonatal/sub￾committee technical group of the Child Health Division √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ HC, PC Completed IOM student apprenticeships and internships in LIBON implementation sites √ √ √ √ √ √ HC, PC Three MPH students did thesis work in Sunsari and Parsa. Plan, conduct and share Operations Research study/results on priority NNH topic √ √ √ √ √ √ √ √ √ HC, PC The OP research for CHX has been completed. Presentation if results in international forum √ HC, PC, HQ backstops Plan to do on MCHIP meeting on Nov 2-3, 2011 Submit financial and program reports to Plan USA √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ PC, AFA, GA Completed Baseline study (LQAS, CSSA, IHFA) √ HC, PC, M&EO, HPC, DLC, Asst DLC, AFA Completed Technical Assistance visits from Plan USA staff √ √ √ √ √ √ √ HQ backstops Completed Annex 4 Nepal LIBON Project - Workplan Major Activities Year 1 Year 2 Year 3 Year 4 Q Personnel Comments 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Jul – Sep 2008 Oct – Dec 2008 Jan – Mar 2009 Apr – Jun 2009 Jul – Sep 2009 Oct – Dec 2009 Jan – Mar 2010 Apr – Jun 2010 Jul – Sep 2010 Oct – Dec 2010 Jan – Mar 2011 Apr – Jun 2011 Jul – Sep 2011 Mid-term evaluation √ HC, PC, M&EO, HPC, DLC, Asst DLC, AFA Completed Final Evaluation √ HC, PC, M&EO, HPC, DLC, Asst DLC, AFA Completed Monthly meeting with USAID funded partners on child survival √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ HC, PC Completed Quarterly coordination meeting with USAID, Local Mission √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ HC, PC Completed Reporting: Annual, Mid-term, Final Evaluation to USAID √ √ √ √ √ HC, PC, M&EO, AFA Completed Annex 5 Nepal LIBON Project – Rapid CATCH tables Annex 5: Nepal LIBON Project - Rapid CATCH Table Rapid CATCH table of Sunsari and Parsa districts Final estimates that are significantly different from the corresponding baseline estimates are highlighted with an “*” symbol. SN Indicator Sunsari Parsa Baseline Mid-term Evaluation Final Evaluation Baseline Mid-term Evaluation Final Evaluation 1 Tetanus Toxoid: % of mothers with children age 0-23 months who received tetanus toxoid 2 plus (TT2+) vaccinations before the birth of their youngest child 89.8% 93.7% 90.2% 95.1% 96.8% 95.5% 2 Skilled Delivery Assistance: % of children age 0-23 months whose births were attended by skilled personnel 47.4% 70.2% 83.5% * 36.4% 47% 70.0% * 3 Post-Natal Visit to Check on the Newborn: % of children age 0-23 months who received a post-natal visit from an appropriate trained health worker within three days after birth 43.2% 66.3% 78.6% * 27.9% 35.6% 61.5% * 4 Exclusive Breastfeeding: % of children age 0-5 months who were exclusively breastfed during the last 24 hours 67.7% 90.6% 74.7% 80.7% 84.5% 89.2% 5 Infant and Young Child Feeding: Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 69.6% 77.4% 69.2% 32.5% 75.6% 75.6% * 6 Vitamin A Supplementation: % of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 87.3% 91.3% 96.3% * 70.7% 67.7% 78.9% 7 Measles Vaccination: % of children aged 12- 23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 85.9% 89.0% 90.2% 77.6% 81.1% 84.1% 8 Access to Immunization Services: % of children aged 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 94.6% 91.2% 95.1% 87.9% 89.6% 95.2% 9 Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 88.0% 86.8% 92.7% 80.4% 79.2% 84.1% 10 Treatment of Fever in Malarious Zones: % 44.4% 40.7% 69.4% * 45.3% 56.3% 79.3% * Annex 5 Nepal LIBON Project – Rapid CATCH tables SN Indicator Sunsari Parsa Baseline Mid-term Evaluation Final Evaluation Baseline Mid-term Evaluation Final Evaluation of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 11 ORT Use: % of children age 0-23 months with diarrhea in the last two weeks who received Oral Rehydration Solution and/or recommended home fluids 39.3% 63.6% 87.5% * 29.4% 53.5% 68.0% * 12 Appropriate Care Seeking for Pneumonia: % of children age 0-23 months with chest￾related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 46.0% 87.0% 82.5% * 36.0% 50% 31.4% 13 Point of Use: % of households of children age 0-23 months that treat water effectively 34.7% 56.8% 21.1% 6.1% 6.9% 19.8% 14 Appropriate Hand Washing Practices: % of mothers of children age 0-23 months who live in households with soap at the place for hand washing 73.0% 77.9% 84.6% 57.5% 57.1% 74.9% * 15 ITN Use: % of children age 0-23 months who slept under an insecticide-treated bed net the previous night (**) 0% 0% 0% 0% 0% 0.0% 16 Underweight: % of children age 0-23 months who are underweight (-SD for the median weight for age, according to WHO/NCHS reference population) 13.0% 6.3% 8.4%* 10.5% 9.5% 4.9%* Annex 5 Nepal LIBON Project – Rapid CATCH tables Rapid CATCH table of Bara district Final estimates that are significantly different from the corresponding baseline estimates are highlighted with an “*” symbol. SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) LQAS Dec'09 (%) LQAS Jun'11 (%) SENTINEL MEASURE OF CHILD HEALTH AND WELL-BEING 1 M1 & M2 Underweight Children Percentage of Children age 0-23 months that is underweight (-2 SD from the median weight￾for-age, according to the World Health Organization (WHO)/National Center for Health Statistics (NCHS) 29 13.2 6.0* 2 M3 Birth Spacing Percent of children age 0-23 months that was born at least 24 months after the previous surviving child 69.4 62.5 64.3 3 M1 Delivery Assistance Percent of children age 0-23 months whose birth were attended by skilled health personal upto MCHW 42.1 45.9 59.4* 4 M1 Maternal Tetanus Toxoid (TT) Percent of mothers with children age 0-23 months that received at least TWO tetanus toxoid injections before the birth of their youngest child. 63.2 14.3 9.8 5 M1 Exclusive Breastfeeding Percent of children age 0-5 months that was exclusively breastfed during the last 24 hours 100.0 82.9 70.4 6 M1 Complementary Feeding Percent of children age 6-9 months that received breast milk and complementary foods during the last 24 hours 95.7 91.9 90.2 7 M2 Full Vaccination Percent of children age 12-23 months that is fully vaccinated (against the five vaccine preventable diseases) before the first birthday 66.9 19.5 45.1 8 M2 Measles Percent of children age 12-23 months that received a measles vaccine 72.2 21.1 45.1 9 M1 & M2 Bednets Percentage of children age 0-23 months that slept under an insecticide-treated net (in malaria risk areas) the previous night 1.5 97.7 3.4 Annex 5 Nepal LIBON Project – Rapid CATCH tables SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) LQAS Dec'09 (%) LQAS Jun'11 (%) 10 M3 HIV/AIDS Percent of mothers with children age 0-23 months that cited at least TWO known ways of reducing the risk of HIV infection 51.1 29.3 48.9 11 M2 Hand Washing Percent of mothers with children age 0-23 months that reported they wash their hands with soap or ash before food preparation and feeding children and after defection and attending to a child who has defecated 63.2 33.1 47.4 MANAGEMENT/TREATMENT OF ILLNESS 12 M1 & M2 Danger Signs Percent of mothers of children aged 0-23 months that knew at least TWO signs of childhood illness that indicate the need for treatment 99.6 93.2 99.6 13 M1 & M2 Sick Child Percent of sick children age 0-23 months that received increased continued feeding during an illness in the past two weeks 94.5 75.3 98.5 14 M1 & M2 Sick Child Percent of sick children age 0-23 months that received increased fluids during an illness in the past two weeks 92.7 44.2 93.8 Note: Indicators indicated (indicator # 13 and 14) are merged in generic Rapid CATCH Tables, but in this instance, the Plan Nepal CS Project collected the information separately to form two separate indicators. Annex 6: Nepal LIBON Project – Final KPC Report Annex 6 Nepal LIBON Project – Final KPC Report i LQAS and CSSA Reports Sunsari, Parsa and Bara Districts Local Innovation for Better Outcomes for Neonates Project (LIBON) Plan Nepal Child Survival Project XXIII Funded by United States Agency for International Development Child Survival and Health Grants Program (CSHGP) Grant No: GHN-A-00-07-00006-00 Bureau for Global Health Office of Health, Infectious Disease, and Nutrition Submitted by: Hari Bhakta Khoju Rural Community Development Society Submitted to Plan Nepal September, 2011 Annex 6 Nepal LIBON Project – Final KPC Report ii ACKNOWLEDGEMENT I acknowledge and express my gratitude to Plan-Nepal especially to Mr. Donal Keane, Country Director and Mr. Subhakar Baidya, Program Support Manager for offering me to prepare a report on Final Evaluation (FE) of Local Innovation for Better Outcomes for Neonates (LIBON) project specially for learning opportunity about Lot Quality Assurance Sampling (LQAS) and Child Survival Sustainability Assessment (CSSA) methods as a tool for baseline survey, planning, monitoring, reviewing and evaluating the results- both in theory and practice in the field. I appreciate Mr. Dipak Dahal, Monitoring and Evaluation Officer for his endless commitment, enthusiasm and effort in convincing, building capacity and confidence of health Supervisor and Officials to conduct the survey for data collection without being bias to subjective judgment and data fabrication. He is a good 'Guru' in LQAS and CSSA tool explanation and application. Mr. Parsuram Shrestha, Chief, Community Based-Integrated Management of Childhood Illnesses (CB-IMCI), Child Health Division, Ministry of Health and Population (MoHP), Mr. Indra Prasad Yadav, District Public Health Office (DPHO) Parsa, Dr. Surendra Prasad Chaudhary, District Health Office (DHO) Bara and Dr. Daya Shankar Lal Karna, District Health Office Sunsari have provided information and inputs for report preparation. Mr. Sher Bahadur Rana, Health Coordinator, Plan Nepal and Mr. Bhagawan Das Shrestha, Project Coordinator-LIBON project, assisted me by providing adequate reading materials, information and accompanying me for field exposures to have direct in-depth field learning situation to prepare this FE report. I acknowledge and extend my heartfelt thanks to field based staff Mr. Deo Ratna Chaudhary, District LIBON Coordinator (DLC) Bara/Parsa, Mr. Diwakar Mishra, Assistant District LIBON Coordinator (ADLC) Bara, Mr. Krishna Bahadur Achhami, Assistant District LIBON Coordinator Parsa, Ms. Meena Kumari Singh, Admin and Finance Assistant, Bara; and Ms. Srijana Rai, Office Assistant, Parsa for providing and supporting me to learn about LQAS and CSSA field situation. I anticipate and appreciate especially Ms. Kalawati Changbang, Health Program Coordinator- Sunsari Program Unit (PU) for her lively and tireless efforts to moderate and facilitate workshop cum training sessions along with her colleagues Mr. Hari Dev Shah, Assistant District LIBON Coordinator, Sunsari. Annex 6 Nepal LIBON Project – Final KPC Report iii ABBREVIATION ADLC Assistant District LIBON Coordinator AHW Auxiliary Health Worker (HP, Sub-HP) ANC Antenatal Care ANM Auxiliary Mid-wives ARI Acute Respiratory Infection BCC Behavioral Change Communication BPP Birth Preparedness Package CATCH Core Assessment Tool for Child Health CB-IMCI Community Based-Integrated Management for Childhood Illness CB-NCP Community Based – Neonatal Care Package CBO Community Based Organization CBS Central Bureau of Statistics CDD Control of Diarrheal Disease CDO Chief District Office CDP Community Drug Program CEDAW Convention on the Elimination of All Forms of Discrimination against Women CHD Child Health Division, Ministry of Health and Population CHW Community Health Worker CPR Contraceptive Prevalence Rate CRC Convention on the Rights of the Children CS Child Survival CSSA Child Survival Sustainability Assessment DACAW Decentralized Action for Children and Women DAG Disadvantage Group DDC District Development Committee DEO District Education Office DHO District Health Office DHS Department of Health Service, MoHP DLC District LIBON Coordinator DPHO District Public Health Office EOP End of Project EPI Expanded Program of Immunization FCHV Female Community Health Volunteers FHD Family Health Division, MoHP FE Final Evaluation GNP Gross National Product GoN Government of Nepal HA Health Assistants (HP, SHP) Annex 6 Nepal LIBON Project – Final KPC Report iv HDI Human Development Index HF Health Facility HFMC Health Facility Management Committee HH Household HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome HMIS Health Management Information System HP Health Post IEC Information Education and Communication ILO International Labor Organization IMR Infant Mortality Rate INGO International Non Governmental Organization INT Insecticide-treated net IOM Institute of Medicine IPRC Institutional Promotion and Resource Center KPC Knowledge, Practice and Coverage LBW Low Birth Weight LE Life Expectancy LIBON Local Innovation for Better Outcomes for Neonates LMIS Logistic Management Information System LQAS Lot Quality Assurance Sampling MCH Maternal and Child Health MCHW Maternal and Child Health Worker (SHP) MDG Millennium Development Goal MFI Micro Finance Institutional MG Mother’s Group MGM Mother’s Group Meeting MINI Morang Innovation for Neonatal Intervention MoAC Ministry of Agriculture and Cooperative MoE Ministry of Education MoHP Ministry of Health and Population, Government of Nepal MoLD Ministry of Local Development MTE Mid-Term Evaluation NCHS National Center for Health Statistics NFHP Nepal Family Health Program NGO Non Governmental Organization NHRC National Human Rights Commission NID National Immunization Day NNH Neonatal Health NNM Neonatal Mortality Annex 6 Nepal LIBON Project – Final KPC Report v NPL National Planning Commission OR Operational Research ORT Oral Rehydration Treated PAF Poverty Alleviation Fund PCI Per Capita Income PHC Primary Health Center PNC Postnatal Care PSBI Possible Severe Bacterial Infections PU Program Unit PWG Pregnant Women Group RBA Right Based Approach RHCC Reproductive Health Coordination Committee RHF Recommended Home Fluid RHFA Rapid Health Facility Assessment RMDC Rural Microfinance Development Center SA Supervision Area SBA Skilled Birth Attendant STD Sexually Transmitted Disease TBA Traditional Birth Attendants TT Tetanus Toxoid UMR Under 5 Mortality Rate UNDP United National Development Program USAID United States Agency for International Development USNO United Stated National Office (Plan International) VDC Village Development Committee VHDC Village Health Development Committee VHW Village Health Worker (SHP) WDO Women Development Organization WHO World Health Organization Annex 6 Nepal LIBON Project – Final KPC Report vi Table of Contents Page Part - One: LIBON Project Description Project Details 1 Part Two: Result Analysis and Interpretation 3 Part Three: Main Report on LQAS Lot Quality Assurance Sampling (LQAS) – GENERAL 3 Lot Quality Assurance Sampling (LQAS) – PARSA 11 Lot Quality Assurance Sampling (LQAS) – SUNSARI 34 Lot Quality Assurance Sampling (LQAS) – BARA 69 Part Four: Main Report on CSSA Child Survival Sustainability Assessment (CSSA) – GENERAL 97 Child Survival Sustainability Assessment (CSSA) – PARSA 107 Child Survival Sustainability Assessment (CSSA) – SUNSARI 139 Child Survival Sustainability Assessment (CSSA) – BARA 155 Findings, Conclusion and Recommendations: 180 Participants List on LQAS and CSSA 188 Project Details - General Annex 6 Nepal LIBON Project – Final KPC Report 1 Final Evaluation Report 1. A brief description of Plan Nepal and LIBON Project 1.1 Plan Nepal and LIBON Project: LIBON is designed to contribute to achieve the MDGs as shown in the table above and the policies, plan and programme of government of Nepal, Ministry of Health and Population. Plan Nepal has been implementing Child Survival XXII project called “Local Innovation for Better Outcomes for Neonates (LIBON)” in collaboration with the Ministry of Health and Population (MoHP) and Institute of Medicine-IOM, Tribhuvan University in Sunsari and Parsa districts and supports Bara DPHO to maintain the health service status of 2006 Final Evaluation Results. These districts are located in the Eastern and central parts in the Southern Terai belt, the lowland plain areas, along the border of India, starting from September 2007.It is a four year Project to cover up-to 2011 September. LIBON Project is designed to address the complex issues to reduce under-five child mortality rate that includes neo-natal and maternal mortality. Child and maternal mortality is caused due to lack of knowledge, information and skill to take care of pregnant mothers during their pregnancy and the newborn and under-5 children and mothers during and after delivery. To address these complex issues LIBON Project proposed following goals, results, strategies, interventions and activities which are in line with MoHP, GON policies and programmes. Goal: To Sustainable Reduce the Burden of Neonatal Mortality in Nepal Results: Result 1: Increased Access to Neonatal Health (NNH) Services in Sunsari and Parsa Result 2: Increased Demand for NNH Services in Sunsari and Parsa Result 3: Increased Quality of NNH Services in Sunsari and Parsa Result 4: Strengthened Support for Neonatal Mortality (NNM) Reduction in Nepal Strategies: • Community-based Service Delivery to increase ACCESS to meet Result 1 • Community Mobilization to increase DEMAND to meet Result 2 • Health Systems strengthening to increase QUALITY to meet Result 3 • Stakeholder sharing and Collaboration to increase SUPPORT to meet Result 4 • Social Inclusion to increase EQUITY to meet Result 1 Project Details - General Annex 6 Nepal LIBON Project – Final KPC Report 2 Project location: Bara, Sunsari and Parsa districts with the population of 1.97 million, accounting for 7.34 percent of the country’s population. Of this population, 51% (1,003,056) are male and 49% (963,721) are female. The three districts cover 229 VDCs and 39 Illaks- the sub districts. Target Beneficiaries: Target Beneficiaries: S.N Age distribution with number Sunsari Parsa Bara Total 1 Infants under 12 months 18945 15771 17761 52477 2 Children 12-23 months 19,430 16,733 18,744 54907 3 Children 0-23 months 38,375 32,504 36,505 107384 4 Children 24-59 months 59,000 51,460 57,432 167892 5 Children 0-59 months 97,375 83,964 93,937 275276 6 Women 15-49 years 142,565 113,440 128,443 384448 Population of Target Areas 750,886 593,668 666,932 2,011,486 Note:- Estimated Target Population calculation based on 2001 census data, CBS and target for 2065/66. LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 3 2. Result Analysis and Interpretation Success cases: Parsa collected from Focused Group Discussion among the field staff members. The reasons of good results are: i. Strong team work ii. Committed staff and quality CBNCP training iii. Performance based FCHV incentive iv. Community based program v. Established birthing centers vi. Regular and timely logistic supply vii. Formation of pregnant women group (PWP), health education (behavioral change communication sessions) in these groups sessions with social and behavioral mapping, and follow up of them. viii. BPP mass campaign ix. Frequent joint monitoring support by Plan and project staff x. Public commitment as an oath taken by pregnant women, husband, parents-in￾laws, and health service providers and also in CBNCP training; xi. Operation research of chlorhexidine application in newborn umbilical stump introduced helped to leverage for the effectiveness of CBNCP. 3. A Description of Lot Quality Assurance Sampling – LQAS Part Two -- Main Report on LQAS Lot Quality Assurance Sampling (LQAS) 3.1 Objectives: General objective: The objective of the Lot Quality Assurance Sampling (LQAS) survey is to document and update the current level of information status about the level of knowledge, practices and coverage of the mothers in health behaviors and practices, health services and outcomes for the survival of new born children and the mothers and pregnant women. 3.1.1 Specific objectives: The specific objectives of the survey and the assessment are to document and update information status on;  Current knowledge level of mothers of newborns about child survival issues including major threats to infant, maternal and child health; safe pregnancy practices; and proper newborn care;  Actual practices of mothers and community health care providers with regard to the child survival intervention area mentioned above including prenatal LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 4 visits; delivery by a skilled birth attendant; and immediate breastfeeding within one hour of birth; 3.1.2 Objectives of using LQAS for end line evaluation of LIBON Project; The objectives of the workshop cum training are to enable participants; 1. To understand the meaning, uses and principles of LQAS 2. To identify interview locations (sampling interval, cumulative population, use of random number) 3. To describe the technique of selecting households, respondents and field practical for numbering and selecting households 4. To explain and apply data collection techniques to be used on survey 5. To tabulate and analyze results-findings 6. To monitor their program by using tabulation and analyzing results 3.2 Method and Process of Data collection and LQAS Survey Method and process of LQAS training is 100% participatory at equal footing through demonstration of discussion topics with open discussion by citing and visualizing examples for participants to transfer capacity to apply LQAS in their Supervision Areas for indicators based monitoring and evaluation of their achievements. Sitting arrangements are made in a non-discriminatory atmosphere among facilitators, resource persons, officials, old and new participants. Facilitators' team comprises LIBON Project Coordinator, Monitoring and Evaluation Officer, Health Coordinators from central to district based offices and District LIBON Coordinators-DLCS. They are good Facilitators without any trace of being a prescriptive trainer, teacher or lecturer. Plenary and all discussion sessions are openly shared and discussed at equal footing for instant replies of the queries of participants by Facilitators and capable, resourceful LIBON's previous participants in LQAS capacity building trainings. Capable and resourceful local participants are welcomed and invited to facilitate the difficult and hard situation arising out of discussions during the sessions for easy convincing and confidence building in local language, social and cultural gestures. Method and process is used as refresher for the old trained participants in LQAS and rigorous efforts and exercises are being made by Facilitators to upgrade the capacity of new participants for full confidence so that no problem, confusion and misunderstanding remains during the actual survey. LQAS- information reading and practicing printed materials are distributed to all participants for reference and for practices on each desk and seat of participants. All most all discussions are made through visual aids with clear-cut explanations by the Facilitator's team members and the previous trained participants spontaneously without overlapping and duplication in explanations. Full sharing and discussions are being made during the sessions regarding survey questionnaires for common LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 5 understanding to avoid errors, mistakes misinformation collection - the misuse of resources during the survey. Method and process of LQAS survey training has three stages by time frame. The first stage is the training of enumerators and supervisors which is of 3 days: day one covers orientation, clarification and explanation on LQAS-what, why and how to use LQAS: day two covers clarification on questionnaires and field testing: day three covers further in-depth practical solutions to the problems faced by the participants during field test along with identifying and determining survey locations, communities, households and respondents through random sapling method. Day three also covered on questionnaire review and role play for further clarification on LQAS survey process as well as preparation for the field data collection. The Monitoring and Evaluation Officer, and the Facilitator team members made hard and participants' friendly efforts to convince and make the participants confident in learning to apply the LQAS tools to collect information during the field survey. Participants are grouped in a team of 2-3 persons depending upon their number during the workshop with representation from DHO, DPHO, partner NGOs and Plan PU offices of Morang, Sunsari and Parsa districts. Field survey: The following 5- 7 days are scheduled for data collection in the actual survey. Facilitators are divided to follow the survey teams closely to provide on-the-spot spontaneous replies, answer and solutions to any problems, questions of the survey team members. Facilitators follow the survey team members for the first and second day very closely to guide and facilitate the real survey process to avoid mistakes and misunderstanding of the survey team members regarding data collection, selection process of households, families and respondent mothers. Participants and Facilitators have contact mobile numbers of each relevant person for assistance and cooperation; close monitoring, tracing the participants while in the field during the survey through mobile communications for distant, constant and instant guidance and supplies of materials and technical services, facilities to the survey team members from the Facilitators and Management and Logistic team. Hand tabulation and presentation of findings and sharing by relevant stakeholders; After completion of data collection, survey team members made hand calculation and tabulation of the data, information collected under the guidance of the Facilitators. Finding and results are openly shared and discussed in the plenary by each survey team with open comments, feedback by each Supervision Area wise (Ilaka) based on the indicators as comparison of baseline threshold, decision rules, programme average percentage and monitoring targets to the findings and results of present LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 6 survey for sharing purpose during the following 3 days hand tabulation and analysis of the collected field data sessions after field survey when and where decision and policy makers of MoHP, regional and central offices, DPHO, DHO, Plan Nepal PUs and LIBON Project participate seriously to know the results and health service and status of each Supervision Areas and the districts. Plan Nepal - LOBON Project handovers the sessions, floor to MoHP, DHO, DPHO to share and discuss the finding and the results openly in line with CB-NCP and CB￾IMCI of MoHP, DPHO, DHO policy, plan, programmes based on the information for decision making for the coming year by formulating follow-up action plan along with corrective measures for improvement, maintenance and sustenance of the health services and results. MoHP, DPHO, DHO and the field supervisors realize their ownership, responsibility and roles to improve health services at community level. 3.3 Concept and Use of LQAS Introduction: It is a sampling and analysis method in data collection process. It was originally developed and applied in America in 1920s (Bell Labs) for quality control of industrial production goods in lots or batches as a random samples to assure the pre￾determined quality the allowable numbers - the decision rule either to reject or accept the lot depending upon the allowable number based on the production standard and the sample size of the products. If the number of defective goods in a sample exceeds a pre-determined number, then the lot is rejected; otherwise it is accepted. Recently, the industrial monitoring experience using LQAS tool has been transferred for baseline and to monitor the quality of health indicators and to improve supervision of the field area. During mid 1980s, it was introduced and adopted to manage integrated public health programmes in the developing countries like, Costa Rica and other Plan program intervention countries. Plan Nepal has introduced the LQAS since 1998 to conduct baseline survey, monitoring and evaluation of the Child Survival Projects. It can be used locally in health Supervision Areas (Ilakas) to identify priority areas whether reaching or not reaching the established performance benchmark/threshold for an indicator and to make informed management decisions for sharing information across Supervision Areas. It can be further used to measure coverage at an aggregate level to quantify results for an entire catchments area like the district, region and nation. It is suitable for reporting purpose as well. 3.4 Purpose of LQAS: As described earlier, it is cost effective and serves the purpose in limited time with minimum confidential errors. The LQAS sampling method has been in use in Plan Nepal Child Survival (CS) Projects since 1998 to collect baseline data, regular monitoring and evaluations both the MTE and Final on project relevant health LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 7 indicators, to determine whether the Supervision Areas are above or below average coverage on specific indicators, to determine the indicators that are well performing and those that are not within a given Supervision Area, and to determine the performance status of Supervision Areas within the total project area compared to other areas and the districts. 3.5 Sample Size and Sample Frame Sample size is the number of responses obtained per Supervision Area for a specific indicator. The total sample size for the catchments area is the aggregated sample size from all supervision areas. For the purpose of data collection, the three districts are divided into existing DHOs/DPHO Supervision Areas - Ilakas including the municipalities' slums and the periphery where health facilities are still in poor condition to measure the achievements and performance results against indicators based on the decision rules. Parsa district is divided into 13 Supervision Areas (SAs) (12 Ilakas of Parsa DPHO and 1 municipality), Sunsari into 15 SAs (12 Ilakas of Sunsari DHO and 3 municipalities) based on Ilakas of DDCs and DHO/DPHO Supervision Area and Bara district into 7 SAs based on CSXVII Project final evaluation Supervision Area. A sample size of 19 households is selected per SA to minimize α and β errors for the sample size of less than 19 and more work that does not necessarily reduce the margin of error for more greater sample size than 19 i.e. less than 10%. In assessing coverage, all the samples taken from each Supervisory Area have been aggregated in order to obtain a large enough sample size as required to estimate the proportion in each population subgroup. Total sample size for Bara is 133 mothers (19 households x 7 Supervisor Areas=133), for Parsa, 247 mothers (19 households x 13 Supervisory Areas = 247) and for Sunsari, 285 mothers (19 households x 15 Supervisory Areas = 285). 3.6 Threshold and Decision Rule Coverage benchmark-the baseline threshold for an indicator is a pre-determined level of coverage that the project aims to reach at a specific time period. Average coverage for an indicator is the number of people in the sample who responded correctly to a question divided by the total number of people responding to that question. The decision rules indicate whether an individual or an intervention area reached the average coverage/ benchmark-threshold or is above or below the average coverage. Initial thresholds/benchmarks for assessing the indicators were selected using the average proportion obtained by aggregating the data of all 13 SAs in Parsa and 15 SAs in Sunsari and 7SAs in Bara. The Decision Rule Table is included in the report. LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 8 3.7 Questionnaire Translated copies of different questionnaire modules developed during the baseline survey of Sunsari and Parsa year 2008 and indicators of final evaluation of CSXVII Project Bara year 2006 corresponding to various groups of target beneficiaries of three districts have been discussed and shared among the participants and stakeholders openly for thorough common understating to collect information. Different sets of questionnaires were prepared for Bara district as per the indicators set for final evaluation of CS-XXVII Project. For Sunsari and Parsa, module 1 is set for mothers of children 0-5 months old, to collect information on mothers’ knowledge of neonatal indicators and Module 2 questionnaires for mothers of children 0-23 months for Rapid Catch Indicators to assess immunization coverage and breastfeeding status. 3.8 Team Composition and Field Plan As described above in Method and Process Section, team composition is made from two to three persons representing each organization e.g. DHO/DPHO, municipality, DDC, DEO, DWO, stakeholders, partner NGOs, Plan Nepal PUs and LIBON Project to join the adjoining districts Sunsari, Bara and Parsa and LIBON field based staff in each district depending upon the number of participants in the workshop. After training, field plan is scheduled for 7 or 8 days to collect information during the survey. Groups are formed according to the number of SAs per district. Details of participants, groups and field plans are attached in the annex 3.9 Training of Enumerators and Supervisors As described above under Methods and Process Section, enumerators and supervisors are comprised of representatives from DHO, DPHO, NGOs-partners, DDC, DEO, DWO, municipality and Plan-Nepal PUs and LIBON field based staff including Family Planning Office and statisticians from concerned offices. Three day in-depth training is conducted for each district on the following topics and time frame as below. The sessions of training are quite rigorous with immediate on-the-spot exercise citing various examples based on the hand book manual provided to each enumerator and supervisor. The first three days are spent on clarification of terminologies and their application procedures and uses while collecting information during the sampling survey, sharing and discussion on questionnaires for common understanding, field testing of the questionnaires, mock survey role playing and preparation for actual survey. Facilitators closely monitored, guided and facilitated the enumerators during the field test in groups. Findings, results of field test of questionnaires are shared openly by each group with feedback and comments. Enumerators and Supervisors realized the ownership of the task for survey as per their jobs and duties. LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 9 Major topics discussed, shared and clarified are as below:  LQAS- What is it?  LQAS and Supervision Areas  LQAS decisions at local level  Advantages of LQAS for local programme management  LQAS application in CS Projects  Steps in applying LQAS: Select the intervention or service to assess; Define supervision areas: Define communities within Supervision Areas; Define benchmarks and define the level of acceptable error  Making decision at the local level  LQAS table for decision rules  A few key LQAS concepts; Sample size; Coverage benchmark; Average coverage, Decision rule  LQAS analysis decisions  LQAS summary tables  Supervision Areas and indicators  Comparing Supervision Areas  A sample of 19 indicates about the higher and lower performing areas, differentiating knowledge and practices with high and low coverage, setting priorities within the Supervision Area with large differences in coverage  A sample does not indicate about calculating the value of coverage in a Supervision Area although useful to calculate coverage for an entire programme and setting priorities among Supervision Area with little difference in coverage.  A sample of 19 provides an acceptable level of error (less than 10%) for making management decisions for practical purpose.  Data collection using LQAS to randomly select communities, households and the respondent for interview during the survey.  Steps in identifying locations for interview: Step-1: List communities and their total population size, Step-2: Calculate the cumulative population by adding the consecutive population of the following communities respectively until the last group of population to form cumulative population equal to the total population; Step-3: Calculate the sampling interval by dividing the total cumulative population by 19; Step-4: Choose the random number by pin pointing exactly on the number provided in the random number table; Step-5: Identify the locations/community for 19 interviews after initial random number and the sampling interval.  LQAS sampling frame for a specific Supervision Area  Selection of Households and assigned numbers; if a list of complete household is available assign a number to each house. If the community size is about 30 HHs or less, make a household list or a map with the location of each household with the help of a key informant from the community and then assign a number to each house. If the community size is more than 30 HHs sub-divide into 2-5 sections with about the same number of HHs in each LQAS - General Annex 6 Nepal LIBON Project – Final KPC Report 10 sections then select one section at random and make a house list or map with the location of each household with the help of the key informant and then assign the number of each household. Once all HHs are numbered, pick a random number using random tables and select the first household in the selected community. If more than one household is needed in the selected community, pick another random number to select the second household in the selected community.  Selecting a respondent and alternate/ additional respondents; if the selected respondent is at the household, interview that person only if she agrees. If she is not at the house, go to the next nearest household from the front entrance to the house and check at the nearest household if the required respondent is available. If the respondent is absent and is 30 minutes away, trace and find the respondent or wait for 30 minute for interview. If she is not available during this time, go to the next nearest household from the front entrance of the previous house to find the required respondent.  Process for field work survey;1) Meet the community leader or the key informant 2) Draw a community/ social map 3) Sub- divide the community into sections 30HH or fewer households 4)Give each section (each group of 30 or fewer household) a number 5) Select a section using a random number 6) Perform steps-3 through 5 again if the selected section is still too large i.e. more than 30 HHs 7) Assign number to Households in the selected sections 8) Select a starting household using a random table. . LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 11 3.10 LQAS Findings and result description Plan Nepal has been applying LQAS tools for participatory database planning, monitoring and evaluation of child survival projects for self-discovery of the level of sustainability of their services, capacity and competence to further promote, maintain and continue quality health services for neonatal child and mothers health programs in its program districts like in Bara, Sunsari and Parsa in joint collaboration with MoHP and its district based health offices, RHCC, Village Health Development Committee (VHDC) and local community organizations and groups. Plan Nepal LIBON Project is committed in its aim and mission to promote neonatal and maternal health improvement in these districts to contribute to and complement to the Plans and programs of MoHP 2017 3.10.1 Parsa District The preliminary LQAS findings of final evaluation survey, Parsa district held on 3 – 14 July 2011. 1.1 Community Outreach Mechanisms Expanded (Table) Result 1: Increased Access to NNH Services in Parsa 1.1 Community Outreach Mechanisms Expanded I. Antenatal KPC Results: Out of 9 indicators surveyed like 5. Percent of mothers of children aged 0-5 months protected against tetanus by getting second dose of TT vaccine 6. Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 7. Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 8. Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 9. Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 10. Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 4 months during their pregnancy 11. Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 6 months during their pregnancy 12. Percent of mothers of children aged 0-5 months suffering from night blindness during their pregnancy and receiving low-dose vitamin A (25,000 IU)* LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 12 13. Percent of mothers of children aged 0-5 months receiving a single dose of albendazole (400 mg) after completion of three month of last pregnancy 8 indicators surpassed the end of project – EOP target September 2011 except one KPC no. 12 which is quite below the EOP target i.e. 6.7% out of 35%. II. Delivery KPC Results: It covers only 2 indicators like; 15. Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM) 16. Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) No. 15 above indicator has result of 60% against 45% EOP target where as No 16 has 66% against 50% EOP target. III. Post Natal KPC Results: There are 11 indicators in the Postnatal. 23. Percent of mothers with children aged 0-5 months whose newborn children with signs of severe illness were seen by a qualified public or private provider 24. Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within the first two days of birth 25. Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within the first two days of birth 26. Percent of mothers with children aged 0-5 months (and their newborns) who received a second post-natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within 3-7 days after birth 27. Percent of mothers with children aged 0-5 months (and their newborns) who received a second post-natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within 3-7 days after birth 28. Percent of newborns whose umbilical stump was first applied with chlorhexidine 4% within 24 hours of birth 29. Percent of mothers of children aged 0-5 months who received vitamin A (200,000 IU) within 45 days after delivery 30. Percent of neonates with PSBI diagnosed by a health worker or FCHV within 48 hours of onset 31. Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset 32. Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 days LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 13 33. Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 to 5 days All the indicators surpassed the EOP-Targets except KPC No. 26 which is 5% less than the EOP-Target i.e. 20.6% in the final results against 25% EOP-Target. The results are as high as 98.8% to 26.7% at the lowest level. 2.1 Mothers recognize risks associated with pregnancy, delivery, and neonatal period (Table) I. Antenatal KPC Results: Both indicators like 1. Percent of mothers of children aged 0-5 months having a birth preparedness plan already coordinated with their closest health worker during their pregnancy; 2. Percent of mothers of children aged 0-5 months who know at least two danger signs during pregnancy surpassed the EOP-Target form 64% to 96% against EOP-Targets 40% and 70%. II. Delivery KPC Results: This indicator # 14, percent of mothers of children aged 0-5 months who know at least two danger signs during delivery has a result of 93% against 45% as EOP￾Target. III. Postnatal KPC Results: All five indicators below surpassed EOP-Target up to 97.6%. 18. Percent of mothers of children aged 0-5 months who know at least two danger signs after delivery 19. Percent of mothers of children aged 0-5 months who know at least two danger signs among newborns 20***. Percent of mothers of children aged 0-5 months who know how to apply chlorhexidine on the umbilical stump 21. Percent of newborns who were breast-fed within one hour of birth 22*. Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 14 3.1 NNH monitoring and planning systems strengthened (Table) I. Antenatal KPC Results: Both the indicators 3, percent of mothers of children aged 0-5 months who were counseled on at least 1 counseling point during antenatal check-up and 4, percent of mothers of children aged 0-5 months who were counseled on at least 3 counseling points during antenatal check-up surpassed the EOP-Target up to 98.7% against 80% and 90.7% against 50%. II. Delivery KPC Results: Like Antenatal, both indicators surpassed the EOP-Target up to 97.2% against 85% and 81.8% against 60%. The indicators are as under; 17. Percent of birth attendants who washed their hands with soap before assisting in the procedure 22. Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours III. Postnatal KPC Results: Indicators; 28. Percent of neonates with PSBI referred to a health worker for parenteral antibiotics within 48 hours of onset 29. Percent of neonates treated with antibiotics due to PSBI who completed the course of antibiotics 31. Percent of children of mothers aged 0-5 months who were fed colostrums 33*. Percent of neonates with possible severe bacterial infections (PSBI) diagnosed by a health worker or FCHV within 48 hours of onset 36. Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 to 5 days Out of 5 postnatal indicators; 3 indicators like 31, 33* and 36 surpassed the EOP￾Target and the remaining like 28 and 29 achieved below 10% than EOP-Target i.e. 44.4% against 55% IV. Indicator Percent of Mothers of 1. Percent of mothers of children aged 0-5 months having eclampsia during pregnancy decreased to 26.3% in the final evaluation from 47.8% in the MTE and the other indicator 2. Percent of mothers of children aged 0-5 months receiving calcium tablets/caps at least for 3 months (90 tablets) during their pregnancy increased to 38.9% in the Final Evaluation from 21.1% in the MTE. There is reverse proportion of calcium supplementation and reduction of pre eclampsia. LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 15 Rapid CATCH Baseline Indicator Values: Indicator values: 1. Tetanus Toxoid: % of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child 2. Skilled Delivery Assistance: % of children age 0-23 months whose births were attended by skilled personnel 3. Post-Natal Visit to Check on the Newborn: % of children age 0-23 months who received a post-natal visit from an appropriate trained health worker within three days after birth 4. Exclusive Breastfeeding: % of children age 0-5 months who were exclusively breastfed during the last 24 hours 5. Infant and Young Child Feeding: Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 6. Vitamin A Supplementation: % of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 7. Measles Vaccination: % of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 7a. Measles Vaccination: % of children aged 12-23 months who received measles vaccine according to the vaccination card by the time of the survey (Card coverage) 8. Access to Immunization Services: % of children aged 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 8a. Access to Immunization Services: % of children aged 12-23 months who received DTP1 according to the vaccination card by the time of survey (Card Coverage) 9. Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 9a. Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card by the time of the survey (Card Coverage) 10. Treatment of Fever in Malarious Zones: % of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti￾malarial drug within 24 hours after the fever began 11. ORT Use: % of children age 0-23 months with diarrhea in the last two weeks who received Oral Rehydration Solution and/or recommended home fluids LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 16 12. Appropriate Care Seeking for Pneumonia: % of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 13. Point of Use: % of households of children age 0-23 months that treat water effectively 14. Appropriate Hand Washing Practices: % of mothers of children age 0-23 months who live in households with soap at the place for hand washing 15. ITN Use: % of children age 0-23 months who slept under an insecticide-treated bed net the previous night 16. Underweight: % of children age 0-23 months who are underweight (-SD for the median weight for age, according to WHO/NCHS reference population) Out of 19 indicators presented above in the table; only 2 indicators 8a and 9a have around 1% less result than MTE result. Rest of the indicators has above MTE level. LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 17 1.1 Community Outreach Mechanisms Expanded (Table) Result 1: Increased Access to NNH Services in Parsa 1.1 Community Outreach Mechanisms Expanded SN KPC Project Objective Indicator Baselin e (Feb 08) Mid￾term (Feb 2010) Final Evaluation Jul 2011 EOP target Sep. 2011 Antenatal 5 To maintain or decrease the incidence of maternal and neonatal tetanus Percent of mothers of children aged 0-5 months protected against tetanus by getting second dose of TT vaccine 88.7% 88.3% 98.0% Maintain 6 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 24.7% 39.3% 62.3% 55% 7 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 6.5% 13.8% 14.6% 35% 8 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 30.0% 44.1% 81.4% 55% 9 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 6.9% 14.2% 25.9% 40% 10 To decrease the percent of women and newborns with iron deficiency anemia Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 4 months during their pregnancy 44.1% 50.2% 90.7% 70% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 18 SN KPC Project Objective Indicator Baselin e (Feb 08) Mid￾term (Feb 2010) Final Evaluation Jul 2011 EOP target Sep. 2011 11 To decrease the percent of women and newborns with iron deficiency anemia Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 6 months during their pregnancy 25.9% 32.0% 78.1% 60% 12 To increase the percent of pregnant women experiencing night blindness who receive treatment Percent of mothers of children aged 0-5 months suffering from night blindness during their pregnancy and receiving low-dose vitamin A (25,000 IU)* 0% 15.6% 6.7% 35% 13 To decrease percent of pregnant women suffering from helminthes during pregnancy Percent of mothers of children aged 0-5 months receiving a single dose of albendazole (400 mg) after completion of three month of last pregnancy 37.7% 41.3% 87.9% 65% Delivery 15 To increase percent of women accessing skilled delivery care Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM) 38.5% 46.6% 60.3% 45% 16 To increase percent of women accessing skilled delivery care Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) 41.3% 49.4% 66.4% 50% Postnatal 23 To maintain or increase percent of sick newborns receiving care Percent of mothers with children aged 0-5 months whose newborn children with signs of severe illness were seen by a qualified public or private provider 93.5% 98% 98.8% maintain LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 19 SN KPC Project Objective Indicator Baselin e (Feb 08) Mid￾term (Feb 2010) Final Evaluation Jul 2011 EOP target Sep. 2011 24 To increase percent of newborns receiving a check up from a skilled provider within two days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within the first two days of birth 23.9% 31.2% 54.3% 50% 25 To increase percent of newborns receiving a check from a skilled provider up within two days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within the first two days of birth 25.9% 34% 61.9% 50% 26 To increase percent of newborns receiving a second check up from a skilled provider within 3-7 days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a second post-natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within 3- 7 days after birth 1.2% 0% 20.6% 25% 27 To increase percent of newborns receiving a second check up from a skilled provider within 3-7 days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a second post-natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within 3-7 days after birth 1.2% 0% 26.7% 25% 30 *** To prevent infection among newborns Percent of newborns whose umbilical stump was first applied with chlorhexidine 4% within 24 hours of birth 0% 2% 78.9% 40% 32 To decrease percent women and children with Vitamin A deficiency Percent of mothers of children aged 0-5 months who received vitamin A (200,000 IU) within 45 days after delivery 47.8% 42.9% 81.8% 75% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 20 SN KPC Project Objective Indicator Baselin e (Feb 08) Mid￾term (Feb 2010) Final Evaluation Jul 2011 EOP target Sep. 2011 33 * To increase treatment of infection among neonates Percent of neonates with PSBI diagnosed by a health worker or FCHV within 48 hours of onset 36.4% 52.9% 77.8% 75% 34 To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset 0% 5.9% 55.6% 40% 35 To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 days 0% 0.0% 44.4% 45% 36 * To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 to 5 days 0% 17.6% 44.4% 40% Cross Cutting – Social Inclusion To increase access to health information and services among DAGs** Percent of DAG members participating in PWGs 0% 28% To increase participation of DAG and representation of the needs of DAG in Health Facility Management Committees / VDC level Percent of HFMC with participation of DAG members NA LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 21 2.1 Mothers recognize risks associated with pregnancy, delivery, and neonatal period (Table) SN KPC Project Objective Indicator Baselin e (Feb 08) Mid-term (Feb 2010) Final Evaluation Jul 2011 EOP target Sept. 2011 Antenatal 1 To increase care seeking for skilled delivery care Percent of mothers of children aged 0-5 months having a birth preparedness plan already coordinated with their closest health worker during their pregnancy 11.3% 33.2% 64.8% 40% 2 To increase care seeking during pregnancy Percent of mothers of children aged 0-5 months who know at least two danger signs during pregnancy 51.0% 91.5% 96.0% 70% Delivery 14 To increase care seeking for emergency intra-partum services Percent of mothers of children aged 0-5 months who know at least two danger signs during delivery 27.1% 71.7% 93.5% 45% Postnatal 18 To increase care seeking during postpartum period Percent of mothers of children aged 0-5 months who know at least two danger signs after delivery 27.5% 70.4% 96.8% 40% 19 To increase care seeking during newborn period Percent of mothers of children aged 0-5 months who know at least two danger signs among newborns 75.7% 91.9% 97.6% 85% 20 To increase preventive measures taken against newborn infection Percent of mothers of children aged 0-5 months who know how to apply chlorhexidine on the umbilical stump 0% 1.6% 75.7% 55% 21 To increase preventive measures taken against newborn morbidity Percent of newborns who were breast-fed within one hour of birth 17.4% 35.6% 75.3% 50% 22* To decrease risk of hypothermia Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours 29.6% 57.1% 85.4% 60% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 22 3.1 NNH monitoring and planning systems strengthened (Table) SN KPC Project Objective Indicator Baselin e (Feb 08) Mid-term (Feb 2010) Final-term (Jul 2011) EOP target Sept. 2011 Antenatal 3 To increase effectiveness of antenatal care Percent of mothers of children aged 0-5 months who were counseled on at least 1 counseling point during antenatal check-up 69.2% 76.5% 98.4% 80% 4 To increase effectiveness of antenatal care Percent of mothers of children aged 0-5 months who were counseled on at least 3 counseling points during antenatal check-up 17.0% 56.7% 90.7% 50% Delivery 17 To decrease risk of infection during delivery Percent of birth attendants who washed their hands with soap before assisting in the procedure 75.7% 73.7% 97.2% 85% 22 * To decrease risk of hypothermia Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours 29.6% 57.1% 81.8% 60% Postnatal 28 To increase care seeking for newborn infection Percent of neonates with PSBI referred to a health worker for parenteral antibiotics within 48 hours of onset 0% 11.8% 44.4% 55% 29 To decrease newborn morbidity and mortality associated with infection Percent of neonates treated with antibiotics due to PSBI who completed the course of antibiotics 0% 0.0% 44.4% 55% 31 To increase preventive measures taken against newborn morbidity Percent of children of mothers aged 0-5 months who were fed colostrums 84.6% 85.4% 98.4% 95% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 23 SN KPC Project Objective Indicator Baselin e (Feb 08) Mid-term (Feb 2010) Final-term (Jul 2011) EOP target Sept. 2011 33 * To increase treatment of infection among neonates Percent of neonates with possible severe bacterial infections (PSBI) diagnosed by a health worker or FCHV within 48 hours of onset 36.4% 52.9% 77.8% 75% 36 * To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 to 5 days 0% 17.6% 44.4% 40% *Indicators 22, 33 and 36 contribute to multiple results *** The GoN approves chlorhexidine for inclusion in LIBON in Parsa district for pilot programming. KPC Indicator MTE (Mar 2010) FE (Jul 2011) 1 Percent of mothers of children aged 0-5 months having eclampsia during pregnancy 47.8% 26.3% 2 Percent of mothers of children aged 0-5 months receiving calcium tablets/caps at least for 3 months (90 tablets) during their pregnancy 21.1% 38.9% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 24 Result 4: Strengthened support for NNM reduction in Nepal 4.1 Data generated and utilized to inform national level policy SN KPC Project Objective Indicator Baseline Sunsari (Jan 08) Mid-term Jan 2010 Final Evaluation Jul 2011 Remarks 1 To increase knowledge and interest in NNH intervention processes and outcomes Number of NNH-focused newsletters published and distributed by LIBON at national level 0 3 1 National Level 2 To increase capacity of MOHP at national level to monitor, assess and refine NNH interventions Number of MOHP units (health facilities) receiving technical assistance from the MOHP in KPC/LQAS 0 40 45 3 To generate knowledge and interest in NNH interventions for policy and program application Number of IOM students with field rotations and internships at LIBON sites. 0 0 3 4 To share knowledge and in regard to NNH interventions for policy and program application Number of papers disseminated and/or presentations made based on LIBON project (authored by LIBON stakeholders: MoHP, IOM students, and Plan Nepal) 0 2 1 National Level *Indicators 22, 33 and 36 contribute to multiple results **DAG are defined in Section 2 and based on the GoN definition and coding system LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 25 Rapid CATCH Baseline Indicator Values (Table) SN Indicator Baseline (Feb 08) Mid-term (Feb 2010) Final Evaluati on Jul 2011 1 Tetanus Toxoid: % of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child 95.1% 96.8% 95.5% 2 Skilled Delivery Assistance: % of children age 0-23 months whose births were attended by skilled personnel 36.4% 47% 70.0% 3 Post-Natal Visit to Check on the Newborn: % of children age 0-23 months who received a post- natal visit from an appropriate trained health worker within three days after birth 27.9% 35.6% 61.5% 4 Exclusive Breastfeeding: % of children age 0-5 months who were exclusively breastfed during the last 24 hours 80.7% 84.5% 89.2% 5 Infant and Young Child Feeding: Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 32.5% 75.6% 75.6% 6 Vitamin A Supplementation: % of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 70.7% 67.7% 78.9% 7 Measles Vaccination: % of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 77.6% 81.1% 84.1% 7a Measles Vaccination: % of children aged 12-23 months who received measles vaccine according to the vaccination card by the time of the survey (Card coverage) 10.3% 19.8% 17.5% 8 Access to Immunization Services: % of children aged 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 87.9% 89.6% 95.2% 8a Access to Immunization Services: % of children aged 12-23 months who received DTP1 according to the vaccination card by the time of survey (Card Coverage) 18.7% 23.6% 22.2% 9 Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the 80.4% 79.2% 84.1% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 26 SN Indicator Baseline (Feb 08) Mid-term (Feb 2010) Final Evaluati on Jul 2011 survey 9a Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card by the time of the survey (Card Coverage) 15.9% 21.7% 20.6% 10 Treatment of Fever in Malarious Zones: % of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 45.3% 56.3% 79.3% 11 ORT Use: % of children age 0-23 months with diarrhea in the last two weeks who received Oral Rehydration Solution and/or recommended home fluids 29.4% 53.5% 68.0% 12 Appropriate Care Seeking for Pneumonia: % of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 36.0% 50% 31.4% 13 Point of Use: % of households of children age 0-23 months that treat water effectively 6.1% 6.9% 19.8% 14 Appropriate Hand Washing Practices: % of mothers of children age 0-23 months who live in households with soap at the place for hand washing 57.5% 57.1% 74.9% 15 ITN Use: % of children age 0-23 months who slept under an insecticide-treated bed net the previous night 0% 0% 0.0% 16 Underweight: % of children age 0-23 months who are underweight (-SD for the median weight for age, according to WHO/NCHS reference population) 10.5% 9.5% 4.9% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 27 General information of under 5 months and compare with baseline and MTE of Parsa districts (Table) SN Indicator Baseline (Feb’08) % MTE (Feb'10) % Final Evaluation Jul 2011 A % of mother with children age 0-23 months who child birth below 19 years age 18.2% 11.7% 13.4% B % of mother with children age 0-23 months who child birth between 20 and 34 years age 78.5% 81.8% 82.2% C % of mother with children age 0-23 months who child birth above 35 years age 3.2% 6.5% 4.5% D % of illiterate mother 72.5% 77.7% 66.4% E % of mother education is informal education 2.0% 1.6% 3.6% F % of mother education is Primary Level (1-5 class) 9.7% 5.7% 14.6% G % of mother education is Secondary level (6-10 class) 13.4% 11.3% 13.0% H % of mother education is Higher Secondary (10+2 class) 1.2% 3.2% 1.6% I % of mother education is University Degree 1.2% 0.4% 0.8% J % of mother occupation is Agriculture 16.2% 19.0% 28.3% K % of mother occupation is Service 2.0% 2.4% 1.2% L % of mother occupation is Business 2.8% 2.8% 0.8% M % of mother occupation is Labor 4.5% 4.9% 1.6% N % of mother occupation is Housewife 73.7% 69.6% 68.0% O % of mother occupation is Others 0.8% 1.2% 0.0% P % of mother with male child 48.6% 55.9% 58.7% Q % of mother with female child 51.4% 44.1% 41.3% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 28 General information of under 23 months and compare with baseline and MTE of Parsa districts (Table) SN Indicator Baseline (Feb’08) % MTE (Feb'10) % Final Evaluation Jul 2011 A % of mother with children age 0-23 months who child birth below 19 years age 15.8% 8.5% 10.9% B % of mother with children age 0-23 months who child birth between 20 and 34 years age 79.8% 87% 84.2% C % of mother with children age 0-23 months who child birth above 35 years age 4.5% 4.5% 4.9% D % of illiterate mother 73.3% 75.3% 65.6% E % of mother education is informal education 4.5% 2.0% 4.0% F % of mother education is Primary Level (1-5 class) 11.3% 7.7% 12.1% G % of mother education is Secondary level (6-10 class) 9.3% 10.9% 15.8% H % of mother education is Higher Secondary (10+2 class) 0.8% 3.6% 2.0% I % of mother education is University Degree 0.8% 0.4% 0.4% J % of mother occupation is Agriculture 14.6% 15.% 26.7% K % of mother occupation is Service 1.2% 3.2% 0.8% L % of mother occupation is Business 1.2% 2% 1.2% M % of mother occupation is Labor 4.9% 4.9% 3.6% N % of mother occupation is Housewife 78.1% 74.9% 67.6% O % of male child birth 50.6% 53.8% 60.3% P % of female child birth 49.4% 46.2% 39.7% Q % of child age less than equal 5 months 36.4% 48.6% 63.6% R % of child age between 6 and 23 months 63.6% 51.4% 36.4% S % of child age between 11 and 23 months 43.3% 42.9% 25.5% LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 29 2.10.1(a) Analysis of data interpretation on both Ilaka and indicators – Parsa Table 1: Number of Mothers with children 0-5 months with inadequate knowledge/practices according to LQAS thresholds (Parsa) in Jul 2011 ** Program Average %: Decision Rule – FE (Jul'11) 100 %: 75.3 %: 13 91.5% : 16 98.4% : 0.4%: 62.3% : 10 81.4%: 14 98.4%: 98%: 78.1% : 13 87.9%: 15 64.8 %: 10 46.2% : 7 81.8% : 14 54.3% : 8 61.9% : 10 20.6%: 2 26.7%: 3 78.9% : 13 75.7%: 13 81.8 %: 14 97.6%: 98.8%: 96%: 93.5%: 16 96.8%: *Monitoring %: Decision Rules (Jul'11) 95%: 16 50%: 7 65%: 10 90%: 14 NA 45%: 6 50%: 7 80%: 13 90%: 15 50%: 7 60%: 9 40%: 5 45%: 6 60%: 9 45%: 6 40%: 5 25%: 2 30%: 3 55%: 8 55%: 8 60%: 9 95%: 16 95%: 16 85%: 14 75%: 12 75%: 12 ** Program Average %: Decision Rule – MTE (Feb'10) 99.2 %: 16 35.6 %: 5 63.6% : 10 85.4% : 15 0.0%: NA 39.3% : 5 44.1%: 6 76.5% : 13 88.3% : 15 32.0% : 4 41.3%: 6 33.2 %: 4 35.6% : 5 57.1% : 9 31.2% : 4 34.0% : 4 0.0%: NA 0.0%: NA 2.0%: 1 1.6%: 1 42.9 %: 6 91.9% : 16 98.0%: NA 83.8%: 14 71.7%: 12 70.4%: 12 ** Program Average %: Decision Rule - Baseline (LQAS-Jan'08) 99.2 %: 16 17.3 %: 1 51.0% : 8 83.6% : 14 2.4%: 1 24.2% : 2 29.2%: 3 69.3% : 11 85.9% : 15 25.0% : 2 36.2%: 5 10.9 %: 1 28.2% : 3 28.1% : 3 22.6% : 2 24.4% : 2 1.1%: 1 1.18%: 1 0.0%: 1 0.0%: 1 44.2 %:6 69.8% : 11 85.9%: 15 46.7%: 7 24.7%: 2 25.0%: 2 Field Area (Parsa district) Breastfeeding Breastfeeding within 1 hour Breastfeeding within 8 hours Colostrums feeding Low dose Vitamin “A” to newborn within 48 hrs after birth ANC check up 4 or more time upto ANM ANC check up 4 or more time upto MCHW Counseled during ANC at least 1 TT +2 coverage Iron tablet during pregnancy 6 months Albendazole during pregnancy after 3 months Birth preparedness Delivery at health institute Kangaroo care, dried off, heating source First PNC check-up within 2 days upto ANM Firs t PNC c hec k-up within 2 days upto MCHW Second PNC check-up within 3 to 7 days upto ANM Second PNC check-up within 3 to 7 days upto MCHW Apply Chlorhexidine on Umbilical stump Apply Chlorhexidine on Umbilical stump within 24 hrs Vitamin A after delivery Know danger sign indicate newborn sick at least 2 Know danger sign of newborn need to seek for treatment at least 1 Know danger sign during pregnancy at least 2 Know danger sign during delivery at least 2 Know danger sign after delivery at least 2 Total substandard intervention Indicator no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 1: Thori 19 10# 17 19 NA 12 15 18 19 15 17 12 6# 17 12 12 0#* 0#* 11#* 11#* 17 19 19 18 18 19 6 2: Sedhawa 19 15 19 19 NA 13 19 19 19 16 19 18 7 17 11 14 8 11 18 18 18 19 19 19 15# 19 1 3: Nichuta 19 17 17 19 NA 11 13# 18 19 16 14# 9# 10 13# 10 11 5 5 12#* 11#* 16 15#* 17 15# 14# 14# 10 4: Bagahi 19 13 16 16 NA 7# 10# 18 18 11# 16 6# 11 13# 4#* 5# 0#* 1#* 14 14 11#* 18 18 17 17 17 10 5: Bageshwori 19 14 17 19 NA 7# 12# 18 19 11 13# 9# 8 17 11 11 3 4 15 14 15 18 19 17 18 19 4 6: Bisrampur 19 12# 15# 19 NA 12 17 19 19 14 16 14 13 15 6# 11 3 6 16 15 15 19 19 19 19 19 3 7: Bhikhampur 19 14 18 19 NA 12 18 19 19 16 17 12 10 14 11 13 1#* 3 16 16 17 19 19 19 19 19 1 8: Langadi 19 18 18 18 NA 13 16 19 18 19 19 12 6# 17 13 14 2 3 18 18 18 19 19 19 16 19 1 9: Pokhariya 19 15 18 19 NA 15 15 19 18 15 17 15 9 16 10 11 5 6 14 14 17 19 19 18 19 18 10: Pakaha 19 14 16 19 NA 12 18 19 19 18 19 14 12 12# 9 12 5 6 15 14 15 19 19 19 19 19 1 11: Sirsiya 19 13 19 19 NA 10 16 19 18 14 18 12 13 15 7# 8# 4 6 14 14 14 19 19 19 19 19 2 12: Birgunj 19 15 17 19 NA 15 17 19 19 13 16 15 6# 18 12 13 5 5 15 14 14 19 19 19 19 19 1 LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 30 ** Program Average %: Decision Rule – FE (Jul'11) 100 %: 75.3 %: 13 91.5% : 16 98.4% : 0.4%: 62.3% : 10 81.4%: 14 98.4%: 98%: 78.1% : 13 87.9%: 15 64.8 %: 10 46.2% : 7 81.8% : 14 54.3% : 8 61.9% : 10 20.6%: 2 26.7%: 3 78.9% : 13 75.7%: 13 81.8 %: 14 97.6%: 98.8%: 96%: 93.5%: 16 96.8%: *Monitoring %: Decision Rules (Jul'11) 95%: 16 50%: 7 65%: 10 90%: 14 NA 45%: 6 50%: 7 80%: 13 90%: 15 50%: 7 60%: 9 40%: 5 45%: 6 60%: 9 45%: 6 40%: 5 25%: 2 30%: 3 55%: 8 55%: 8 60%: 9 95%: 16 95%: 16 85%: 14 75%: 12 75%: 12 ** Program Average %: Decision Rule – MTE (Feb'10) 99.2 %: 16 35.6 %: 5 63.6% : 10 85.4% : 15 0.0%: NA 39.3% : 5 44.1%: 6 76.5% : 13 88.3% : 15 32.0% : 4 41.3%: 6 33.2 %: 4 35.6% : 5 57.1% : 9 31.2% : 4 34.0% : 4 0.0%: NA 0.0%: NA 2.0%: 1 1.6%: 1 42.9 %: 6 91.9% : 16 98.0%: NA 83.8%: 14 71.7%: 12 70.4%: 12 ** Program Average %: Decision Rule - Baseline (LQAS-Jan'08) 99.2 %: 16 17.3 %: 1 51.0% : 8 83.6% : 14 2.4%: 1 24.2% : 2 29.2%: 3 69.3% : 11 85.9% : 15 25.0% : 2 36.2%: 5 10.9 %: 1 28.2% : 3 28.1% : 3 22.6% : 2 24.4% : 2 1.1%: 1 1.18%: 1 0.0%: 1 0.0%: 1 44.2 %:6 69.8% : 11 85.9%: 15 46.7%: 7 24.7%: 2 25.0%: 2 Field Area (Parsa district) Breastfeeding Breastfeeding within 1 hour Breastfeeding within 8 hours Colostrums feeding Low dose Vitamin “A” to newborn within 48 hrs after birth ANC check up 4 or more time upto ANM ANC check up 4 or more time upto MCHW Counseled during ANC at least 1 TT +2 coverage Iron tablet during pregnancy 6 months Albendazole during pregnancy after 3 months Birth preparedness Delivery at health institute Kangaroo care, dried off, heating source First PNC check-up within 2 days upto ANM Firs t PNC c hec k-up within 2 days upto MCHW Second PNC check-up within 3 to 7 days upto ANM Second PNC check-up within 3 to 7 days upto MCHW Apply Chlorhexidine on Umbilical stump Apply Chlorhexidine on Umbilical stump within 24 hrs Vitamin A after delivery Know danger sign indicate newborn sick at least 2 Know danger sign of newborn need to seek for treatment at least 1 Know danger sign during pregnancy at least 2 Know danger sign during delivery at least 2 Know danger sign after delivery at least 2 Total substandard intervention 13: Birgunj NP 19 16 19 19 NA 15 15 19 18 15 16 12 3# 18 18 18 10 10 17 14 15 19 19 19 19 19 1 Total substandard 2 1 2 3 1 2 3 4 3 3 2 3 2 2 2 1 1 1 2 1 * Decision rule based on Monitoring/Coverage Target; ** Decision rule based on Program Average Coverage. - Number with hash (#) is below program average coverage; - Number with asterisk (*) is below monitoring/coverage target; - Number with asterisk and circle is below program average coverage and monitoring/coverage target. Ilaka wise description: Two Ilakas namely Ilaka no. 3 Nichuta and 4 Bagahi have 10 indicators below programme average, Ilaka no. 1 Thori has 6 indicators and Ilaka No. 5 Bageshwori and 6 Bisrampur have 4 and 3 indicators below programme average. Ilaka no. 11 Sirsiya has 2 indicators below program average, while the rest except Ilaka no. 9 Pokhariya have 1 indicator below program average. LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 31 Indicator wise Description:  Indicator no. 13 Delivery at health institute has 4 Ilakas below programme average like Ilaka no. 1 Thori, no. 8. Langadi, no. 12 Birgunj, no. 13 Birgunj NP.  Indicator no. 7 ANC check up 4 or more time up to MCHW has 3 Ilakas i.e. no. 3. Nichuta, no. 4 Babahi and no. 5 Bageshwori below programme average.  Indicator no. 12 Birth preparedness has 3 Ilaka below programme average decision rule like no. 3 Nichuta, no. 4, Babahi and no. 5 Bageshwori.  Indicator no. 14 Kangaroo Care has 3 Ilakas below programme average decision rule like no. 3 Nichuta, no. 4, Babahi and no. 10 Pakaha.  Indicator no. First PNC check-up within 2 days upto ANM has 3 Ilakas below programme average decision rule like no. Babahi, no. 6 Bisrampur, no. 11 Sirsiya.  Indicator no. 17 Second PNC check-up within 3 to 7 days upto ANM has 3 Ilakas below programme average decision rule like no. 1. Thori, no. 3 Nichuta and no. 7 Bhikhampur. There are 5 indicators which are no. 1 Breast feeding, no. 4 Colostrums feeding, no. 8 Counseled during ANC at least 1, no. 9 TT +2 coverage, no 23 Know danger sign of newborn need to seek for treatment at least 1 which are above programme average decision rule in all the Ilakas. Remaining indicators have either 1 or 2 Ilakas with below programme decision rule. LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 32 Table 2: Number of Mothers with children 0-23 months with inadequate knowledge/practices according to LQAS thresholds (Parsa district) in July 2011 ** Program Average %: Decision Rule – FE (Jul'11) 95.5%: 11 70%: 10 61.5%: 9 19.8%: 1 74.9%: 12 95.1%: 15 *Monitoring %: Decision Rules (Jul'11) 95%: 16 60%: 9 50%: 7 20%: 1 75%: 12 90%: 15 ** Program Average %: Decision Rule – MTE (Feb'10) 93.1%: 16 47.0%: 7 35.6%: 5 6.9%: 1 57.1%: 9 88.3%: 15 ** Program Average %: Decision Rule - Baseline (LQAS-Jan'08) 95.1%: 16 36.3%: 5 27.7%: 3 6.0%: 1 57.5%: 9 87.4%: 15 Field Area (Parsa district) TT +2 coverage Skill delivery attendant PNC visit for newborn from an appropriate trained health worker with 3 days Family used treat water with effectively Mother live in HH with soap at the place for hand washing Normal weight Total substandard intervention 1: Thori 19 15 14 4 11#* 19 1 2: Sedhawa 19 15 14 1 15 19 3: Nichuta 19 12 12 0#* 9#* 18 2 4: Bagahi 17 10 6#* 5 15 19 1 5: Bageshwori 16 15 13 1 10#* 18 1 6: Bisrampur 19 7#* 6#* 5 14 18 2 7: Bhikhampur 19 13 12 6 18 18 8: Langadi 18 15 8# 0#* 17 16 2 9: Pokhariya 17 12 13 8 12 19 10: Pakaha 19 11 10 6 14 19 11: Sirsiya 18 15 12 3 17 19 12: Birgunj 19 15 15 4 15 17 13: Birgunj NP 17 18 17 6 18 16 Total substandard 1 2 2 3 * Decision rule based on Monitoring/Coverage Target; ** Decision rule based on Program Average Coverage. - Number with hash (#) is below program average coverage; - Number with asterisk (*) is below monitoring/coverage target; - Number with asterisk and circle is below program average coverage and monitoring/coverage target. LIBON – LQAS PARSA Annex 6 Nepal LIBON Project – Final KPC Report 33 Ilaka wise programme average coverage decision rule description:  Ilaka no. 3 Nichta has two indicators no. 4 Family used treat water with effectively and no. 5 Mother live in HH with soap at the place for hand washing below programme average decision rule.  Ilaka no. 6 Bisrampur has 2 indicators no. 2 Skill delivery attendant and no. 3 PNC visit for newborn from an appropriate trained health worker with 3 days below programme average decision rule.  Ilaka no. 8 Langadi has 2 indicators no. 3 PNC visit for newborn from an appropriate trained health worker with 3 days and no. 4 Family used treat water with effectively below programme average decision rule.  Ilakas 2 Sedhuwa, no. 7 Bhikhampur, no. 9 Pokharia, no. 10 Pakaha, no. 11 Sirsiya, no. 12 Birgunj andno. 12 Birgunj NP all have poor program average decision rule.  Ilaka no. 1 Thori has1 indicator no. 5 Mother live in HH with soap at the place for hand washing, Ilaka no. 4 Bagahi have all 1 indicator below program average decision rule. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 34 3.10.2 Sunsari District: The preliminary LQAS findings of final evaluation survey, Sunsari district on 27 May and 9 June 2011 DHO Sunsari and Plan Nepal 1.1 Community Outreach Mechanisms Expanded Result 1: Increased Access to NNH Services in Sursari I. Antenatal KPC Results: Out of 8 indicators survey like; 5. Percent of mothers of children aged 0-5 months protected against tetanus by getting second dose of TT vaccine 6. Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 7. Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 8. Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 9. Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 10. Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 4 months (120 tablets) during their pregnancy 11. Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 6 months (180 tablets) during their pregnancy 12*. Percent of mothers of children aged 0-5 months suffering from night blindness during their pregnancy and receiving low-dose vitamin A (25,000 IU) (*) 13. Percent of mothers of children aged 0-5 months receiving a single dose of albendazole (400 mg) after completion of three month of last pregnancy All 7 indicators have surpassed the EOP-Targets except indicator no. 13 which is 10% less than the EOP-Target i.e. 75.4% in the final against 85% EOT-Target. The results range from 45.6% against 35% EOP-Target in no. 7 to 93% against 80% EOP-Target in no. 10. II. Delivery KPC Results: The 2 Indicators viz. 15. Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM) and 16. Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) have both 82.5% results against 55% in no. 15 and 60% in no. 16 EOP-Target. III. Postnatal KPC Results: LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 35 There are 11 indicators which are as under; 23. Percent of mothers with children aged 0-5 months whose newborn children with signs of severe illness were seen (visited) by a qualified public or private provider 24. Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within the first two days of birth 25. Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within the first two days of birth 26. Percent of mothers with children aged 0-5 months (and their newborns) who received a second post-natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within 3-7 days after birth 27. Percent of mothers with children aged 0-5 months (and their newborns) who received a second post-natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within 3-7 days after birth 30***. Percent of newborns whose umbilical stump was first applied with chlorhexidine 4% within 24 hours of birth (***) 32. Percent of mothers of children aged 0-5 months who received vitamin A (200,000 IU) within 45 days after delivery 33*. Percent of neonates with PSBI diagnosed by a health worker or FCHV (Merge) within 48 hours of onset 60% 34. Percent of neonates with PSBI given a first dose of oral antibiotics (Cotrim) within 48 hours of onset 35. Percent of neonates with PSBI given a first dose of oral antibiotics (Cotrim) within 48 hours of onset for 3 days 36*. Percent of neonates with PSBI given a first dose of oral antibiotics (Cotrim) within 48 hours of onset for 3 to 5 days 7 indicators surpassed the EOP-Target except 4 which are no 23 – 94.4% against 97.2% in the MTE; no 26 – 15.8% against 25% the EOP-Target; no. 27 – 20% aginst 25%; no. 33 – 84.2% against 90% the EOP-Target. The range of results raise from 70% to 94% in the final evaluation. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 36 Result 2: Increased Demand for NNH Services in Sunsari 2.1 Mothers recognize risks associated with pregnancy, delivery, and neonatal period I. Antenatal KPC Results: Both indicators which are Percent of mothers of children aged 0-5 months having a birth preparedness plan already coordinated with their closest health worker during their pregnancy; Percent of mothers of children aged 0-5 months who know at least two danger signs during pregnancy have surpassed the EOP￾Target i.e. 69.8% against 55% in no. 1 and 91.6% against 70% EOP-Target in no. 2. II. Delivery KPC Results: Indicator no. 14 Percent of mothers of children aged 0-5 months who know at least two danger signs during delivery surpassed the EOP-Target i.e. 82.1% against 45% EOP-Target. III. Postnatal KPC Results: All indicators surpassed the EOP-Target i.e. 86.7% against 40 in no. 18; 94.4% against 85% in no. 19; 83.5% against 65% in no. 21 and 88.4 against 65% EOP￾Target in no. 23. Indicators are as under; 18. Percent of mothers of children aged 0-5 months who know at least two danger signs after delivery 19. Percent of mothers of children aged 0-5 months who know at least two danger signs among newborns 20***. Percent of mothers of children aged 0-5 months who know how to apply chlorhexidine on the umbilical stump (***) 21. Percent of newborns who were breast-fed within one hour of birth 22*. Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for (within) 24 hours LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 37 Result - 3: Increased Quality of NNH Services in Sunsari 3.1 NNH monitoring and planning systems strengthened I. Antenatal KPC Results: Two indicators like; 3. Percent of mothers of children aged 0-5 months who were counseled on at least 1 counseling point during antenatal check-up; 4. Percent of mothers of children aged 0-5 months who were counseled on at least 3 counseling points during antenatal check-up Surpassed the EOP-Target i.e. 93.7 against 80% in no. 3 and 85.3% against 55 EOP-Target in no. 4 II. Delivery KPC Results: Two indicators like 17. Percent of birth attendants who washed their hands with soap before assisting in the procedure; 22*. Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours surpassed the EOP-Target i.e. 96.8% against 85% in no. 17 and 88.4% against 68% EOP-Target in no. 22*. III. Postnatal KPC Results: There are 5 indicators; 28. Percent of neonates with PSBI referred to a health worker for parenteral antibiotics within 48 hours of onset 29. Percent of neonates treated with antibiotics due to PSBI who completed the course of antibiotics 31*. Percent of children of mothers aged 0-5 months who were fed colostrums 33*. Percent of neonates with possible severe bacterial infections (PSBI) diagnosed by a health worker or FCHV within 48 hours of onset 36*. Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 to 5 days: 4 indicators have surpassed the EOP-Target for example; 57.9% against 55% in no. 28 and no. 29; 9.5% against 95 EOP-Target in no. 31; 84.2% against 90% in no. 33* and 73.7% against 65% EOP-Target in no. 36*. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 38 Draft findings of Final Evaluation through LQAS method of 0-5 months child of Sunsari district on May-Jun 2011 Result 1: Increased Access to NNH Services in Sunsari 1. Community Outreach Mechanisms Expanded SN KP C Objective Indicator Baseline (Jan 08) Mid- term Jan 2010 FE (Jun 2011) EOP target Sep. 2011 Antenatal 5 To maintain or decrease the incidence of maternal and neonatal tetanus Percent of mothers of children aged 0-5 months protected against tetanus by getting second dose of TT vaccine 83.5% 90.2% 94.0% Maintain 6 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 29.1% 53.3% 74.0% 55% 7 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by ANM or AHW or Staff Nurse or HA or doctor 8.8% 21.8% 45.6% 35% 8 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 4 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 43.5% 69.1% 86.3% 65% 9 To increase the percent of pregnant women receiving adequate antenatal care Percent of mothers of children aged 0-5 months with 6 times ante-natal visit who were checked by MCHW, ANM or AHW or Staff Nurse or HA or doctor 13.7% 26.3% 53.3% 40% 10 To decrease the percent of women and newborns with iron deficiency anemia Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 4 months (120 tablets) during their pregnancy 63.2% 85.6% 93.0% 80% 11 To decrease the percent of women and newborns with iron deficiency anemia Percent of mothers of children aged 0-5 months receiving iron foliate tablets/caps at least for 6 months (180 tablets) during their pregnancy 47.7% 75.1% 85.6% 75% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 39 SN KP C Objective Indicator Baseline (Jan 08) Mid- term Jan 2010 FE (Jun 2011) EOP target Sep. 2011 12* To increase the percent of pregnant women experiencing night blindness who receive treatment Percent of mothers of children aged 0-5 months suffering from night blindness during their pregnancy and receiving low-dose vitamin A (25,000 IU) (*) 10.3% 14.3% 45% 13 To decrease percent of pregnant women suffering from helminthes during pregnancy Percent of mothers of children aged 0-5 months receiving a single dose of albendazole (400 mg) after completion of three month of last pregnancy 62.8% 80.7% 75.4% 85% Delivery 15 To increase percent of women accessing skilled delivery care Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM) 45.3% 67.7% 82.5% 55% 16 To increase percent of women accessing skilled delivery care Percent of mothers of children aged 0-5 months whose birth was attended by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) 46.7% 69.1% 82.5% 60% Postnatal 23 To maintain or increase percent of sick newborns receiving care Percent of mothers with children aged 0-5 months whose newborn children with signs of severe illness were seen (visited) by a qualified public or private provider 89.1% 97.2% 94.4% Maintain 24 To increase percent of newborns receiving a check up from a skilled provider within two days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within the first two days of birth 29.5% 60.0% 73.7% 55% 25 To increase percent of newborns receiving a check from a skilled provider up within two days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within the first two days of birth 30.9% 61.1% 76.1% 60% 26 To increase percent of Percent of mothers with children aged 0-5 months 0.7% 2.5% 15.8% 25% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 40 SN KP C Objective Indicator Baseline (Jan 08) Mid- term Jan 2010 FE (Jun 2011) EOP target Sep. 2011 newborns receiving a second check up from a skilled provider within 3-7 days of birth (and their newborns) who received a second post￾natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within 3-7 days after birth 27 To increase percent of newborns receiving a second check up from a skilled provider within 3-7 days of birth Percent of mothers with children aged 0-5 months (and their newborns) who received a second post￾natal checkup by a skilled provider (doctor or nurse or HA or AHW or ANM or MCHW) within 3-7 days after birth 0.7% 2.5% 20.0% 25% 30 *** To prevent infection among newborns Percent of newborns whose umbilical stump was first applied with chlorhexidine 4% within 24 hours of birth (***) 0% 1.1% 40% 32 To decrease percent women and children with Vitamin A deficiency Percent of mothers of children aged 0-5 months who received vitamin A (200,000 IU) within 45 days after delivery 60.4% 75.1% 86.3% 80% 33* To increase treatment of infection among neonates Percent of neonates with PSBI diagnosed by a health worker or FCHV (Merge) within 48 hours of onset 60% 69.2% 80.0% 84.2% 90% 34 To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics (Cotrim) within 48 hours of onset 17.9% 10.0% 73.7% 60% 35 To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics (Cotrim) within 48 hours of onset for 3 days 2.6% 35.0% 73.7% 50% 36* To increase treatment of infection among neonates Percent of neonates with PSBI given a first dose of oral antibiotics (Cotrim) within 48 hours of onset for 3 to 5 days 17.9% 15.0% 73.7% 65% Cross Cutting – Social Inclusion LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 41 SN KP C Objective Indicator Baseline (Jan 08) Mid- term Jan 2010 FE (Jun 2011) EOP target Sep. 2011 To increase access to health information and services among DAGs** Percent of DAG members participating in PWGs 0% 23% To increase participation of DAG and representation of the needs of DAG in Health Facility Management Committees / VDC level Percent of HFMC with participation of DAG members NA NA Result 2: Increased Demand for NNH Services in Sunsari 2.1 Mothers recognize risks associated with pregnancy, delivery, and neonatal period SN KP C Objective Indicator Baseline (Jan 08) Mid-term (Jan 2010) FE (Jun 2011) EOP target Sept. 2011 Antenatal 1 To increase care seeking for skilled delivery care Percent of mothers of children aged 0-5 months having a birth preparedness plan already coordinated with their closest health worker during their pregnancy 25.6% 57.5% 69.8% 55% 2 To increase care seeking during pregnancy Percent of mothers of children aged 0-5 months who know at least two danger signs during pregnancy 46.7% 79.6% 91.6% 70% Delivery 14 To increase care seeking for emergency intra￾Percent of mothers of children aged 0-5 months who know at least two danger signs during delivery 17.2% 67.7% 82.1% 45% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 42 SN KP C Objective Indicator Baseline (Jan 08) Mid-term (Jan 2010) FE (Jun 2011) EOP target Sept. 2011 partum services Postnatal 18 To increase care seeking during postpartum period Percent of mothers of children aged 0-5 months who know at least two danger signs after delivery 20.4% 73.3% 86.7% 40% 19 To increase care seeking during newborn period Percent of mothers of children aged 0-5 months who know at least two danger signs among newborns 62.8% 90.5% 94.4% 85% 20 *** To increase preventive measures taken against newborn infection Percent of mothers of children aged 0-5 months who know how to apply chlorhexidine on the umbilical stump (***) 0% 1.1% 55% 21 To increase preventive measures taken against newborn morbidity Percent of newborns who were breast-fed within one hour of birth 33.0% 67.7% 83.5% 65% 22* To decrease risk of hypothermia Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for (within) 24 hours 36.8% 74.7% 88.4% 65% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 43 Result 3: Increased Quality of NNH Services in Sunsari 3.1 NNH monitoring and planning systems strengthened SN KP C Objective Indicator Baseline (Jan 08) Mid￾term Jan 2010 FE (Jun 2011) EoP target Sept. 2011 Antenatal 3 To increase effectiveness of antenatal care Percent of mothers of children aged 0-5 months who were counseled on at least 1 counseling point during antenatal check-up 71.6% 87.4% 93.7% 80% 4 To increase effectiveness of antenatal care Percent of mothers of children aged 0-5 months who were counseled on at least 3 counseling points during antenatal check-up 33.0% 77.5% 85.3% 55% Delivery 17 To decrease risk of infection during delivery Percent of birth attendants who washed their hands with soap before assisting in the procedure 74.7% 87.7% 96.8% 85% 22* To decrease risk of hypothermia Percent of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours 36.8% 74.7% 88.4% 68% Postnatal 28 To increase care seeking for newborn infection Percent of neonates with PSBI referred to a health worker for parenteral antibiotics within 48 hours of onset 2.6% 5.0% 57.9% 55% 29 To decrease newborn morbidity and mortality associated with infection Percent of neonates treated with antibiotics due to PSBI who completed the course of antibiotics 0% 0.4% 57.9% 55% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 44 SN KP C Objective Indicator Baseline (Jan 08) Mid￾term Jan 2010 FE (Jun 2011) EoP target Sept. 2011 31 To increase preventive measures taken against newborn morbidity Percent of children of mothers aged 0-5 months who were fed colostrums 84.6% 95.1% 97.5% 95% 33* To increase treatment of infection among neonates Percent of neonates with possible severe bacterial infections (PSBI) diagnosed by a health worker or FCHV within 48 hours of onset 69.2% 80.0% 84.2% 90% 36* To increase treatment of infection among neonates: Percent of neonates with PSBI given a first dose of oral antibiotics within 48 hours of onset for 3 to 5 days: 17.9% 15.0% 73.7% 65% *Indicators 22, 33 and 36 contribute to multiple results Note: (*) No low-dose vitamin A (25,000 IU) program in Sunsari district (***) No chlorhexidine program in Sunsari district. KPC Indicator MTE (Mar 2010) FE (Jun 2011) 1 Percent of mothers of children aged 0-5 months having eclampsia during pregnancy 29.5% 22.8% 2 Percent of mothers of children aged 0-5 months receiving calcium tablets/caps at least for 3 months (90 tablets) during their pregnancy 24.6% 65.6% After MTE, calcium tablet was distributed to pregnant women via pregnant women group (1 gm per day minimum for 90 days suppl LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 45 DHO Sunsari and Plan Nepal Rapid CATCH FE Indicator: Findings of Sunsari district on May-Jun 2011 through LQAS method of under 2 years SN Indicator Baseline (Jan-Feb 08) Mid￾term (Jan 2010) Final￾term (Jun 2011) 1 Tetanus Toxoid: % of mothers with children age 0-23 months who received tetanus toxoid 2 plus (TT2+) vaccinations before the birth of their youngest child 89.8% 93.7% 90.2% 2 Skilled Delivery Assistance: % of children age 0-23 months whose births were attended by skilled personnel 47.4% 70.2% 83.5% 3 Post-Natal Visit to Check on the Newborn: % of children age 0-23 months who received a post-natal visit from an appropriate trained health worker within three days after birth 43.2% 66.3% 78.6% 4 Exclusive Breastfeeding: % of children age 0-5 months who were exclusively breastfed during the last 24 hours 67.7% 90.6% 74.7% 5 Infant and Young Child Feeding: Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 69.6% 77.4% 69.2% 6 Vitamin A Supplementation: % of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 87.3% 91.3% 96.3% 7 Measles Vaccination: % of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 85.9% 89.0% 90.2% 7a Measles Vaccination: % of children aged 12-23 months who received measles vaccine according to the vaccination card by the time of the survey (card coverage) 21.7% 40.7% 41.5% 8 Access to Immunization Services: % of children aged 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 94.6% 91.2% 95.1% 8a Access to Immunization Services: % of children aged 12-23 months who received 31.5% 44.0% 47.6% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 46 SN Indicator Baseline (Jan-Feb 08) Mid￾term (Jan 2010) Final￾term (Jun 2011) DTP1 according to the vaccination card by the time of survey (card coverage) 9 Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 88.0% 86.8% 92.7% 9a Health Systems Performance Regarding Immunization Services: % of children aged 12-23 months who received DTP3 according to the vaccination card by the time of the survey (Card Coverage) 30.4% 42.9% 47.6% 10 Treatment of Fever in Malarious Zones: % of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 44.4% 40.7% 69.4% 11 ORT Use: % of children age 0-23 months with diarrhea in the last two weeks who received Oral Rehydration Solution and/or recommended home fluids 39.3% 63.6% 87.5% 12 Appropriate Care Seeking for Pneumonia: % of children age 0-23 months with chest￾related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 46.0% 87.0% 82.5% 13 Point of Use: % of households of children age 0-23 months that treat water effectively 34.7% 56.8% 21.1% 14 Appropriate Hand Washing Practices: % of mothers of children age 0-23 months who live in households with soap at the place for hand washing 73.0% 77.9% 84.6% 15 ITN Use: % of children age 0-23 months who slept under an insecticide-treated bed net the previous night (**) 0% 16 Underweight: % of children age 0-23 months who are underweight (+_ 3SD for the median weight for age, according to WHO/NCHS reference population) 13.0% 6.3% 8.4% Note: (**) No program for insecticide treated bed net in Sunsari LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 47 Sunsari DHO and Plan Nepal Draft findings through hand tabulation Jun 2011 General information of under 6 months and compare with baseline, MTE and FE of Sunsari district S N Indicator Baseline (Jan’08) % MTE (Jan'10) % FE (Jun'11) % A % of mother with children age 0-5 months who child birth below 19 years age 10.2% 13.7% 14.7% B % of mother with children age 0-5 months who child birth between 20 and 34 years age 86.3% 83.5% 83.5% C % of mother with children age 0-5 months who child birth above 35 years age 3.5% 2.8% 1.8% D % of illiterate mother 52.3% 41.0% 34.7% E % of mother education is informal education 4.9% 7.4% 5.6% F % of mother education is Primary Level (1-5 class) 11.9% 8.4% 13.3% G % of mother education is Secondary level (6- 10 class) 24.9% 34.7% 33.7% H % of mother education is Higher Secondary (10+2 class) 5.3% 8.1% 9.1% I % of mother education is University Degree 0.7% 1.4% 3.5% J % of mother occupation is Agriculture 16.8% 13.3% 15.1% K % of mother occupation is Service 1.8% 3.9% 2.8% L % of mother occupation is Business 4.2% 2.1% 3.9% M % of mother occupation is Labor 10.2% 9.1% 6.7% N % of mother's as housewives 66.7% 71.2% 71.2% O % of mother occupation is Others 0.4% 0.4% 0.4% P % of mother with male child 56.8% 54.0% 49.1% Q % of mother with female child 43.2% 46.0% 50.9% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 48 General information of under 24 months and compare with baseline, MTE and FE of Sunsari district S N Indicator Baseline (Jan’08) % MTE (Jan'10) % FE (Jun'11) % A % of mother with children age 0-23 months who child birth below 19 years age 8.1% 11.6% 10.9% B % of mother with children age 0-23 months who child birth between 20 and 34 years age 87.4% 83.9% 87.4% C % of mother with children age 0-23 months who child birth above 35 years age 4.6% 4.6% 1.8% D % of illiterate mother 51.2% 41.1% 34.4% E % of mother education is informal education 4.9% 6.0% 5.6% F % of mother education is Primary Level (1-5 class) 13.0% 8.4% 14.4% G % of mother education is Secondary level (6-10 class) 24.6% 35.4% 33.3% H % of mother education is Higher Secondary (10+2 class) 5.3% 7.4% 9.8% I % of mother education is University Degree 1.1% 1.8% 2.5% J % of mother occupation is Agriculture 19.3% 13.3% 12.6% K % of mother occupation is Service 1.1% 2.8% 2.5% L % of mother occupation is Business 4.2% 1.1% 3.9% M % of mother occupation is Labor 12.3% 7.7% 3.5% N % of mother occupation is Housewife 63.2% 74.4% 77.2% O % of mother with male child 56.5% 55.4% 48.4% P % of mother with female child 43.5% 44.6% 51.6% Q % of child age less than equal 5 months 44.6% 60.4% 62.5% R % of child age between 6 and 23 months 55.4% 39.6% 37.5% S % of child age between 11 and 23 months 32.3% 29.1% 28.8% LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 49 2.10.2 (a) Draft Table 1: Number of Mothers with children 0-5 months with inadequate knowledge/practices according to LQAS thresholds (Sunsari) in May-Jun 2011 *Monitoring %: Decision Rules (May-Jun'11) 99% 80%: 13 90%: 15 90%: 15 55%: 8 70%: 11 90%: 15 90%: 15 75%: 12 80%: 13 60%: 9 60%: 9 75%:1 2 65%: 10 65%: 10 20%:1 20%"1 75%: 12 90%:1 5 95%:1 6 80%:1 3 70%:1 1 75%:1 2 ** Program Average %: Decision Rule – FE (May-Jun'11) 99.6% 83.5%: 14 99.3% 97.5% 74.0%: 12 86.3%: 15 95.4% 94.0%: 16 85.6%: 15 90.5%: 16 69.8%: 11 77.9%: 13 88.4%: 15 73.7%: 12 76.1% : 13 15.8%: 1 20.0%: 1 86.3%: 15 94.4%: 16 98.6% 91.6%: 16 82.1%: 14 86.7%: 15 ** Program Average %: Decision Rule – MTE (Jan'10) 99 .6%: 16 69.5%: 11 89.8%: 15 95.1%: 16 53.3%: 8 69.1%: 11 87.7%: 15 90.2%: 16 75.1%: 12 80.7%: 14 57.5%: 9 57.2%: 9 74.7%: 12 60%: 9 61.1%: 10 2.5%: 1 2.5%: 1 75.1%: 12 90.5%: 16 97.2%: 16 80%: 13 67.7%: 11 73.3%: 14 ** Program Average %: Decision Rule – Baseline (Jan'08) 98 .2%: 16 33.0%: 4 71.9%: 12 84.6%: 14 29.1%: 3 43.5%: 6 71.6%: 12 83.5%: 14 47.7%: 7 62.8%: 10 25.6%: 3 35.8%: 5 36.8%: 5 29.5%: 3 30.9%: 4 0.7%: 1 0.7%: 1 60.4%:1 0 62.8%: 10 89.1%: 15 46.7%: 7 17.2%: 1 20.4%: 2 Field Area (Sunsari district) Breastfeeding Breastfeeding within 1 hour Breastfeeding within 8 hrs Colostrums feedin g ANC check up 4 or more time upto ANM ANC check up 4 or more time upto MCHW Counseled during ANC at least 1 TT 2 coverage Iron tablet during pregnancy 6 months Albendazole during pregnancy after 3 months Birth preparedness Delivery at health institute Kangaroo care, dried off, heating source First PNC check - up within 2 days up to ANM First PNC check￾up within 2 days up to MCHW Second PNC check-up within 3 to 7 days up to ANM Second PNC check-up within 3 to 7 days up to MCHW Vitamin A after deliver y Know danger sign indicate newborn sick at least 2 Know danger sign of newborn need to seek for treatment at least 1 Know danger s ign during pregnancy at least 2 Know danger sign during delivery at least 2 Know danger sign after delivery at least 2 Total substandard intervention 1: Itahari 19 13# 19 19 15 15 19 19 16 14# 13 17 17 17 17 2 2 17 17 19 16 11# 11#* 4 2: Chatara 19 15 19 19 17 18 18 18 15 18 18 13 15 16 16 6 6 17 19 19 19 19 19 0 3: Madhuwan 19 19 19 19 11# 15 19 18 19 19 17 12# 16 6 11# 4 11 17 19 19 19 19 19 3 4: Harinagara 19 17 19 19 12 17 18 19 16 19 12 14 15 12 12# 0#* 1 18 18 19 18 18 18 2 5: Satterjhora 19 18 19 18 9# 11# 17 19 18 19 14 11# 15 10# 10 1 1 18 18 18 18 18 18 4 6: Inaruwa 19 11#* 19 19 7# 18 19 19 19 18 13 15 18 15 15 8 10 18 18 19 19 19 19 2 7: Prakaspur 19 16 19 18 17 18 19 19 17 19 18 11# 14# 12 12# 1 1 17 17 19 16 16 16 3 LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 50 8: Bakalauri 19 16 19 18 17 17 19 19 12# 19 12 16 17 13 13 1 1 17 19 19 19 18 19 1 9: Madhelee 19 18 19 19 16 16 18 18 18 18 11 17 19 16 16 0#* 0#* 18 17 18 19 15 14# 3 10: Sitagunj 19 16 19 17 14 17 18 17 16 17 12 15 19 14 14 1 2 17 17 18 14 12# 14#* 2 11: Dewagunj 19 18 19 18 9# 14# 18 19 19 18 18 14 18 15 17 3 3 19 19 19 19 19 19 2 12: Bhutaha 19 18 18 19 15 18 19 19 16 15# 14 15 17 13 13 7 8 19 19 19 19 19 19 1 13: Itahari NP 19 15 19 19 19 19 19 16 14# 17 10# 19 17 19 19 3 3 13# 18 19 17 7#* 13# 5 14: Dharan NP 18 13# 18 19 15 15 16 12#* 14# 13# 5#* 18 19 17 17 3 3 11#* 16 19 12#* 6#* 11#* 9 15: Inaruwa NP 19 15 19 18 18 18 16 17 15 15 12 15 16 15 15 5 5 10#* 18 18 17 18 18 1 Total 3 4 2 1 3 3 2 3 1 1 3 2 1 3 1 4 5 LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 51 Ilaka wise result description:  Ilaka no. 14 Dharan NP has 9 indicators below program average coverage.  Ilaka no. 13 Itari NP has 5 indicators below program average coverage.  Ilaka no. 5 Saterjhora has 4 indicators below program average coverage.  Ilaka no. 3 Madhuban has 3 indicatros below program average coverage.  Ilaka no. 7 Prakashpur has 3 indicators below program average coverage.  Ilaka no. 9 Madheli has 3 indicatros below program average coverage. The rest of the Ilakas except Ilaka no. 2 Chatara having all indicators above program average coverage, have 1 to 2 indicatros below program average coverage. Indicators wise result description:  Indicator no. 23 Know danger sign after delivery at least 2 has 5 Ilakas like Ilaka no. Itahari, no. 9 Maheli, no. 10 Shia Gunj, no. 13 Itahari NP, no. 14 Dharan NP with below programme average coverage.  Indicator no. 22 Know danger sign during delivery at least 2 has 4 Ilakas like Ilaka no. 1 Itahari, no. 10 Sitagunj, no. 13. Itahari NP, no. 14 Dharan NP with below programme average coverage.  Indicator no. 2 Breastfeeding within 8 hrs; no. 9 Iron tablet during pregnancy 6 months; no. 10 Albendazole during pregnancy after 3 months; no. 12 Delivery at health institute; no. 15 First PNC check-up within 2 days up to MCHW and no. 18 Vitamin A after delivery – all have 3 Ilakas each below programme average coverage.  Indicator no. 1. Breastfeeding; no. 3 Breastfeeding within 8 hrs; no. 4 Colostrums feeding; no. 7 Counseled during ANC at least 1; no. 19 Know danger sign indicate newborn sick at least 2; no. 20 Know danger sign of newborn need to seek for treatment at least 1 have all Ilakas above programme average coverage.  Rest of the indicators have 1 to 2 Ilakas with below programme average coverage. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 52 Table 2: Number of Mothers with children 0-23 months with inadequate knowledge/practices according to LQAS thresholds (Sunsari district) in May-Jun 2011 *Monitoring %: Decision Rules (May-Jun'11) 95%: 16 80%:13 75%:12 45%:6 80%:13 90%:15 ** Program Average %: Decision Rule – FE (LQAS M 90.2%: 16 83.5%: 14 78.6%: 13 21.1%: 2 84.6%: 14 91.6%: 16 ** Program Average %: Decision Rule - MTE (LQAS-Jan'10) 89.8%: 15 70.9%: 12 67.7%: 11 61.4%: 10 79.6%: 13 95.8%: 16 ** Program Average %: Decision Rule - Baseline (LQAS-Jan'08) 89.8%: 15 47.4%: 7 43.2%: 6 34.7%: 5 73.0%: 12 87.0%: 15 Field Area (Sunsari district) TT +2 coverage Skill delivery attendant PNC visit for newborn from an appropriate trained health worker with 3 days Family used treat water with effectively Mother live in HH with soap at the place for hand washing Normal weight Total substandard intervention 1: Itahari 17 18 17 10 18 18 2: Chatara 19 16 16 9 18 19 3: Madhuwan 19 16 11#* 0#* 18 11#* 3 4: Harinagara 19 15 13 3* 16 18 5: Satterjhora 19 14 13 5* 14 18 6: Inaruwa 17 14 15 1#* 19 17 1 7: Prakaspur 18 12#* 13 0#* 10#* 17 3 8: Bakalauri 17 16 16 2* 13# 18 1 9: Madhelee 13#* 16 9#* 4* 15 19 2 10: Sitagunj 10#* 17 17 3* 13# 17 2 11: Dewagunj 19 17 17 1#* 18 19 1 12: Bhutaha 19 16 16 1#* 17 17 1 13: Itahari NP 16 16 16 8 17 18 14: Dharan NP 17 19 19 12 19 18 15: Inaruwa NP 18 16 16 1#* 16 17 1 Total 2 1 2 6 3 1 LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 53 Ilaka wise programme average coverage decision rule description:  Ilaka no. 3 Madhuban has 3 indicators no. 3 PNC visit for newborn from an appropriate trained health worker with 3 days; no. 4 Family used treat water with effectively and no. 6 Normal weight below programme average decision rule.  Ilaka no. 7 Prakashpur has 3 indicators namely no. 2 Skill delivery attendant; no. 4 Family used treat water with effectively and no. 5 Mother live in HH with soap at the place for hand washing below program average decision rule.  Ilaka no. 9 Madheli has 2 indicators like no. 1 TT +2 coverage and no. 3 PNC visit for newborn from an appropriate trained health worker with 3 days below programme average decision rule  Ilaka no. 10 Sitagunj has 2 indicators like no. 1 TT +2 coverage and no. 5 Mother live in HH with soap at the place for hand washing below programme average decision rule.  Ilakas no. 1 Itahari, no. 2 Chatara, no. 4 Harinagara, no. 5 Satterjhora, no. 13 Itahari NP, no. 14 Dharan NP have all programme averge decision rule  The rest of the Ilakas have 1 indicator below programme average decision rule. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 54 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 15- Inaruwa Date: 26-2-068 M# Indicators Reason Recommended strategy Activities 1 Counseling during ANC at least Lack of awareness on importance and utilization of ANC service in local health facility. Awareness raising is necessary to pregnant mothers. Strengthen health facility with skilled manpower. Mother group formation for counseling and information sharing. Use of local FM radio and newspaper for awareness raising. 1 Iron tablet during pregnancy 6 months. Lack of information knowledge for taking iron tablet. Shortage of tablets. Availability of iron tablets in health facility. Health education on the importance of using iron tablets. Regular supply of iron tablets. BCC is needed to pregnant mothers. BCC? 1 Albendazole during pregnancy after 3 months. Lack of awareness and shortage of the time. Health education program about utilization of Albendazole. Availability of Albendazole. Regular supply. Increase BCC activities. 1 Vitamin ‘A’ after delivery. Lack of awareness and shortage of vitamin “A’ tablet. Health education about utilization of vitamin ‘A’. Regular supply. Increase BCC activities about vitamin A and extend Nutrition education. 2 Insecticide treated bed net the previous night. Not available in the market. No supply from the central office. Increase the supply of insecticide net in Sunsari district. Free distribution and supply in the market. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 55 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 14-Dharan Date: 9-June-2011 M# Indicators Reason Recommended strategy Activities 1 Breast feeding within 1 hour. Complicated pregnancy c/s Complication in babies. Inadequate knowledge. Health workers: re￾enforcement by training. Education: inclusion of staffs in teaching hospital. Information to public via mass media. Mobilization of FCHVs. Provide trainings to health workers and monitoring, evaluation of their perfomance. Training to FCHVs. 2 TT2 coverage Recall bias? Primi mothers? Skipping of MNT.? Re-campaigning Re-emergence of MNT programme Effective recording/reporting. Ensure TT injection during pregnancy by health workers. Awareness raising among mothers and parents. 3 Iron tablet during pregnancy Mother’s negligence or ignorance. Poor Health care and weak counseling. Updating of knowledge among health workers. Antenatal visit: increment. Effective recording/reporting. Training to and Evaluation of health workers. Awareness raising among mothers by mass media. Mobilization of FCHVs. 4 Albendazole during pregnancy after 3 months. Lack of knowledge and awareness among mothers. Health workers’ weak counseling. Belief of miscarriage due to albendazole. IEC: strengthening of IEC (effective) Promotion of antenatal care. Training of health workers, FCHVs. Use of mass medias, to provide information regarding albendazole to remove misconception. Counseling to mothers. Essential drugs available in teaching hospital. 5 Birth preparedness People believe that hospital facilities are nearby. Lack of counseling by health professionals. Effective IEC method. Reinforcement of health workers. Mobilization of FCHVs. Training FCHVs. Recruitment or posting of counselors. Provide adequate number of staff a/c to patients flow. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 56 Health professionals are overburdened. Lack of time Lack of knowledge on BPP. 6 Vitamin A after delivery Low socio￾economic status of people. Lack of strategy for vitamin A Strategy for vitamin A and after delivery. Record card of maternal services. Record keeping of each and every service. Vitamin A distribution after institutional delivery. Mobilization of FCHVs for vitamin A distribution. 7 Know danger sign of newborn. Lack of knowledge and awareness and the efficiency of mass media, or information materials. Effective IEC. Health professional training. Counseling to mothers. Training and Effective design, distribution of information materials. Inclusion of material or reproductive health in curriculum of secondary school level.? 8 Danger signs during pregnancy Lack of knowledge and awareness and the efficiency of mass media, information materials. Information, EC methods. Does DEO or Ministry agrees? Counseling to mothers. Training and Effective design, distribution of information material. Inclusion of materials or reproductive health in curriculum of secondary school level. 9 Danger signs after delivery. Lack of knowledge and awareness and the efficiency of mass media, information material. Information, EC methods. Counseling to mothers Training, Effective design, and distribution of information material. Inclusion of material or LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 57 reproductive health in curriculum of secondary school level. Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 13-Itahari NP Date: 26-02-2068 M# Indicators Reason Recommended strategy Activities 1 Breast feeding within 1 hour Poor knowledge Operative procedure and Attitude of staff. Mass awareness Training to all level of health workers Encourage for institutional delivery Training to all level of health workers and FCHVs; Routinely monitoring and evaluation; Proper counseling during prenatal and postnatal period to mothers. 2 TT2 coverage Lack of counseling for next dose of TT Negligence by women and Improper recording. Public awareness for compulsory ANC visit at nearest health facility. BCC? Reinforce mothers to receive next dose of TT 3 Birth preparedness Unawareness and lack of counseling Mass awareness; Reinforce health worker and FCHVs for proper counseling for BPP Timely/ proper delivery of health services; Use of behavior mapping in all VDCs. BCC; Proper counseling to pregnant women and family during ANC visit; Monthly PWGs meetings 4 Vitamin A after delivery Home delivery Lack of PNC visit Encourage for institutional delivery; Reinforce FCHVs and HWs Proper counseling to PWGs; Monitoring and evaluation of FCHVs and HWs performance. 5 Knowledge of danger sign during delivery at Lack of proper counseling; Lack of Public awareness through mass media BCC; Proper counseling to LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 58 least (2) education; Attitude of HWs PWGs and family during ANC visit 6 Knowledge of danger signs after delivery at least 2. Lack of proper counseling; Lack of education; Attitude of HWs Public awareness through mass media Develop positive attitude; how? Refresher training to HWs and FCHVs. Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 11-Dewanganj Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 ANC check-up 4 or more times up to ANM. Lack of health worker (ANM); Lack of health education Border area? Present political situation? Coordination with DHO/DPHO to depute ANM; Provide health education regularly Advise clients at own institution? Coordination with HMC & institution. Advice to DHO at district monthly meeting; Health education to mother groups; Coordination with HMC and clients. 1 ANC check-up 4 or more times up to MCHW. Lack of health worker (ANM); Lack of health education Border area? Present political situation? Coordination with DHO/DPHO for ANM Provide health education regularly Advice to client at own institution? Coordination with HMC & institution. Advice to DHO at district monthly meeting. Health education to mother groups. Coordination with HMC and client. 1 1st pregnancy check-up within 2 days up to ANM. Lack of health worker (ANM) Lack of health education Border area Present political situation Coordination with DHO/DPHO for ANM Provide health education regular Advice to client at own institution Coordination with HMC & institution. Advice with DHO at district monthly meeting. Health education for mother groups. Coordination with HMC and client. 2 Family use treat water with effectively. Poverty Poor health education Continue health education program. Mothers group meeting; School health education for school age children. 2 ? Insecticide treated bed net at night Poverty Poor health education Continue health education program. Mothers group meeting School health LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 59 ? education for school age children. Recommendation activities not complying Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka#10-Sitagunj Date: 26-02-2068 M# Indicators Reason Recommended strategy Activities 1 Know danger sign during pregnancy at lest 2. Poor/weak Health education. Health education provision for VDC and ward. Training to FCHV and health worker. 1 Know danger sign during delivery at last 2 Poor/weak Health education. Health education provision for VDC and ward. FCHV and health worker ANM and birthing center 2 TT+2 coverage Family used treat water and effectively Data verification and source. Awareness. Health education Re-data analysis. Health education promotion of VDC and ward. Immunization clinic; VHW/MCHW and health post incharge. 2 Mother live in HG with soap at the place for hand washing Poor/weak Health education Mother group meeting Health education promotion for VDC and ward Increasing the mother groups meetings. FCHV and health worker training; Review orientation/ health education during mother groups meetings LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 60 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 9-Madheli Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 TT+2 coverage Survey and data tabulation? Pregnant mothers to be focused on Immunization program Reinforce program by increasing supervision in health centers. 1 PNC visit for newborn from an appropriate trained health worker within 3 days. Due to low PNC visit Motivate antenatal mothers for the check up of new born babies. Activate FCHVs; Make ORC effective; and Effective supervision 1 Family used treat water and effectively Data survey and tabulation? Health education Motivate mothers towards ORC and health centers 1 Mother live in HH and soap at the place for hand washing Data survey and tabulation? Health education Motivate mothers towards ORC and health centers 2 Second PNC check up within 3- 7 days up to ANM Lack of motivation in mothers Motivate mothers for the 1st PNC Motivate FCHVs for the 2nd PNC Health education in FCHVs meeting and ORC 2 Second PNC check up within 3- 7 days up to MCHW Lack of motivation in mothers Motivate mothers for the 1st PNC Motivate FCHVs for the 2nd PNC Make ORC effective. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 61 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 8 - Baklauri Date: M# Indicators Reason Recommended strategy Activities 1 Iron tablet during pregnancy (6 months) Shortage of iron tablet in DHO; pregnant mothers used to take iron tablet buying from the market. Continue the FCHVs monthly meeting regularly; Prioritize the counseling parts and DAG communities; Increase counseling in ORC, MGM Continue supply of iron tablets Financial support for the FCHVs monthly meeting. 1 First PNC check up within 2 days up to ANM Lack of home visit for check up; Mothers unable to visit health posts for postnatal check ups Increase home visit by ANM for postnatal check up; Increase counseling part during review meeting in MGM Focus more in dalit community Increase ANM’s supervision and PNC check up; Financial support for the meetings. Programs focused to Dalit community. 1 1st PNC check up within 2 days up to ANC No post of MCHW in health centers.? - - 1 2nd PNC check up within 3-7 days up to ANM Lack of ANM mobilization with in 2 days visit. ANM should be mobilized for PNC check up. Focus on counseling part during monthly meeting. Financial support for the necessary arrangements. 1 2nd PNC check up with in 3-7 days to MCHW No post of MCHW in health centers.? - - 2 Family used treat water with effectively Use river water for drinking Health education; Water should be purified/filtered before drinking. Provide health education. 2 Insecticide treated bed net the previous night No distribution of bed net in the district Request for supply Distribute after supply LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 62 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 7-Prakashpur Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 Delivery at health institute Lack of skilled person at health institutes and heath facility staffs. Fulfill the skilled person at health institute from higher level or office. Advocate/pressurize to depute staff. 2 TT+2 coverage Lack of awareness; Mother groups meeting not conducted regularly. Conduct Mothers group monthly meetings regularly; Conduct PWG meetings regularly BPP counseling EPI clinic Strengthen Conduct Mother group meetings regularly. 2 Skilled delivery attendant Lack of skilled manpower and adequate birthing center Fulfill the skilled person Promote increase the birthing centers Encourage pregnant mothers for HI delivery Plan for birthing centers 2 Family used treat water with effectively Use of hand pump water Raise awareness to take treated water Conduct awareness programs 2 Mother live in HH with soap at the place for hand washing Lack of knowledge of cleaning with soap. Mother group meeting will be conducted regularly. Health education on the use of soap Conduct mother group meeting regularly. Promote awareness programs LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 63 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 5-Satterjhora Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 1st ANC check up within 2 days up to MCHW By tradition they do not visit newly born baby’s mother within 2 days Mobilization of health workers up to MCHW ORC should be continued by ANM/MCHW Educate all the related mothers in MGM 1 ANC check up 4 or more times up to MCHW Lack of knowledge and awareness They should be informed about the importance of all ANC visit. Discussion will be done in ORC. FCHV will be involved for upgrading awareness of concerning mothers. 1 Delivery at health institution Far from birthing centers Lack of transportation appropriately Birthing center should be established in PHC Satterjhora Manage for emergency transportation. Discussion will be done in local level Staff will be updated Ambulance number will be provided to the concerning mother and their relatives. 1 First PNC check up within 2 days up to ANM Lack of ANM mobilization within 2 days visit. ANM should be mobilized for PNC check up. Health education in community level by FCHV Health education for all pregnant mothers and their guardians with the importance of PNC visit. 2 TT+2 coverage Lack of knowledge of mothers about TT+2 vaccination Inform all mothers about the importance of TT+2 vaccination Talk about TT+2 in mother’s group meeting during ANC check up and ORC. Regular vaccination and supply vaccination materials. 2 Family used treat water with effectively Misconcept of mothers about the deep tube well water as potable. Treat water for safe drinking. Teach them about boiling water for 30 minutes for safe drinking purpose. Use chemicals for purifying. 2 Mother live in HH with soap at the place for hand washing Poverty Illiteracy Lack of knowledge of importance of hand washing with soap. Educate them about the importance of hand washing with soap. Health education program in all related place LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 64 2 Insecticide treated bed net the previous night No risk malaria area No distribution of ITBN Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 4-Harinagara Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 Breast feeding within 1 hour is low. Lack of education PHC, ORC, MGM not effective Lack of health education in focal group. Continue MGM Inform about ANC check up during PHC, ORC Awareness about the health education to pregnant mothers during MGM, ORC 1 1st PNC check up within 2 days up to ANM Lack of education Provide health education through different means. Continue PHC, ORC, MGM regularly and effectively. Inform about the importance of PNC and other health education during MGM, PHC and ORC. 1 1st PNC check up within 2 days up to MCHW PHC, ORC, MGM not effective Provide health education through different means. Continue PHC, ORC, MGM regularly and effectively. Inform about the importance of PNC and other health education during MGM, PHC and ORC 2 Breast feeding within 1 hour is low. Lack of education and its importance about the colostrums. PHC, ORC, MGM not effective Lack of health education in focal group. Continue MGM Inform about ANC check up during PHC, ORC Awareness raising and health education to pregnant mothers during MGM, ORC on the importance of breast feeding 2 1st PNC check up within 2 days up to ANM Lack of Information Provide health education through different means. Continue PHC, ORC, MGM regularly and effectively. Inform about the importance of PNC and other health education during MGM, PHC and ORC. 2 1st PNC check up within 2 days up to MCHW PHC, ORC, MGM not effective Provide health education through different means. Continue PHC, ORC, MGM regularly and effectively. Inform about the importance of PNC and other health education during MGM, PHC and ORC. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 65 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 3-Madhuwan Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 Delivery at health institute Lack of skilled person and helping person hands Vacancy should be fulfilled promptly Concerned offices should fulfill the staff to increase institutional delivery. BPP counseling. 1 Second PNC check up within 3-7 days up to ANM Lack of awareness and nursing staff Vacancy should be fulfilled promptly Concerned offices should fulfill the staff to increase PWC check up PWG meeting continue 1 Second PNC check up within 3-7 days up to MCHW Lack of staff in sub health post as MCHW Vacancy should be fulfilled promptly Increase BPP counseling in PWG 2 PNC visit for new born from on appropriate and trained health workers within 3 days. Lacking of interest from staff side. Incentive for encouragement Staff meeting Conversation ANC/PNC clinic should be regular BPP counseling to pregnant mother. 2 Family used treat water with effectively Concept of pipe water n clean and no pathogenic Create awareness through health education Activate to treat water 2 Insecticide treated bed net the previous night Not available Poverty No knowledge Supply from government side Health education Provide knowledge for the need to use the net 2 Normal wt. Lacking of at least 4 times ANC visit and having no health education about nutrition. Increase at least 4 ANC visit with having nutrition education. Strengthen nutrition program Continue ANC clinic regularly Health education about nutrition program in each ward per month. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 66 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 2-Chatara Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 PNC 1st visit and 2nd visit Institutional delivery and home visit of PNC mother from health activity staff within 7 days BPP counseling to pregnant mother in each ward Joint supportive supervision to FCHVs Regular meeting of pregnant mother groups Check up in PNC in ORC for ANM staff Increase FCHV’s home visit for ANC of mothers and newborn baby. 2 Used insecticide treated bed net the previous night This intervention is not implemented in Sunsari district. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 67 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 1-Itahari Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 ANC check up to 4 or more then up to MCHW Lack of knowledge of importance of ANC check up Traditional attitude. Refresher for FCHVs Awareness program for mothers group/ pregnant mother Encourage FCHVs Monitoring and supervision of HW and FCHV at least 15 % FCHV. Compulsory meeting of mother group 1 Know the danger sign indicate newborn seek at least 2 Lack of knowledge of new born seek reason at least 2 Refresher for FCHVs Awareness program for mothers group/ pregnant mother Encourage FCHV Monitoring and supervision for HW and FCHV at least 15 % FCHV. Compulsory meeting of mother group Knowledge of danger sign during pregnancy Lack of knowledge danger sign during pregnancy Refresher for FCHV Awareness program for mothers group/ pregnant mother Encourage FCHV Monitoring and supervision for HW and FCHV at least 15 % FCHV. Compulsory meeting of mother group Knowledge of danger sign after pregnancy Lack of knowledge of danger after pregnancy. Refresher for FCHV Awareness program for mothers group/ pregnant mother Encourage FCHV Monitoring and supervision for HW and FCHV at least 15 % FCHV. Compulsory meeting of mother group 2 TT+2 coverage Lack of knowledge of tetanus +2 vaccine in pregnancy Appropriate record: Maintain cards Public awareness Maintain record of TT+2 Educate to maintain cards 2 Insecticide treated net Lack of distribution of insecticide treated net Provide insecticide treated net for household. Carry on to provide such insecticide treated nets. LIBON – LQAS SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 68 Ilaka-wise Recommendations for improvement in poor indicator(s) data based on finding during LQAS survey on May-June 2011-Sunsari District Ilaka# 12-Bhutaha Date: 9th June 2011 M# Indicators Reason Recommended strategy Activities 1 Kangaroo care dried off Lack of supervision No presence of health workers in MGM Supervision of VHW and HW HW should be compulsorily present during MGM. Increase awareness Inform about ANC during MGM Know danger sign of new born need to seek for pregnant at least Lack of health education and ANC check up Lack of FCHVs awareness program Provide health education and ANC check ups Increase counseling by FCHVs/MCHWs Counseling by the health workers and FCHVs Know danger sign after delivery at least 2 Lack of counseling Lack of education about importance of ANC Increase awareness and counseling about health education Counseling by the health workers and FCHVs 2 Family use treat water with effective Use of tube well in most community Use of tube well water deep upto 40-50 ft . Drink boiled water Counsel about safe drinking water during MGM and PWG meeting. Insecticide treated bed net the previous night No such program in the district Awareness raising on the program. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 69 3.10.3 Bara District: District Health Office, Bara and Plan Nepal Child and maternal health related survey of Bara district through Lot Quality Assurance Sampling (LQAS) on Jun-Jul 2011 Comparison of coverage proportion for key indicators collected between period (Jun 2006, Dec 2009 and Jun-Jul 2011) in Bara district 1. BREAST FEEDING AND CHILD NUTRITION INDICATORS like 1. Percent of children aged 0-11 months who are breastfed with in the first hour after birth; 2. Percent of infants aged 0-5 months who were fed breastfed milk only in the last 24 hours; 3. Percent of infant aged 6-9 months who received breast milk and solid foods in the last 24 hours; 4. Percent of children aged 12-23 months who are still breast feeding; 5. Percent of children aged 12-23 months who received a vitamin A does in the last six months have a range of above 70% to 100% coverage in the final evaluation 20011 in comparison to 66% to 100% coverage in 2006 and 83% to 98% coverage in 2009, except indicator no. 2 and 3 which have shown less coverage percentage ranging from 2% to 13% than 2009 and 6% to 30% in 2006. 2. CHILDHOOD IMMUNIZATION INDICATORS 6. Percent of Children aged 12-23 months who have a Vaccination Card; 7. Percent of children aged 12-23 months who received DPT 1; 8. Percent of children aged 12-23 months who received measles vaccine; 9. Percent of drop out- rates between DPT1 and DPT 3; 10. Percent of children aged 12-23 months who received BCG, DPT3, OPV3 and measles vaccines before the first birthday; 11. Percent of children aged 12-23 months who received OPV 3 have a range of 45% coverage which is lesser than the coverage of 2006 and higher than of 2009 (The reason is provided in a separate description included along with this report. 3. SICK CHILD: Indicator 12 Percent of mothers of children aged 0-23 months who know at least THREE signs of childhood illness that indicate the need for treatment has 98% coverage same as 2006 and higher than that of 2009 i.e. 75%. 4. DIARRHEA INDICATORS: All most all indicators viz. 13. Percent of children aged 0-23 months with diarrhea in the last two weeks; 14. Percent of children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/ or recommended home fluids (RHF); 15. Percent of children aged 0-23 who received breastfed same amount or more during diarrhea in last two weeks.; 16. Percent of children aged 0-23 months with diarrhea in the last two weeks who were offered the same amount or more drink / fluid during the illness; 17. Percent of children aged 0-23 months with diarrhea in the last two weeks who were offered the same amount or more food during the LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 70 illness; 18. Percent of Children aged 0-23 months with diarrhea in the last two weeks whose mothers Sought outside advice or treatment for the illness; 19. Percent of mothers who can correctly prepare ORS; 20. Percent of mothers who usually wash their hands with soap or ash before food preparation.; 21. Percent of mothers who usually wash their hands with soap or ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated; Except no. 19 which has 89% coverage compared to 2006 – 84% and 209 – 61% have less percentage of coverage than in 2006 and 2009. The reason may be seasonal variation, because during winter such cases are mostly lower than in summer/rainy season. Both the surveys of 2006 and 2009 were conducted during December and January while the final was conducting during June and July – the peak season for diarrhea cases. 5. ARI IDICATOR: The coverage is less 44% compared to 2006 (80%) and 2009 61%. This is a good sign of improvement. The indicator is no. 22 Percent of Children aged 0-23 months with cough and fast / difficult breathing in the last two weeks who were taken to a health facility or received treatment. 6. PRENATAL CARE INDICATORS: Explanation provided for unavailability of card during final evaluation in survey period, as the mothers do not need to maintain them after 12 moths of their children; which included in CSSA Bara success case report. Indicator no. 25 Percent of mothers who had at least ONE prenatal visit prior to the birth of her youngest child less than 12 months of age has significant coverage of 91% compared to 78% of 2006 and 40% of 2009 while indicator no. 26 Percent of mothers who received /brought iron supplements while pregnant with the youngest child less than 12 months of age has 86% coverage compared to 93% in 2006 and 86% in 2009. The reason may be unavailability of iron tables in health facility and the poor mothers many not have access to private clinics. 7. PLACE OF DELIVERY AND DELIVERY ATTENDED: All the six indicators numbering 27 to 32 have rise, fall and rising trend in the coverage like rise in 2006, fall in 2009 and again rise in 2011. However, the coverage size is not so much variant compared to 2006 and 2009, with slight variation from 2% to 10% less coverage in comparison to 2% to 17% higher coverage than 2006 and 2009. Indicators are as under: 27. Percent of children aged 0-11 months whose delivery was attended by a skilled health personal upto TBA level 28. Percent of children aged 0-11 months whose delivery was attended by a skilled health personal upto MCHW level 29. Percent of children aged 0-11 months whose delivery involved use of a clean birth kit or whose cord was cut with a new razor LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 71 30. Percent of children aged 0-11 months whose delivery involved use of a clean birth kit 31. Percent of children aged 0-11 months who were immediately breastfed with the mother immediately after birth. 32. Percent of children aged 0-11 months who were placed with the mother immediately after birth 8. POSTPARTUM CARE with indicator 33 Percent of mother who had at least ONE postpartum check-up has 47% coverage higher than 2009 – 33% and lower than 2006 – 63%. Indicator no. 34 Percent of mothers able to report at least TWO known maternal danger signs during the postpartum period and no. 36 Percent of mothers able to report at least TWO known neonatal danger signs have 100% coverage from 98% in 2006 and 92% in 2009, while indicator no. 38 Percent of mothers who received at least 1 month iron tablets during the first two months after delivery has decreased to 65% from 2006 – 75% and increased than 2009 – 49%. The reason may be unavailability of iron tablets and poor access for poor mothers. 9. CHILD SPACING: Out of 4 child spacing indicators, 3 indicators have lesser coverage like no. 39 Percent of non pregnant mothers who desire no more children in the next two years or are not sure, who are using a modern method of child spacing has 48% in 2011 from 2006 – 66% and higher than 2009 – 41%; indicator no. 40 Percent of mothers who report at least one place where she can obtain a method of child spacing has 95% in 2011 coverage than 2006 – 100% and no. 41 Percent of children aged 0-23 months who were born at least 24 months after the previous surviving child has 64% in 2011 than 2006 – 69% and 2009 – 63%, while no. 42. Percent of children aged 0-23 months who were born at least 36 months after the previous surviving child has 14% in 2011 in comparison to 14% in 2006 and 20% in 2009. 10. KNOWLEDGE OF DANGER SIGNS DURING PREGNANCY, POSTNATAL AND NEW BORN CHILD: All the 6 indicators have above 95% to 100% coverage in comparison to 2006 and 2009 where the coverage dropped to 53% to 78% in 2009, except no 47, which remains only 6% less in 2009 from 98% in 2006. The indicators are as under; 43. Percent of mothers (15-49 years) who know at least TWO danger signs/symptoms during pregnancy 44. Percent of mothers (15-49 years) who know at least THREE danger signs/symptoms during pregnancy LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 72 45. Percent of mothers who knows at least TWO danger signs/ symptoms of after delivery 46. Percent of mothers who knows at least THREE danger signs/ symptoms of after delivery 47. Percent of mothers who know at least TWO danger sign of new born 48. Percent of mothers who know at least THREE danger sign of new born 11. DANGER SIGNS OF PNEUMONIA AND DIARRHEA: Two indicators in danger signs of Pneumonia and diarrhea have 93% to 95% coverage in comparison to 98% and 92% in no. 49 and no. 50 in 2006 and 68% and 44% in no 49 and no 50 in 2009. The indicators are 49. Percent of mothers who know at least THREE danger signs/ symptoms of pneumonia; 50. Percent of mothers who know at least THREE danger sign of diarrhea / dysentery 12. KNOWLEDGE ON HIV/AIDS/STD: Two indicators no. 51 and 52 ( 51. percent of mothers who knows at least ONE HIV/AIDS and STD transmission (MOT); 52. Percent of mothers who knows at least ONE HIV/AIDS and STD prevention (MOT)) have 62% coverage in both the indicators in comparison to 68% and 69% in 2006 and 40% each in 2009. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 73 Comparison of coverage proportion for key indicators collected between period (Jun 2006, Dec 2009 and Jun-Jul 2011) in Bara district SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± BREAST FEEDING AND CHILD NUTRITION INDICATORS 1 M1 Breastfeeding Initiation Percent of children aged 0-11 months who are breastfed with in the first hour after birth 66 8.04 98 2.07 100 2 M1 Exclusive Breast feeding Rate Percent of infants aged 0-5 months who were fed breastfed milk only in the last 24 hours 100 83 8.47 70 12.18 3 M1 Complementary Feeding Rate Percent of infant aged 6-9 months who received breast milk and solid foods in the last 24 hours 96 4.81 92 8.80 90 7.47 4 M2 Continued breastfeeding Percent of children aged 12-23 months who are still breast feeding 85 12.23 88 5.53 89 5.22 5 M2 Vitamin "A" Coverage Percent of children aged 12-23 months who received a vitamin A does in the last six months 99 1.47 91 4.87 98 2.07 CHILDHOOD IMMUNIZATION INDICATORS 6 M2 Possession of vaccination Card Percent of Children aged 12-23 months who have a Vaccination Card 74 7.41 25 7.34 45 8.46 7 M2 EPI Access Percent of children aged 12-23 months who received DPT 1 71 7.68 23 7.10 45 8.46 8 M2 RAPID Catch Indicator: Measles Vaccination Coverage Percent of children aged 12-23 months who received measles vaccine 72 7.62 21 6.93 45 8.46 9 M2 Droup Out Rate Percent of drop out- rates between DPT1 and DPT 3 3 3.38 6 8.14 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 74 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 10 M2 Rapid Catch Indicator EPI Coverage Percent of children aged 12-23 months who received BCG, DPT3, OPV3 and measles vaccines before the first birthday 67 8.00 20 6.74 45 8.46 11 M2 EPI Coverage II (Liberal Criteriaon ) Percent of children aged 12-23 months who received OPV 3 72 7.62 22 7.02 45 8.46 SICK CHILD 12 M1 & M2 Maternal Knowledge of child danger sign Percent of mothers of children aged 0-23 months who know at least THREE signs of childhood illness that indicate the need for treatment 98 1.78 75 5.22 98 1.46 DIARRHEA INDICATORS 13 M1 & M2 Diarrhea prevalence Percent of children aged 0-23 months with diarrhea in the last two weeks 21 4.87 29 5.45 24 5.16 14 M1 & M2 ORT use during a Diarrhea Episode Percent of children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/ or recommended home fluids (RHF) 60 12.95 23 9.45 49 12.15 15 M1 & M2 Increased breastfeed During a Diarrhea Episode Percent of children aged 0-23 who received breastfed same amount or more during diarrhea in last two weeks. 95 6.00 75 9.63 98 2.99 16 M1 & M2 Increased drink during a diarrhea Episode Percent of children aged 0-23 months with diarrhea in the last two weeks who were offered the same amount or more drink / fluid during the illness 93 6.86 44 11.09 94 5.84 17 M1 & M2 Increased food during a diarrhea Episode Percent of children aged 0-23 months with diarrhea in the last two weeks who were offered the same amount or more food during the illness 95 6.00 39 10.89 86 8.40 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 75 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 18 M1 & M2 Care–seeking for Diarrhea Percent of Children aged 0-23 months with diarrhea in the last two weeks whose mothers Sought outside advice or treatment for the illness 91 7.60 71 10.09 83 9.12 19 M2 Maternal Competency in ORS Preparation Percent of mothers who can correctly prepare ORS 84 6.20 61 8.29 89 5.38 20 M2 Maternal Hand Washing before Food Preparation Percent of mothers who usually wash their hands with soap or ash before food preparation. 92 4.68 67 8.00 85 6.07 21 M2 Maternal Hand Washing before Food Preparation before feeding /after attending to a child who has defecated Percent of mothers who usually wash their hands with soap or ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated. 78 7.02 31 7.85 62 8.26 ARI IDICATOR 22 M1 & M2 ARI Care -seeking Percent of Children aged 0-23 months with cough and fast / difficult breathing in the last two weeks who were taken to a health facility or received treatment. 80 14.31 61 9.63 44 11.48 PRENATAL CARE INDICATORS 23 M1 Maternal Health Card Presentation Percent of mothers with a maternal card (Card-confirmed) for the youngest child less than 12 months of age 65 8.12 17 6.31 10 5.05 24 M1 Tetanus Toxoid Coverage Percent of mothers who received at least TWO tetanus toxoid injections (Card confirmed) before the birth of the youngest child less than 12 months of age. 63 8.20 14 5.95 10 5.05 25 M1 Prenatal Care Coverage Percent of mothers who had at least ONE prenatal visit prior to the birth of her youngest child less than 12 months of age 78 7.02 40 8.32 91 4.87 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 76 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 26 M1 Iron Supplementation Coverage Percent of mothers who received /brought iron supplements while pregnant with the youngest child less than 12 months of age. 93 4.27 86 5.95 86 5.95 PLACE OF DELIVERY AND DELIVERY ATTENDED 27 M1 Delivery by skilled Health Personnel Percent of children aged 0-11 months whose delivery was attended by a skilled health personal upto TBA level 77 7.19 54 8.47 75 7.34 28 M1 Delivery by skilled Health Personnel Percent of children aged 0-11 months whose delivery was attended by a skilled health personal upto MCHW level 42 8.39 46 8.47 59 8.35 29 M1 Clean Cord Care Percent of children aged 0-11 months whose delivery involved use of a clean birth kit or whose cord was cut with a new razor 98 2.07 100 30 M1 Clean Cord Care Percent of children aged 0-11 months whose delivery involved use of a clean birth kit 75 7.34 45 8.46 65 8.12 31 M1 Immediate Breast Feeding Percent of children aged 0-11 months who were immediately breastfed with the mother immediately after birth. 41 8.35 58 8.39 32 M1 Placement at Birth Percent of children aged 0-11 months who were placed with the mother immediately after birth 82 6.54 75 7.34 86 5.95 POSTPARTUM CARE 33 M1 Postpartum Contact Percent of mother who had at least ONE postpartum check- up 63 8.20 33 8.00 47 8.49 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 77 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 34 M1 Knowledge of maternal Danger Signs Percent of mothers able to report at least TWO known maternal danger signs during the postpartum period 77 7.10 100 35 M1 Knowledge of Neonatal Danger Signs Percent of mothers able to report at least THREE known neonatal danger signs 98 2.07 77 7.19 99 1.47 36 M1 Knowledge of Neonatal Danger Signs Percent of mothers able to report at least TWO known neonatal danger signs 98 2.07 92 4.68 100 37 M1 Maternal Vitamin A supplementation Percent of mothers who received a Vitamin A dose during the first six weeks after delivery 80 6.74 67 8.00 89 5.38 38 M1 Maternal iron supplementation Percent of mothers who received at least 1 month iron tablets during the first two months after delivery 75 7.34 49 8.50 65 8.08 CHILD SPACING 39 M3 Contraceptive Use Among Mothers Who Want to limit or space births Percent of non pregnant mothers who desire no more children in the next two years or are not sure, who are using a modern method of child spacing 66 8.04 41 8.37 48 8.49 40 M3 Knowledge of source of Child spacing methods Percent of mothers who report at least one place where she can obtain a method of child spacing 100 97 2.90 95 3.53 41 M3 Adequate birth interval between surviving children Percent of children aged 0-23 months who were born at least 24 months after the previous surviving child 69 12.90 63 12.68 64 12.55 42 M3 Adequate Birth interval Between youngest Surviving Children (Less Stringent Criteria) Percent of children aged 0-23 months who were born at least 36 months after the previous surviving child 14 9.80 20 10.41 14 9.17 KNOWLEDGE OF DANGER SIGNS DURING PREGNANCY, POSTNATAL AND NEW BORN CHILD LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 78 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 43 M1 Danger signs/ symptoms during pregnancy Percent of mothers (15-49 years) who know at least TWO danger signs/symptoms during pregnancy 100 78 7.02 100 44 M1 Danger signs/ symptoms during pregnancy Percent of mothers (15-49 years) who know at least THREE danger signs/symptoms during pregnancy 99 1.47 60 8.32 100 45 M1 Danger signs after delivery Percent of mothers who knows at least TWO danger signs/ symptoms of after delivery 98 2.07 77 7.10 100 46 M1 Danger signs after delivery Percent of mothers who knows at least THREE danger signs/ symptoms of after delivery 95 3.80 53 8.48 95 3.80 47 M1 Danger signs of new born Percent of mothers who know at least TWO danger sign of new born 98 2.07 92 4.68 100 48 M1 Danger signs of new born Percent of mothers who know at least THREE danger sign of new born 98 2.07 77 7.19 99 1.47 DANGER SIGNS OF PNEUMONIA AND DIARRHEA 49 M2 Danger signs/ symptoms of pneumonia Percent of mothers who know at least THREE danger signs/ symptoms of pneumonia 98 2.52 68 7.90 93 4.27 50 M2 Danger signs / symptoms of diarrhea/ dysentery Percent of mothers who know at least THREE danger sign of diarrhea / dysentery 92 4.48 44 8.43 95 3.80 KNOWLEDGE ON HIV/AIDS/STD 51 M3 Knowledge about HIV/AIDS and STD transmission Percent of mothers who knows at least ONE HIV/AIDS and STD transmission (MOT) 68 7.95 40 8.32 62 8.26 52 M3 Knowledge about HIV/AIDS and STD Prevention Percent of mothers who knows at least ONE HIV/AIDS and STD prevention (MOT) 69 7.85 40 8.32 62 8.26 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 79 Table 6: Rapid Core Assessment Tool for Child Health (CATCH) of Jun 2006 and Dec 2009 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± SENTINEL MEASURE OF CHILD HEALTH AND WELL-BEING 1 M1 & M2 Underweight Children Percentage of Children age 0-23 months that is underweight (-2 SD from the median weight-for-age, according to the World Health Organization (WHO)/National Center for Health Statistics (NCHS) 29 5.45 13.2 4.06 6.0 2.86 2 M3 Birth Spacing Percent of children age 0-23 months that was born at least 24 months after the previous surviving child 69.4 12.90 62.5 12.68 64.3 12.55 3 M1 Delivery Assistance Percent of children age 0-23 months whose birth were attended by skilled health personal upto MCHW 42.1 8.39 45.9 8.47 59.4 8.35 4 M1 Maternal Tetanus Toxoid (TT) Percent of mothers with children age 0-23 months that received at least TWO tetanus toxoid injections before the birth of their youngest child. 63.2 8.20 14.3 5.95 9.8 5.05 5 M1 Exclusive Breastfeeding Percent of children age 0-5 months that was exclusively breastfed during the last 24 hours 100.0 82.9 8.47 70.4 12.18 6 M1 Complementory Feeding Percent of children age 6-9 months that received breast milk and complementary foods during the last 24 hours 95.7 4.81 91.9 8.80 90.2 7.47 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 80 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 7 M2 Full Vaccination Percent of children age 12-23 months that is fully vaccinated (against the five vaccine preventable diseases) before the first birthday 66.9 8.00 19.5 6.74 45.1 8.46 8 M2 Measles Percent of children age 12-23 months that received a measles vaccine 72.2 7.62 21.1 6.93 45.1 8.46 9 M1 & M2 Bednets Percentage of children age 0-23 months that slept under an insecticide-treated net (in malaria risk areas) the previous night 1.5 1.46 97.7 2.52 3.4 2.17 10 M3 HIV/AIDS Percent of mothers with children age 0-23 months that cited at least TWO known ways of reducing the risk of HIV infection 51.1 8.50 29.3 7.74 48.9 8.50 11 M2 Hand Washing Percent of mothers with children age 0-23 months that reported they wash their hands with soap or ash before food preparation and feeding children and after defection and attending to a child who has defecated 63.2 8.20 33.1 8.00 47.4 8.49 MANAGEMENT/TREATMENT OF ILLNESS 12 M1 & M2 Danger Signs Percent of mothers of children aged 0-23 months that knew at least TWO signs of childhood illness that indicate the need for treatment 99.6 0.74 93.2 3.02 99.6 0.74 13 M1 & M2 Sick Child Percent of sick children age 0-23 months that received increased continued feeding during an illness in the past two weeks 94.5 6.00 75.3 9.63 98.5 2.99 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 81 SN Mod# Indicator Indicator/ Definition LQAS Jun'06 (%) Confidence Interval ± (CI) LQAS Dec'09 (%) CI± LQAS Jun￾Jul'11 (%) CI± 14 M1 & M2 Sick Child Percent of sick children age 0-23 months that received increased fluids during an illness in the past two weeks 92.7 6.86 44.2 11.09 93.8 5.84 Note: Indicators indicated (indicator # 13 and 14) are merged in generic RAPID CATCH but the Plan Nepal; CS Project in the same indicators has been collecting information separately. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 82 2.10.3(a) Table-1: Number of Mothers with children 0-11 months with inadequate knowledge or with practices according to LQAS thresholds and decision rules [benchmark percentage (based on monitoring targets) of Jun'06, Dec'09 and Jun-Jul 2011 LQAS; and details figures/numbers presented against program average and monitoring targets for the eighth LQAS]. *Threshold: Decision Rules (LQAS-Jun'06) 70%:1 1 95%:16 85%:14 90%:15 50%:7 50%:7 50%:7 70%:1 1 60%:9 80%:1 3 70%:1 1 60%:9 40%:5 60%:9 95%:16 85%:14 95%:16 70%:1 1 70%11 80%:13 85%:14 85%:14 95%:16 ** Program Average %: Decision Rule (LQAS-Jun'06) 66%:1 1 94%:16 78%:13 79%:13 43%:6 39%:5 34%:4 64%:1 0 62%:1 0 76%:1 3 70%:1 1 65%:1 0 63%:1 0 53%:8 93%:16 77%:13 100%: 56%:9 63%:10 80%:14 75%:12 82%:14 98%: *Threshold: Decision Rules (LQAS-Dec'09) 66%:1 1 94%:16 78%:13 79%:13 43%:6 39%:5 34%:4 64%:1 0 62%:1 0 76%:1 3 70%:1 1 65%:1 0 63%:1 0 53%:8 93%:16 77%:13 100%: 56%:9 63%:10 80%:14 75%:12 82%:14 98%: Quality of Counseling Field Area Breastfeeding Initiation Breastfeeding within One hour Colostrums feeding Prenatal Care upto MCHW Prenatal Care upto TBA Delivery Preparation Breastfeeding Child Spacing EPI Danger signs of pregnancy Nutrition Next Visit Possession of TT Card TT Coverage Prenatal Visit (4 visit) Iron supplementation prenatal iron Covera ge Delivery by skilled Health Personnel upto MCHW Clean cord cut (CHDK + New Razer) Clean cord cut (CHDK) Postpartum Contact Maternal Vitamin A supplementation Maternal iron postnatal supplementation Placement at Birth Knowledge of Neonatal Danger Signs (Any three) Knowledge of Postnatal Danger Signs (Any three) Total substandard intervention 1: Simara and Nijgudh PHCs 19 14 19 16 16 7# 1#* 1#* 12 9* 12* 6#* 0#* 16 14 16 18 19 18 7* 18 15 18 19 14# 6 2: Rampurwa and Haraiya HPs 19 15 19 18 18 15 12 15 14 14 16 14 3* 19 19 18 14 19 16 14 19 17 19 19 19 3: Bhodaha & Rampur HPs 19 9 19 17 17 10 7 3#* 8#* 11 9#* 9* 1* 18 12 17 11* 19 14 12 16 11#* 16 19 19 4 4: Parsauni and Phetaha HPs 19 6#* 19 18 18 12 4#* 1#* 9#* 8#* 13 12 2* 17 12 19 9* 19 13 3#* 14# 8#* 19 19 19 8 5: Ganjabhawanipur PHC and 19 13 18 17 17 9# 14 12 17 11 10* 7* 2* 19 14 14#* 11* 19 10 11 19 10#* 13#* 19 18 4 ** Program Average %: Decision Rule (LQAS-Dec'09) 97%:1 6 41%: 6 86%: 15 78%: 13 78%: 13 21%: 2 25%: 2 17%: 2 42%: 6 28%: 3 51%: 8 41%: 6 17%: 1 77%: 13 38%: 5 86%: 15 46%: 7 98%: 16 45%: 6 33%: 4 67%: 11 49%: 7 75%: 12 77%: 13 53%: 8 *Threshold: Decision Rules (LQASJun-Jul'11) 66%:1 1 50%: 7 94%:16 78%:13 79%:13 43%:6 39%:5 34%:4 64%:1 0 62%:1 0 76%:1 3 70%:1 1 65%:1 0 63%:1 0 53%:8 93%:16 77%:13 100%: 56%:9 63%:10 80%:14 75%:12 82%:14 98%: 70%: 11 ** Program Average %:Decision Rule (LQASJun-Jul'11) 100%: 57.9%:9 98.5%: 90%:15 90%:15 61%:1 0 46%:7 37%:5 64%:1 0 58%:9 62%:1 0 49%:7 10%: 94%:1 6 71%:1 2 88%:15 60%:9 100%: 65%:1 0 48%:7 89%:15 66%:12 86%:15 100%: 95%:16 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 83 Bariyarpur HP 6: Chiutaha and Gadahal HPs 19 13 18 19 19 18 18 15 18 17 15 11 4* 19 16 19 12* 19 12 14 19 19 19 19 19 7: Simrahganj, Kabahigoat HPs and Hardia PHC 19 7# 19 14# 14# 10 5# 2#* 6#* 6#* 7#* 5#* 1* 17 7#* 13#* 4#* 19 3#* 2#* 13#* 7#* 10#* 18 18 17 Total substandard SA 2 1 1 2 3 4 3 2 2 2 1 1 2 1 1 2 2 4 2 1 Decision rule based on Monitoring/Coverage Target; Decision rule based on Program Average Coverage. - Number with hash (#) is below program average coverage; - Number with asterisk (*) is below monitoring/coverage target; - Number with asterisk and circle is below program average coverage and monitoring/coverage target. Table 1: Field area Ilaka wise coverage description 1. Ilaka no. 7 Simrahganj, Kabahigoat HPs and Hardia PHC has 17 indicators with inadequate knowledge or practices according to LQAS thresholds and decision rules. List of indicators out of 25 indicators are; 2 4 5 7 8 9 10 11 12 15 16 17 19 20 21 22 23 23 Breastfeeding within One hour Prenatal Care upto MCHW Prenatal Care upto TBA Breastfeeding Child Spacing EPI Danger signs of pregnancy Nutrition Next Visit Prenatal Visit (4 visit) Iron supplementation prenatal iron Coverage Delivery by skilled Health Personnel upto MCHW Clean cord cut (CHDK) Postpartum Contact Maternal Vitamin A supplementation Maternal iron postnatal supplementation Placement at Birth Knowledge of Neonatal Danger Signs (Any three) 2. Ilaka no. 4 Parsauni and Phetaha HPs has 8 indicators with inadequate knowledge or practice according to LQAS thresholds and decision rules. List of indicators out of 26 are; 2 7 8 9 10 20 21 22 Breastfeeding within One hour Breastfeeding Child Spacing EPI Danger signs of pregnancy Postpartum Contact Maternal Vitamin A supplementation Maternal iron postnatal supplementation 3. Ilaka no. 1 Simara and NIjgudh PHCs has 6 indicators with indicators with inadequate knowledge or practices according to LQAS thresholds and decision rules. List of indicators are; LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 84 6 7 8 12 13 25 Delivery Preparation Breastfeeding Child Spacing Next Visit Possession of TT Card Knowledge of Postnatal Danger Signs (Any three) 4. Ilaka no 3 Bhodaha and Rampuruwa HPs has 4 indicators with inadequate knowledge or practices according to LQAS thresholds and decision rules. List of indicators are; 8 9 11 22 Child Spacing EPI Nutrition Maternal iron postnatal supplementation 5. Ilaka no 5 Ganjabhawanipur PHC and Bariyarpur HP has 4 indicators with with inadequate knowledge or practices according to LQAS thresholds and decision rules. List of indicators are; 6 16 22 23 Delivery Preparation Iron supplementation prenatal iron Coverage Maternal iron postnatal supplementation Placement at Birth 6. Ilaka no. 2 Rampurwa and Haraiya HPs and Ilaka no. 6 Chiutaha and Gadahal HPs have shown adequate knowledge in all 25 indicators. Indicator wise description of inadequate knowledge and practices 1. Indicator no. 8 Child spacing has 4 Ilakas namely 1. Simraha and Nijgudh HPs,: 3. Bhodaha & Rampur HPs; 4. Parsauni and Phetaha HPs; 7 Simrahganj, Kabahigoat HPs and Hardia PHC with inadequate knowledge and practices according to LQAS thresholds and decision rules. 2. Indicator no 22. Maternal iron postnatal supplementation has 4 Ilakas namely 3: Bhodaha & Rampur HPs; 4: Parsauni and Phetaha HPs ; 5: Ganjabhawanipur PHC and Bariyarpur HP and 7: Simrahganj, Kabahigoat HPs and Hardia PHC with inadequate knowledge and practices according to LQAS thresholds and decision rules. 3. Except 5 indicators namely 1. Breastfeeding Initiation; 3 Colostrums feeding; 14 TT Coverage; 18 Clean cord cut (CHDK + New Razer) and 24 Knowledge of Neonatal Danger Signs (Any three); all indicators are evenly distributed in the Ilakas from 1 to 3 indicators with inadequate knowledge and practices according to LQAS thresholds and decision rules. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 85 Table-2: Number of Mothers with children 12-23 months with inadequate knowledge or with practices according to LQAS thresholds and decision rules [benchmark percentage (based on monitoring targets) of Jun'06, Dec'09 and Jun-Jul 2011 LQAS; and details figures/numbers presented against program average and monitoring targets for the eighth LQAS]. Threshold: Decision Rules (LQAS-Jun'06) 95%:16 85%:14 85%:14 80%:13 75%:12 95%:16 95%:16 90%:15 85%:14 75%:12 Program Average %:Decision Rule (LQAS-Jun’06) 99%: 74%:12 71%:12 72%:11 72%:12 98%: 92%:16 84%:14 92%:16 78%:13 Threshold: Decision Rules (LQAS-Dec'09) 99%: 74%:12 71%:12 72%:11 72%:12 98%: 92%:16 84%:14 92%:16 78%:13 Program Average %:Decision Rule (LQAS-Dec'09) 90%:15 25%:2 22%:2 20%:1 15%:1 68%:11 44%:6 61%:10 67%:11 31%:4 *Threshold: Decision Rules (LQASJun-Jul'11) 99%: 74%:12 71%:12 72%:12 72%:12 98%: 92%:16 84%:14 92%:16 78%:13 ** Program Average %:Decision Rule (LQASJun-Jul'11) 98.5%: 45.1%:7 45.1%:7 45.1%:7 45.1%:7 94%:16 94.7%:16 88.7%:15 85%:14 61.7%:10 Field Area Vitamin "A" Possession of vaccination Card EPI Access Measles Vaccination Coverage EPI Coverage (All) ARI danger sign (any three) Diarrhea danger sign (any three) Maternal Competenc y in ORS Preparation Maternal Hand Washing before Food Preparation Maternal Hand Washing before Food Preparation before feeding/after attending to a child who has defecated Total substandard intervention 1: Simara and Nijgudh PHCs 19 11* 11* 11* 11* 13#* 15#* 12#* 10#* 5#* 5 2: Rampurwa and Haraiya HPs 19 7* 7* 7* 7* 19 19 18 18 13 3: Bhodaha & Rampur HPs 18 15 15 15 15 18 19 17 17 9#* 1 4: Parsauni and Phetaha HPs 18 9* 9* 9* 9* 19 18 17 19 13 5: Ganjabhawanipur PHC and Bariyarpur HP 19 5#* 5#* 5#* 5#* 19 19 18 15* 14 4 6: Chiutaha and Gadahal HPs 19 9* 9* 9* 9* 18 18 19 15* 11* 7: Simrahganj, Kabahigoat HPs and Hardia PHC 19 4#* 4#* 4#* 4#* 19 18 17 19 17 4 Total substandard SA 2 2 2 2 1 1 1 1 2 Decision rule based on Monitoring/Coverage Target; Decision rule based on Program Average Coverage. - Number with hash (#) is below program average coverage; - Number with asterisk (*) is below monitoring/coverage target; - Number with asterisk and circle is below program average coverage and monitoring/coverage target. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 86 Ilaka wise description: 1. Ilaka no 1 Simara and Nijgudh PHCs has 5 indicators namely 6. ARI danger sign (any three); 7. Diarrhea danger sign (any three); 8. Maternal Competency in ORS Preparation; 9. Maternal Hand Washing before Food Preparation; 10. Maternal Hand Washing before Food Preparation before feeding/after attending to a child who has defecated with inadequate knowledge and practices according to LQAS thresholds and decision rules. 2. Ilaka no. 5: Ganjabhawanipur PHC and Bariyarpur HP, and Iilaka no. 7 Simrahganj, Kabahigoat HPs and Hardia PHC have 4 indicators namely 2. Possession of vaccination Card; 3. EPI Access; 4. Measles Vaccination Coverage and 5. EPI Coverage (All) with inadequate knowledge and practices according to LQAS thresholds and decision rules. 3. Rest of the Ilakas have shown with adequate knowledge and practices except Ilaka no. 3: Bhodaha & Rampur HPs which has 1 indicator no. 10 Maternal Hand Washing before Food Preparation before feeding/after attending to a child who has defecated with inadequate knowledge and practices according to LQAS thresholds and decision rules. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 87 Table 3: Number of Women age 15-49 years with inadequate family planning practices according to LQAS thresholds and decision rules [benchmark percentage (based on monitoring targets) of Jun'06, Dec'09 and Jun-Jul 2011 LQAS; and details figures/numbers presented against program average and monitoring targets for the eighth LQAS]. Threshold: Decision Rules (LQAS-Jun'06) 75%:12 95%:16 70%:11 70%:11 Program Average %:Decision Rule (LQAS￾Jun'06) 66%:11 100%: 68%:11 69%:11 Threshold: Decision Rules (LQAS-Dec'09) 66%:11 100%: 68%:11 69%:11 Program Average %:Decision Rule (LQAS￾Dec'09) 41%:5 91%:16 40%:5 40%:5 *Threshold: Decision Rules (LQASJun-Jul'11) 66%:11 100%: 68%:11 69%:11 ** Program Average %:Decision Rule (LQASJun-Jul'11) 48.1%:7 95.5%: 61.7%:10 61.7%:10 Field Area Contraceptive use among women/mothers who want to limit or space birth Knowledge of source of child spacing method HIV/AIDS Knowledge (Mode of transmission at least one) HIV/AIDS Knowledge (prevention at least one) Total substandard intervention 1: Simara and Nijgudh PHCs 8* 19 14 14 2: Rampurwa and Haraiya HPs 11 19 14 14 3: Bhodaha & Rampur HPs 12 19 14 14 4: Parsauni and Phetaha HPs 11 19 6#* 6#* 2 5: Ganjabhawanipur PHC and Bariyarpur HP 10 14#* 10* 10* 1 6: Chiutaha and Gadahal HPs 7* 19 18 18 7: Simrahganj, Kabahigoat HPs and Hardia PHC 5#* 18 6#* 6#* 3 Total substandard SA 1 1 2 2 Decision rule based on Monitoring/Coverage Target; Decision rule based on Program Average Coverage. - Number with hash (#) is below program average coverage; - Number with asterisk (*) is below monitoring/coverage target; - Number with asterisk and circle is below program average coverage and monitoring/coverage target. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 88 Ilaka wise Description: 1. Ilaka no 7 Simrahganj, Kabahigoat HPs and Hardia PHC has 3 indicator namely 1. Contraceptive use among women/mothers who want to limit or space birth; 3. HIV/AIDS Knowledge (Mode of transmission at least one) and 4. HIV/AIDS Knowledge (prevention at least one) with inadequate knowledge and practices according to LQAS thresholds and decision rules. 2. Ilaka no 4: Parsauni and Phetaha HPs has 2 indicators 3. HIV/AIDS Knowledge (Mode of transmission at least one) and 4. HIV/AIDS Knowledge (prevention at least one) with inadequate knowledge and practices according to LQAS thresholds and decision rules. 3. Rest of Ilakas has shown adequate knowledge and practices according to LQAS thresholds and decision rules in all indicators except Ilaka no. 5 Ganjabhawanipur PHC and Bariyarpur HP with 1 indicator no. 2 Knowledge of source of child spacing method with inadequate knowledge and practices according to LQAS thresholds and decision rules. Indicator wise description: All indicators have 1 to 2 Ilakas with inadequate knowledge and practices according to LQAS thresholds and decision rules. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 89 FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 01 (Simara and Nijgadh) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities 1  Quality of counselin g.  Delivery preparati on  Lack of counseling.  Irregularity in the meeting of MG/PWG.  Low check up of ANC.  ORC clinic should be improved.  Quality ANC check up.  Regular mobilization of ORC/MGM/ANM/MCH W.  Regular supervision. 1 TT Card  Low health education/couns eling.  Untimely supply of TT card. Effective and timely supply of TT card.  Manage TT card timely.  Good counseling at the time of ANC and EPI. 1 Postnatal danger sign  Lack of counseling.  Lack of check up in ANC  Hospital delivery.  Effective counseling.  Awareness program for hospital delivery.  Mobilization of extra￾team in remote and industrial area for ANC/ORC/EPI clinic. 2 ARI/CDD  Low awareness on ARI/CDD due to remote/forest area.  Regular meeting of VHW/MCH/ PWG/MGM  Monthly meeting of FCHVs.  Distribution of posters and pamphlets in PHC/ORC/EPI clinic. FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 02 (Rampurwa and Haraiya) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities 1  Placenta at birth  Inadequate knowledge of health education in ORC/MGM.  Promotion of institutional delivery.  Awareness raising on Placenta at birth.  Regular meeting of FCHW/ MGM/PWG/Ilak a level.  Monthly meeting of FCHV  Manage suitable place and equipments for check up of ANC. 1 TT/EPI Card  Low health education/counselin g.  Untimely supply of TT card. Effective and timely supply of TT card.  Manage TT card timely.  Good counseling at the time of ANC and EPI. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 90 FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 03 (Rampur- Tokani and Bhodaha) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities 1 Breast feeding within one hour Lack of awareness and knowledge  Counseling service  Health education  Street drama  Mother group meeting  Monthly meeting of FCHV  PHC/ORC clinic conduction  distribution of pamphlet, poster  Street drama  ANC/PNC visit. 1 Child spacing counseling  Low ANC visit.  Lack of counseling from staff.  Health education  Quality service for ANC visit by PHC\ORC clinic  Training of staff  Manage suitable place and equipments for check up of ANC.  Re-enforce on training, supervision and monitoring. 1 EPI counseling Lack of awareness and knowledge.  Health education  PHC/ORC/EPI clinic.  Counseling in clusters.  Meeting of MGM/PWG.  Monthly meeting of FCHVs.  Distributions posters and pamphlets in PHC/ORC/EPI clinic. 2 Maternal hand washing before food preparation/after attending to child w/w has defecated.  Lack of knowledge  No importance given  Health education street drama  Exhibition on health education.  Meeting of MGM/PWG/staff meeting.  Posters/pamphlets distribution  Broadcast through media on health education.  Street drama by DHO/NGO/INGOs. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 91 FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 04 (Pheta and Prasauni VDC) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities 1 Breast feeding within one hour Lack of health education  Regular PWG/MGM.  Increase institutional delivery.  Encouragements to the ANM/MCHW for counseling.  Regularization of the meeting of MCHW/MGM/PW G.  Distribution of pamphlets, posters  Coordination with HFMC and VDC 2 Counseling  Breast feeding  EPI child spacing  Dangerous sign.  Lack of health education  Promote the ANC/PNC service.  Manage physical facilities and human resources.  Develop the key message.  Encourage ANM and MCHW. 3 ANC fourth Visit.  Vacancy of nursing staff, physical facilities.  Lack of awareness about ANC check up.  Coordinate DHO/DPHO  Orient the community members for ANC/PNC check up.  Organize the regular meeting with DHO/DPHO.  Sharing with community members during planning. 4 Delivery by skilled health person.  Inadequate knowledge about dangerous sign.  Insufficient birthing centers.  Transfer of staff to other places.  Awareness package on delivery by skilled health person. eg. School health mother group, FCHV, health management committee.  Regular meeting with MCHW, MGM, PWG.  Awareness raising program.  Coordination with stakeholders. 5 PNC Visit.  Inadequate knowledge  Behavior change problem.  Awareness package on PNC visit.  Awareness raising program in the community. LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 92 FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 05(Ganjbhawanipur and Bariyarpur) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities 1  Breast feeding within one hour  Iron supplementati on prenatal Iron coverage  Lack of awareness and knowledge  Inadequate supply of iron tab  Lack of knowledge of mother about Iron tab  Counseling service  Health education  Street drama  Adequate regular supply of Iron tab  Mother group meeting  Monthly meeting of FCHV  PHC/ORC clinic conduction  Distribution of pamphlets, posters  Street drama  ANC/PNC visit.  Supply during Ilaka staff meeting 1 Child spacing counseling  Low ANC visit.  Lack of counseling from staff.  Lack of information about FP  Social and Cultural barrier  Health education  Quality service for ANC visit by PHC\ORC clinic  Training of staff  Awareness raising specially in Muslim community  Manage suitable place and equipments for check up of ANC.  Re-enforce on training, supervision and monitoring.  Operate health facility regularly and timely 1 EPI counseling and card  Lack of awareness and knowledge.  Irregular supply of EPI card  Carelessness about EPI card  Health education  PHC/ORC/EPI clinic.  Counseling in clusters.  Regular supply  Canceling about importance of EPI card  Meeting of MGM/PWG.  Monthly meeting of FCHVs.  Distribution poster and pamphlets in PHC/ORC/EPI clinic. 2 Maternal hand washing before food preparation/after attending to child w/w has defecated.  Lack of knowledge  No importance given  Poverty  Health education street drama  Exhibition on health education.  Meeting of MGM/PWG/staff meeting.  Posters/pamphlets distribution  Broadcast through media on health education.  Street drama by DHO/NGO/INGOs . LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 93 LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 94 FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 06 (Gadhal and Chyutuha ) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities 1 TT card Card received during the vaccination of TT but the record card lost Counseling on the importance of TT vaccination Card for protection in future Mobilization of FCHV, PWGs and Mother Groups to encourage women to protect card for future record 2 Hand Washing Lack of awareness / information and importance of hand washing Health education on Hand Washing  Public Sanitation day / awareness raising by PWGs , MGM and FCHV FA-wise recommendations for improvement in poor indicators data based on finding during LQAS survey on June-July, 2011 FA # 07 (Simourangadh, Hardiya and Kabhi Goth) Date: 2068/03/17 M# Indicators Reason Recommended strategy Activities M1 Breast feeding with in 1 hrs of delivery  Inadequate heath education teaching in HI's, MGs, PWGs groups  Lack of Nursing Staff  Activate MGs, PWGs meeting  Fulfill the vacant posts  MCH clinic should be functional  Activate all MGs, PWGs meeting from coming month  MCH clinic in every weeks M1 Prenatal care by MCHW  Lack of Nursing Staff  Less functioning of PHC/ORC  Absenteeism in His  Fulfill of Nursing staff  Regular Functioning of PHC/ORC  Motivation to MCHWs  Regular PHC/ORC  Supervision and monitoring  Fulfill nursing staff as soon as possible M1 Quality of Counseling in ANC/PNC  Lack of Nursing Staff  Service provider hurry in work  Regularize MCH/ORC  Regular MCH clinic twice in a week  timely functioning of PHC/ORC M1 Possession of TT card  Not given by service provider  Low importance given to protect card by mothers  Service provider hurry in work  Lack of TT card  Supply of TT card regularly  Health education and counseling  Regular supervision and monitoring  Full time for EPI clinic  Health Education to PWGs M1 Prenatal Visit (4th time )  Lack of awareness and  Quality of counseling in  Regular MCH/ANC LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 95 counseling in ANC clinic  Lack of Nursing Staff ANC Clinic M1 Iron supplementation prenatal iron coverage and post natal iron  Lack of functioning of MCH clinic  Lack of awareness and iron supply  Regular supply of iron  Regular PWGs meeting  Regular functioning of MCH  Regular MCH/ANC Clinic  FCHV should supply iron M1 Delivery by Skilled health professional up to MCHW  Lack of skilled MCHW, counseling, birthing centre and awareness raising among community people  Capacity building training to MCHW  Fulfill Vacant Position  Establishment of Birthing Centre  Fulfill vacant post immediately  SBA training to all health worker M1 CHDR  No supply of CHDR  Lack of awareness and no availability of CHDR in rural market  Supply CHDR regularly  Regular PWG meeting  Supply of CHDR to all as soon as possible M2 Possession of Vaccination Card  Lack of Vaccination card  Low importance given by guardian  Card not given vaccinator  Supply the vaccination Card  Provide Health education to Guardians  Compulsory distribution of vaccination card  Supply of Vaccination card to all intuition as soon as possible  Health education in EPI clinic M2 EPI/EPI access coverage and measles vaccination  Less due to not functioning of EPI clinic full time  No defaulter tracking  Full time should be given to EPI clinic  Defaulter should be tracked  EPI campaign should be implemented  EPI clinic must be on time  Defaulter children should be brought to increase in EPI clinic M3 Contraceptive use among women/ mothers who want to limit or birth spacing  lack of education about importance of contraceptive  Low functioning of MGs, PWGs  Regular MGs/ PWGs meeting  MGs/ PEGs meeting M3 Mot and Prevention of HIV/AIDS  Lack of health education  Low functioning of MGs, PWGs  Lack of HIV/AIDS program  To make regular MGs, PWGs meeting  Launch HIV/AIDS related program  MGs, PWGs meeting regularly  HIV/AIDS related program should be implemented at rural level LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 96 Bara – CSSA Status description: The first component, Health Outcomes, represents people’s health, which is generally addressed through proxy health objectives such as immunization coverage, child growth, exclusive breastfeeding, and/or improved knowledge (e.g. management of the sick child, danger sign during pregnancy, delivery and postnatal period). The outcomes in the component is significantly decrease to 53 indices in 2011 rather than 63 indices in 2006, although significant improvement has been made in 2011 than mid-term achievement 41 indices in 2009. The low results during the mid-term occurred due to unstable political situation. However, situation improved after 2009 and continued again from the stakeholders and DHO realized the low performance in these components. Increased knowledge of mothers and their practices supports in their behavior has complemented to improve the indices in the final evaluation. The second component consists of elements in the health and social services approach such as quality, cost and accessibility which will influence the durability of any health improvement, effectiveness, equity, appropriateness and appropriateness of the activities. The component increased to 73 indices in final evaluation in the year 2011 from 63 indices in 2006 and 62 indices in 2009. The major factor of the achievement was regular month meeting, providing timely reporting and availability of essential drug in health facilities as well as regular supportive supervision. The third component represents the organizational capacity focused on the health facility management committee, which needs to exist in the local partner(s) to maintain performance and its capacity. Component achievement has slightly decreased to 60 indices in 2011 from 67 indices in 2006 and 63 indices in 2009 due to less community participation and in contribution of cash or kind to their health facility activities and its support program. The fourth component represents the organizational viability which is the overlapping element of organizational capacity focused on the same health facility management committee and/or the key local partners. Dependency relates not only to financial viability, but also to the other essential types of support on which an organization may depend to continue existing and fulfilling its mission. The component slightly increased to 54 indices in the final evaluation in 2011 from 51 indices in 2006 and 33 indices in 2009. The factor of improvement is the organizational role for coordination, networking and alliances with stakeholders and local resource mobilization which has been increased. The village health development committee followed the district health policy and guideline and the system that made the improvement in the results. The fifth component refers to community capacity and the overlapping elements of cultural acceptance and social cohesion. All these elements can be viewed under the umbrella concept of community competence. The outcomes in the component have no changes between then year 2011 and 2006 which is to 76 indices. It was 44 indices in the mid term in 2009. The changes slowed down in mid-term due to LIBON – LQAS BARA Annex 6 Nepal LIBON Project – Final KPC Report 97 unstable political situation. However, the situation improved and realized by DHO. Continued support from the stakeholders as well as increased knowledge of mothers and their practice in the behavior has complemented to improve the indices in final evaluation. The sixth and last component includes a number of elements within the environment, of the project in the largest sense: national policies, the economic and political environment, and the environmental and human development situation. These elements are frequently, but not always, outside of a project’s scope of intervention. They may, however, be relevant to a sustainability assessment within a CS project, as they indicate important transitional stages of development, which project cannot ignore. The component increased to 50 indices in final evaluation 2011 from 32 indices in 2006 and 21 indices in 2009. The major factor of the achievement was stable political situation and no disruption to medicine supply and literacy rate in the district has been increased. LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 98 4. CSSA Final Evaluation Report Part Three – Main Report on CSSA Child Survival Sustainability Assessment workshops 4.1. Background Sustainability in an open and larger social laboratory for child and maternal health promotion in joint collaboration with and participation of various kinds and nature of stakeholders, actors, individuals, communities, disadvantaged groups, community organizations, government, non-government, para-statal bodies, private sectors with their own interest and way of actions is un-predictable with 100 percent precision in its achievement of performance. With diverse social, cultural belief and traditional practices, ultra resource poor, marginalized and discriminated communities where girl children and women are treated at sub-human level, child and maternal health program may not be in their top priorities in the highly low literate communities. Child survival projects have been expanded and scaled up openly with shared common vision and mission among various agencies, government, non-government, local communities and disadvantaged groups, children and mothers by Plan Nepal in most resource poor districts of Nepal In such cases, common commitment and obligation for performance results, delegated and decentralized roles and responsibilities, sensitivity and sensibility of stakeholders and actors for accountability to their moral social obligation to poor communities, capacity and competence of communities to utilize and mobilize health services are accounted much for sustainability and continuity of the good results of health facilities as a used￾to habit formation of all stakeholders and actors and communities. 4.2 Introduction to CSSA and Child Survival Projects Evolution of Sustainability: Stage 1: Since 1985 to 1995, Plan Nepal has challenges of performing its results in small manageable, sizeable and controllable atmosphere. Stage 2: Since 1995, it has challenges of expanding, scaling up of its services to the un-reached children, mothers and communities of Nepal beyond its control, resources and management in open social laboratories with joint collaboration with cooperation and participation of various relevant actors, stakeholders and the communities. LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 99 Some of the pertinent challenges are as below. The three mores that are being demanded of Private Volunteer Organization (PVOs)/NGOs: 1. More reduction in mortality, fertility, and everything else – through greater equity, quality etc. 2. More people reached: Scale 3. More lasting impact: Sustainability; to implement interventions where health systems are very weak or non￾existent, access to health facilities is poor, few trained health workers, ultra poor and marginalized groups with low level of awareness, information and education. Challenges in producing further reductions in mortality  Increase equity: Reach the poorest and those farthest away  Increase quality of implementation  Address other causes of mortality that are more difficult to decrease e.g. neonatal mortality More quality & complexity Further reductions in mortality and fertility require interventions that:  Have better quality and greater complexity  More effectively reach the poorest More quality & complexity  The paradox:  Biggest demand for more quality & complexity is in rural and suburban areas hard hit by poverty, HIV/AIDS, malaria, tuberculosis, malnutrition, diarrhea, pneumonia and other communicable diseases.  These same areas have the least ability to implement complex interventions: Health workers with less training, communities with lower literacy, transport and communication more difficult More people reached: Scale Four types of scaling up processes identified:  Quantitative scale up: ↑ beneficiaries  Functional scale up: ↑ technical areas  Political scale up/policy dialog  Organization scale up Scaling up processes  Work in advocacy, coalition building, policy dialog etc. often invisible  Reasonable expectations: Time, funding, personnel for scale-up  Response to the large demand to “go to scale”  Implementation at scale ultimately entails some loss of control LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 100 Accountability in a multi-district CS project (Quantitative scale up)  PVO and wider range of partners at district, state and national levels  Targeted resource poor communities & households are located in remote and inaccessible areas in many districts where projects are implemented  Less intensive monitoring & oversight by PVO  Outcomes are less certain Accountability for results when implementing at scale  Need to rely on partners to implement and solve problems as they occur  Some will be effective in problem-solving, others will not  This will naturally result in uneven implementation: Areas of high and low coverage Loss of control  Issues in scale and sustainability are related  Working at scale means dealing with loss of control and uncertainty in the present  Sustainability means dealing with loss of control and uncertainty in the future  How to maintain benefits for the population even when we have limited control? Equity concerns related to sustainability  Identify innovative ways and means to address – “Planning for maintaining equity gains” A definition of sustainability Sustainability in primary health care projects is a contribution to development of conditions enabling individuals, communities, and local organizations to express their potential, improve local functionality, develop mutual relationships of support and accountability, decrease dependency on insecure resources (financial, human, technical, informational), in order for local stakeholders to negotiate their respective roles in the pursuit of health, wellbeing and development beyond project intervention. The present thinking about sustainability: There has been ongoing discussion about the need for sustainability within USAID and the CS grants program.  In the late 90s, this “crystallized” into thinking about how to measure sustainability, hence was born the Sustainability Initiative Study in 2000.  The thinking and tools have evolved through an iterative process of dialogue with PVO HQ and field staff  The present CSSA has emerged “Project Thinking” versus “Development (Sustainability) Thinking” Project Planning (Results Framework or Logical Framework) is based on reducing reality to a simple equation: Inputs → processes → outputs → outcomes LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 101 The “real world” in which development occurs is actually much more complex:  There are many actors that affect outcomes  Variables are interdependent  There are factors outside control of project The basic premise of sustainability Planning Individuals, communities, and local organizations (“local actors”) constitute a local system within an overall environment. Based on their own understanding of their health and development, the coordinated interactions and efforts of these local actors will lead to lasting (sustainable) health impact. LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 102 System thinking: many actors contribute to sustainability CS sustainability self-assessment of 22 projects (2001) Elements of Sustainability Framework = Having the ability to maintain impact END OF Sustained community health Finding solutions Build together Sustainability As you promote Health! Health outcomes Services Org. Capaci ty Org. Viability Comm Capacity Environ PROJECT RESULTS (outcomes and processes) SUSTAINED IMPACT LOCAL PROCESS Project Community Organizations MoH / Gov. Private sector Traditional care providers NGO Health facility Districts Community Health Workers Local System Media Other sectors LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 103 Health Outcomes: Health Outcomes, represents the population’s health, which is generally addressed through proxy health objectives such as immunization coverage, child growth, healthy household behaviors (exclusive breastfeeding, weaning practices, sleeping under bed nets) and/or improved knowledge (e.g. management of the sick child, risk of HIV transmission). Health services: Health and Social Services, consists of elements in the health and social services approach, such as quality, cost, accessibility, equity, appropriateness and coverage—whether through public or private, community or facility-based service delivery. Organizational Capacity: Organizational Capacity represents the capacity that needs to exist in local organizations in order to maintain essential services and activities. Organizational capacity refers to a range of functions that are necessary to the life of an organization, to its administration, and its ability to perform its mission (Lafond et al., 2002). Organizational Viability Organizational Viability, relates not only to financial viability, but also to other essential types of support and relationships—connectedness— which an organization depends on to fulfill its mission. This is not so much self-reliance, an optimistic and ambiguous concept at best, but a rational profile of organizational dependency, or interdependency, in a given institutional environment. Organizational capacity and viability are two overlapping concepts, though sometimes considered one and the same. Community Competence & Capacity: Community Competence/Capacity, refers to overlapping elements that affect the community, such as cultural acceptance of positive changes, social cohesion, collective efficacy, etc. All these elements can be looked at under the umbrella concept of community competence (Cottrell, 1983). Ecological, human, economic, political and policy environment: Ecological, Human, Economic, Political and Policy Environment - includes a number of elements within the environment of the local system: national and regional policies, the economic and political environment, the environmental/ecological conditions and human development situation. These elements are frequently outside of a project’s scope of intervention, but represent important transitional stages of development, which NGOs cannot ignore LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 104 Diagrammatic Presentation of Sustainability Framework – An Interdependence Approach for Holistic Performance Results Stepwise action for sustainability assessment Six steps for conducting a sustainability assessment 1. Defining the system to be assessed, its vision and its goals and results 2. Identifying elements for the local system for sustainability 3. Choosing indicators and identifying scales to assess the progress they measure 4. Measuring the status of the individual indicators 5. Mapping indicators along the scales to define progress combining the indicators into indices 6. Review of results and formulation of a follow-up Action Plan based on results. A locally-driven, participatory process to improve community health in a sustainable way LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 105 4.3 Survey Proceedings: All the three workshops were held as scheduled in the three districts. Participation of representatives from relevant stakeholders, actors and partners like central and regional divisional heads, chiefs of child and maternal health, CB-NCP, CB-IMCI of MoHP, DHO/DPHO, DDC, municipalities, FPAN field office, WDO, DEO and local partner NGOs was quite lively and inquisitive regarding the results from the Black Box to know the formula of interpretation of data by the participants. As per set objectives, the workshop followed all the 6 steps for sustainability assessment as a self-discovery tool to know, to realize and to improve the situation of child and maternal health condition through follow-up action plan for the coming year. Facilitator team members from central to field office made hard efforts as usual for data exploration, analysis and to make the stakeholders, actors and partners realize their ownership and responsibility for informed planning and management. Findings of results and workshop are presented systematically in step wise below and proceeding including list of participants are annexed under respective district headings. 4.4 Objectives: Objective of the Workshop for MTE The objectives of the workshop were to:  To define sustainability within the context of health programs.  To assess the sustainability of LIBON Project in Sunsari and Parsa and develop a Plan of action.  To assist local partner organizations to assess their own sustainability. 4.5 Methodology: Step 1: Defining the system to be assessed, vision, goals and results Key actors and participants  Formal health service providers: public, private: MoHP, District DHOs, DPHOs, IOM, RHCs, VHDCs, DDCs, VDCs  NGOs and private organizations  CBOs  Households and individuals  Mothers and Pregnant Women’s Groups  Communities Clarity on vision of sustainability Vision statements lead to:  Building a vision is part of the strategy for change Assessment is a part of building capacity  Achievements lead to greater visions  Evaluations lead to more realistic visions LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 106 Building a common vision for sustainability  Planning contextually  Building ownership  Finding a working consensus  Mapping out a direction Facilitators’ team clarified the objectives of the CSSA – Workshop as an assessment tool for MTE of LIBON Project Districts. After usual proceedings, groups are formed to assess the results as follows. Representative participants worked together in groups and unanimously agreed on the following vision along with goals, sub-goals, results and strategies. Vision: Sunsari: VISION: A community where the women and children enjoy their full right for health and survival through an active participation and organized effort of a well established network of public and private organizations in the community Parsa: VISION: “A healthy community with well established network of public and private sectors where women and children enjoy their full rights of health and survival ensured through active participative and collaborative effort of all stakeholders” Bara: VISION: "That all our community members, especially mothers and children stay healthy" 4.6 Finalizing Indicators: 2. Identifying elements for the local system 3. Choosing indicators and identifying scales to assess the progress they measure Defining Elements and Group Works on Elements and Indicators Monitoring and Evaluation Officer (Mr. Dipak Dahal) highlighted on the dimension, component, element and indicator. After discussions and clarification the participants worked in the same previous groups to develop indicators in the areas of each of the component and elements. The following dimensions and components are agreed in the plenary. Dimension 1: Health and health Services Component 1: Health Outcomes Component 2: Health Services Dimension 2: Organizational Component 1: Local Organizational Capacity Component 2: Local Organizational Viability LIBON – CSSA GENERAL Annex 6 Nepal LIBON Project – Final KPC Report 107 Dimension 3: Community and social Ecological Component 1: Community competence and capacity Component 2: Ecological, human, economic political and policy environment The group discussed about the ownership of the future health of community along with influence on health program, roles and responsibilities and relationships among various factors in the communities. DHO shared the present status of the community and availability of services, existing capacity of Health Management Committee and observed areas of improvements. Internal and external environment and possible threats in achieving the vision is openly shared and discussed. After the group works, all the three groups presented their vision and elements including indicators indicating the health and health service, organizational capacity and viability and community competency and socio political, ecological environment. Finally, the group finalized the common elements and indicators of each component. The sources are identified and consensus on the indicator settings is made. The sources of indicators are HMIS, LQAS and other information from DHO, District Education Office (DEO), Women Development Organization (WDO), health facility information and external reports. LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 108 4.7. CSSA Survey Final Evaluation Report - Parsa District (1 – 3 August 2011) Major Findings and results in the Final Evaluation The three days CSSA workshop was held from 1 – 3 August 2011 in Birgunj, Parsa. The participants were representing from DPHO, Municipalities, DDCs, DEO, DWO, CDO, local partner and others. They were aware on child survival evolution and sustainability assessment. After that, the participants were involved in preparing the coverage/measure of each indicator defined in last workshop on March 2010 and shared the individual dimension in the respective groups then it was finalized in the plenary session. The outcomes of the each indicator support to prepare dashboard as well as spider web graphic with the help of black box. Based on the findings, team has prepared the plan of action with remarkable recommendation for the further improvement and achievement in future. The major findings are in Dimension-1, Component-1, Health outcome index has increased to 75% in 2011, from 54.9% in 2008 and 54.7% in 2010 and component 2 Health services index increased to 61% from 52% in 2008 and decreased by 4% than in 2010. Dimension 2, component 3, organizational capacity index increased to 72% from 47% in 2008 and 51% in 2010 and component 4 organizational viability has increased to 47% from 16% in 2008 and decreased by 2% in 2010. While Dimension 3, component 5 Community capacity index has increased to 50% in 2011 from 48% in 2008 and 42% in 2010. Component 6 environmental index remained 43% in 2011 and 2008 and decreased in 2010 by 3% The Dash Board results and the table presentation show that there has been an increased improvement in the achievements of components irrespective of problems being faced as have been shown in the action plan formulation. Regarding, level of achievements, Dimension 2, component 4 organizational viability although the figure is quite high in 2011 compared to the initial stage in 2008, but still for homogenous progress and achievement, it is lower to other components like health outcome index and organizational capacity index. Similarly, Dimension 3, component 6, environmental index remains to be the same in 2008 and 2011. So, there is a need to reflect and review such heterogeneous figures during regular meetings at Ilaka level and district level for homogeneity in achievement that reflects steady and winning situation in sustaining the results in a balanced and harmonious way. However, the achievements of the results are quite encouraging compared to Mid Term level. For lasting sustainability, component 4, 5 and 6 namely organizational viability, community capacity and environmental indices, there is a need for address the issues for integrated and joint collaboration through linkage, networking and coordination among the stakeholders like DDC, VDCs, CBOs, MGs, PWGs, Saving LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 109 and credit groups through integrated approach of the line agencies more particularly with District Agriculture and Cooperative office, District Education Office, Women Development Office, District Health Office and the local self-governance bodies. At the end of the workshop, participants make specific recommendations to improve the situation of child and mother’s health condition based on the findings and the results including their past experiences and lessons learned. Recommendations are included after action plan. LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 110 Indicators by Components Developed by the Participants – Parsa District on 1 – 3 August 2011 Dimension 1: Component 1: Health outcomes Elements Indicators Source of Information Measure (% or scale) Score Mortality  Neonatal mortality rate National source 3.3% 93.4  Maternal mortality ratio National source 0.28% 99.2 Immunization  % of BCG coverage HSIS 95% 90.0  % of HB/DPT III coverage HSIS 90% 80.0  % of Measles coverage HSIS 85% 73.4  % of TT2 coverage HSIS 70% 55.1 Nutrition  % of under weight children of under 5 years HSIS 6% 3.4  % of new growth monitoring of under 5 years children HSIS 56% 41.0  % of mother who breastfed within one hour after child birth LQAS 78.9% 65.2  % of exclusive breastfeeding of under 6 months LQAS 98.7% 97.4  % of mother of children aged 0-5 months consuming/folic acid tablet at 6 months during their pregnancy LQAS 77.7% 63.6  % of mother of children aged 0-5 months who received vitamin ‘A’ 200000 IU within 45 days of their birth LQAS 83.4% 71.3  % of pregnant mother supplemented with albendazole LQAS 87.9% 77.3 CB-IMCI  % of severe pneumonia & very severe disease among total cases HSIS 0.6% 0.3  Incidence of Diarrhea/1,000 population HSIS 37% 48.0  % of severe dehydration among total cases HSIS 0.05% 99.9 Safe motherhood  % of 4 times ANC visit LQAS 68% 53.1  % of delivered at institutional by SBA (Doctor, Nurse, ANM whether received training or not) LQAS 59.5% 44.5  % of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within the first two LQAS 98.8% 97.6 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 111 Elements Indicators Source of Information Measure (% or scale) Score days of birth  % of mothers of children aged 0-5 months who know at least two danger sign during delivery LQAS 91.5% 83.0  % of mothers of children aged 0-5 months who know at least two danger sign among newborns LQAS 97.6% 95.2  % of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours LQAS 89.5% 79.5 Family planning  Contraceptive Prevalence Rate (CPR) HSIS 67% 52.1 Sanitation  % of mothers of children age 0-23 months who live in households with soap at the place for hand washing LQAS 72.9% 58.0 Recording and reporting  % of timely reporting DPHO 83% 70.7 Total 1875.4 Average 75.01 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 112 Dimension 1: Component 2: Health services Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) Functionality of Health facilities  Immunization clinic held per month HSIS 5 80.0 1. No immunization clinic 2. Immunization clinic upto 20% tool 3. Immunization clinic upto 40% tool 4. Immunization clinic upto 60% tool 5. Immunization clinic upto 80% tool 6. Immunization clinic more than 80%  Dalit / Janajati children immunized measles vaccine. HSIS 5 80.0 1. No immunized measles vaccine 2. Immunized measles vaccine upto 20% tool 3. Immunized measles vaccine upto 40% tool 4. Immunized measles vaccine upto 60% tool 5. Immunized measles vaccine upto 80% tool 6. Immunized measles vaccine more than 80%  ORC clinic held per month people served by per clinic HSIS 2 20.0 1. No ORC clinic 2. ORC clinic upto 20% 3. ORC clinic upto 40% 4. ORC clinic upto 60% 5. ORC clinic upto 80% 6. ORC clinic more than 80%  VHW/MCHW attendance in mother’s group meeting HSIS 3 40.0 1. No attend in MGM 2. Attend in MGM upto 20% 3. Attend in MGM upto 40% 4. Attend in MGM upto 60% LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 113 Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) 5. Attend in MGM upto 80% 6. Attend in MGM more than 80% Logistic  % of LMIS report received by quarterly basis DPHO report 83% 70.7  % of stock out of 10 essential drug commodities + gentamycine (Condom, pills, iron, Vit A, ORS, Cotrim, CHDK, gentamycine, CHX) DPHO report 5 80.0 1. Stock-out more than 80% 2. Stock out upto 80% 3. Stock out upto 60% 4. Stock out upto 40% 5. Stock out upto 20% 6. No stock out Supervision and monitoring  % of supervision and monitoring of HF HSIS 4 60.0 1. No supervision and monitoring 2. Supervision and monitoring upto 20% 3. Supervision and monitoring upto 40% 4. Supervision and monitoring upto 60% 5. Supervision and monitoring upto 80% 6. Supervision and monitoring more than 80% Total 430.7 Average 61.5 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 114 Dimension 2: Component 1: Organizational Capacity Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) Human Resources  % of fulfillment of sanctioned post DPHO 95% 90.0  % of trained human resource including FCHVs on program package (CB-NCP) DPHO 96% 92.0 Information Management  Availability and use of tools (OPD register, services register, child health card, treatment book) at HF level Health facility & DPHO report 5 80.0 1. No 2. Available upto 20% 3. Available upto 40% 4. Available upto 60% 5. Available upto 80% 6. Available more than 80%  Availability and use of monthly monitoring sheet (ARI treatment book, home therapy card, referral book, classification card, cotrimoxazole, timer) at community level Health facility & DPHO report 5 80.0 1. No 2. Available upto 20% 3. Available upto 40% 4. Available upto 60% 5. Available upto 80% 6. Available more than 80% Financial Management  % of HF with financial audit Health facility & DPHO report 6 100.0 1. No Financial audit 2. Financial audit upto 20% 3. Financial audit upto 40% 4. Financial audit upto 60% 5. Financial audit upto 80% 6. Financial audit more than 80% Physical infrastructure  % of HF with their own building Health facility & DPHO 60% 45.0 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 115 Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) report  % of HF with space for delivery Health facility & DPHO report 4 70.7 1. No space for delivery 2. Space for delivery upto 20% 3. Space for delivery upto 40% 4. Space for delivery upto 60% 5. Space for delivery upto 80% 6. Space for delivery more than 80%  % of HF with toilet & water Health facility & DPHO report 4 26.4 1. No toilet and tube well 2. Toilet and tube well upto 20% 3. Toilet and tube well upto 40% 4. Toilet and tube well upto 60% 5. Toilet and tube well upto 80% 6. Toilet and tube well more than 80% Planning & evaluation  % of HFMC with monthly meeting Health facility minute 5 45.0 1. No monthly meeting 2. Monthly meeting upto 20% 3. Monthly meeting upto 40% 4. Monthly meeting upto 60% 5. Monthly meeting upto 80% 6. Monthly meeting more than 80%  % of Ilaka level monthly reporting & meeting HF minute and HSIS 100% 100.0 Total 729.2 Average 72.9 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 116 Dimension 2: Component 2: Organizational Viability Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) Community Contribution  % of HF with staff support from local governing body HF & local government report 3 40.0 1. No staff support 2. Staff support upto 20% 3. Staff support upto 40% 4. Staff support upto 60% 5. Staff support upto 80% 6. Staff support more than 80%  % of HF support for FCHV monthly meeting at community level HF & local government report 5 80.0 1. Support for NID & Vit “A” 2. Support for monthly meeting upto 20% 3. Support for monthly meeting upto 40% 4. Support for monthly meeting upto 60% 5. Support for monthly meeting upto 80% 6. Support for monthly meeting upto 100% Transparency of program and finance  Monthly performance & planning meeting at HF level with representation of DHO/Ilaka and VDC/HFMC HFMC minute 4 60.0 1. No meeting 2. Meeting with staff only 3. HFMC meeting 4. Meeting with staffs and HFMC members 5.HFMC Meeting with representation of DPHO/Ilaka 6. Meeting, decision made in favor of Dalit, women Social/public Auditing  % of HF social/public audit conducted HF & local government report 1 10.1 1. No social/public audit 2. Social audit/public upto 20% 3. Social audit/public upto 40% 4. Social audit/public upto 60% 5. Social audit/public upto 80% 6. Social audit/public more than 80% Total 190.1 Average 47.5 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 117 Dimension 3: Component 1: Community Competence/Capacity Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) Community participation  % of mother of children of 0-5 months who knows at least two danger sign during pregnancy LQAS 96.8% 93.6  % of VDC with access to emergency fund for delivery. DACAW 34.1% 19.5  % of PHC/ORC conducted Group work 50% 35.1 Functionality of HMC  Regularity of meeting HSIS 27.8% 15.9 Social inclusion  % of HFMC formed as per protocol (marginalized, so-called Dalit, women) HF report 75% 60.0  Decision made in the favor of Dalit and women 5 80.0 1. No decision 2. Decision but no participation 3. Decision with participation 4. Decision but not implementation 5. Decision with partial implementation 6. Decision with full implementation Total 304.1 Average 50.7 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 118 Dimension 3: Component 2: Ecological, human, Economic, Political & Policy Environment Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) Policy  Policy on child rights Nepal Planning Commission (NPC) document 3 40.0 1. No policy 2. Policy at place but not implemented 3. Policy at place but partially implemented 4. Policy fully implemented 5. Policy implemented, monitored, supervised & evaluated 6. Policy implemented & sustained  Policy on women rights NPC document 3 40.0 1. No policy 2. Policy at place but not implemented 3. Policy at place but partially implemented 4. Policy fully implemented 5. Policy implemented, monitored, supervised & evaluated 6. Policy implemented & sustained  Priority on child and maternal health programs MoHP & DoHS 5 80.0 1. No Priority 2. Priority but not implemented 3. Priority but partially implemented 4. Priority with fully implemented 5. Priority implemented, monitored, evaluation & supervised 6. Priority implemented & sustained Political commitment  Involvement of political (formal and informal) leaders in health campaign Supervision and feedback, national document 3 40.0 1. No commitment 2. Commitment but not involvement LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 119 Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale) 3. Commitment with less than 50% involvement 4. Commitment with between 51% to 80% involvement 5. Commitment with above 80% involvement 6. Commitment with above 80% involvement including community mobilization  Political commitment on health related issues. Supervision and feedback, national document 3 40.0 1. No commitment 2. Commitment but not involvement 3. Commitment with less than 50% involvement 4. Commitment with between 51% to 80% involvement 5. Commitment with above 80% involvement 6. Commitment with above 80% involvement including community mobilization Literacy  Women literacy rate LQAS (Module1) 31.2% 17.9 Socio-economic status  HDI (LE, PCI/GNP, Literacy) UNDP, 2004 59% 44.0 Total 301.9 Average 43.1 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 120 Outcome of CS Sustainability Assessment Framework Workshop of Parsa district, August 2011  Mortality  Immunization  Nutrition  CB-IMCI  Safe motherhood  Family planning  Sanitation  Recording and reporting  Immunization clinic held per month  Dalit/Janajati children immunized measles vaccine.  ORC clinic held per month people served by per clinic  VHW/MCHWs attendance in mother’s group meeting  % of LMIS report received by quarterly basis  % of stock out of 10 essential drug commodities + gentamycine  % of supervision and monitoring of HF  Policy on child rights  Policy on women rights  Priority on child and maternal health programs  Involvement of political (formal and informal) leaders in health campaign  Political commitment on health related issues.  Women literacy rate  HDI (LE, PCI/GNP, Literacy)  % of mother of children of 0-5 months who knows at least two danger sign during pregnancy  % of VDC with access to emergency fund for delivery.  % of PHC/ORC conducted  Regularity of meeting  % of HFMC formed as per protocol (marginalized, so-called Dalit, women)  Decision made in the favor of Dalit and women  % of fulfillment of sanctioned post  % of trained human resource including FCHVs on program package (CB-NCP)  Availability and use of tools (OPD register, services register, child health card, treatment book) at HF level  Availability and use of monthly monitoring sheet (ARI treatment book, home therapy card, referral book, classification card, cotrimoxazole, timer) at community level  % of HF with financial audit  % of HF with their own building  % of HF with space for delivery  % of HF with toilet & water  % of HFMC with monthly meeting  % of Ilaka level monthly reporting & meeting  % of HF with staff support from local governing body  % of HF support for FCHV monthly meeting at community level  Monthly performance & planning meeting at HF level with representation of DHO/Ilaka and VDC/HFMC  % of HF social/public audit conducted LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 121 Sustainability dashboard of Parsa District Aug 2008, March 2010 and Aug 2011 Dimension Component # Component Indices (Aug 2008) Indices (Mar 2010) Indices (Aug 2011) 1 1 Health Outcome index 54.97 54.76 75.01 2 Health Services index 52 65.7 61.5 2 3 Organizational Capacity Index 47.5 51.2 72.9 4 Organizational Viability index 16.2 49.2 47.5 3 5 Community Capacity index 48.9 42.9 50.7 6 Environmental index 43.7 40 43.1 Sustainability Dashboard 0 20 40 60 80 100 Health Outcome index Health Services index Organizational Capacity Index Organizational Viability index Community Capacity index Environmental index Aug_08 Mar_10 Aug_11 LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 122 CSSA Action plan – Parsa district, Aug 2011 Dimension 1: Component 1: Health outcomes Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  Neonatal mortality rate 3.3% 2.8%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during antenatal check-up (ANC) and postnatal check-up (PNC) visit  Mobilization of Female Community Health Volunteers(FCHV)  Effective continuation of Community Based-Newborn Care Program (CB-NCP) implementation activities  Delivery from Skill Birth Attendant (SBA)  Promotion of institutional delivery practices  Availability of trained human resources  Timely fulfillment of the vacant positions Aug 2012 DDC/VDC DPHO HF WDO VDC NFHP-II  Maternal mortality ratio 0.28% 0.24%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during antenatal check-up (ANC) and postnatal check-up (PNC) visit  Mobilization of on Female Community Aug 2012 DDC/VDC DPHO HF WDO VDC LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 123 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks Health Volunteers (FCHV)  Effective Continuation of Community Based-Newborn Care Program (CB-NCP) implementation activities  Delivery from Skill Birth Attendant (SBA)  Promotion of institutional delivery practices  Availability of trained human resources  Timely fulfillment the vacant position NFHP-II  % of BCG coverage 95% 97%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Maintain and regularize EPI program  Fulfill the vacant position  Supportive supervision and monitoring  Timely reporting Aug 2012 DDC/VDC DPHO HF NFHP-II  % of HB/DPT III coverage 90% 97%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Maintain and regularize EPI program  Supportive supervision and monitoring  Fulfill the vacant position  Timely reporting Aug 2012 DDC/VDC DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 124 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of Measles coverage 85% 97%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Maintain and regularize EPI program  Supportive supervision and monitoring  Fulfill the vacant position  Timely reporting Aug 2012 DDC/VDC DPHO HF NFHP-II  % of TT2 coverage 70% 80%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC and PNC  Promote school health program and continue TT campaign in school  Regular supply of TT vaccine Aug 2012 DPHO HF NFHP-II  % of under weight children of under 5 years 6% 5%  Continue the existing nutrition program  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC and PNC Aug 2012 DPHO HF NFHP-II  % of new growth monitoring of under 5 years children 56% 65%  Continue the existing nutrition program  Awareness raising program through FM, mother’s group meeting, mass Aug 2012 DPHO HF LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 125 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks campaigning and pregnant women group (PWG)  Counseling during ANC and PNC NFHP-II  % of mother who breastfed within one hour after child birth 78.9% 85%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Continue the CB-NCP  Counseling during ANC and PNC  Promotion of health institution delivery practices Aug 2012 DPHO HF NFHP-II  % of exclusive breastfeeding of under 6 months 98.7% Maintain  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Continue the CB-NCP  Counseling during ANC and PNC visit (focus on FP)  Promoting of institution delivery practices Aug 2012 DPHO HF NFHP-II  % of mother of children aged 0- 5 months consuming/folic acid tablet at 6 months during their pregnancy 77.7% 90%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Activate MGM  Regular supply of Iron tablet Aug 2012 DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 126 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  Counseling during ANC and PNC visit  Regular supply of Iron tablet up to FCHV level  % of mother of children aged 0- 5 months who received vitamin ‘A’ 200000 IU within 45 days of their birth 83.4% 90%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Activate MGM  Regular supply of Vit ‘A’  Counseling during ANC and PNC visit Aug 2012 DPHO HF NFHP-II  % of pregnant mother supplemented with albendazole 87.9% 95%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC  Regular and timely supply of albendazole Aug 2012 DPHO HF NFHP-II  % of severe pneumonia & very severe disease among total cases 0.6% 0.5%  Continue CB-NCP and CB-IMCI  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC and PNC  Regular supply of Cotrim HF to FCHVs Aug 2012 DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 127 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  Incidence of Diarrhea/1,000 population 37% 30%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Promotion of personal hygiene  Proper use of toilet  Pure drinking water and fresh food  Counseling during ANC and PNC  Regular supply of Zinc and ORS at HF and FCHV Aug 2012 DPHO HF NFHP-II  % of severe dehydration among total cases 0.05% 0.05%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Promotion of personal hygiene  Proper use of toilet  Pure drinking water and fresh food  Counseling during ANC and PNC  Regular supply of ORS and Zinc to HF and FCHV Aug 2012 DPHO HF NFHP-II  % of 4 times ANC visit 68% 75%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling and promotion of ANC visit Aug 2012 DDC/VDC DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 128 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  Timely fulfillment of the vacant positions  % of delivered at institutional by SBA (Doctor, Nurse, ANM whether received training or not) 59.5% 75%  Produce more SBA and provide trainings to health staff  Promotion of institution delivery practices  Establish birthing center  Counseling and promotion of ANC visit  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG) Aug 2012 DPHO HF NFHP-II  % of mothers with children aged 0-5 months (and their newborns) who received a first checkup by a skilled provider (doctor or nurse or HA or AHW or ANM) within the first two days of birth 98.8% Maintain  Produce SBAs  Promotion of institution delivery practices  Establish birthing centers  Counseling and promotion of ANC visit and PNC visit  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG) Aug 2012 DPHO HF NFHP-II  % of mothers of children aged 0-5 months who know at least two danger sign during delivery 91.5% 95%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC visit and PNC visit Aug 2012 DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 129 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of mothers of children aged 0-5 months who know at least two danger sign among newborns 97.6% Maintain  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC visit and PNC visit Aug 2012 DPHO HF NFHP-II  % of newborns immediately after birth, who were dried off, exposed to a heating source (including kangaroo care) and avoided bathing for 24 hours 89.5% 95%  Continue CB-NCP program  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC visit and PNC visit Aug 2012 DPHO HF NFHP-II  Contraceptive Prevalence Rate (CPR) 67% 70%  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC visit and PNC visit  Regular supply of temporary family planning at HF and FCHV  Increase trained human resources Aug 2012 DPHO HF NFHP-II  % of mothers of children age 0- 23 months who live in households with soap at the place for hand washing 72.9% 80%  Promotion of personal hygiene  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Counseling during ANC visit and PNC visit Aug 2012 DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 130 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of timely reporting 83% 100%  Develop and provide regular feedback and coaching practices  Regular follow-up for timely reporting Aug 2012 DPHO HF NFHP-II Dimension 1: Component 2: Health services Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  Immunization clinic held per month 5 6  Maintain the running immunization clinic  Reactivate immunization clinics  Supportive supervision and monitoring  Regular supply  Timely fulfillment of vacant position  Mobilization of FCHVs Aug 2012 DPHO HF NFHP-II  Dalit/Janjati children immunized measles vaccine. 5 6  Awareness raising program through FM, mother’s group meeting, mass campaigning and pregnant women group (PWG)  Regular EPI clinic  Mobilization of FCHVs  Timely fulfillment of vacant position  Follow-up for recording and reporting based on disaggregated data Aug 2012 DPHO HF NFHP-II FCHV LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 131  ORC clinic held per month people served by per clinic 2 3  Maintain running ORC clinics  Reactivate ORC clinic  Supportive supervision and monitoring  Regular supply  Timely fulfillment of vacant position  Mobilization of FCHVs Aug 2012 DPHO HF NFHP-II FCHV  VHW/MCHW attendance in mother’s group meeting 3 4  Regular meetings of MGMs  Timely fulfillment of vacant position  Supportive supervision and monitoring  Mobilize FCHV and VHW/MCHW Aug 2012 DPHO HF NFHP-II FCHV  % of LMIS report received by quarterly basis 83% 100%  Develop and provide feedback and coaching practices  Regular follow-up for timely reporting Aug 2012 DPHO HF NFHP-II  % of stock out of 10 essential drug commodities + gentamycine 5 6  Regular supply  Supportive supervision and monitoring Aug 2012 DPHO HF NFHP-II  % of supervision and monitoring of HF 4 5  Supportive supervision and monitoring  Feedback and coaching during visit  Practice to develop and provide field visit reports. Aug 2012 DPHO HF NFHP-II LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 132 Dimension 2: Component 1: Organizational Capacity Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of fulfillment of sanctioned post 95% 99%  Increase and initiate advocacy for support in hiring ANM/ CMA/ to VDC/DDC  Request for timely fulfillment of vacant posts to DoHS, RHD/MoHP Aug 2012 DPHO/ HFs DDC/ VDC  % of trained human resource including FCHVs on program package (CB-NCP) 96% 99%  Training to new FCHVs/HWs Aug 2012 DPHO/CHD  Availability and use of tools (OPD register, services register, child health card, treatment book) at HF level 5 6  Timely logistics supply and proper use Aug 2012 LMD DPHO/ HFs/NFHP  Availability and use of monthly monitoring sheet (ARI treatment book, home therapy card, referral book, classification card, cotrimoxazole, timer) at community level 5 6  Organize and maintain regular of monthly Ilaka meeting  Organize Quarterly review meeting  Proper logistics demand and supply on quarterly basis Aug 2012 LMD HFs/ DPHO/ store /NFHP LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 133 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of HF with financial audit 6 Maintain  Regularity of financial audits Aug 2012 HF/ DPHO/ NFHP  % of HF with their own building 60% 70%  Coordination and net working with DDC/VDCs  Advocacy for HF building construction Aug 2012 DPHO/ HFs/ MoHP  % of HF with space for delivery 4 5  Explore the need of space for delivery  Advocacy for /Promotion of institutional deliveries Aug 2012 HFs/ DPHO  % of HF with toilet & water 4 5  Provision of toilets and water supply Aug 2012 DDC/VDC/DPHO/ Concern NGOs/ INGOs/NRCS/ District water and sanitation office  % of HFMC with monthly meeting 5 6  Instruction for regular Monthly meeting  Supervision and monitoring  Proper feedback Aug 2012 HF incharge/ DPHO LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 134 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of Ilaka level monthly reporting & meeting 100% Maintain  Regularity of meeting Aug 2012 HF/DPHO Dimension 2: Component 2: Organizational Viability Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of HF with staff support from local governing body 3 4  Net working and coordination with governance bodies.  Advocacy for staff recruitments Aug 2012 VDC/ DDC/ DPHO/MoHP  % of HF support for FCHV monthly meeting at community level 5 6  Advocacy for support  Monitoring & supervision  Boost up the morale of HWs to facilitate the meetings Aug 2012 VDC/HFs/DPHO  Monthly performance & planning meeting at HF level with representation of DHO/Ilaka and VDC/HFMC 4 5  Instruction for regular Monthly meeting  Supervision and monitoring  Proper feedback  Regularity of meeting Aug 2012 VDC/HFs/DPHO LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 135  % of HF social/public audit conducted 1 3  Regularity of social audit linking with free health services (FHS) program Aug 2012 HF/ HFMC/DPHO Dimension 3: Component 1: Community Competence/Capacity Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  % of mother of children of 0-5 months who knows at least two danger sign during pregnancy 96.8% Maintain  Continue health education to mothers groups and pregnant women, husband, mother-in-laws (by using mother cards)  Health education to interest group of Women and Children Office (WCO) (by using mother cards)  Female Community Health Volunteer (FCHV) to disseminate the key health message about danger sign during pregnancy Aug 2012 DPHO WCO I/NGO NFHP-II RHCC  % of VDC with access to emergency fund for delivery. 34.1% 84%  Coordinate with Local governance community development program of DDC to mobilize resources for emergency fund for delivery Aug 2012 WCO, NGOCC, DDC/VDC/ Municipality DPHO 79 VDCs out of 82  % of PHC/ORC conducted 50% 60%  Supportive supervision and logistic Aug 2012 DDC/VDC LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 136 Indicators Current Status Expected outcome Activities to be done By when By whom Remarks supply by DPHO  Demand creation: awareness to mother group and pregnant women group  Timely fulfillment of the vacant position DPHO WCO  Regularity of meeting - HFMC 27.8% 50%  Allocate budget for snacks for meeting Aug 2012 DPHO HFMC  % of HFMC formed as per protocol (marginalized, so￾called Dalit, women) 75% 85%  Awaken and remind about HFMC protocol at monthly district review meeting and also in Ilaka level review meeting Aug 2012 DPHO  Decision made in the favor of Dalit and women 5 Maintain  Coordinate with DDC to mobilize VDC fund during the VDC secretary meeting  Coordination with LGCDP Aug 2012 WCO DEO DPHO LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 137 Dimension 3: Component 2: Ecological, human, Economic, Political & Policy Environment Indicators Current Status Expected outcome Activities to be done By when By whom Remarks  Policy on child rights 3 4  Advocacy and coordinate with DDC/VDC for fund allocation during the VDC secretary meeting  Advocacy and coordination with Local Government Community Development Program (LGCDP)  Advocacy campaign Aug 2012 WCO and DCWB Paralegal committee DEO DPHO Child Club  Policy on women rights 3 4  Advocacy and coordinate with DDC/VDC for fund allocation during the VDC secretary meeting  Advocacy and coordination with Local Government Community Development Program (LGCDP) for local health governance strengthening program by linking with PWG and CB-NCPs  Advocacy campaigns Aug 2012 DDC / VDC WCO Paralegal committee  Priority on child and maternal health programs 5 Maintain  Continue monitoring of CBNCP, BPP and CBIMCI programs  Continue pregnant women groups Aug 2012 DPHO LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 138  Involvement of political (formal and informal) leaders in health campaign 3 4  Pre-campaign meeting with all GOs, NGOs, INGOs and political parties  Mobilization of women groups of WDO  Resource Person (RP) for monthly meeting – open school in campaign day Aug 2012 DDC/DAO DPHO WCO DEO  Political commitment on health related issues. 3 4  Advocacy for commitment by political parties for health related issues of Parsa district Aug 2012 DDC/DPHO  Women literacy rate 31.2% 35%  Women literacy plan via community learning centers (CLC)  Continue formal girls education Aug 2012 DEO 50 classes X 30 persons  HDI (LE, PCI/GNP, Literacy) 59% 59%  Livehood support program  Literacy campaign Aug 2012 DDC / VDC DEO, I/NGOs UNICEF LIBON – CSSA PARSA Annex 6 Nepal LIBON Project – Final KPC Report 139 RECOMMENDATION:  Continuity for monitoring of data collection through Lot Quality Assurance Sampling (LQAS) survey technique  Coordination for CSSA action plan by sharing with stakeholders (DDC and VDC secretary network) and implementation as per action plan  Orientation to mother’s group meeting for the role and responsibilities of MG and maternal and child health package  Strengthening of PHC/ORC (timely logistic supply, management and supportive supervision)  Review and refresher training of CB-NCP and recording reporting  Integrated child health review meeting to be expand from 3 to 4 days - CHD  Review and follow-up of CSSA workshop  CB-NCP and CB-IMCI form and format to be regularly available through government existing supply system  CB-NCP training to be provided to newly transfer and hired staff  Ensure the involvement of municipality health staff in district level health program activities  CB-NCP program to be introduced in health facilities of municipalities areas in coordination with Child Health Division and PHC revitalization divisions  Orientation of cold-chain management to focal person in Ilaka health facilities  Maintenance of freeze/defreeze or new supply  Continue support from Plan Nepal for three years  Introduce of Local Health Governance Strengthening (LHGS) program into LGCDP  Dissemination of health message through mass media such as FM  Mass campaign and PWG/MGM continuity and follow-up LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 140 4.8 CSSA Survey Report – Sunsari District (9 – 11 August, 2011) Major Findings and Results Sunsari The three days CSSA workshop was held from 9 – 11 August 2011 in Inaruwa, Sunsari. The participants were representing from DHO, Municipalities, DDCs, DEO, DWO, CDO, local partner and others. They were aware on child survival evolution and sustainability assessment. After that, the participants were involved in preparing the coverage/measure of each indicator defined in last workshop on January 2010 and shared the individual dimension in the respective groups then it was finalized in the plenary session. The outcomes of the each indicator support to prepare dashboard as well as spider web graphic with the help of black box. Based on the findings, team has prepared the plan of action with remarkable recommendation for the further improvement and achievement in future. The overall, there is no any decrease in the results of achievement in this district except in Dimension 2 component 4, organizational viability, but, increase in achievement 3, component 5 and 6 namely Organizational Capacity, Community capacity and environment respectively however, component-5 is quite remarkable like 80% in 2011 from 34% in 2008. But, on the whole, the results are quite encouraging towards sustainability. Some of the results are as high as up to 80% in 2011 compared to low results of 47% in Mid Term as per the Dash board and the result table, but, increasing trend is quite encouraging. Now, focus is needed for a more informed, balance and harmonious progress towards sustainability. But, compared to 2008 and 2010, the results have been remarkably increased like component 1 health outcome 58% from 45%; component 2 Health services 81% from 57%; component 3 Organizational capacity 60% from 45%; component 5 Community Capacity 80% from 40%; and component 6 Environmental Index 54% from 35% except component 4 Organization viability which is slightly increased by 47% from 43% in Final 2011 from the initial phase 2008. So, there are enough roles to promote organizational viability in future. At the end of the workshop, participants make specific recommendations to improve the situation of child and mother’s health condition based on the findings and the results including their past experiences and lessons learned. Recommendations are included after action plan. LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 141 Measuring the status of individual indicators: Indicators and measure exercise during CSSA workshop of Sunsari district held in 9 – 11 August 2011 Dimension 1: Component 1: Health outcomes Elements Indicators Source of Information Measure (% or scale) Score  Immunization  % of BCG coverage  HMIS 92% 84.0  % of DPT/HB III coverage  HMIS 80% 73.4  % of measles coverage  HMIS 81% 66.7  Nutrition  % of under weight children below 5 years (* under 3 years)  HMIS 3.3% 91.0  % of children under 6 months exclusively breastfed  LQAS 74.7% 81.4  Average number of growth monitored (20 times = 100%)  HMIS 16.5% 6.3  % of post partum mother received vitamin ‘A’  HMIS 84% 56.1  Pneumonia  % of pneumonia among new cases of under five  HMIS 41% 28.0  % of children treated by Cotrim during pneumonia  HMIS 100% 28.0  Diarrhea  % of children treated by ORS  HMIS 88% 92.0  Safe Motherhood  % of pregnant women who visit at least 4 times for ANC  HMIS 44% 37.1  % of mother consumed iron tablet during pregnancy at least 4 months  LQAS 93% 74.8  Family Planning  CPR (Contraceptive Prevalence Rate)  HMIS 50% 35.1 Total 753.9 Average 58.0 LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 142 Dimension 1: Component 2: Health services Elements Indicators Source of Information Measure (% or scale) Score  Immunization clinic  % of functional EPI clinic (12 months data of FY’067/68)  HMIS 98% 96.0  Community based intervention (IMCI)  % of mothers group meeting held in a year per FCHV  HMIS 77% 62.7  Monitoring & Supervision  % of monthly Ilaka review meeting (12 months of FY’067/68)  DHO report 100% 100.0  Recording & reporting  % timely reporting  HMIS 100% 100.0  Institutional delivery  % of delivery conducted by skilled birth attendant  HMIS 65% 50.1  Health institution  % of availability of essential drugs (seven commodities)  Group discussion, LMIS 90% 80.0 Total 488.7 Average 81.5 LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 143 Dimension 2: Component 1: Organizational Capacity Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale)  Functional Health Facility Management Committee  % of monthly meeting  HMIS, Group discussion 3 40.0 1. 0-2 times 2. 3-4 times 3. 5-6 times 4. 7-8 times 5. 9-10 times 6. 11-12 times  Human resource  % of fulfillment of sanctioned position of health facility of FY'67/68  DHO report 95% 90.0  Public/Social audit  % of HF have done public/social audit in annual basis  DHO report 1 10.1 1. 0 – 9 HFs 2. 10 – 18 HFs 3. 19 – 27 HFs 4. 28 – 36 HFs 5. 37 – 45 HFs 6. 46 – 52 HFs  Health facility Planning  % of HF having the regular health program Plan  Group discussion 6 100.0 1. 0 – 9 HFs 2. 10 – 18 HFs 3. 19 – 27 HFs 4. 28 – 36 HFs 5. 37 – 45 HFs 6. 46 – 52 HFs Total 240.1 Average 60.0 LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 144 Dimension 2: Component 2: Organizational Viability Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale)  Coordination with other related NGO/CBO/GO  Number of coordination meeting held in supporting with NGO/CBO/GO by annual basis (e.g. RHCC meeting)  DHO report 50% 35.1  Financial resource  Number of health facility who received fund from concerned DDC/VDC and municipality  Health facility report,  Group discussion 6 100.0 1. 0 – 9 HFs 2. 10 – 18 HFs 3. 19 – 27 HFs 4. 28 – 36 HFs 5. 37 – 45 HFs 6. 46 – 52 HFs  Transparency of program and finance  Participation on key stakeholders in annual review/reflection session  Health facility report  Group discussion 50% 35.1  Participation of social inclusion in decision making  Participation of children, woman, marginalized, disable people in activities against planned  Observation  Minutes  Group discussion 2 20 1. No participations 2. Partial participation 3. Full participation in less than 25% of HF 4. Full participation in 25% to 49% of HFs 5. Full participation in 50% to 74% of HFs 6. Full participation in more than 75% of HFs Total 190.2 Average 47.6 LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 145 Dimension 3: Component 1: Community Competence/Capacity Elements Indicators Source of Information Measure (% or scale) Score Definition of scale (where we are using scale)  Resource generation and mobilization  % of community contribution (cash, kind, land etc.)  Health facility report  Group discussion 6 100.0 1. No contribution 2. <25% contribution in 25% HFs 3. 25% contribution in 25% HFs 4. 25% contribution in 25% to 50% HFs 5. 25% contribution in 50% to 75% HFs 6. 25% contribution in >75% HFs  Decision making  % of female & marginalized group members in Health Facility Management Committee  Health facility  Group discussion 90% 80.0  Participation in health services  % of mothers group meeting / FCHV  HMIS/DHO report 77% 62.7  Demand for service  % of mothers who know at least 2 danger sign during ANC  LQAS 91.6% 83.2  % of mother who know at least 2 danger sign during PNC  LQAS 86.7% 75.7 Total 401.6 Average 80.3 LIBON – CSSA SUNSARI Annex 6 Nepal LIBON Project – Final KPC Report 146 Dimension 3: Component 2: Ecological, human, Economic, Political & Policy Elements Indicators Source of information Measure (% or scale) Score Definition of scale (where we are using scale)  Policy  Policy on maternal and newborn health  MoHP, DHS 5 80.0 1. No policy 2. Policy at place but not implement 3. Policy at place but Planning to implemented 4. Policy implemented 5. Policy implemented with supervision, monitoring, evaluation; and 6. Policy implemented and sustained  Political stability  Political situation  Community  DDC  Newspaper 5 80.0 1. Worse situation 2. Access to movement in 25% HFs 3. Access to movement in 26% to 50% HFs 4. Access to movement in 51% to 75% HFs 5. Access to movement in 76% to 100% HFs 6. Full secure  Literacy  Female literacy rate  (LQAS-2) 65.3% 50.4  Income/purch asing power  Human Development Index  ICIMOD  UNDP 50% 35.1  Economic  % of mothers who received incentive during last delivery as per pregnancy (institutional delivery)  DHO report 38.8%* 23.8 Total 269.2 Average 53.8 * Excluded the institutional delivery of 8,767 of BPKIHS (BP Koirala Institute of Health Science) among 14,339 delivery of Sunsari distric LIBON – CSSA SUNSARI Plan Nepal – LIBON 147 Step 2 & 3: 2. Identifying elements for the local system; 3. Choosing indicators to identify scales to assess the progress they measure Outcome of CS Sustainability Assessment Framework Workshop of Sunsari district, August 2011  Policy on maternal and newborn health  Political situation  Female literacy rate  Human Development Index  % of mothers who received incentive during last delivery against expected pregnancy  % of BCG coverage  % of DPT/HB III coverage  % of measles coverage  % of under weight children below 5 years (* under 3 years)  % of children under 6 months exclusively breastfed  Average number of growth monitored  % of post partum mother received vitamin ‘A”  % of pneumonia among new cases of under five  % of children treated by Cotrim during pneumonia  % of children treated by ORS  % of pregnant women who visit at least 4 times for ANC  % of mother consumed iron tablet during pregnancy at least 4 months  CPR (Contraceptive Prevalence Rate)  % of functional EPI clinic (12 months data of FY’067/68)  % of mothers group meeting held in a year per FCHV  % of monthly Ilaka review meeting (12 months of FY’067/68)  % timely reporting  % of delivery conducted by skilled birth attendant  % of availability of essential drug  % of community contribution (cash, kind, land etc.)  % of female & marginalized group members in Health Facility Management Committee  % of mothers group meeting / FCHV  % of mothers who know at least 2 danger sign during ANC  % of mother who know at least 2 danger sign during PNC  % of monthly meeting  % of fulfillment of sanctioned position of Health facility  % of HF have done public audit in annual basis  % of HF having the health Plan  Number of coordination meeting held in supporting with NGO/CBO/GO by annual basis (e.g. RHCC meeting)  Number of health facility who received fund from concern VDC and municipality  Key stakeholders will participated in annual review/reflection session  Participation of children, woman, marginalized, disable people in activities against Planned LIBON – CSSA SUNSARI Plan Nepal – LIBON 148 Dimension Component # Component Indices (May 2008) Indices (Jan 2010) Indices (Aug 2011) 1 1 Health Outcome index 45.2 58 58 2 Health Services index 57.9 67.6 81.5 2 3 Organizational Capacity Index 45.0 60.5 60 4 Organizational Viability index 43.1 60 47.6 3 5 Community Capacity index 33.9 48.7 80.3 6 Environmental index 35.0 53.6 53.8 0 20 40 60 80 100 Health Outcome index Health Services index Organizational Capacity Index Organizational Viability index Community Capacity index Environmental index Sustainability Dashboard May_08 Jan_10 Aug_11 LIBON – CSSA SUNSARI Plan Nepal – LIBON 149 Action Plan CSSA workshop of Sunsari district held on Aug 2011 Dimension 1: Component 1: Health outcomes Indicators Measure (% or scale) Activities to be done Expected Outcome By when By Whom  % of BCG coverage 92%  Prompt fulfillment if vacant positions  Mobilize FCHVs  Increase counseling in ORC  Counseling during ANC  Regularize monthly FCHVs meetings  Awareness raising through FM, mass campaign, MGM, PWG  Regular supply of materials, drugs 95% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  % of DPT/HB III coverage 80%  Prompt fulfillment if vacant positions  Mobilize FCHVs  Increase counseling in ORC  Counseling during ANC  Regularize monthly FCHVs meetings  Awareness raising through FM, mass campaign, MGM, PWG  Regular supply of materials, drugs 90% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  % of measles coverage 81%  Prompt fulfillment if vacant positions  Mobilize FCHVs  Increase counseling in ORC  Counseling during ANC  Regularize monthly FCHVs meetings  Awareness raising through FM, mass campaign, MGM, PWG  Regular supply of materials, drugs 90% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal LIBON – CSSA SUNSARI Plan Nepal – LIBON 150 Indicators Measure (% or scale) Activities to be done Expected Outcome By when By Whom  % of under weight children below 5 years (*under 3 years) 3.3%  Maintain and continue the exiting program and activities 3% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  % of children under 6 months exclusively breastfed 74.7%  Awareness raising through FM, mass campaign, MGM, PWG  BPP counseling during ANC and PNC  Regularize ORC and EPI session 80% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  Average number of growth monitored (20 times = 100%) 16.5%  Mobilize FCHVs  Growth monitoring of ORC and EPI session with supervision and monitoring  BPP counseling during ANC and PNC  Well maintain timely recording reporting (IMCI) 20% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  % of post partum mother received vitamin ‘A’ 84%  Regular supply  Systematical collection of records and reporting from municipalities 90% Aug 2012 Store, DHO, HFs, VHW/MCHW, FCHVs  % of pneumonia among new cases of under five 41%  Mobilize FCHV and VHW/MCHW effectively  Awareness raising during MGM  Early cases deduction and treatment seeking  Re-strengthening of ORC clinic 30% Aug 2012 DHO, HFs, VHW/MCHW, FCHVs  % of children treated by Cotrim during pneumonia 100%  Maintain and continue the existing program and activities Maintain Aug 2012 DHO, HFs, VHW/MCHW, FCHVs LIBON – CSSA SUNSARI Plan Nepal – LIBON 151 Indicators Measure (% or scale) Activities to be done Expected Outcome By when By Whom  % of children treated by ORS 88%  Maintain and continue the existing program and activities  Regular supply of ORS 90% Aug 2012 DHO, HFs, VHW/MCHW, FCHVs  % of pregnant women who at least 4 times visit for ANC 44%  Awareness raising through FM, mass campaign, MGM, PWG  BPP counseling during ANC  Regularize ORC and EPI session 50% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  % of mother consumed iron tablet during pregnancy at least 4 months 93%  Regular supply of Iron tablet  Awareness raising through FM, mass campaign, MGM, PWG  BPP counseling during ANC 95% Aug 2012 MoHP, DHO, HFs, VHW/MCHW, FCHVs, World Vision, Plan Nepal  CPR (Contraceptive Prevalence Rate) 50%  Regular supply of contraceptives  Awareness raising through FM, mass campaign, MGM, PWG  Counseling during ANC and PNC Maintain Aug 2012 DHO, HFs, VHW/MCHW, FCHVs, FP, MS, LIBON – CSSA SUNSARI Plan Nepal – LIBON 152 Dimension 1: Component 2: Health services Indicators Meas ure (% or scale) Activities to be done Expected Outcome By when By Whom  % of functional EPI clinic (12 months data of FY’067/68) 98%  Prompt fulfillment if vacant positions  Regular supply  Re-strengthening EPI clinic Maintain Aug 2012 MoHP, DDC, DHO, HFs, VHW/MCH W  % of mothers group meeting held in a year per FCHV 77%  Regularize the mother group meeting  Regular supply of IEC  Supportive supervision and monitoring  Regular participation of VHW/MCHW 85% Aug 2012 DHO, HFs, VHW/MCH W, FHCV  % of monthly Ilaka review meeting (12 months of FY’067/68) 100%  Continue and maintain the monthly Ilaka review meeting Maintain Aug 2012 DHO, HFs  % timely reporting 100%  Continue and maintain for timely recording report Maintain Aug 2012 DHO, HFs  % of delivery conducted by skilled birth attendant 65%  Promote institutional delivery  Counseling during ANC  Strengthening of recording and reporting system 70% Aug 2012 DHO, HFs  % of availability of essential drug 90%  Regular supply of essential drug  Coordination with central/regional level 100% Aug 2012 DHO, HFs LIBON – CSSA SUNSARI Plan Nepal – LIBON 153 Dimension 2: Component 1: Organizational Capacity Indicators Measur e (% or scale) Activities to be done Expected Outcome By when By Whom  % of monthly meeting (HFMC) 3  Regularize HFMC meeting  Coordination with community 4 Aug 2012 DHO, HFMC, HF  % of fulfill of sanctioned position of health facility of FY'67/68 95%  Coordination with central and regional level to fulfill the vacant position 98% Aug 2012 MoHP, DHO, DDC  % of HF have done public/social audit in annual basis 1  Coordinate with HFMC and community 2 Aug 2012 DHO, HFs  % of HF having the regular health program Plan 6  Maintain the existing program and activities Maintain Aug 2012 DHO, HFs Dimension 2: Component 2: Organizational Viability Indicators Measure (% or scale) Activities to be done Expected Outcome By when By Whom  Number of coordination meetings with NGO/CBO/GO by annual basis (RHCC meeting) for mutual support 50%  Regularize annual meeting  Coordination with stakeholders 60% Aug 2012 DHO, HFs, stakeholders and partners  Number of health facility who received fund from concerned VDCs and municipality 6  Maintain the existing program and activities Maintain Aug 2012 DHO and stakeholders, partners  Key stakeholders will participate in annual review/reflection session 50%  Regularize annual meeting  Coordination with stakeholders 60% Aug 2012 DHO and stakeholders, partners  Participation of children, woman, marginalized, disable people in activities against Planned 2  Involve target members for decision making and participation  Coordination with community 3 Aug 2012 DHO, HFs, community LIBON – CSSA SUNSARI Plan Nepal – LIBON 154 Dimension 3: Component 1: Community Competence/Capacity Indicators Measure (% or scale) Activities to be done Expected Outcome By when By Whom  % of community contribution (cash, kind, land etc.)* 6  Maintain coordination with community, VDC and DDC Maintain Aug 2012 DHO, HF, VDC, DDC  % of female & marginalized group members in Health Facility Management Committee* 90%  Reinforcement of existing policy and practice 95% Aug 2012 DHO, HF,  % of mothers group meeting / FCHV 77%  Regularize the mother group meeting  Regular supply of IEC  Supportive supervision and monitoring  Regular presence of VHW/MCHW 85% Aug 2012 DHO, HFs, VHW/MCHW, FHCV  % of mothers who know at least 2 danger sign during ANC 91.6%  Awareness raising through FM, mass campaign, MGM, PWG  BPP counseling during ANC and PNC  Regularize ORC and EPI session 95% Aug 2012 DHO, HFs, VHW/MCHW, FHCV, World Vision, Plan Nepal  % of mother who know at least 2 danger sign during PNC 86.7%  Awareness raising through FM, mass campaign, MGM, PWG  BPP counseling during ANC and PNC  Regularize ORC and EPI session 95% Aug 2012 DHO, HFs, VHW/MCHW, FHCV, World Vision, Plan Nepal Dimension 3: Component 2: Ecological, human, Economic, Political & Policy Indicators Measur e (% or scale) Activities to be done Expected Outcome By when By Whom  Policy on maternal and newborn health 5  Maintain the existing program and activities Maintain Aug 2012 MoHP,  Political situation 5  Maintain the existing program and activities Maintain Aug 2012 Political parties LIBON – CSSA SUNSARI Plan Nepal – LIBON 155  Female literacy rate 65.3%  Coordination with DEO 70% Aug 2012 DEO, DHO  Human Development Index 50%  Maintain the existing program and activities Maintain Aug 2012  % of mothers who received incentive during last delivery against expected pregnancy (institutional delivery) 38.8%*  Awareness raising through FM, mass campaign, MGM, PWG  Coordination with BPKHIS  Promote institutional delivery  Counseling during ANC 80% Aug 2012 DHO, BPKHIS, HFs * Excluded the institutional delivery of 8, 767 of BPKIHS (BP Koirala Institute of Health Science) among 14,339 delivery of Sunsari district Recommendation:  Regular coordination with stakeholders for annual review meeting  Strengthening of ORC/EPI clinic  Regularize mother’s group meeting  Prompt fulfillment vacant positions from the concerned departments  Include health message on other line agencies and civil society organization and involvement of local health staff  Regularize social and public audit on annual basis  Maximum involvement of marginalized group and female in decision making  Exposure visit to national and international events , trainings, meetings for selected health worker and FCHVs  Regular basis supportive supervision and monitoring from different level  Regular supply  Regular media coverage  Timely recording and reporting  Coordination with BPKHIS  Strengthening of Local Health Governance Support Program (LHGSP)  Review meeting / refresher training on CB-NCP  Increase Youth participation LIBON – CSSA BARA Plan Nepal – LIBON 156 4.9 CSSA Survey Report – Bara District (26 – 28 July, 2011) Major Findings and Results Proceedings: The three workshops on CSSA held on different dates rigorously contemplated to produce and process information and data from different sources among the participants to cover all 6 components. Participants range local self governance representatives and line ministries, district based agencies like VDCs, Municipalities, DDCs, DEO, DWO, CDO and others. The workshop team discuss, share the information at equal footing and process them to framework and dashboard then they exercise to formulate action plan and recommendations based on the information available including their valuable experiences and learning in the past. The findings and results are presented below in district base. Bara District: The three days CSSA workshop was held from 26 – 28 July 2011 in Kalaiya, Bara. The participants were representing from DHO, Municipalities, DDCs, DEO, DWO, CDO, local partner and others. They were aware on child survival evolution and sustainability assessment. After that, the participants were involved in preparing the coverage/measure of each indicator defined in last workshop in December 2009 and shared the individual dimension in the respective groups then it was finalized in the plenary session. The outcomes of each indicator support to prepare dashboard as well as spider web graphic with the help of black box. Based on the findings, team has prepared the plan of action with remarkable recommendations for further improvement and achievement in future. The major findings are in Dimension 1, component 1, Health outcome index result has decreased to 53% in 2011 compared to 63% in 2006, although it has increased to 10% from Mid Term achievement i.e. 41% in 2009; while component 2 health service index has increased to 73% in 2011 from 63% in 2006, with a difference of 11% from Mid Term achievement i.e. 62% in 2009. Similarly, Dimension 2, component 3, organizational capacity has slightly decreased to 60% in 2011 from 67% in 2006 and 63% in 2009, while achievements in components 4 and 5 namely organizational viability and community capacity have been better maintained as 54% and 76% in 2011 compared to 51% and 67% in 2006, but, there is a remarkable achievement in Dimension 3, component 6, Environmental index showing 50% in 2011 from 32% in 2006 and 21.8% in 2009. The indices of all 6 components have decreased in the Mid Term 2009 from the final survey of Child Survival (CS) project in 2006 so called initial. The reasons are drastic pullout of Plan staff members from 33 to 2 staffs and withdraw of Plan Nepal activities due to conflict after year 2006. When the situation became stable after 2009, Mid Term; the progress results became positive as shown in the survey result. LIBON – CSSA BARA Plan Nepal – LIBON 157 So, compared to the initial and the Mid Term, the results are quite encouraging. The root cause of achievement is informed planning through the visible instruments of LQAS and CSSA shown by the Dash Board and the result table. The other reasons are as follows. As pointed out in the Action Plan, problems come from transfer and delayed fulfillment of the staff members and local unfavorable political environment in decision making. So, mass level campaigns, orientations should encompass political decision makers at VDC, DDC and other relevant levels to focus on new born child and the mother. At the end of the workshop, participants make specific recommendations to improve the situation of child and mother’s health condition based on the findings and the results including their past experiences and lessons learned. Recommendations are included after action plan. LIBON – CSSA BARA Plan Nepal – LIBON 158 CSSA workshop of Bara district held on 26 to 28 July 2011 Exercise to measure value (% or scale) and its definition of scale by the Participants Dimension 1: Component 1: Health Outcomes Indicators Indicators/Definition Source of informati on Measured value (% or Scale) Score Definition of Scale (where we are using scale) Underweight Children Underweight Children < 2yrs (0-24 months) LQAS 6.0% 88.0 Exclusive Breast feeding Rate Percent of infants aged 0-5 months who were fed breastfed milk only in the last 24 hours LQAS 70.4% 55.5 Vitamin "A" Coverage Percent of Children aged 12-23 months who received a vitamin A does in the last six months LQAS 98% 96.0 Possession of vaccination Card Percent of Children aged 12-23 months who have a Vaccination Card LQAS 45% 30.1 Diarrhea prevalence Percent of children aged 0-23 months with diarrhea in the last two weeks LQAS 24% 61.3 ORT use during a Diarrhea Episode Percent of children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/ or recommended home fluids (RHF) LQAS 49% 34.1 Care-Seeking for Diarrhea Percent of Children aged 0-23 months with diarrhea in the last two weeks whose mothers Sought outside advice or treatment for the illness LQAS 98% 96.0 Maternal Hand Washing before Food Preparation before feeding /after attending to a child who has defecated Percent of mothers who usually wash their hands with soap or ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated. LQAS 62% 47.0 ARI Care - seeking Percent of Children aged 0-23 months with cough and fast / difficult breathing in the last two weeks who were taken to a health facility or LQAS 44% 29.0 LIBON – CSSA BARA Plan Nepal – LIBON 159 Indicators Indicators/Definition Source of informati on Measured value (% or Scale) Score Definition of Scale (where we are using scale) received treatment. Tetanus Toxoid Coverage Percent of mothers who received at least TWO tetanus toxoid injections (Card confirmed) before the birth of the youngest child less than 12 months of age. LQAS 10% 5.7 Iron Supplimentatio n Coverage Percent of mothers who received /brought iron supplements while pregnant with the youngest child less than 12 months of age. LQAS 86% 74.8 Delivery by skilled Health Personnel Percent of children aged 0-11 months whose delivery was attended by a skilled health personal up to MCHW level LQAS 59% 44.0 Postpartum Contact Percent of mother who had at least ONE postpartum check-up LQAS 47% 32.1 Maternal Vitamin A supplementati on Percent of mothers who received a Vitamin A dose during the first six weeks after delivery LQAS 89% 78.8 Contraceptive Use Among Mothers Who Want to limit or space births Percent of non pregnant mothers who desire no more children in the next two years or are not sure, who are using a modern method of child spacing LQAS 48% 33.1 Adequate birth interval between surviving children Percent of children aged 0-23 months who were born at least 24 months after the previous surviving child LQAS 64% 49.0 Knowledge about HIV/AIDS and STD Prevention Percent of mothers who knows at least ONE HIV/AIDS and STD prevention (MOT) LQAS 62% 47.0 Total 901.5 Average 53.03 LIBON – CSSA BARA Plan Nepal – LIBON 160 Dimension 1: Component 2: Health Services (System) Indicators Source of information Measured value (% or Scale) Score Definition of Scale (where we are using scale) Proportion of health facilities who had received at least one supervisory visit in the last 6 months HMIS 3 40.0 1. No supervision 2. Supervision at least 1 time within six months 3. #2 and regularly visit 4. #3 and as per supervision checklist 5. #4 and coaching 6. #5, supply and reporting timely Proportion of district level meeting held in the district DHO report, Meeting minute 100% 100.0 Monthly Ilaka review meeting DHO report, meeting minute 100% 100.0 Percent of HFs having monthly reporting timely DHO report 100% 100.0 Percent of HFs having availability of essential drugs for 12 months LMIS 100% 100.0 % of under 2 months sick children among under five years visited to health facilities IMCI / HMIS report DHO 1.2% 0.7 Total 440.7 Average 73.4 LIBON – CSSA BARA Plan Nepal – LIBON 161 Dimension 2: Component 3: Organization Capacity Indicators Source of information Measured value (% or Scale) Score Definition of Scale (where we are using scale) % of health facility committees formed based on national guideline DHO 90% 80 Health facility managing income and expenditure based on guideline DHO 5 80.0 1. Fund request 2. # 1 and received fund 3. # 2 and bank deposit 4. # 3 and meeting minute 5. # 4 and expenditure based on meeting decision 6. # 5 and audit / social audit Health facility with annual review/reflection and annual plan Key Informant Workshop 3 40.0 1. No plan 2. Sketchy plan without full documentation 3. Annual review/reflection and plan prepared by committee member only 4. # 3 and involving community members to some extend 5. # 4 and periodic review 6. Annual plan, periodic review involving community, groups and local organizations Community contributed cash or kind to their health facility activities Key Informant Workshop 4 60.0 1. No contribution 2. Kind contribution like land as event 3. Token contribution on ad hoc basis 4. Contribution based on community demand basis like FCHV demand for snack during annual campaign and during epidemic 5. VDC regular contribution to strengthen regular health program 6. VDC and other local resource mobilization for long term support of local health program Female community health volunteers supported by community Key Informant Workshop 2 20.0 1. No support and without mothers' group 2. Mothers' groups are meeting but irregular 3. Mothers' group are meeting regularly (at least 8 times a year) 4. # 3 and active involvement of mothers' group in health campaign LIBON – CSSA BARA Plan Nepal – LIBON 162 Indicators Source of information Measured value (% or Scale) Score Definition of Scale (where we are using scale) 5. # 4 with revolving scheme 6. # 5 with no stock out in the last year % of health facility without (essential drugs) stock out in the last year DHO report 54% 39.1 Procurement at district level is timely and district inventory is based on national guideline DHO 5 80.0 1. No procurement plan in advance 2. There is procurement plan in place 3. # 2 and there is responsible person to oversee on regular basis 4. # 3 and list of item and amount to be procured ready with distribution plan 5. # 4 and following national inventory management procedure 6. No stock out in the catchments health faculties in the last year District decision are based on the data and information (HMIS) DHO Key Informant Workshop 5 80.0 1. Never use program data for management decision and reported data use to report higher level only 2. Routine collection of data as per requirement but rarely use locally 3. Routine collection of data but only use by few people at DHO 4. Routine collection of data and use by DHO based staff only 5. Routine collection of data and supervisory information for program decision 6. # 5 and help and support local health facility staff to use their data for local decision Total 479.1 Average 59.9 LIBON – CSSA BARA Plan Nepal – LIBON 163 Dimension 2: Component 4: Organization Viability Indicators Source of information Measured value (% or Scale) Score Definition of Scale (where we are using scale) % of VDC follow approach of district health system Key Informant, Review meeting 100% 100.0 % of health facility who are mobilizing local resources i.e. VDC, local NGOs, etc Key Informant, Review meeting 75% 60.0 % of VDC who have networking and alliance with other stakeholders Key Informant Workshop 60% 45.0 Involvement of children, youth, women and disadvantaged group in health facility management committee functioning Key Informant Workshop 2 20.0 1. No involvement 2. Annual involvement of some groups only 3. Annual involvement all the groups for review and planning 4. Periodic involvement of review and planning 5. Involvement in review, planning and program implementation 6. # 5 and involvement before or during major decision of children, youth, women and disadvantaged group VDC level strategic planning and management Key Informant Workshop 3 40.0 1. No plan 2. Sketchy plan without full documentation 3. Plan prepared by committee member only 4. # 3 and involving community member to some extent 5. # 4 and periodic review and management 6. Strategic plan, annual plan, periodic review and management involving community, groups and local organizations % of VDC general assembly discussed health issue and allocate budget proportionate to other program Key Informant Workshop 75% 60.0 Total 325.0 Average 54.2 LIBON – CSSA BARA Plan Nepal – LIBON 164 Dimension 3: Component 5: Community Competence/Capacity Indicators Source of information Measured value (% or Scale) Score Definition of Scale (where we are using scale) % of community involved different group in the health program Key Informant Workshop 70% 55.1 % of VDC with functioning mothers' or interest group Key Informant Workshop 60% 45.0 % of VDC involved in national health campaign in planned way Key Informant Workshop 60% 45.0 % of mother who know at least 3 danger signs/symptoms during pregnancy LQAS 100% 100.0 % of mother who know at least 3 danger signs/symptoms of after delivery LQAS 95% 90.0 % of mother who know at least 3 danger signs of new born LQAS 99% 98.0 % of mother who know at least 3 danger signs/symptoms of pneumonia LQAS 93% 86.0 % of mother who know at least 3 danger signs of diarrhea/dysentery LQAS 95% 90.0 Total 609.1 Average 76.1 LIBON – CSSA BARA Plan Nepal – LIBON 165 Dimension 3: Component 6: Ecological, human, Economic, Political & Policy Indicators Source of information Measured value (% or Scale) Score Definition of Scale (where we are using scale) % of literacy DEO Bara Flash report 2066 60% 45.0 % of women literacy LQAS (M-1) 31% 17.8 % of landless population CBS 2058 9% 82.0 Number of times of medicine supplies disruption last year Key Informant Workshop 5 80.0 Supplies disrupted due to unrest, bandh or central problem 1. Supplies disrupted more than equal 5 times 2. Supplies disrupted more than 4 times 3. Supplies disrupted more than 3 times 4. Supplies disrupted more than twice 5. Supplies disrupted only once in a year 6. No supply disruption Decentralization plan and implementation status Key Informant Workshop 2 20.0 1. No policy 2. Policy at place but not implemented 3. Policy at place but planning to implemented 4. Policy implemented 5. Policy implemented with monitoring, evaluation and supervision 6. Policy implemented and sustained NGO desk at DDC Key Informant Workshop 4 60.0 1. No desk 2. Desk decided but not function 3. Desk function when needed 4. Desk function without any plan 5. Desk function with plan 6. Desk function with strategic plan and monitor implementation Total 304.8 Average 50.8 LIBON – CSSA BARA Plan Nepal – LIBON 166 Outcome of CS Sustainability Assessment Framework Workshop of Bara district, July 2011  Underweight Children  Exclusive Breast feeding Rate  Vitamin "A" Coverage  Possession of vaccination Card  Diarrhea prevalence  ORT use during a Diarrhea Episode  Care-Seeking for Diarrhea  Maternal Hand Washing before Food Preparation before feeding /after attending to a child who has defecated  ARI Care -seeking  Tetanus Toxoid Coverage  Iron Supplementation Coverage  Delivery by skilled Health Personnel  Postpartum Contact  Maternal Vitamin A supplementation  Contraceptive Use Among Mothers Who Want to limit or space births  Adequate birth interval between surviving children  Knowledge about HIV/AIDS and STD Prevention  Proportion of health facilities who had received at least one supervisory visit in the last 6  Proportion of district level meeting held in the district  Monthly Ilaka review meeting  Percent of HFs having monthly reporting timely  Percent of HFs having availability of essential drugs for 12 months  % of under 2 months sick children among under five years visited to health facilities  % of VDC follows approach of district health system  % of health facility who are mobilizing local resources i.e. VDC, local NGOs, etc  % of VDC who have networking and alliance with other stakeholders  Involvement of children, youth, women and disadvantaged group in health facility management committee functioning  VDC level strategic planning and management  % of VDC general assembly discussed health issue and allocate budget proportionate to other program  % of health facility committees formed based on national guideline  Health facility managing income and expenditure based on guideline  Health facility with annual review/reflection and annual plan  Community contributed cash or kind to their health facility activities  Female community health volunteers supported by community  % of health facility without (essential drugs) stock out in the last year  Procurement at district level is timely and district inventory is based on national guideline  District decision are based on the data and information (HMIS)  % of community involved different group in the health program  % of VDC with functioning mothers' or interest group  % of VDCs involved in national health campaign in planned way  % of mother who know at least 3 danger signs/symptoms during pregnancy  % of mother who know at least 3 danger signs/symptoms of after delivery  % of mother who know at least 3 danger signs of new born  % of mother who know at least 3 danger signs/symptoms of pneumonia  % of mother who know at least 3 danger signs of diarrhea/dysentery  % of literacy  % of women literacy  % of landless population  Number of times of medicine supplies disruption last year  Decentralization plan and implementation status  NGO desk at DDC LIBON – CSSA BARA Plan Nepal – LIBON 167 Dimension Component # Component Indices (Jul 2006) Indices (Dec 2009) Indices (Jul 2011) 1 1 Health Outcome index 63.0 41.5 53.0 2 Health Services index 63.1 62.1 73.4 2 3 Organizational Capacity Index 67.0 63.3 59.9 4 Organizational Viability index 51.4 33.5 54.2 3 5 Community Capacity index 76.6 44.5 76.1 6 Environmental index 32.3 21.8 50.8 Sustainability Dashboard 0 20 40 60 80 100 Health Outcome index Health Services index Organizational Capacity Index Organizational Viability index Community Capacity index Environmental index Jul_06 Dec_09 Jul_11 LIBON – CSSA BARA Plan Nepal – LIBON 168 Child Survival Sustainability Assessment (CSSA) Workshop DHO, Bara and Plan Nepal, Bara PU, LIBON project 26-28 July 2011 Action Plan C1: Health Outcome Component Current status Activities to be done Expected outcome By when By whom Remar ks Underweight Children < 2yrs (0-24 months) 6.0%  Increase awareness program through FM, mother's group, PWG, mass campaign  Increase ANC and PNC visits  Organize exhibition program  Nutrition program  Refresher trainings at district to community level 5% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of infants aged 0-5 months who were fed breastfed milk only in the last 24 hours 70.4%  Increase awareness program through FM, mother's group, PWG, mass campaign  Increase ANC and PNC visits  Promote on breastfeeding week 80% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of Children aged 12- 23 months who received a vitamin A does in the last six months 98%  Timely Supply and distribution of Vit "A" in concerned areas  Coverage of all children in the bi-annual mass campaign without fail  Increase awareness program through FM, mother's group, PWG, mass campaign 99% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of Children aged 12- 23 months who have a Vaccination Card 45%  Supply of vaccination card  Provide the message on the importance of vaccination card during ANC and PNC visit as well as EPI clinic  Increase awareness program through FM, mother's group, PWG, mass campaign  Check and verify vaccination cards during supportive supervision 60% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of children aged 0-23 months with diarrhea in the last two weeks 24%  Promote hand washing practices  Awareness on safe and pure water and hygienic food 20% Jul'12 DHO Bara Health Facility FCHV LIBON – CSSA BARA Plan Nepal – LIBON 169 Component Current status Activities to be done Expected outcome By when By whom Remar ks  Increase awareness program through FM, mother's group, PWG, mass campaign  Specific focus on marginalized groups  Promote personal and environmental hygiene program and activities NFHP-II Percent of children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/ or recommended home fluids (RHF) 49%  Regular and timely supply and distribution of ORS  ORS should be available at FCHV level  Activate for the re-functioning of ORT corners in all health facilities  Increase awareness program through FM, mother's group, PWG, mass campaign 70% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of Children aged 0-23 months with diarrhea in the last two weeks whose mothers Sought outside advice or treatment for the illness 98%  Maintain the existing activities and programs 98% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of mothers who usually wash their hands with soap or ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated. 62%  Increase awareness program through FM, mother's group, PWG, mass campaign  Provide counseling to women during ANC and PNC visit  Actively organize and conduct World Hand Washing day 80% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of Children aged 0-23 months with cough and fast / difficult breathing in the last two weeks who were taken to a health facility or received treatment. 44%  Increase awareness program through FM, mother's group, PWG, mass campaign  Re-functioning of IMCI clinic in all health facilities  Review/refresher training to FCHV with specific focused on CB-IMCI 70% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of mothers who received at least TWO tetanus toxoid injections (Card confirmed) before the birth of 10%  Supply of vaccination card  Provide the message on the importance of vaccination card during ANC and PNC visit as well as EPI clinic 60% Jul'12 DHO Bara Health Facility FCHV NFHP-II LIBON – CSSA BARA Plan Nepal – LIBON 170 Component Current status Activities to be done Expected outcome By when By whom Remar ks the youngest child less than 12 months of age.  Increase awareness program through FM, mother's group, PWG, mass campaign  Check and verify vaccination cards during supportive supervision Percent of mothers who received /brought iron supplements while pregnant with the youngest child less than 12 months of age. 86%  Supply and distribute iron tablets  Provide counseling on ANC and PNC visit  Increase awareness program through FM, mother's group, PWG, mass campaign  Promote and activate Birth Preparedness Plan package 95% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of children aged 0-11 months whose delivery was attended by a skilled health personal up to MCHW level 59%  Promote institutional delivery  Expansion of birthing centers  Full-fill vacant positions on time  Increase awareness program through FM, mother's group, PWG, mass campaign 75% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of mother who had at least ONE postpartum check￾up 47%  Provide counseling on ANC and PNC visit  Increase awareness program through FM, mother's group, PWG, mass campaign  Promote and activate Birth Preparedness Plan package 60% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of mothers who received a Vitamin A dose during the first six weeks after delivery 89%  Supply and distribution of Vit "A" in concerned areas  Provide counseling on ANC and PNC visits  Increase awareness program through FM, mother's group, PWG, mass campaign  Vit A should be available at FCHV level 95% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of non pregnant mothers who desire no more children in the next two years or are not sure, who are using a modern method of child spacing 48%  Counseling on ANC and PNC visit  Increase awareness program through FM, mother's group, PWG, mass campaign  Promote and activate Birth Preparedness Plan package  Availability of family planning contraceptives at health facilities and FCHVs 55% Jul'12 DHO Bara Health Facility FCHV NFHP-II LIBON – CSSA BARA Plan Nepal – LIBON 171 Component Current status Activities to be done Expected outcome By when By whom Remar ks Percent of children aged 0-23 months who were born at least 24 months after the previous surviving child 64%  Counseling on ANC and PNC visit  Increase awareness program through FM, mother's group, PWG, mass campaign  Promote and activate Birth Preparedness Plan package  Availability of family planning contraceptive at health facilities and FCHVs 70% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of mothers who knows at least ONE HIV/AIDS and STD prevention (MOT) 62%  Increase awareness program through FM, mother's group, PWG, mass campaign  Specific focus on marginalized group  Prepare and implement long term-plan  Increase DACC activities at all levels 75% Jul'12 DHO Bara DACC Bara Health Facility NFHP-II NGO partners DDC LIBON – CSSA BARA Plan Nepal – LIBON 172 C2: Health Services Component Current status Activities to be done Expected outcome By when By whom Remar ks Proportion of health facilities who had received at least one supervisory visit in the last 6 3  Seek additional budget for supportive supervision  Planning for supportive supervision  Develop check-list  Regular jointly supportive supervision visit  Provide onsite coaching and provide feedback and suggestion  Prepare report and utilize in regular basis 5 Jul'12 DHO Bara NFHP-II Proportion of district level meeting held in the district 100%  Maintain existing program and activities 100% Jul'12 DHO Bara Health Facility FCHV NFHP-II Monthly Ilaka review meeting 100%  Maintain existing program and activities 100% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of HFs having monthly reporting timely 100%  Maintain existing program and activities 100% Jul'12 DHO Bara Health Facility FCHV NFHP-II Percent of HFs having availability of essential drugs for 12 months 100%  Maintain existing program and activities 100% Jul'12 DHO Bara Health Facility FCHV NFHP-II % of under 2 months sick children among under five years visited to health facilities 1.2%  Increase awareness program through FM, mother's group, PWG, mass campaign  Re-functioning of IMCI clinic in all health facilities  Review/refresher training to FCHV with special focused on CB-IMCI mass campaign  Referral mechanism should be continued and maintained  Request to implement CB-NCP program in Bara district 2% Jul'12 DHO Bara Health Facility FCHV NFHP-II LIBON – CSSA BARA Plan Nepal – LIBON 173 C3: Organizational Capacity Component Current status Activities to be done Expected outcome By when By whom Remar ks % of health facility committees formed based on national guideline 90%  Advocacy during DDC monthly secretariat meeting  Advocacy DDC/VDC general assembly for local health governance strengthening program for maternal and child health 100% Jul'12 DPHO Local HF Health facility managing income and expenditure based on guideline 5  Organize regularize Social Audit and General Audit  Monitoring  Timely reporting 6 Jul'12 HF Health facility with annual review/reflection and annual plan 3  Circular for annual review and planning by DHO  Implement annual review reflection meeting and planning in each health facility  Monitoring from DHO  Advocacy during DDC/VDC general assembly for local health governance strengthening program for maternal and child health 6 Jul'12 DHO HFMC Community contributed cash or kind to their health facility activities 4  Advocacy during DDC monthly secretary meeting and DDC general Assembly along with VDC general Assembly  HFMC need to coordinate with VDC 5 Jul'12 DHO/HF Female community health volunteers supported by community 2  FCHV conduct MGM timely and regularly  Conduct MGM in the presence of VHW/MCHW and supervise MGM by local HFI and DHO supervisors regularly  Coordination with other stakeholders 4 Jul'12 DHO supervisors Stakeholders HF LIBON – CSSA BARA Plan Nepal – LIBON 174 Component Current status Activities to be done Expected outcome By when By whom Remar ks % of health facility without (essential drugs) stock out in the last year 54%  Regular supply from district store  Supportive supervision and monitoring  Authorized Stock Level (ASL)/Emergency Order Point (EOP) should be maintained by the support of HFOMC (local management)  Follow-up pull system 100% Jul'12  Store Focal Person  HF  HFOMC Procurement at district level is timely and district inventory is based on national guideline 5  Make procurement plan and follow it timely  Regular supply from district store  Supportive supervision and monitoring  Authorized Stock Level (ASL)/Emergency Order Point (EOP) should be maintained by the support of HFOMC (local management) 6 Jul'12  Store Focal Person District decision are based on the data and information (HMIS) 5  Data to be utilized and make decision based on outcomes by health facility staff  Planning and implementation to be done  Monitoring and supervision to be done  Ilaka meeting should be strengthened along with HF monthly meeting 6 Jul'12 DHO Supervisors HFIs LIBON – CSSA BARA Plan Nepal – LIBON 175 C4: Organizational Viability Component Current status Activities to be done Expected outcome By when By whom Remar ks % of VDC follow approach of district health system 100%  Maintain existing system and the ongoing activities 100% Jul'12 DHO HFI % of health facility who are mobilizing local resources i.e. VDC, local NGOs, etc 75%  Advocacy during DDC monthly secretariat meeting  Advocacy during DDC general Assembly for local health governance strengthening program for maternal and child health along with VDC general assembly  Coordination with local NGOs/CBOs 90% Jul'12 DPHO Local HF % of VDC who have networking and alliance with other stakeholders 60%  Close coordination, networking, sharing and alliance with stakeholders at VDC and District level 80% Jul'12 HFI Involvement of children, youth, women and disadvantaged group in health facility management committee functioning 2  Advocacy at national level to include youth and children and active participant  Follow national guidelines for functional health facility management committee  Monitoring and supervision 5 Jul'12 DHO HFI VDC level strategic planning and management 3  Advocacy for the strategic planning and management in DDC/VDC general assembly  Involve community people for planning and management 4 Jul'12 DHO/HFI % of VDC general assembly discussed health issue and allocate budget proportionate to other program 75%  Discuss health issue and allocate budget in proportionate to other program during VDC/DDC general assembly  Participation of health staff during planning in VDC general assembly 100% Jul'12 DHO/HFI LIBON – CSSA BARA Plan Nepal – LIBON 176 C5: Community Competency and capacity Component Current status Activities to be done Expected outcome By when By whom Remar ks % of community involved different group in the health program 70%  Cooperative Group initiation to promote health activities  Regularization of mother’s group meeting by regular monitoring of health facilities  Health education to head teacher and resource for coordination between teachers resource center and local health facilities 80% Jul'12 WCO DHO DEO % of VDC with functioning mothers' or interest group 60%  Cooperative Group initiation to promote health activities  Regularization of mother’s group meeting by regular monitoring of health facilities  Health education to head teacher and resource for coordination between teachers resource center and local health facilities 70% Jul'12 WCO DHO DEO % of VDCs involved in national health campaign in planned way 60%  Coordination with DDC to involve VDCs in national health campaigns 65% Jul'12 DHO DDC % of mother who know at least 3 danger signs/symptoms during pregnancy 100%  Health education of dangers signs/symptoms during pregnancy to Cooperative Group through the support (mother’s card) of DHO  Continue birth preparedness campaign to pregnant women, husbands, mother in laws etc. by health facility in each months  Health education of dangers signs /symptoms during pregnancy in each ward of Kalaiya municipality through the FCHV by support (mother’s card) of DHO  Health education of dangers signs/symptoms Maintain Jul'12 DHO WCO Municipality DEO LIBON – CSSA BARA Plan Nepal – LIBON 177 Component Current status Activities to be done Expected outcome By when By whom Remar ks during pregnancy in each higher secondary and secondary schools by health and population teachers through the support (mother’s card) of DHO % of mother who know at least 3 danger signs/symptoms of after delivery 95%  Health education of dangers signs/symptoms after delivery to Cooperative Group through the support (mother’s card) of DHO  Continue birth preparedness campaign to pregnant women, husbands, mother in laws etc. by health facility in each months  Health education of dangers signs /symptoms after delivery in each ward of Kalaiya municipality by FCHV through the support (mother’s card) of DHO  Health education of dangers signs/symptoms after delivery in each higher secondary and secondary schools by health and population teachers through the support (mother’s card) of DHO Maintain Jul'12 DHO WCO Municipality DEO % of mother who know at least 3 danger signs of new born 99%  Health education of dangers signs of newborn to Cooperative Group through the support (mother’s card) of DHO  Continue birth preparedness campaign to pregnant women, husbands, mother in laws etc. by health facility in each months  Health education of dangers signs of newborn in each ward of Kalaiya municipality by FCHV through the support (mother’s card) of DHO  Health education of dangers signs of newborn in each higher secondary and secondary schools by health and population teacher through the support (mother’s card) of DHO Maintain Jul'12 DHO WCO Municipality DEO LIBON – CSSA BARA Plan Nepal – LIBON 178 Component Current status Activities to be done Expected outcome By when By whom Remar ks % of mother who know at least 3 danger signs/symptoms of pneumonia 93%  Health education of dangers signs/symptoms of pneumonia to Cooperative Group through the support (mother’s card) of DHO  Continue health education session on pneumonia to pregnant women, husbands, mother in laws etc. by health facility in each months  Health education of dangers signs/symptoms of pneumonia in each ward of Kalaiya municipality by FCHV through the support of DHO  Health education of dangers signs/symptoms of pneumonia in each higher secondary and secondary schools by health and population teacher through the support of DHO Maintain Jul'12 DHO WCO Municipality DEO % of mother who know at least 3 danger signs of diarrhea/dysentery 95%  Health education of dangers signs of diarrhea to Cooperative Group through the support (mother’s card) of DHO  Continue health education sessions on danger signs of diarrhea mothers group by health facility in each months  Health education of dangers signs in each ward of Kalaiya municipality by FCHV through the support of DHO  Health education of dangers signs of diarrhea in each higher secondary and secondary schools by health and population teacher through the support of DHO Maintain Jul'12 DHO WCO Municipality DEO LIBON – CSSA BARA Plan Nepal – LIBON 179 C6: Ecological, Human, Economical Political & Policy Component Current status Activities to be done Expected outcome By when By whom Remar ks % of literacy 60%  Support literacy program by Local government (DDC), VDC, DHO, WCO, municipality ( technical support from DEO) 70% Jul'12 DEO % of women literacy 31%  Support literacy program by Local government (DDC), VDC, DHO, WCO, municipality ( technical support from DEO) 40% Jul'12 DEO % of landless population 9%  Jul'12 Political stability is needed to implemen t the policy Number of times of medicine supplies disruption last year 5  Request for medicines to RMS and LMD before stock out 6 Jul'12 DHO Decentralization plan and implementation status 2  Jul'12 Political stability is needed to implemen t the policy NGO desk at DDC 4  Coordination with DDC to activate the NGO desk at DDC 5 Jul'12 DHO Findings, Conclusions and Recommendations Plan Nepal – LIBON 180 CSSA Bara Recommendation  Implementation of Community Based Newborn Care Program (CB-NCP) for mass level coverage through orientation on CB-NCP  Implementation of Local Health Governance Strengthening (LHGS) program for community participation  Institutionalization of maternal and child health clinic and PHC/ORC clinics  Continuity of birth preparedness plan (BPP) mass campaign  Follow-up for capacity building activities of MGMs/PWGs for their stronger advocacy to local governance bodies - DDC/VDCs, Municipalities for allocation of funds for maternal and new born child health program  Linkages and networking of PWGs with PHC/ORC clinics and birth preparedness programs BPP  Joint integrated planning on mother and child health, education, livelihood for joint monitoring, supervision based on HMIS/LMIS data and information  Strengthening and continuation of monthly FCHV, Ilaka and district level review meeting  Functional working coordination, networking, sharing meetings of health related agencies such as Reproductive Health Coordination Committee (RHCC), Quality Assurance Working Group (QAWG), District AIDS Coordination Committee (DACC) at district level  Follow up for regular operationalization of drugs and inputs procurement plan as per government national guidelines for regular supply and delivery  Expansion of birthing center and family planning service sites  Promotion of satellite clinics for functional family planning methods  Promote Behavior Change Communication (BCC)/Information Education and Communication (IEC) activities  Continue Lot Quality Assurance Sampling (LQAS) and Child Survival Sustainability Assessment (CSSA) for informed sustainable planning, monitoring and evaluation. Findings, Conclusions and Recommendations Plan Nepal – LIBON 181 5. Conclusions and Recommendations: Conclusions: Overall findings, recommendations and action-plan of LQAS and CSSA in 3 LIBON districts stand valid and relevant to final evaluation findings and results for analysis and interpretation of results and information. The problems stated in the government policies and programmes are still the same in the field level. The policies and the programmes are still relevant to LIBON programme details. Tools like LQAS and CSSA used for collecting data and information for informed planning, monitoring, supervision, review and evaluation including follow up action plan and recommendations for future implementation, monitoring and evaluation proved to be eye opening means to all stakeholders mostly decision makers, implementers, supervisors, frontline functionaries in health promotion like FCHVs, VHWs, MCHW, PWGs, MGs The tools proved to be instrumental, meaningful in changing the attitude because of its transparency, accountability and responsibility of all individuals as a Team member representing institutions and agencies. The motivating, touching and mind changing factor in behaviors of stakeholders is the visibility of results in a participatory manner due to the methods and techniques adopted in LQAS and CSSA. The results achieved in all three districts as presented are quite positive and encouraging. Recommendations: As the results are positive and encouraging, but, the remaining lot of being left out, un￾reached marginalized, vulnerable groups, the DAGs are still a challenge – as the mores to cover – as their fundamental rights to health, education, livelihood, shelter and so on. So in this regard, instead of total phasing out the area, Plan Nepal should better slightly change or shift its strategy for improved mechanism with wider, open and broader participation through its initiation for integrated informed planning, monitoring and evaluation practices for the holistic development of the target communities through rights based approach to meet their fundamental rights to health, education, livelihood. So, coordinated and integrated approach at departmental, Divisional Level of line Ministries of Health, Education, Women, Child and Social Welfare, Local Development, Agriculture and Cooperative for streamlining the activities in a more synergistic and effective manner would be a favorable wining game for all stakeholders towards informed planning and gaining achievements and for ensured sustainability and continuity of benefits. It would be a cost sharing basis among the stakeholders with minimum low cost of technical inputs for coordination mechanism and informed and integrated planning, monitoring and Findings, Conclusions and Recommendations Plan Nepal – LIBON 182 evaluation for holistic development. LQAS and CSSA are meaningful tools to en-light the insight of people. It should be replicated up to VDC level – SHP level, where all relevant ministries merge together as focal target community. It is an acute need of the holistic planning and development where all human needs, requirements are met. Findings, Conclusions and Recommendations Plan Nepal – LIBON 183 Annex I Major highlights: 4.1 Government policy and programmes relevant to Plan Nepal, LIBON Project Problems, challenges, opportunities, long term vision, objectives, strategies and programmes identified as mentioned in the 3 Year Interim Plan 2007/8-2009/2010. Problems  Lack of skilled human resources and problems in their mobilization to health centers.  Centralization of general and financial administration.  Very slow pace of decentralization process.  Inadequate supply of Equipment and Drugs.  Political interference in management.  Weak supervision.  Lack of physical infrastructure and inadequate repair and maintenance of physical infrastructure. Challenges:  Delivery of equal health services to the people belonging to various cultural/gender, geographical regions and social status. Opportunities:  The Three Year Interim Constitution recognized that health is the fundamental human rights of all citizens.  Health institutions have been extended upto VDC level.(Community)  Decentralization policy implementation is underway for DDCs and VDCs.  Private sector's and NGOs involvement to a considerable extent is noteworthy. Long Term Vision: To establish appropriate conditions of quality health services delivery, accessible to all citizens, with a particular focus on the low income citizens and contribution to the improvement of health of all citizens in Nepal. Objectives: To ensure citizen's fundamental rights to have improved health services through access to quality health services without any discrimination by region, class, gender, ethnicity, religion, political belief and social and economic status keeping in view the broader context of social inclusion. The constituent elements of the objectives are:  To provide quality health service.  To ensure easy access to health services to all citizens (geographical, cultural, economic and gender)  To ensure enabling environment for utilizing available health services. Findings, Conclusions and Recommendations Plan Nepal – LIBON 184 Strategies The strategies are as bellow:  Public health promotion will be focused on through public health education.  Inter linkage between health profession education, treatment and public health services will be strengthened as part of the health sector management for making health services pro-people and efficient.  Management of human, financial and physical resources will be made more effective in order to upgrade the quality of health services being provided by the private, government and non- government sectors.  Special attention will be given to health improvement of the economically and socially disadvantaged people and communities.  A policy to deal with NGOs, the private sector, community and cooperatives will be prepared and implemented.  Decentralization process will be strengthened as integrate part of community empowerment.  Mobile health services camps with specialized services will be launched for the benefit of the marginalized, poor Adibasi Janajati the Madhesi and Muslim communities.  Free and basic health services and other health provisions will be brought into practice and in every health institution a citizens' charter will be placed in a distinctly visible manner.  Communicable disease control programs will be continued with added emphasis to the problems of drug addicts, and control of HIV/AIDS. Regular program Safer Motherhood and New-born Child Health Program  Basic obstetric care will be available at health institutions down to the level of primary health centers. The maternity services will be provided by the health posts and sub￾health posts, provided that they are equipped with necessary infrastructure and health human resources. For the Comprehensive Emergency Obstetric Care, physical infrastructure in various additional hospitals will be delivered by such hospitals. Until the skilled birth attendances are available trained health workers with general training will be further trained to provide delivery services.  Safe motherhood promotive program, life security program and skilled birth attendant program will be conducted effectively. For this, the private sectors and NGOs will also be involved.  To operate the youth Reproductive Health Service Program up to the village level, rural clinic will be strengthened by mobilizing the local bodies and other organizations. Child Health Program  Expanded program of immunization and polio eradication programs will be conducted effectively by upgrading the quality of the services. Additional effective measure for Findings, Conclusions and Recommendations Plan Nepal – LIBON 185 polio eradication will be taken up. Some new immunization campaigns like combined measles, mumps/rubell will be lunched in the selected districts.  The Community Based Integrated Management of Child Illness-CB-IMCI, will be reviewed and extended to all the 75 districts within 3 years. The quality of diarrhea and respiratory disease treatment services will be enhanced for easy increasing of access. Drug Management:  Procurement of standard quality drugs by their generic names will be done at national level from the pre-qualified suppliers. The central level will negotiate contract prices of drugs to be so procured with arrangement for the delivery of such drugs to the districts. The payment of such delivery will be done by the concerned districts. Public Health Promotive Program through Health Education:  Education, information and communication components will be included in all health programs.  All available communication media will be used for health education and communication promotion.  Education, information and communication materials will be supplied through all distribution systems of private and public health service agencies.  Local FM radio and magazines will be used for production, promotion and dissemination of health education, information and communication of local communities.  For the promotion of community participation in health improvement program, local bodies like consumer groups, mother groups' management committees and local clubs will be mobilized. Decentralization Program:  At the central level, there will be a committee of the ministries of Health, Finance, Local Development, Women, Children and Social Welfare, and the National Planning Commission.  Local health management committees will be given orientation and training.  There will be a separate unit of management in the region and department to conduct programs related to the decentralization scheme in the districts and local levels.  Progress measurement, supervision and monitoring will be conducted by the central and regional levels without any external interference.  There will be a coordination committee established from central to districts levels to make the health decentralization scheme more effective in consultation with the Ministries of Health, Finance and Local Development. In addition, a health decentralization policy will be prepared and its implementation process launched as an integral part of community empowerment. Findings, Conclusions and Recommendations Plan Nepal – LIBON 186 Urban Health Promotion:  To strengthen the health departments of municipalities, technical support will be provided.  Support for developing a mechanism to deliver health services at ward levels of the municipalities will be provided.  For the supply of safe drinking water, public toilets and sanitation, necessary support will be provided with the coordination among the concerned ministry, the private sector and NGOs. Second Long Term Health Plan-1997-2017 of the Ministry of Health and Population (MoHP)  To reduce the infant mortality rate to 34.4 per thousand live birth.  To reduce under - 5 mortality rate to 62.5 per thousand.  To reduce the total fertility rate to 3.05.  To increase life expectancy to 68.7 years.  To reduce the maternal mortality rate (MMR) to 250 per thousand births.  To increase the contraceptive prevalence rate to 58.2  To increase the percentage of deliveries attended by trained personal to 95 percent.  To increase the percentage of pregnant women attending a minimum of four antenatal visit to 80 percent.  To reduce the percentage of iron- deficiency anemia among pregnant women to 15 percent.  To reduce the percentage of women of child-bearing age (15-44) who receive TT2 to 90 percent.  To decreases the percentage of newborns weighing less than 2500 gram to 12 percent. 4.2 Overall Findings and Recommendations of CSSA in 3 LIBON districts  As described in the beginning of CSSA regarding indicative results of scale up of the program due to loss of control, reduced monitoring and supervision that may lead to decreased result values, there is a slight reduction in the outcomes of the program in Bara district due to suspension the program for few months in 2007. Plan Nepal and DHO mutually agreed that DHO will maintain the results of health outcomes and Plan Nepal will support in monitoring and reviewing of progress through the application of LQAS and CSSA that helps DHO-Bara for informed planning and monitoring of health programs related to neonatal and maternal mortality rate reduction. In this regards, indicators for Mothers Groups (MGs) and Pregnant Women’s Groups (PWGs) need to be developed and assessed for including in the indices under Dimension III, Component V and VI to maintain and sustain community competence and capacity in the community because MGs and PWGs are the base to mobilize and maintain health services as pressure groups even after the phase out of LIBON. Capacity building components to empower PWGs and MGs to advocate as their fundamental human rights to health, education, livelihood and women empowerment Findings, Conclusions and Recommendations Plan Nepal – LIBON 187 are essential tools to sustain health services for neonatal and maternal survival by enhancing organizational & institutional strength of PWGs and MGs.  Promotion, linkage, networking and alliance building of MGs and PWGs with micro finance cooperatives, agencies, and institutions are vital components for their survival and sustainability which lead to sustain and maintain basic human needs like health, education, livelihood as fundamental human rights according to basic human living condition. Micro-finance component has been internationally approved as a basic and fundamental tool to empower the powerless, discriminated and marginalized communities like the World Bank, Asian Development Bank and many donor agencies which support government and national financial institutions like Rastra Bank, Rural Micro Finance Development Center (RMDC) and others to extend support to the neediest communities in the country. Poverty Alleviation Fund (PAF) and Micro Finance Institutions (MFIs) are basic two venues suitable for long institutional development through linkage, networking and alliance building with the MGs and PWGs beyond the life span of the present mothers up to many generations to come.  Official registration of MGs and PWGs is essential for their legal status and legitimacy to claim their rights legally. So, these groups need to be promoted both as micro finance group/cooperative societies and they can be registered under Cooperative Act under the Ministry of Agriculture and Cooperative and under Social Organization Act with District Administration Office under Ministry of Home Affairs. These groups need to be federated and inter-federated at VDC, Ilaka – Supervision Area and district level. Inter-district, regional and national federation of these groups can be formed under Plan Nepal LIBON Project within its intervention period. It will facilitate for easy access to linkages, networking and alliance building with similar agencies, institutions and organizations in future for broader and wider coverage for louder voice to advocate their basic human rights apart from health services. International Human Rights Instruments like Convention on the Rights of Children (CRC), Convention on Elimination of All forms of Discrimination against Women (CEDAW), International Labor Organization ILO 169 and Minorities Rights are meant for these groups.  Regarding Dimension III & Component VI, slight decrease in indices of 3 districts from the base line indicates the urgent need to address external forces which are very vital to promote and sustain health services at the community level. These urgent needs are to increase the level of literacy of the communities and women which are very low. Landlessness of the target communities is another burning issue which is out of control of this project. To address these issues, rights based approach like fundamental human rights to education and property acquisition are vital components for integration in the program. These issues fall under Constitutional Provision as fundamental human rights of citizens. So, Inter-Ministerial and Inter￾Government Departmental networking linkages and coordination to alleviate illiteracy, poverty and mortality of children and mothers under various ministries like Ministry of Health and Population (MoHP), Ministry of Education (MoE), Ministry of Agriculture and Cooperative (MoAC), Ministry of Local Development (MoLD) and National Findings, Conclusions and Recommendations Plan Nepal – LIBON 188 Human Rights Commission (NHRC), Commission for Women, Indigenous people, Dalits, Madhesis, Muslims and the minorities including national human rights organizations - NGOs need to be promoted and integrated to address the human rights issues of the citizens focusing on MGs and PWGs from MTE onward.  Local self governance bodies like VDCs, Municipalities, DDCs are responsible agencies to promote primary health services, literacy and primary education, livelihood and basic infrastructure to address the acute basic needs of the people which fall under fundamental human rights of people. Community organizations like MGs and PWGs need to be empowered and capacitated under rights based approach to advocate their rights to ministries, departments and government as well as non governmental national human rights, local self governance bodies which are directly responsible while planning and implementing regular programs in their respective institutions like VDCs, DDCs and municipalities. Community organizations need to be informed and raised their awareness level through sensitization process regarding their fundamental rights to participation for their development in the community, Positive Discrimination provisions and special arrangements for the marginalized communities in the Interim Constitution and Three Year Interim Plan of Nepal. People fear because they are poor and powerless because they do not have information, knowledge and skill to advocate their rights to participation and development. They require organizational and institutional strength for their solidarity to advocate and put pressure on the concerned bodies, agencies, institutions for their rights and basic needs provisioned in the Constitution and the Three Year Interim Plan.  There is a need for paradigm shift from welfare model development approach to rights based development approach that ensures fundamental rights of the people to health, education, livelihood, shelter and dignity in a sustained way. Because, it is the moral obligation of higher authorities and responsibility of the government to protect fundamental human rights of people by providing basic human needs to the needy poor people.  However, the Action Plan prepared by local concerned stakeholders has indicated the above issues for improvement but still basic needs and fundamental human rights specifically rights to organizations of people to protect and defend their own rights by themselves and for themselves is much more important for their empowerment that capacitates them to put pressure on and demand for the continuation of quality health services as sustainability indicator. Microfinance activities will support PWGs & MGs for livelihood promotion that will sustain the groups to demand and advocate their rights to health, education, participation and development as a holistic development approach of poor communities. Findings, Conclusions and Recommendations Plan Nepal – LIBON 189 Annex 2: LQAS Participants: Participant name list for LQAS survey for Final Evaluation, Parsa district 3 July -14 July 2011 SN Name Organization Position 1 Chandra Kanta Lal Karna 2 Satya Narayan Yadav Sirsiya HP SAHW 3 Raghunath Chaurasiya 4 Mahesh Prasad Singh Pakaha HP PHO 5 Sashi Kant Singh Pokhariya Hospital PHI 6 Chhote Lal Langadi HP PHI 7 Bal Krishna Chaudhary Bhikhampur PHC PHO 8 Ram Bahadur Chaudhary Sedhawa HP SAHW 9 Kaushledra Mishra Nichuta HP HAO 10 Damodar Yadav Bageshwori PHC SAHW 11 Indra Dev Sah Bagahi PHC PHO 12 Ashok Raut Thori HP SAHW 13 Kameshwro Chaurasiya DPHO PHO 14 Prem Chandra jaiswal DPHO PHO 15 Phulena Prasad Sriwastav DPHO PHO 16 Uma Shankar Yadav DPHO PHO 17 Ashwini Dubedi DPHO VCO 18 Deokant Mishra DPHO EPI 19 Bhawnath Jha DPHO PH 20 Sonalal Chaurasiya Jhauwa SHP 21 Sri Ram Sah Bairiya AHW 22 Yogendra Chaurasiya 23 Saroj giri 24 Rajesh Rauniyar 25 Prabhendra Sah Auraha SHP 26 Ram Binay Gupta Shivbarba SAHW 27 Shambhu Sah Tulsibarwa SAHW 28 Basu Rimal Bahauwa SAHW 29 Bhujendra Yadav SAHW 30 Kavindra Kishor Yadav Bhawanipur SAHW 31 Newa Lal Thakur Maniyari SAHW 32 Lal Babu Prasad Prasaunibirta SAHW 33 Jagdish Singh DPHO Kharidar 34 Raj Kishor Prasad Chaudhary Plan Nepal LF 35 Ram Dev Sah Lipnibirta SAHW 36 Ramesh Mehata Surjaha SHP SAHW 37 Satrudhan Yadav Bindabasini SAHW 38 Shyam Prasad Sah Langadi HP SAHW 39 Subash Chanda Gupta Sirsiya HP AHW Findings, Conclusions and Recommendations Plan Nepal – LIBON 190 40 Devendra Sah Jagatnathpur 41 Sher Bahadur Rana Plan Nepal HC 42 Hari Bhakta Khoju RUWDES 43 Sonal lal Raut DPHO OA 44 Diwakar Mishra Plan Nepal ADLC 45 Krishna Achhami Plan Nepal ADLC 46 Ejaz Ansari Plan Nepal LF 47 Ramesh Sah 48 Bijay Sah Plan Nepal LF 49 Sajit Kumar Adhikari Plan Nepal LF 50 Krishna Dev Tiwari RYC PC 51 Rajendra Pradhan RYC 52 Arjun Bikram Hamal DPHO Acct 53 Rajendra Sah Plan Nepal LF 54 Jay Mangal Thakur Plan Nepal LF 55 Srijana Rai Plan Nepal AA 56 J. M. Pradhan DPHO Stat Ass 57 Bhagawan Das Shrestha Plan Nepal PC 58 Rajeshwar Prasad DPHO Storekeeper 59 Devnath Pokharel RHD Section Officer 60 Shashank Bajimaya NFHP Asst Field Officer 61 Prabesh Jaiswal Plan Nepal Acct 62 Yuwaraj KC TTV 63 Ghanshyam Chaudhary Plan Nepal ICO 64 Sarita Singh DPHO PHO Findings, Conclusions and Recommendations Plan Nepal – LIBON 191 Participant name list for LQAS survey for Final Evaluation, Sunsari district 27 May - 9 Jun 2011 SN Name Designation Organisation Remarks 1 Ram Dhan Mehta ARD ERHD 2 Indra Narayan Das DHO DHO 3 Shiv Narayan Yadav PHI DHO 4 Ram Charitra Mehta HA DHO 5 Sonelal Yadav SAHW Satterjhora PHC 6 Bijay Guragain DHO 7 Ram Babu Shrestha SAHW Sitaganj HP 8 Khadga Singh Chouhan HPI Bhutaha HP 9 Devendra Pokharel PHI Chatara PHC 10 Harideo Thakur SAHW Baklauri HP 11 Urmila Budhathoki HEO DHO 12 Sulochana Chaudhary HA DHO 13 Sitaram Gupta HA Madheli HP 14 Maiya Sanjel PHN DHO 15 Karuna Timsina Staff Nurse Itahari PHC 16 Prem Kumar Das VCS DHO 17 Amol Narayan Chaudhary CCS DHO 18 Bal Bahadur Basnet FPO DHO 19 Kameshwor Jha MRO DHO 20 Bhuban Kumar Bhandari CO DHO 21 Md. Shamim Ansari PHO Madhuwan PHC 22 Shivan Thakur VCO DHO 23 Ramesh Kumar Shah HA Prakashpur HP 24 Mahesh K Yadav DEC ERHD 25 Madhav Lal Deo PHO Harinagara PHC 26 Rameshwor Sah PHO Dewanganj HP 27 Kapleshwar Prasad Shah EPIS officer DHO 28 Indra Mani Pokharel SAHW Dharan SHP 29 Raj Narayan Mandal PHI DHO 30 Shiv Dayal Mehta PHO DHO 31 Ram Charan Chaudhary PHO Itahari PHC 32 Pramila Rai MPH Student BPKHIS 33 Pooja Pant MPH KHS College, Brt 34 Krishna Dev Tiwari PC RYC 35 Sita Kumari Sah PWGF RYC 36 Rajendra Shrestha RYC 37 Hari Dev Shah ADC Plan Nepal 38 Rajendra Pd. Sah LIBON facilitator Plan Nepal Findings, Conclusions and Recommendations Plan Nepal – LIBON 192 39 Yam Bahadur Thapa LIBON facilitator Plan Nepal 40 Premchandra Pd. Jayswal LIBON facilitator Plan Nepal 41 Bijay Kumar Sah LIBON facilitator Plan Nepal 42 Kalawati Changbang HPC Plan Nepal 43 Dipak Dahal M&E Officer Plan Nepal Faciliator Participant name list for LQAS survey for Final Evaluation, Bara district 22 Jun 2011 to 1 July 2011 Sn Name Organization Position Remarks 1 Amaleshwor Mishra DHO,Bara PHO 2 Anil Kumar Mishra DHO,Bara F.P.N 3 Ashok Jaiswal Simara PHC HA 4 Babu Lal Swarnakar Haraiya HP P.H.O 5 Bal chand Prasad Bhodaha HP Sr.AHW 6 Balmaya Ghale NFHP II F.O 7 Bhagawan Das Shrestha Plan Nepal PC-LIBON 8 Bijay Kumar Sah Plan Nepal L.F 9 Deepak kumar Neupane Parsauni HP Sr.AHW 10 Dipak Dahal Plan Nepal M&EO Facilitator 11 Diwakar Mishra Plan Nepal ADLC 12 Dr. Surendra pd. Chaudhary DHO ,Bara DHO 13 Jagannath pd. Jaiswal DHO,Bara PHI 14 Jagannath pd. Jaiswal Ganjbhawanipur HA 15 Kaushal Kishor Jha DHO,Bara 16 Kishori prasad Chaudhary Gadhal HP PHI 17 Krishna Dev Tiwari RYC,Sunsari P.C 18 Md. Sabir DHO,Bara PHO 19 Nathuni Mishra RYC CMA 20 Punit prasad Chaudhary Rampur HP Sr.AHW 21 Raj Kishore pd. Chaudhary Plan Nepal LF 22 Raj Kishore Prasad Rampur HP PHO 23 Rajendra pd. Sah Plan Nepal LF 24 Rajendra Pradhan RYC 25 Ram Binehi Yadav DHO,Bara D.T.L.O 26 Ram Naresh Yadav DHO,Bara S.O 27 Ramesh Sah 28 Rameshwor pd. Sharma Feta HP Sr.AHW 29 Roop Narayan pd. Yadav Bariyarpur PHO 30 Sabir Ojha RYC 31 Sandip Kushwaha NFHP II 32 Shankar pd. Gupta DHO,Bara V.C.I 33 Sher Bd. Rana Plan Nepal HC 34 Sunil Kumar sriwastav DHO,Bara ISO 35 Suresh Kumar Shah Hardiya PHC Sr.AHW Findings, Conclusions and Recommendations Plan Nepal – LIBON 193 36 Sursen pd. Chaudhary Simraungad HP PHO 37 Tej Narayan Singh DHO,Bara V.C.I 38 Tulsi pd. Mahato Chiutaha PHO 39 Vijay Kumar Paswan Kabhigoth HA 40 Yam Bdr. Thapa Plan Nepal LF 41 Yogendra Shah Nijgad PHC HA CSSA Participants: Participant name list for CSSA workshop of Parsa district from 1 to 3 Aug 2011 SN Name Organization Position Remarks 1 Bachu Lal Chaudhary DEO SO 2 Binod Mehta NRCS PC 3 Shiv Raj P Mahto NGOCC FO 4 Kameshwor Pd Chaurasiya DPHO PHO 5 Deo Kant Mishra DPHO EPIO 6 Proful Mishra DPHO CCA 7 Raj Kumar Mishra DPHO LA 8 Kishor Giri DPHO CO 9 JM Pradhan DPHO 10 Ram Lochan Mukhiya DPHO 11 Gyanendra Kumar Singh DPHO SO 12 Savitri Kumari Bhandari DCWB CO 13 Hari Bhakta Khoju Plan Nepal Consultant 14 Reeta Lamichhane NFHP-II Officer 15 Khusbu Mishra DPHO Staff Nurse 16 Ram Bishwas Sah DPHO Lab Tech 17 Phulena Pd. Shrivastav DPHO PHI 18 Anil Kumar DPHO OA 19 Bhawnath Jha DPHO PHO 20 Inarjit Pd. Chaurasiya NSRH OA 21 Srijana Rai Plan Nepal AA 22 Krishan Bahadur Achhami Plan Nepal ADLC 23 Sajit Kumar Adhikari Plan Nepal LF 24 Dipak Dahal Plan Nepal M&EO Facilitator 25 Deo Ratna Chaudhary Plan Nepal DLC 26 Sumitra Lama DPHO SO 27 Sumita Dhakal DPHO SN 28 Urbara Luitel WCO WDO 29 Bhagawan Das Shrestha Plan Nepal PC LIBON 30 Ashwini Kumar Dwivedi DPHO VCO 31 Sher Bahadur Rana Plan Nepal HC 3rd day only 31 Deepak Poudel USAID 3rd day only 32 Ann Mc Cauley USAID 3rd day only Findings, Conclusions and Recommendations Plan Nepal – LIBON 194 Participant name list for CSSA workshop of Sunsari district from 9 to 11 Aug 2011 SN Name Organization Remarks 1 Dr. I. N. Das DHO, Sunsari Partially 2 Sone Lal Yadav Satejhora PHC 3 Devendra Pokharel Chatra PHC 4 Ranjhana Pokharel WCCO 5 Maya Rai DDC 6 Gita Subedi (Nepal) Inarwa Municipality 7 Rameshwor Sah Dewangunj HP 8 Samim Ansari Madhuwan PHC 9 Ram Babu Shrestha Sitagunj HP 10 Sita Ram Gupta Madheli HP 11 Madhav Lal Deo Harinagara PHC 12 Prakash Adhikari DHO, Sunsari 13 Puspa Bhattarai NGOCC 14 Kapaleshwor Prasad Sah DHO, Sunsari 15 Haridev Thakur Baklauri HP 16 Urmila Budhathoki DHO, Sunsari 17 Ramesh Kumar Sah Prakashpur HP 18 Amol Narayan Chaudhary DHO, Sunsari 19 Sudhir Kumar Mehata Inarwa HP 20 Bal Bahadur Basnet DHO, Sunsari 21 Khadga Singh Chauhan Bhutaha HP 22 Bhuwan Bhandari DHO, Sunsari 23 Kameshwor Jha DHO, Sunsari 24 Bijaya Kumar Sah Plan Nepal 25 Sulochana Chaudhary DHO, Sunsari 26 Hari Bhakta Khoju Plan Nepal 27 Kedar Koirala NFHS 28 Bijaya Guragain DHO, Sunsari 29 Ramesh Kumar Yadav Youth Kriyasan S. S 30 Shanti Limbu World Vision 31 Shiv Dayal Mehato DHO, Sunsari 32 Ram Chanrand Chaudhary DHO, Sunsari 33 Shanti Ram Niraula DHO, Sunsari 34 Kisan Karki DHO, Sunsari 35 Shiv Narayan Yadav DHO, Sunsari 36 Maya Sanjel DHO, Sunsari 37 Rajendra Pd. Sah Plan Nepal 38 Yam Bahadur Thapa Plan Nepal 39 Prem Chandra Pd Jaiswal Plan Nepal 40 Kalawati Changbang Plan Nepal 41 Dipak Dahal Plan Nepal Facilitator 42 Bhagawan Das Shrestha Plan Nepal Findings, Conclusions and Recommendations Plan Nepal – LIBON 195 43 Hari Dev Shah Plan Nepal 44 Yogesh Niraula Plan Nepal Partially 45 Sher Bahadur Rana Plan Nepal Partially 46 Shankar Joshi Child Health Division Partially 47 Narayan Khadka ERHD Partially Participant list - CSSA workshop, Bara district from 26 to 28 July 2011 SN Name Position Organization Remarks 1 Basanta Kumar Upadhayay CDO DAO 2 Krishna Pd. Yadav CPO DCWB, Bara 3 Ashok Rauniyar SS DEO 4 Mohammad Sabir DPHO DHO Bara 5 Sunil Kumar Shrevastav IJO DHO Bara 6 Amleshwor Mishra PHO DHO Bara 7 Jhagru Prasad Yadav Storekeeper DHO Bara 8 Ram Binehi Yadav DTLO DHO Bara 9 Dipendra Tiwari DACW DHO Bara 10 Ram Naresh Yadav SO DHO Bara 11 Jagannath Prasad Jaiswal PHI DHO Bara 12 Jagat Kumar Singh Accontant DHO Bara 13 Ram Raja Dhungana OA DHO Bara 14 Krishna Pd. Yadav CPO DCWB, Bara 15 Ashok Rauniyar SS DEO 16 Sujit Aryal Reporter Kripa Daily 17 Punti Kumari Chaudhary M&EO Mahila Tatha Bal Bikas 18 Brij Bhusan Singh Assistant Kalaiya Municipality 19 Sandeep Kushwaha CHA NFHP-II 20 Madan Raj Thapa IM NFHP-II 21 Renu Kumari Ray CHA NFHP-II 22 Bhagawan Das Shrestha PC Plan Nepal 23 Raj Kishor Pd. Chaudhary LF Plan Nepal 24 Diwakar Mishra ADLC Plan Nepal 25 Hari Bhakta Khoju Consultant Plan Nepal 26 Deo Ratna Chaudhary DLC Plan Nepal 27 Dipak Dahal M&EO Plan Nepal Facilitator 28 Prajwal Khatiwada DC Plan Nepal 29 Srijana Rai OA Plan Nepal Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 1 - Annex 7: Nepal LIBON Project - CHW Training Matrix Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status 1 Kathmandu district National Level Master Training of Trainers (MTOT) on CB-NCP 7 days Government Paid Aug 08 25 Training on technical skill of newborn care & management of danger signs and recording reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight  Completed  The training was funded by UNICEF Nepal with coordinati on with CHD, SC, Plan, Care etc 2 Sunsari and Parsa districts Planning meeting at district level/program orientation for CB-NCP 2 days Government Paid Sept 08 77 CB-NCP administrative orientation  Completed 3 Sunsari and Parsa districts District Training of Trainers (DTOT) on 7 days Government Paid Sept 08 39 Training on technical skill of newborn care & management of  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 2 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status CB-NCP danger signs and recording reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight 4 Sunsari and Parsa districts Health Facility (HF) Ilaka level training on CB-NCP 7 days Government Paid Oct 08 – Jan 09, Oct-Dec 09 and Sep’11 390 Training on technical skill of newborn care & management of danger signs and recording reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight  Completed 5 Sunsari and Parsa districts VHW/MCHW – SHP level training on CB-NCP 6 days Government Paid Apr-Jun 09 Jan-Mar 10 235 Training on technical skill of newborn care & management of danger signs and recording  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 3 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight 6 Sunsari and Parsa districts Basic training to FCHVs on CB-NCP 7 days CHW Volunteer Oct 08 – Jan 09 Oct-Dec10 1,962 Training on technical skill of newborn care & management of danger signs and recording reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight  Completed 7 Sunsari and Parsa districts Orientation to traditional healer on CB￾NCP 1 day CHW Volunteer Sep’10 – Feb’11 364 Orientation on CB-NCP program  Completed 8 Sunsari and Parsa districts Follow-up after training on CB-NCP 11 days Government , CHW and partner Paid and Volunteer Oct￾Dec’10 483 Training on technical skill of newborn care & management of  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 4 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status danger signs and recording reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight 9 Sunsari and Parsa districts CB-NCP software 2 days Government Paid Jun & Dec’10 22 Training on technical skill to update CB-NCP data into developed software  Completed 10 Sunsari district Regional ToT on CB-NCP 7 days Government and partner Paid Feb 2009 24 Training on technical skill of newborn care & management of danger signs and recording reporting, for:  Infection  Hypothermia  Birth asphyxia  Low birth weight  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 5 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status 11 Sunsari and Parsa districts PWG training 2 days Government and CHW Paid and FCHV volunteer Jul’08 to Jun’09 2,185 Training focus on demand, service and know about danger sign during pregnancy, delivery, postnatal and newborn  Completed 12 Kathmandu district LQAS training to IOM student, Kathmandu 4 days Student Volunteer Sep & Dec’08 87 Training focus on survey technique; data collection through selection community, household and respondent as well as data hand tabulation and analysis  Completed 13 Kathmandu district LQAS orientation to IOM faculty member, Kathmandu 4 days Partner Paid Sep’08 17 Training focus on survey technique; data collection through selection community, household and respondent as well as data hand tabulation and  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 6 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status analysis 14 Kathmandu district LQAS Master TOT 5 days Government and Partner Paid Jan’08 25 Training focus on survey technique; data collection through selection community, household and respondent as well as data hand tabulation and analysis  Completed 15 Bara, Parsa and Sunsari district LQAS training 4 days Government and Partner Paid Jan’08, Feb’08, Dec’09 to Feb’10 and May￾Aug’11 384 Training focus on survey technique; data collection through selection community, household and respondent as well as data hand tabulation and analysis  Completed 16 Bara, Parsa and Sunsari district CSSA workshop 3 days Government, stakeholder and Partner Paid May’08, Aug’08, Dec’09 to Mar’10 and Jul to 319 Workshop on how to program sustainable after project completion and developed  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 7 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status Aug’11 action plan 17 Sunsari district Rapid Health Facility Assessment 9 days Government, stakeholder and Partner Paid Feb’10 21 Training focus on survey technique for health facilities assessment  Completed 18 Parsa district Orientation on Chlorhexidine (CHX) 1 day Government, stakeholder and Partner Paid Oct’09 20 Orientation for use of CHX in umbilical stump of newborn baby  Completed 19 Parsa district CHX training to Hospital staff 1 day Government Paid Nov’09 92 Training for apply of CHX in umbilical stump of newborn baby within 1 or 2 hours  Completed 20 Parsa district CHX training to district and HF staff 1 day Government Paid Oct’09 & Jan’10 122 Training for apply of CHX in umbilical stump of newborn baby within 1 or 2 hours  Completed 21 Parsa district CHX training to VHW/MCHW 1 day Government Paid Nov & Dec’09 132 Training for apply of CHX in umbilical stump of newborn baby within 1 or 2 hours  Completed 22 Parsa CHX training 1 day CHW Volunteer Jan to 738 Training for apply  Completed Annex 7 -- Nepal LIBON CHW Training Matrix.doc - 8 - Project Area (Name of district or community) Type of Training Duration Official Government, CHW and Partner Paid or Volunteer Planning Scheduled Date Number of Trained Focus of Training Status district to FCHV Jun’10 of CHX in umbilical stump of newborn baby within 1 or 2 hours Annex 8 Nepal LIBON Project – Evaluation Team Members Annex 8: Nepal LIBON Project - Evaluation Team Organization Name of Member Titles External Consultant Dr. Mahesh K Maskey Team Leader FHD – MoHP Mangala Manandhar Sr. Public Health Officer ERHD - MoHP Ram Dhan Mehata Regional Director DHO Sunsari Dr. Shree Ram Sah District Health Officer Shiv Narayan Yadav Public Health Officer DPHO Parsa Indra Dev Yadav District Public Health Officer Phulena Shreevastav Public Health Officer DHO Bara Md. Sabir District Public Health Officer Amleshwor Mishra Public Health Officer USAID local mission Narmaya Limbu AID Development Program Management Specialist Care Nepal Shanti Thakali Field Officer Plan USA Harpreet Anand Program Development Manager Plan NCO Sher Bahadur Rana Health Coordinator Bhagawan Das Shrestha Project Coordinator - LIBON Plan Sunsari PU Yogesh Niraula Acting Program Unit Manager Kalawati Changbang Health Program Coordinator Hari Dev Shah Assistant District LIBON Coordinator Plan Bara PU Deo Ratna Chaudhary District LIBON Coordinator Krishna Bahadur Achhami Assistant District LIBON Coordinator Diwakar Mishra Assistant District LIBON Coordinator Dipak Dahal Monitoring and Evaluation Officer Community (FCHVs) Januka Chaudhary – Sunsari Community Volunteer Naina Devi Sah – Parsa Community Volunteer Kausaliya Devi Chaudhary - Bara Community Volunteer Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 1 - Annex 9: Nepal LIBON Project - Evaluation Assessment Methodology Plan Nepal Terms of Reference for the Consultant for Final Evaluation of Local Innovation for Better Outcomes for Neonates (LIBON) Project and Chlorhexidine Operational Research 1. Introduction Plan is a child-centered community development organization without religious, political or governmental affiliation. Plan' vision is of a world in which all children realize their full potentials in societies, which respect people's rights and dignity. Child sponsorship is the basic foundation of the organization. USAID Child Survival and Health Grant awarded Plan Nepal to implement Local Innovation for Better Outcomes for Neonates (LIBON) Project in Bara, Parsa and Sunsari districts jointly with the Ministry of Health and Population (MoHP) and other collaborating organizations in Nepal. The duration of the LIBON project is from 30 September 2007 to 29 September 2011. The goal of the project is to sustainably reduce the burden of neonatal mortality in Nepal. This goal will be achieved through the implementation of the following results: Result 1: Increased Access to NNH (neonatal health) Services in Parsa Result 2: Increased Demand for NNH Services in Parsa Result 3: Increased Quality of NNH Services in Parsa Result 4: Strengthened support for NNM (neonatal mortality) reduction in Nepal The following strategies inform the LIBON program design:  Community Based Service Delivery  Community Mobilization  Health Systems Strengthening  Stakeholder Sharing and Collaboration  Social Inclusion 2. Scope of Work Qualitative evaluation as a part of final evaluation of the LIBON project as well as final evaluation of chlorhexidine operational research in Parsa will be done in September 2011. The external consultant selected from USNO with concurrence from USAID Headquarters will complete this task. Local consultants will collect the quantitative information of Sunsari, Parsa and Bara districts for final evaluation and CHX ops research (in Parsa only) from May 2011 to August 2011 through Lot Quality Assurance Survey (LQAS) technique and Child Survival Sustainability Assessment (CSSA) framework workshop. The surveys and CSSA workshop will Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 2 - be held in Sunsari, Parsa and Bara (May 2011 – Aug 2011). S/he will prepare reports of LQAS and CSSA. The reports will be provided to the external consultant for further analysis and references. The external consultant will collect qualitative information through interaction with different key personnel, groups, stakeholders at national, districts and community levels as a means to triangulate the quantitative information. The outcome of quantitative and qualitative information will be de-briefed and shared with Plan Nepal staff and stakeholder’s representative at national level. Finally, the external consultant will prepare the final evaluation report based on attached USAID guideline and will submit to USNO for finalization. 3. Tentative work plan for FE of external consultant (LIBON and CHX ops research) Activities Tentative Date and Venue # of days Remarks Review project documents Team planning meetings with key PVO and partner staff to explain the purpose of the evaluation, and with the evaluation team to organize specific activities Sept 8-9, 2011 Meeting with Plan Nepal CMT and concern staff (Meeting with CHD/ FHD/ DoHS/ SC / USAID Local Mission/ NFHP etc.) Prepare for quantitative information tools 2 days Field work and data collection: site visits and interviews (key informants and/or focus groups) Sept 10-18, 2012 Field visit in Bara, Parsa and Sunsari districts – LIBON site 9 days Sep 10-12 Sunsari Bara/Parsa: Sept 13-18 In-country debriefing preparation and drafting report Sept 19-22, 2011 (Mon-Thu) Preparation of draft report and presentation 4 days In-country FE finding sharing to all the stakeholders of Nepal Sept 23, 2011 Fri (Asoj 6) Findings of FE share with stakeholders, partners 1 day Drafting and finalizing report. Sept 24-29, 2011 Prepare final report and submit to USNO 5 days TOTAL DAYS 21 Days 4. Professional skill and experience Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 3 -  5-7 years of professional skills and knowledge on child survival project monitoring and evaluation and operational research  Practical experience conducting quantitative and qualitative research  Professional work experience in evaluating USAID funded child survival project  Excellent analytical and report writing skills  Proficiency of evaluation methods  Good communication and facilitation skills  Fluency in English  Advanced university degree in public health and related field  Knowledge of the country and regional context is an asse Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 4 - Qualitative study methodology  Review of key documents  Lot Quality Assurance Sampling (LQAS) report  Child Survival Sustainability Assessment (CSSA) report  USAID guidelines for Final Evaluation  Details Implementation Plan (DIP)  Mid-term Evaluation report  Annual reports  Chlorhexidine (CHX) report  Team planning meeting with key project staff  Development of tools for FGD and IDI for key beneficiaries and stakeholder groups  Debriefing and feedback on tools from Country Management Team (CMT)  Field work for data collection – 3 districts (Sunsari, Parsa and Bara)  Preparation debriefing presentation (including quantitative and qualitative information) to national stakeholders  Drafting and finalization of report Data collection tools:  PWG (FGD) – 2 per district  Mothers-in-law (FGD) – 2 per district  Husband (FGD) – 2 per district  FCHV (IDI) – 2 per district  Health facility in-charge (IDI) – 2 per district  DHO/DPHO (IDI) – 1 per district Data collection timeline:  Sunsari: 10 – 12 September 2011  Bara: 13 – 15 September 2011  Parsa: 16 – 18 September 2011  3 days per district (first of each day for field visit and data collection; second half of the day for debriefing between team members and data quality check)  One team per FGD or IDI and for consistency purposes; the team leader/facilitator for each session remained the same  Informed verbal consent prior to initiating each interview/FGD  Based on experience from the field, we separated the mother’s in law and husband groups into two separate FGDs in an attempt to increase male participants in the FGD Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 5 - Visited place in Sunsari district Sonapur – Sub health post Chimdi – Sub health post Community supported birthing center Government supported birthing center Marginalized “Dalit” community Muslim community Musahar ward has pregnant women group Muslim ward has pregnant women group CB-NCP program CB-NCP program No Chlorhexidine (CHX) No Chlorhexidine Visited place in Parsa district Madhuwan Mathaol – Sub health post Bindabasini – Sub health post Community supported birthing center No birthing center Mixed community Marginalized community No pregnant women group Bindabasini ward has pregnant women group CB-NCP program CB-NCP program Chlorhexidine Chlorhexidine Visited place in Bara district Chhatapipara – Sub health post Karaiya – Sub health post No birthing center nearby (closest is 15 minute drive) No birthing center nearby (closest in Birgunj or Kalaiya) Mixed community Mixed community Pregnant women group Pregnant women group No CB-NCP No CB-NCP No CHX No CHX Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 6 - FGD for decision maker (recently delivered mother’s husband and mother-in-law) Plan Nepal, LIBON Project, Final Evaluation, September 2011 District: __________________ VDC: _____________________________ Name of Village_______________________, Ward no: _______ Interview date: __________________ Name of facilitator:______________________ Name of note taker(s):________________________ Greeting, introduction and verbal consent! You may be aware that the Plan Nepal, LIBON project has provided financial and technical support to District (Public) Health Office to implement Community Based Newborn Care Program (CB-NCP) in this community. Its objective is to improve neonatal and maternal health. We are here for gathering your opinion about the achievement and constraints of the program. This will enable us to disseminate good practices and also improve upon the strategies that did not work, in our future program. This will be a confidential discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one hour. It is your right to participate or not to participate in the discussion ………………, if we have your permission to proceed then we can start discussion. Topic for FGD 1. I understand that there are different kinds of groups in your ward. Which are the most common groups in which pregnant women participate? 2. What does it mean for you to be in this kind of group? (Need probe) 3. What topics are discussed in this group meeting? What are the activities of this group?  Did you get support from your mother-in-law / husband to come in the meeting? 4. Have you heard about Community Based Newborn Care Program (CB-NCP)? 5. What is the status of maternal and neonatal health services? (Need probe)  Before and after implementation of CB-NCP program.  Maternal and newborn care practices before and after CB-NCP program 6. Is PWG useful? If yes, why? How it helps to utilize maternal and neonatal health services? 7. What are the factors that contributed to its utilization (better and under utilization)? (Need probe behavior mapping and self monitoring “Tika”) 8. Do you know about Birth Preparedness Plan (BPP)? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 7 - 9. Did you make a BPP? How did you know about it? 10. Did you make public commitments on utilization of maternal health services? If yes, what is your opinion on this? 11. Have your daughter-in-law / wife ever antenatal check-up during pregnancy? If yes, how many times? If not or less than 4 times, why? 12. Where did your daughter-in-law / wife deliver and why? (need probe for incentive) 13. If delivery at home, who did it? 14. Did daughter-in-law / wife have postnatal check-up for yourself and newborn? If not, what are the reason/factors? Only for Parsa district 15. Do you hear about Kawach (Chlorhexidine)? If yes, did your newborn get Kawach (Chlorhexidine)? If not applied Kawach (Chlorhexidine), why? 16. What is your opinion on Kawach (Chlorhexidine) application to newborn umbilical stump? Advantage and disadvantage? Thank you!! Note: Participant list will be listed in separate page Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 8 - FGD for mothers’ group (recently delivered mother / pregnant women) Plan Nepal, LIBON Project, Final Evaluation, September 2011 District: __________________ VDC: _____________________________ Name of Village_______________________, Ward no: _______ Interview date: __________________ Name of facilitator:______________________ Name of note taker(s):________________________ Greeting, introduction and verbal consent! You may be aware that the Plan Nepal, LIBON project has provided financial and technical support to District (Public) Health Office to implement Community Based Newborn Care Program (CB-NCP) in this community. Its objective is to improve neonatal and maternal health. We are here for gathering your opinion about the achievement and constraints of the program. This will enable us to disseminate good practices and also improve upon the strategies that did not work, in our future program. This will be a confidential discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one hour. It is your right to participate or not to participate in the discussion ………………, if we have your permission to proceed then we can start discussion. Topic for FGD 17. Are you a member of mothers’ group / pregnant women group (PWG)? 18. What does it mean for you to be in this kind of group? (Need probe) 19. What topics are discussed in this group meeting? What are the activities of this group?  Did you get support from your mother-in-law / husband to come in the meeting? 20. Have you heard about Community Based Newborn Care Program (CB-NCP)? 21. What is the status of maternal and neonatal health services? (Need probe)  Before and after implementation of CB-NCP program.  Maternal and newborn care practices before and after CB-NCP program 22. Is PWG useful? If yes, why? How it helps to utilize maternal and neonatal health services? 23. What are the factors that contributed to its utilization (better and under utilization)? (Need probe behavior mapping and self monitoring “Tika”) 24. Do you know about Birth Preparedness Plan (BPP)? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 9 - 25. Did you make a BPP? How did you know about it? 26. Did you make public commitments on utilization of maternal health services? If yes, what is your opinion on this? 27. Have you ever antenatal check-up during pregnancy? If yes, how many times? If not or less than 4 times, why? 28. Where did you deliver and why? (need probe for incentive) 29. If delivery at home, who did it? 30. Did you have postnatal check-up for yourself and newborn? If not, what are the reason/factors? Only for Parsa district 31. Do you hear about Kawach (Chlorhexidine)? If yes, did your newborn get Kawach (Chlorhexidine)? If not applied Kawach (Chlorhexidine), why? 32. What is your opinion on Kawach (Chlorhexidine) application to newborn umbilical stump? Advantage and disadvantage? Thank you!! Note: Participant list will be listed in separate page Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 10 - In Depth Interview Guideline for Health Facility In-charge Plan Nepal, LIBON Project, Final Evaluation, September 2011 District: __________________ VDC: _____________________________ Type of health facility___________________, Ward no: _______ Interview date: _______________ Name of facilitator:______________________ Name of note taker:________________________ Greeting, introduction and verbal consent! You may be aware that the Plan Nepal, LIBON project has provided financial and technical support to District (Public) Health Office to implement Community Based Newborn Care Program (CB-NCP) in this community. Its objective is to improve neonatal and maternal health. We are here for gathering your opinion about the achievement and constraints of the program. This will enable us to disseminate good practices and also improve upon the strategies that did not work, in our future program. This will be a confidential discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one hour. It is your right to participate or not to participate in the discussion ………………, if we have your permission to proceed then we can start discussion. 1. Are you aware of CB-NCP program being implemented in your Ilaka? 2. What has been your role in promoting maternal and newborn health (MNH) in your area? Please describe. 3. What is the support you receive from the higher facility or supervisors in implementing your activities in relation to CB-NCP? Probe for how often is the guidance received? How does the support being received now compare to the support received four years ago? 4. How do you compare the skills and capacities of the facility and its workers in addressing neonatal, child and mother health issues to that prevalent four years ago? 5. What are some of the additional skills and capacities still required to deal with MNH issues? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 11 - 6. What is your relationship with the FCHVs? What role do they perform and how does this differ from your role? 7. Are you a participant in the HFMOC? Please describe its activities and some achievements. Please also identify some of the areas which could not be addressed successfully by the HFMOC. 8. How many mothers groups / pregnant women group are there in your coverage area? How often do you get to interact with them? Do you think the mothers will continue to be grouped after the project staff stops visiting the communities? What can be done to sustain them? 9. What materials has the project provided to generate awareness and change behavior? Do you have some of these with you? Which tool did you think worked the best? Which will you use once the project comes to an end? 10. How do you compare the way care is being provided in your health facilities now to four years ago? What are the additional changes required to completely address MNH issues. 11. How has the availability of essential drugs and equipment to your health functionaries changed in the last four years? If it has improved then do you think it will continue to remain following the closure of the project? 12. What are some of the contributions of the CB-NCP program/successes? (look for community perception about public health services, community behaviors, health outcomes, access to marginalized communities, community empowerment), Please give us some specific examples 13. What are some of the areas which could have been dealt with more effectively? 14. Now that the project has come to an end what are some of the activities which a) Will be continued and who will support it b) Will not be continued 15. Any other comments Only for Parsa district 33. What is your opinion on Kawach (Chlorhexidine) application to newborn umbilical stump? Advantage and disadvantage? Thank you indeed for your insightful remarks. Note: Participant list will be listed in separate page Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 12 - In Depth Interview Guideline for District (Public) Health Office staff Plan Nepal, LIBON Project, Final Evaluation, September 2011 District: __________________ Interview date: _______________ Name of facilitator:______________________ Name of note taker(s):________________________ Greeting, introduction and verbal consent! You may be aware that the Plan Nepal, LIBON project has provided financial and technical support to District (Public) Health Office to implement Community Based Newborn Care Program (CB-NCP) in this community. Its objective is to improve neonatal and maternal health. We are here for gathering your opinion about the achievement and constraints of the program. This will enable us to disseminate good practices and also improve upon the strategies that did not work, in our future program. This will be a confidential discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one hour. It is your right to participate or not to participate in the discussion ………………, if we have your permission to proceed then we can start discussion. Implementation: Training, logistic and other support 1. What kind of support (training, supplies, logistics) did this office receive under this project? 2. How do you compare the skills and capacities of the facility and its workers in addressing neonatal, child and mother health issues to that four prevalent four years ago? 3. What are some of the additional skills and capacities still required to deal with MNCH issues? 4. What materials has the project provided to generate awareness and change behavior? Do you have some of these with you? Which tool did you think worked the best? Which will you use once the project comes to an end? 5. How do you compare the way care is being provided in your health facilities now to four years ago? What are the additional changes required to completely address MNCH issues. Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 13 - 6. How has the availability of essential drugs and equipment to your health functionaries changed in the last four years? If it has improved then do you think it will continue to remain following the closure of the project? 7. What has been the result of the other inputs (note for only those inputs mentioned by the DHO) a. Facility strengthening b. Coordination c. Advocacy d. Community mobilization e. Community empowerment f. Equity interventions 8. Considering the project objectives and strategies and DHO partnership with LIBON, what has worked well? 9. What are some of the program management challenges that you have faced and how did you deal with them? 10. What are the areas for improvement or changes? Sustainability: 11. Now that the project has come to an end what are some of the activities which a. Will be continued and who will support it b. Will not be continued Summary: 12. When you assess the MNCH in your area, what is the perceived change in the four years of project implementation 13. In your opinion, what is the major success of the program 14. What could have been done differently? What did not worked well? 15. Do you have any other comments that you would like to make Only for Parsa district 34. What is your opinion on Kawach (Chlorhexidine) application to newborn umbilical stump? Advantage and disadvantage? Thank you indeed for your insightful remarks. Note: Participant list will be listed in separate page Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 14 - FGD Guidelines for FCHV for Pars and Sunsari districts in Nepali मिहला ःवाःथ्य ःवयंसेिवका (म ःवा ःव से) संग गिरनेछलफलको िनदेर्िशका प्लान नेपाल, िलवन पिरयोजना अिन्तम मूल्यांकन गािवस: ___________________________ ःथान: _________________ वाडर्नं _________________ िमित: _________________ सहजकताको र् नाम: ____________________________ अिभलेखकताको र् नाम: _________________ अिभवादन, पिरचय तथा सुिचत मौिखक सहमित: प्लान नेपाल, िलवन पिरयोजनाको आिथर्क तथा ूािविधक सहयोगमा िजल्ला (जन) ःवाःथ्य कायालयद्धारा र् संचालन गदैर्आएको नवजात िशशुःयाहार कायबमबार र् ेयहाँहरुलाई अवगतैछ । यस कायबमल र् ेूाप्त उपलब्धी तथा रोकावटको बारेमा तपाईहरुको िवचार अनुभव बुझ्न यहाँहामी उपिःथत छौं । यसले आगामी िदनहरुमा हाॆो राॆा व्यवहारलाई सम्ूेषण गनर् तथा हाॆा रणिनितहरुलाई पिरमाजर्न गनर्सहयोग गनेर्छ । यो छलफल गोप्य हु नेछ र तपाईहरुको नाम कतै उल्लेख गिरनेछैन । यो छलफलको लागी किरब १ घण्टा जित समय लाग्छ । यस छलफलमा तपाईहरुको सहभागी हु नेवा नहु नेतपाईहरुकै अिधकार हो…………….., यदी हु नेहो भने, के छलफल शुरु गरौं । १) के तपाईलेआमा समहको ू बैठक संचालन गनेर्गनुर्भएको छ? छ, भनेकित कित समयमा? २) आमा समहको ू बैठकका सहभागीहरु को को हु न? तपाईको आमा समहमा ू िसमािन्तकृ त समदायको ु सहभािगता कःतो छ? ३) के आमा समहको ू बैठकमा नवजात िशशुःयाहार कायबमर् (CB-NCP) को बारेमा छलफल हु न्छ? हु न्छ भनेकु न कु न िवषयमा? ४) समदायमा ु आधािरत नवजात िशशुःयाहार कायबमर् /जीवन सुरक्षा कायबमका र् कु न कु न िबयाकलापलेराॆो छाप पारयो ् , कुनलेपारेन र िकन ? ५) तपाईको िवचारमा यो कायबमका र् सवल र कमजोर पक्षहरु के के रहेका छन ? ् ६) यो कायबमल र् ेसमदायमा ु जनचेतना जगाउनेकायबममा र् कित्तको मद्दत पुरयाएको ् छ? यदी छ भनेके कारणहरुलेत्यसो भएको हो? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 15 - ७) तपाईलाई यस कायबमल र् े समदायमा ु जनचेतना जगाउन के कःता सामामी उपलब्ध गराएको छ ? के तपाईसंग कु नैसामामी छ ? तपाईको िवचारमा सबैभन्दा उत्तम सामामी कु न हो ? ८) यस कायबमल र् ेसमदायको ु ःवाःथ्य ब्यवहारमा पिरवतर्न ल्याउन कःतो ूभाव पारेको छ? कु नैउदाहरण िदन सक्नुहु न्छ ? ९) यो कायबमर् माफर् त तपाईलेिदई रहेको सेवालाई मद्दत पुरयाउन ् ेतत्वहरु के छन्र वाधक तत्वहरु के छन? ् १०) यस कायबमल र् ेतपाईहरुको ज्ञान र सीप वृिद्धमा मद्दत पुरयाएको ् छ िक छैन । छ भनेकसरी: ११) कु न कु न अवःथामा नवजात िशशुलाई िरफर गनुर् पछर् र के के गनुर् हु न्छ र कःतो कःतो सुझाव िदनुहु न्छ? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 16 - CB-NCP Training I’d like to ask you some questions about the training that you received as part of the CB￾NCP. 12. How many types of training have you participated in under the CB-NCP? Please describe each of these. When did they take place? 13. What were your impressions of the training? What did you like about the training? 14. If you could, what would you change about the training to make it easier for you to do your work? 15. Please comment on how well you were taught to do the following during the training: i. Provide postnatal care to newborns? To mothers? ii. Use the scales and manage newborns with low birth weight? iii. Use the thermometer and manage newborns with hypothermia? iv. Use the Delay’s suction and bag-and-mask and manage newborns with birth asphyxia? v. Use the timer and manage newborns with infections? 16. Were you visited by a district supervisor a few months after the training and asked a number of questions about the NCP and asked to demonstrate your skills using NCP equipment? If yes, what were your impressions of that activity? 17. I’d like to ask you about some of the equipment that you were give for NCP: (Fill out the following table, FCHV should show you each item of equipment): Equipment Do you have working equipment now? Please show me. When did you receive it? (relate to before / after / during training) Scales Color-coded thermometer DeLee suction Bag-and-mask Timer NCP flipchart NCP job aid Action card Incentives Under the NCP you are given an incentive for completing certain tasks. 18. Please describe what you need to do to receive the NCP incentive. 19. Have you ever received an incentive? How many times have you received it? How much did you receive? 20. Did you receive the correct amount? Do you know how to calculate the amount of incentive that you are supposed to receive? 21. How has the performance-based incentive for CB-NCP affected your work on other programs? (probe: how do they affect the way you prioritize your work?) Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 17 - 22. How has the performance-based incentive for CB-NCP affected your motivation to be a FCHV? (probe: how has it affected how hard you work at your job?) 23. What do you think about the NCP incentive program? What changes, if any, would you like to see made to the NCP incentives program for FCHVs? तपाईलाई यस कायबमर् बारेकेही थप भन्नुछ िक? तपाईको अमल्यू सुझावको लािग धन्यवाद । Only for Parsa district 1. Do you hear about Kawach (Chlorhexidine)? If yes, did your newborn get Kawach (Chlorhexidine)? If not applied Kawach (Chlorhexidine), why? 2. What is your opinion on Kawach (Chlorhexidine) application to newborn umbilical stump? Advantage and disadvantage? सहभागीको लागी धन्यबाद !!! सहभागीको नामावली छुट्टैपानामा िलनुपनेर्छ । Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 18 - FGD for decision maker (recently delivered mother’s husband and mother-in-law) Plan Nepal, LIBON Project, Final Evaluation, September 2011, Bara district District: __________________ VDC: _____________________________ Name of Village_______________________, Ward no: _______ Interview date: __________________ Name of facilitator:______________________ Name of note taker(s):________________________ Greeting, introduction and verbal consent! You may be aware that the Plan Nepal, LIBON project has provided financial and technical support to District (Public) Health Office to implement Community Based Newborn Care Program (CB-NCP) in this community. Its objective is to improve neonatal and maternal health. We are here for gathering your opinion about the achievement and constraints of the program. This will enable us to disseminate good practices and also improve upon the strategies that did not work, in our future program. This will be a confidential discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one hour. It is your right to participate or not to participate in the discussion ………………, if we have your permission to proceed then we can start discussion. Topic for FGD 3. I understand that there are different kinds of groups in your ward. Which are the most common groups in which pregnant women (your daughter in law / wife) participate? 4. Do you allow your daughter in law /wife to join the PWG? If yes why? If no why? 5. Do you know anyone in your community who do not want to allow joining their daughter in law /wife the PWG? If so why do you think? 6. Do you know what topics are discussed in this group meeting? What are the activities of this group? 7. Have you heard about child survival/ Birth Preparedness Plan (BPP)? 8. What is the status of maternal and neonatal health services? (Need probe)  Before and after implementation of child survival/BPP program. 9. Is PWG useful? If yes, why? How it helps to utilize maternal and neonatal health services? 10. What are the factors that contributed to its utilization (better and under utilization)? (Need probe behavior mapping and self monitoring “Tika”) 11. Did you make public commitments on utilization of maternal health services? If yes, what is your opinion on this? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 19 - 12. Have your daughter-in-law / wife ever antenatal check-up during pregnancy? If yes, how many times? If not or less than 4 times, why? 13. Where did your daughter-in-law / wife deliver and why? (need probe for incentive) 14. If delivery at home, who did it? Why? 15. Did daughter-in-law / wife have postnatal check-up and also for newborn? If not, what are the reason/factors? Thank you!! Note: Participant list will be listed in separate page Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 20 - FGD for mothers’ group (recently delivered <1 year mother / pregnant women) Plan Nepal, LIBON Project, Final Evaluation, September 2011, Bara District: __________________ VDC: _____________________________ Name of Village_______________________, Ward no: _______ Interview date: __________________ Name of facilitator:______________________ Name of note taker(s):________________________ Greeting, introduction and verbal consent! You may be aware that the Plan Nepal, LIBON project has provided financial and technical support to District (Public) Health Office to implement Community Based Newborn Care Program (CB-NCP) in this community. Its objective is to improve neonatal and maternal health. We are here for gathering your opinion about the achievement and constraints of the program. This will enable us to disseminate good practices and also improve upon the strategies that did not work, in our future program. This will be a confidential discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one hour. It is your right to participate or not to participate in the discussion ………………, if we have your permission to proceed then we can start discussion. Topic for FGD 16. Are you a member of pregnant women group (PWG) /mothers’ group? 17. How often does this group meet? . 18. What does it mean for you to be in this kind of group? (Need probe) 19. What topics are discussed in this group meeting? What are the activities of this group?  How often? Did you get support from your mother-in-law / husband to come in the meeting? 20. Have you heard about Child Survival/LIBON Project? 21. What is the status of maternal and child health services? (Need probe)  Maternal and child care practices before and after Child Survival/LIBON program 22. Is PWG useful? If yes, why? How it helps to utilize maternal and child health services? Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 21 - 23. What are the factors that contributed to its utilization (better and under utilization)? (Need probe behavior mapping and self monitoring “Tika”) 24. Do you know about Birth Preparedness Plan (BPP)? 25. Did you make a BPP? How did you know about it? 26. Did you make public commitments on utilization of maternal health services? If yes, what is your opinion on this? 27. Have you ever received antenatal check-up during pregnancy? If yes, how many times and where? If not or less than 4 times, why? 28. Where did you deliver and why? (need probe for incentive) 29. If delivery at home, who has done it? 30. Did you have postnatal check-up for yourself and newborn? If not, what are the reason/factors? Thank you!! Note: Participant list will be listed in separate page Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 22 - FGD Guidelines for FCHV for Bara district in Nepali मिहला ःवाःथ्य ःवयंसेिवका (म ःवा ःव से) संग छलफलको िनदेर्िशका प्लान नेपाल, िलवन पिरयोजना अिन्तम मूल्यांकन, बारा िजल्ला गािवस: ___________________________ ःथान: _________________ वाडर्नं _________________ िमित: _________________ सहजकताको र् नाम: ____________________________ अिभलेखकताको र् नाम: ____________________________ अिभवादन, पिरचय तथा सुिचत मौिखक सहमित: प्लान नेपाल, िलवन पिरयोजनाको आिथर्क तथा ूािविधक सहयोगमा िजल्ला (जन) ःवाःथ्य कायालयद्धारा र् संचालन गदैर्आएको नवजात िशशुःयाहार कायबमबार र् ेयहाँहरुलाई अवगतैछ । यस कायबमल र् ेूाप्त उपलब्धी तथा रोकावटको बारेमा तपाईहरुको िवचार अनुभव बुझ्न यहाँहामी उपिःथत छौं । यसले आगामी िदनहरुमा हाॆो राॆा व्यवहारलाई सम्ूेषण गनर् तथा हाॆा रणिनितहरुलाई पिरमाजर्न गनर्सहयोग गनेर्छ । यो छलफल गोप्य हु नेछ र तपाईहरुको नाम कतै उल्लेख गिरनेछैन । यो छलफलको लागी किरब १ घण्टा जित समय लाग्छ । यस छलफलमा तपाईहरुको सहभागी हु नेवा नहु नेतपाईहरुकै अिधकार हो…………….., यदी हु नेहो भने, के छलफल शुरु गरौं । १) के तपाईलेःवाःथ्य आमा समहको ू बैठक संचालन गनेर्गनुर्भएको छ? छ, भनेकित कित समयमा? २) आमा समूह वा गभवती र् आमा समहको ू बैठकका सहभागीहरु को को हु न? तपाईको आमा समहमा ू िसमािन्तकृ त समुदायको सहभािगता कःतो छ? ३) आमा समूह वा गभवती र् आमा समहको ू बैठकमा बाल बचाउ पिरयोजना अन्तगर्त कु न कु न िवषयमा छलफल हु न्छ? ४) बाल बचाउ पिरयोजनालाई अझ ूभावकारी बनाउन के गनुर् पनेर्देिखन्छ? (आमा तथा बच्चाको ःवाःथ्य सम्बिन्ध ूगतीको बारेमा, CB-IMCI {CDD, ARI, Pneumonia}, Nutrition, FP, HIV/AIDS) ४) जीवन सुरक्षा कायबममा र् केगनुर्भयो केगनुर्भएन? ५) यस कायबमको र् कु न कु न िबयाकलापलेराॆो छाप पारयो ् , कुनलेपारेन र िकन ? ६) तपाईको िवचारमा यो कायबमका र् सवल र कमजोर पक्षहरु के के रहेका छन ? ् Annex 9 -- Nepal LIBON Evaluation Assessment Methodology.doc - 23 - ७) यो कायबमल र् ेसमदायमा ु जनचेतना जगाउनेकित्तको मद्दत पुरयाएको ् छ? यदी छ भनेके कारणहरुलेत्यसो भएको होला? ८) यस कायबमर् अन्तगर्त तपाईलाई समदायमा ु जनचेतना जगाउन के के सामामी उपलब्ध गराएको छ ? के तपाईसंग कु नैसामामी छ ? तपाईको िवचारमा सबैभन्दा उत्तम सामामी कु न हो ? ९) यस कायबमल र् ेसमदायको ु ःवाःथ्य ब्यवहारमा पिरवतर्न ल्याउन कःतो ूभाव पारेको छ? कु नैउदाहरण िदन सक्नुहु न्छ ? १०) यो कायबमर् शुरु भएयता संःथागत ूसतीमा ु बृिद भएको छ िक छैन ? ११) माफर् त तपाईलेिदई रहेको सेवालाई मद्दत पुरयाउन ् ेतत्वहरु के छन्र वाधक तत्वहरु के छन? ् १२) यस कायबमल र् ेतपाईहरुको ज्ञान र सीप वृिद्धमा मद्दत पुरयाएको ् छ िक छैन । छ भनेकसरी: १३) जीवन सुरक्षा अनुसार िलनुपनेर्सेवा िलन सामिहु क ूितबद्धता (गभवती र् , सास, ु ौीमान, ् म ःव ःवा से, र ःवाःथ कायकता र् ) र् बारेतपाईलाई कःतो लाग्छ ? १४) जीवन सुरक्षा कायबमलाई र् अझ ूभावकारी बनाउन केगनुर्पछर्होला? Documents reviewed Before the FE team held meeting to plan field visit and develop tools to gather qualitative data, several documents were carefully reviewed by the final evaluation team such as USAID guidelines for Final Evaluation, Detail Implementation Plan (DIP), final (LQAS) and CSSA report, Mid-term Evaluation report, Plan Nepal Annual reports, Chlorhexidine (CHX) report Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 1 - Annex 10: Nepal LIBON Project - List of persons interviewed and contacted during Final Evaluation MG/PWG interaction on 10 Sep 2011 Sonapur - 2, Sunsari SN Name of participant Age 1 Sangita Chaudhary 22 2 Pavitra Rai 24 3 Gita Devi Sah 32 4 Parwari Rishidew 19 5 Laxmi Rishidew 25 6 Phulo Rishidew 20 7 Meena Rishidew 20 8 Gita Rishidew 25 9 Madhudevi Sah 25 10 Rangita Rishidew 20 11 Ranju 20 12 Sunar Rishidew 27 13 Sunita Rishidew 30 14 Rita Sah 28 15 Asha Rishidew 20 16 Anusha Rishidew 20 17 Lila Devi Rishidew 25 18 Sarita Sah 27 19 Lalita Rishidew 23 20 Rekha Rishidew 21 21 Nisha Rishidew 25 22 Sanichari Rishidew 75 Harpreet Anand Team Leader Dr. Shree Ram Sah Facilitator Sher Bahadur Rana Note taker Kalawati Changbang Note taker FCHV SN Name of participant 1 Meena Devi Rai Januka Chaudhary Facilitator Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 2 - Yogesh Niraula Note taker Dipak Dahal Note taker Mother-in-law interaction on 10 Sep 2011 Sonapur - 2, Sunsari SN Name of participant Age 1 Patali Devi Rishidev 50 2 Manru Devi Rishidev 35 3 Dhamki Devi Rishidev 60 4 Phulsariya Devi 45 5 Nela Devi 35 6 Jhaku Rishidev 45 Narmaya Limbu Team Leader Shiv Narayan Yadav Facilitator Bhagawan Das Shrestha Note taker Hari Dev Shah Note taker MG/PWG interaction on 11 Sep 2011 Chimidi-5, Sunsari SN Name of participant Age PW/PNM 1 Tanjila Khatun 25 PNM 2 Hadija Khatun 22 Member 3 Sanjila Khatun 22 Member 4 Sanjila Khatun 21 Member 5 Hadija Khatun 20 Member 6 Jaitun Khatun 22 Member 7 Jatun Khatun 22 Member 8 Sabina Khatun 23 Member 9 Taranam Khatun 22 Member 10 Jamila Khatun 20 Member 11 Samma Khatun 22 Member 12 Taranam Khatun 23 Member 13 Hadija Khatun 22 Member 14 Sanjita Khatun 23 Member 15 Jananam Khatun 24 Member Dr. Mahesh Maskey Team Leader Harpreet Anand Note taker Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 3 - Dr. Shree Ram Sah Facilitator Bhagawan Das Shrestha Note taker Kalawati Changbang Note taker FCHV SN Name of participant 1 Radha Devi Das Januka Chaudhary Facilitator Dipak Dahal Note taker Names of in-charge of Sonapur on 11 Sep 2011 SN Name of in-charge 1 Kundan Das Dr. Mahesh Maskey Dr. Shreeram Prasad Sah Bhagawan Das Shrestha Names of in-charge of Chimdi on 11 Sep 2011 SN Name of in-charge 1 Apolo Kumar Bhagat Dr. Mahesh Maskey Dr. Shreeram Prasad Sah Bhagawan Das Shrestha Kalawati Changbang IDI with DHO on 12 Sep 2011 SN Name of Participants Designation Organisation 1 Dr. Shree Ram Shah DHO DHO Sunsari 2 Dr. Mahesh Maskey Team Leader 3 Sher Bahadur Rana HPC Plan NCO 4 Bhagawan Das Shrestha LPC Plan NCO 5 Harpreet Anand Program Manager Plan USNO 6 Naramaya Limbu Division Chief USAID 7 Kalawati Changbang HPC Plan Nepal Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 4 - Mother-in-law interaction on 13 Sep 2011 Chhatapipara - 5, Bara SN Name of participant 1 Pasupati Devi Chaudhary 2 Sima Devi Paswan 3 Sampati Chaudhary 4 Phul Kumari Chaudhary 5 Raj Kumari Chaudhary Kausaliya Devi Chaudhary Faciliator Bhagawan Das Shrestha Note taker FCHV SN Name of participant 1 Shiwarati Chaudhary Dipak Dahal Facilitator Raj Kishor Chaudhary Note taker Names of in-charge SN Name of in-charge 1 Mukunda Bahadur Gubhaju Deo Ratna Chaudhary Faciliator Md. Sabir Note taker Mother-in-law interaction on 14 Sep 2011 Karaiya - 5, Bara SN Name of participant 1 Shalshwa Devi Baral 2 Kalpana Chaudhary 3 Parbati Chaudhary 4 Susatiya Sahani 5 Shyam Pati Ram 6 Manari Suhuriya Shanti Thakali Facilitator Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 5 - Bhagawan Das Shrestha Note taker FCHV SN Name of participant 1 Bishnu Devi Baral Dipak Dahal Facilitator Raj Kishor Chaudhary Note taker Names of in-charge SN Name of in-charge 1 Pramod Prasad Kuswaha Deo Ratna Chaudhary Facilitator Md. Sabir Note taker DHO team interaction in DHO, Bara on 15 Sep 2011 DHO-Bara, Kalaiya SN Name of participant 1 Dr. Surendra Pd Chaudhary 2 Md. Sabir 3 Amleshwor Mishra 4 Shiv Pd. Sahani 5 Anil Mishra Dr. Mahesh Maskey Team Leader Harpreet Anand Mangala Manandhar Badri Shrestha Sher Bahadur Rana Bhagawan Das Shrestha Deo Ratna Chaudhary Diwakar Mishra Kausaliya Devi Chaudhary Shanti Thakali Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 6 - Mother-in-law interaction on 16 Sep 2011 Madhuwan Mathol, Parsa SN Name of participant 1 Dineshree Devi tharu 2 Meena Devi Tharu 3 Sugandi Devi Lohar 4 Laxmi Devi Tharu 5 Phulmati Devi Ram 6 Panmati Devi Tharu 7 kanti Devi Tharu 8 Kunti Devi Ram 9 Dropati Devi Ram 10 Chandrawati Devi Ram 11 Panwa Devi Ram 12 Girija devi Tharu 13 Jhokali Devi Majhi 14 Shriya devi Ram Dr. Indra Pd Yadav Facilitator Sajit K Adhikari Facilitator Bhagawan Das Shrestha Note taker FCHV SN Name of participant 1 Nirmala Silwal Naina Devi Sah Facilitator Dipak Dahal Note taker Interview with health facility in-charge of Madhuwan Mathaul SN Name of in-charge 1 Deep Narayan Mahato Krishna Bahadur Achhami Facilitator Deo Ratna Chaudhary Note taker Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 7 - Mother-in-law interaction on 17 Sep 2011 Bindabasini, Parsa SN Name of participant 1 Silpati Devi Paswan 2 Parbha Devi Paswan 3 Phulmati Devi Paswan 4 Sunera Devi Ram 5 Khanti Sah Kalwar 6 Radhika Yadav 7 Urmila Devi Singh 8 Rajani Devi Ram 9 Sail Devi Sunar 10 Phulmati Devi Shah 11 Aashiya Devi Ram 12 Maya Devi Ram 13 Chandrakala Ram 14 Santi Devi Ram 15 Dhupiya Devi Ram 16 Pramila Devi Ram 17 Gadariya Devi Ram 18 Ramabati Devi Ram 19 Kalita Devi Ram 20 Lalmati Devi Ram 21 Rajpati Devi Yadav 22 Tetari Devi Paswan 23 Dewamat Devi Ram Dr. Indra Pd Yadav Facilitator Sajit K Adhikari Facilitator Bhagawan Das Shrestha Note taker FCHV SN Name of participant 1 Ramila Thapa Magar Naina Devi Sah Facilitator Dipak Dahal Note taker Interview with health facility in-charge of Bindabasini Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 8 - SN Name of in-charge 1 Satrughan Prasad Yadav Krishna Bahadur Achhami Facilitator Deo Ratna Chaudhary Note taker Information sharing meeting with DPHO, 18 Sep 2011 Birgunj, Parsa SN Name of participant 1 Dr. Indra Pd Yadav 2 Phulena Shreevastav Dr. Mahesh Maskey Team Leader Harpreet Anand Sher Bahadur Rana Bhagawan Das Shrestha Deo Ratna Chaudhary Krishna Bahadur Achhami Sajit Kumar Adhikari Jay Mangal Thakur Ejaz Ansari Meena Singh Srijana Rai Dipak Dahal Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 9 - Ministry of Health and Population & Plan Nepal Participant list of Final Evaluation Sharing Workshop of LIBON Project Hotel Summit, Lalitpur, 23 September 2011 SN Name Designation Organization 1 Amaleshwar Mishra PH0 DHO,Bara 2 Naramaya Limbu Team Leader, FP/MNCH/Nutrition USAID 3 Bhim Kumari Pun PC Save the Children 4 Sher Bahadur Rana HC Plan Nepal 5 Krishna Shrestha PME-O Plan Nepal 6 Donal Keane CD Plan Nepal 7 Harpreet Anand PM USNO Plan USA 8 Dr.B.K.Subedi Chief PPICD,MOHP MOHP 9 Dr.Shilu Aryal Sr.Cors.OT/Gyn FHD/DOHS 10 Dr.Shree Ram Shah DHO DHO Sunsari 11 Subhakar Baidya PSM Plan Nepal 12 Janardan Thaiba CFM Plan Nepal 13 Badri Shrestha PUM Plan Nepal 14 Prabhakar K.C PM Plan Nepal 15 Sabina Baniya MO Nepal CRS Compani 16 D.P. Raman Country Director RTI/NTD Control Program 17 Yogesh Niraula APUM Plan Nepal 18 Kalawati Changbang HPC Plan Nepal 19 Soni Pradhan Team Leader Plan Nepal 20 Shib Narayan Yadhav P.H.O DHO,Sunsari 21 Chandra Rai Project Director Health Right International 22 Jyoti R Shrestha Coordinator MIRA 23 Hari Bahadur Rana Training Coordinator RTI/NTD Control Program 24 Mohan Krishna Shrestha Central Member NEPHA ( Nepal Public Health Association) 25 Mohan Paudel M&E Coordinator Health Right International 26 Laxmi Narayan Deo Deputy Director NHTC 27 Yam Bahadur Thapa LIBON Facilitator Plan Nepal LIBON 28 Tribikram Karmacharya Kanti Bal Hospital Board Chairman Kanti Bal Hospital 29 Krishna Bahadur Achhami ADLC Plan Nepal LIBON 30 Kamalesh Kumar Lal P&C Manager Plan Nepal 31 Sabita Tuladhar P.O M&E NFHP II 32 Leela Khanal Sr. Program Officer NFHP II 33 Robin Huston DCOP NFHP II 34 Gaurav Sharma MH Advisor DFID Annex 10 -- Nepal LIBON List of persons interviewed during .doc - 10 - SN Name Designation Organization 35 Jaganath Sharma Coordinator NFHP 36 Dilip Chandra Paudel Tea Leader CH NFHP 37 Dr.Balkrishna Kalakheti Consultant UNICEF 38 Prashu Ram Shrestha Chief IMCI/CHD CHD 39 Dipak Dahal M&EO Plan Nepal 40 Diwakar Mishra ADLC Plan Nepal 41 Rajendra Prasad Sah LIBON Facilitator Plan Nepal 42 Bijaya Kumar Sah LIBON Facilitator Plan Nepal 43 Sajit Kumar Adhikari LIBON Facilitator Plan Nepal 44 Ejaz Ansari LIBON Facilitator Plan Nepal 45 Jay Mangal Thakur LIBON Facilitator Plan Nepal 46 Rajkishor Prasad Chaudhary LIBON Facilitator Plan Nepal 47 Shrijana Rai Office Assistant Plan Nepal 48 Deo Ratna Chaudhary DLC Plan Nepal 49 Muiya Rai Office Assistant Plan Nepal 50 Meena Singh AFO Plan Nepal 51 Rudra Sapkota Plan OA Plan Nepal 52 Prajwal Jung Pandey Director Marketing LOMUS Pharmaceutcals Pvt 53 Shushil Joshi PPM Business Lead Plan IH 54 Bhagawan Das Shrestha PC LIBON Plan Nepal 55 Phulena Pd. Shrivastaw P.H.O DHO ParsaMa 56 Dr.Mahesh Maskey Team Leader LIBON Final Evaluation Plan Nepal Annex 11: Nepal LIBON Project – Final Operations Research Report Annex 11 Nepal LIBON Project – Final Operations Research Report End Line Report Operational Research on Chlorhexidine Application on Newborn’s Umbilicus Stump Parsa District Local Innovation for Better Outcomes for Neonates Project (LIBON) Plan Nepal Child Survival Project XXII Funded by United States Agency for International Development Child Survival and Health Grants Program (CSHGP) Grant No. GHN-A-00-07-00006-00 Bureau for Global Health Office of Health, Infectious Disease, and Nutrition Submitted by Hari Bhakta Khoju Rural Community Development Society Submitted to Plan Nepal August, 2011 Annex 11 Nepal LIBON Project – Final Operations Research Report Acknowledgement We acknowledge and express our gratitude to Plan-Nepal especially to Mr. Donal Keane, Country Director and Mr. Subhakar Baidya, Program Support Manager for offering us to prepare a report to Community Based-Newborn Care Program (CB-NCP) of Sunsari and Parsa Districts, Local Innovation for Better Outcomes for Neonates Project (LIBON), Plan Nepal Child Survival Project XXII. Mr. Bhagawan Das Shrestha, Project Coordinator-LIBON and Mr. Sher Bahadur Rana, Health Coordinator, Plan Nepal deserves our heartfelt sincere thanks for their constant accomplishment and assistance in field work for data collection, data analysis and report preparation. We would like to appreciate Mr. Dipak Dahal, Monitoring and Evaluation Officer for his endless commitment, enthusiasm and effort in convincing, building capacity and confidence of health supervisor and officials to conduct the survey for data collection without being bias to subjective judgment and data fabrication. Dr. Naresh Pratap Rana, Director Family Health Division, Shilu Aryal FHD, Leela Khanal, NFHP, Mr. Parasuram Shrestha, Chief, Community Based-Integrated Management of Childhood Illness (CB￾IMCI), Child Health Division, Ministry of Health and Population (MoHP), Mr. Indra Dev Yadav, District Public Health Office (DPHO) Parsa are also thankful to us, who provided information and inputs for report preparation. We extend our heartfelt thanks to field based staff Mr. Deo Ratna Chaudhary, District LIBON Coordinator (DLC) Bara/Parsa, Mr. Krishna Bahadur Achhami, ADLC Parsa, Ms. Meena Kumari Singh, Admin and Finance Assistant and Ms. Srijana Rai, Office Assistant, Parsa for supporting the enumerators during data collection field work. We should not forget to appreciate and thank to Mr. Ram Khoju Shrestha and Mohan Prasad Adhikari, who dedicated to coding, entering and cleaning data during data processing work of this project. At last but not least, we are thankful to the survey respondents for their valuable time and patience in cooperating and providing information. Authors Hari Bhakta Khoju Rural Community Development Society Annex 11 Nepal LIBON Project – Final Operations Research Report 3 CONTENTS EXECUTIVE SUMMARY ....................................................................................................................................... 5 Chapter 1: Introduction .............................................................................................................................................. 6 Chapter 2: Methodology ............................................................................................................................................ 7 2.1. Concept and Use ............................................................................................................................................ 7 2.2. Purpose of LQAS ........................................................................................................................................... 7 2.3. Sample Size .................................................................................................................................................... 7 2.4. Sampling Frame ............................................................................................................................................. 7 2.5. Threshold and Decision Rule ......................................................................................................................... 8 2.6. Survey Questionnaire ..................................................................................................................................... 8 2.7. Team Composition and Field Plan ................................................................................................................ 8 2.8. Training of Enumerators and Supervisors ..................................................................................................... 8 2.9. Data Collection ............................................................................................................................................... 8 2.10 Data cleaning and analysis .......................................................................................................................... 10 Chapter 3: Characteristics of the Respondents ........................................................................................................ 11 Chapter 4: Umbilicus Care Practices of Newborns: ................................................................................................ 11 Conclusion: ............................................................................................................................................................... 20 Recommendation: .................................................................................................................................................... 20 Annex-1: Sample frame of Parsa district ................................................................................................................. 21 Annex-2: Survey instrument – questionnaire for Chlorhexidine (CHX and brand name in Nepal is Kawach) .... 26 Annex-3: Chlorhexidine operational Research Time Line of Parsa district ........................................................... 31 Annex-4: Leaflet for Chlorhexidine operational Research in Parsa district Sep 2011 ........................................... 32 Annex 11 Nepal LIBON Project – Final Operations Research Report 4 TABLES Table 3.1: Percent distribution of RDW by level of education ............................................................................... 11 Table 4.1: Percent distribution of RDW who used of Clean Delivery Kit (CDK) during their last child birth .... 11 Figure 4.2: Percent distribution of RDW who used of Clean Delivery Kit (CDK) during their last child birth ... 11 Table 4.3: The time period of umbilicus cord of newborn ..................................................................................... 12 Table 4.4: Percent distribution of RDW by who applied something in umbilicus stump after cutting cord of their newborn in last child birth ..................................................................................................................... 12 Table 4.5: Percent distribution of RDW by type of things applied in umbilicus stump after cutting cord of their newborn in last child birth ..................................................................................................................... 12 Figure 4.6: Percent distribution of RDW by type of things applied in umbilicus stump after cutting cord of their newborn in last child birth ..................................................................................................................... 13 Table 4.7: Percent distribution of RDW by areas of application of CHX in their last chid. .................................. 13 Figure 4.8: Percent distribution of RDW by areas of application of CHX in their last chid. ................................ 13 Table 4.9: Percent distribution of RDW who wash hand before applying CHX ................................................... 14 Table 4.10: Percent distribution of newborns as of the time period of CHX applied before applying CHX ........ 14 Figure 4.11: Percent distribution of newborns who applied CHX .......................................................................... 14 Figure 4.12: Percent distribution of newborns as of amount of CHX applied ....................................................... 15 Table 4.13: Percent distribution of newborns as of times of CHX applied ............................................................ 15 Table 4.14: Percent distribution of newborns as of keeping umbilicus stump without touching cloths after CHX applied .................................................................................................................................................... 16 Table 4.15: Percent distribution of RDWs who received CHX in their last pregnancy ........................................ 16 Table 4.16: Percent distribution of RDWs from whom/where did they receive or buy the CHX in their last pregnancy ............................................................................................................................................... 16 Table 4.17: Percent distribution of RDWs who received advices from health workers and FCHVs on the importance of CHX application during in their last pregnancy orientation ......................................... 16 Table 4.18: Percent distribution of RDWs as of time period of CHX received during in their last pregnancy .... 17 Table 4.19: Percent distribution of RDWs as of process of CHX application during in their last pregnancy ...... 17 Figure 4.20: Percent distribution of newborns whose umbilicus stump has some problem .................................. 18 Figure 4.21: Number distribution of RDWs action taken after newborns’ umbilicus stump has some problem .. 18 Figure 4.22: Percent distribution of newborns applying various things on umbilicus stump among PWG and Non PWG ....................................................................................................................................................... 19 Table 4.23: Percent distribution of RDWs by member of PWG ............................................................................ 19 Table 4.24: Comparison between Pregnant Women Group (PWG) member and CHX applied: .......................... 20 Annex 11 Nepal LIBON Project – Final Operations Research Report 5 EXECUTIVE SUMMARY Local Innovation for Better Outcomes for Neonates (LIBON) project aims to reduce neo-natal mortality rate and maternal mortality ratio. Current neonatal mortality rate of 33 per 1000 live births in Nepal translates to around 23,000 neonatal deaths per annum. Studies have shown that immediate cleansing of umbilical cord with 4 per cent Chlorhexidine (CHX) (brand name Kawach) reduces the cord infection and reduces neonatal mortality by about 23 per cent. After the results of a study to compare efficacy of Chlorhexidine lotion versus aqueous and another study to examine acceptability and case in the use of two different CHX formulations (liquid or lotion) for prophylactic application on freshly cut umbilical cord stumps in Nepal the Department of Health Services (DoHS) endorsed a pilot CHX program in four districts (Banke, Bajhang, Jumla and Parsa). Parsa district was supported by Plan Nepal funded by USAID whereas other districts by NFHP-II. In Parsa district, program was initiated through district level orientation on Oct 2009 and continued to provide training of trainers to district supervisors and health facility staff as well as training to Village Health Workers and Maternal and Child Health Worker separately. The CHX training program is aligned with Community Based Newborn Care Program training package at Female Community Health Volunteer completed in September 2010. The overall objective of the study was to measure the coverage and compliance of Kawach at community level in Parsa district. The data was collected through Lot Quality Assurance Sampling (LQAS) technique. Total 494 (13 SAs X 38) recently delivered women (RDW) defined as married women of age group 15-49 who had given a live birth and were living in the family with the baby were interviewed using a structured questionnaire in the district. Systematic random sampling design was used through LQAS methods by dividing the areas into 13 supervision areas (SAs) where 38 RDWs were interviewed per supervision area in July 2011. About 88.2 percent birth attendants reported washing their hands by before touching the newborn. Similarly, 94.4 percent reported washing their hands before applying CHX. 96.4 percent reported applying full tube of Kawach to newborn baby. Umbilical cord care: About 82.9 percent RDWs of Parsa district reported to have their newborns’ umbilical cord cut with safe instruments Clean Delivery Kit (CDK). 78.6 percent RDWs received CHX from Female Community Health Volunteer (FCHV), 17.3 per cent from health facilities, 1.1 per cent from shop-CHX separately, 1.0 per cent from shop-CHX with CHDK and remaining 1.0 per cent from others. Most of the pregnant women, 65.2 per cent received CHX in eight months of their pregnancy period and 29.6 per cent in nine months of pregnancy. There is high coverage of Kawach application on the stump of newborns 82.7 percent in Parsa district. The compliance (application of whole tube of Kawach at single event in the cord stump and surrounding areas of newborn within 2 hours of cord cut among those who applied Kawach) is almost to coverage 66.4%. Comparison between Pregnant Women Group (PWG) member and CHX applied shows that 1.3 times more CHX is applied by PWG members than non-PWG members. In the conclusion, CHX program can be scaled up to other districts of Nepal by integrating other programme like CBNCP and its coverage can be increased by supplying through government existing health system like hospitals, health facilities, birthing centres and from community health volunteers in the monthly pregnant women group meeting. Annex 11 Nepal LIBON Project – Final Operations Research Report 6 Chapter 1: Introduction Plan Nepal has been implementing Child Survival XX-III project called “Local Innovation for Better Outcomes for Neonates (LIBON)” in collaboration with the Ministry of Health and Population (MoHP) and Institute of Medicine (IOM), Tribhuvan University in Sunsari and Parsa districts to support to implement Community Based Newborn Care Program (CB-NCP) and supports Bara district to maintain the health service status of 2006 Final Evaluation Results. These districts are located in the Eastern and Central parts in the Southern Terai belt, the lowland plain areas, along the border of India, starting from September 2007. It is a four year project to cover up-to 2011 September. To address these complex issues, LIBON project proposed following goals, results, strategies, interventions and activities which are in line with MoHP, Government of Nepal (GoN) policies and programs. The main Goal of the project is “To Sustainably Reduce the Burden of Neonatal Mortality in Nepal” The goal will be achieved through the implement of the following results: Result 1: Increased Access to Neonatal Health (NNH) Services in Sunsari and Parsa Result 2: Increased Demand for NNH Services in Sunsari and Parsa Result 3: Increased Quality of NNH Services in Sunsari and Parsa Result 4: Strengthened Support for Neonatal Mortality (NNM) Reduction in Nepal Strategies:  Community-based Service Delivery to increase ACCESS to meet Result 1  Community Mobilization to increase DEMAND to meet Result 2  Health Systems strengthening to increase QUALITY to meet Result 3  Stakeholder sharing and Collaboration to increase SUPPORT to meet Result 4  Social Inclusion to increase EQUITY to meet Result 1 LIBON project is designed to address the complex issues to reduce neo-natal mortality rate which is caused due to lack of awareness, knowledge, information and skill and access to health services to take care of pregnant mothers during their pregnancy, at birth and after delivery and newborn dangers sings. One of the leading causes of the newborn is infection. The infection may start from umbilicus stump infection among the newborns. It can be prevented by tropical application of chlorhexidine hydrochloride 4% (CHX) (local brand name is Kawach) ointment at umbilicus stump and around it. The major reasons for pilot programming of CHX are: • Umbilical cord infection is one of the major causes of neo-natal infection (Neo-natal Health strategy 2004) • Umbilical cord infection is about 62 % of local Bacterial Infection ( Report of MINI Morang) • CHX application on the umbilical cord prevents from infection • Aapplication of Chlorhexidine to the umbilical area of the neonate was associated with a 24% decrease in neonatal mortality, 34% if applied on day of delivery (Mullany et al, 2006). • Near universal use of CHX up to 1/3 reduction in mortality over the neonatal period • 70-80% reduction in incidence of severe omphalitis (infection of umbilicus stump) • National Medical Standards, volume 3 – dry cord care as general recommendation, but when adequate hygiene cannot be assured in household setting, CHX should be used Annex 11 Nepal LIBON Project – Final Operations Research Report 7 Chapter 2: Methodology A Lot Quality Assurance Sampling (LQAS) technique was applied to conduct survey in Parsa district in July 2011. 2.1. Concept and Use LQAS was developed in the 1920s for quality control of industrial production goods. The basic principle is that a line manager/supervisor takes a small random sample of a recent batch, or lot, of goods from a production unit such as an assembly line. If the number of defective goods in a sample exceeds a pre-determined number, then the lot is rejected; otherwise it is accepted. The pre￾determined (allowable) number is called the “decision rule.” This allowable number is based on a production standard and the sample size. Recently, the industrial monitoring experience was transferred to monitor the quality of health indicators and to improve supervision of the field area. 2.2. Purpose of LQAS The LQAS sampling method was used in the LIBON project to collect baseline data on project￾relevant health indicators, to determine whether the supervision areas were above or below average coverage on specific indicators, to determine the indicators that were well performing and those that were not within a given supervision area, and to determine how supervision areas within the total project area compared with another area. 2.3. Sample Size Sample sizes were calculated with the following formula: n = z2 (pq)/d2 ; where n = sample size; z = statistical certainty chosen; p = estimated prevalence/coverage rate/level to be investigated; q = 1-p; and d = precision desired. The value of p was defined by the coverage rate that requires the largest sample size (p= 0.5). The value of d was dependent on the precision, or margin of error, desired (in this case d=0.1). The statistical certainty was chosen to be 95% (z=1.96). Given the above values, the necessary sample size turns out to: n = (1.96x1.96) (0.5x0.5)/(0.1x0.1) = (3.84)(0.25)/0.01 = 96 As the value of “p” is not known, we took a conservative approach and set p=0.5. The estimate of confidence limits for the survey results was calculated using the following formula: 95% confidence limit = p ± z (square root of pq/n); where p = proportion in population found from survey; z = statistical certainty chosen (for 95% certainty, z = 1.96); q = 1-p; and n = sample size. 2.4. Sampling Frame For the purpose of the LQAS Survey, Parsa district was divided into 13 SAs (12 Ilakas of Parsa DHO and 1 district municipality - Birgunj). A sample size of 19 households (HH) was selected per SA for this assessment. The reason for choosing 19 is that any sample that is less than 19 will have  and  errors greater than 10%, which is not desired. Similarly, increasing the sample size to greater than 19 creates more work and does not necessarily reduce the margin of error. In assessing coverage, we have aggregated all the samples taken from each SA in order to obtain a large enough sample size as required to estimate the proportion in each population subgroup. The total sample size for Parsa for CHX was 494. It was calculated as 247 mothers (19 HHs x 13 SAs that is MoHP’s Ilaka) from the module 1 – recently delivered women (RDW) having 0-5 months child and in the same way next 247 RDW from module 2 – RDW having 0-11 months child. Annex 11 Nepal LIBON Project – Final Operations Research Report 8 2.5. Threshold and Decision Rule Initial thresholds/benchmarks for assessing the indicators were selected using the average proportion obtained by aggregating the data of all 13 SAs in Parsa district. 2.6. Survey Questionnaire The survey questionnaire were used from Family Health Division which was used by Nepal Family Health Program II in next three CHX program piloting districts namely Banke, Jumla and Bajang. The questionnaire was already filed tested in Parsa district. The questionnaire is attached in the annex. 2.7. Team Composition and Field Plan The district teams were requested to select the supervisors and enumerators ensuring that they would include an CB-IMCI focal person, a statistician, an EPI supervisor, a FP supervisor, and in-charge of Ilakas of District Public Health Offices Parsa. From the pool of representatives from DPHO, NGO, and Plan Nepal teams consisting of two persons (one from each group) were formed. The team is mixed with Government staff and NGOs/Plan staff to minimize the vested interests and subjective errors. 2.8. Training of Enumerators and Supervisors The three-days training was conducted for DPHO, NGO/partner and Plan Staff of Parsa district which included dummy practice of the questionnaire filling including real field practices in the ward which is not included in the real sample. There was sharing of the field practice and misunderstanding and make consensus in the plenary for common understanding among all the team members and supervisors. 2.9. Data Collection A standard procedure was applied for data collection. First, a sampling frame was constructed for each field area consisting of 2-9 VDCs, their 9 wards with population sizes. Secondly, dividing the total population size of a field area by the LQAS sample size of 19 created a sampling fraction. Third, a random number between 1 and the sampling fraction was selected by standard random table. The ward having the corresponding person in the sampling frame’s cumulative population column was selected as the first sample. Adding the sampling fraction to the selected sample identified the next ward. All remaining samples were selected by continuing the addition of the sampling fraction to the preceding sum. Identifying locations for interview: Step 1: List communities and their total population Step 2: Calculate the cumulative population Step 3: Calculate the sampling interval Step 4: Choose a random number Step 5: With an initial random number and the sampling interval, identify communities for the 19 sets of interviews After the selection of community; interviewers visit that area and take the information from the key informants or self assessment in that location. If there are more than 30 households, they are subdivided into two or more (almost equal HHs) groups which is manageable to clearly identify the location. Then select one location of these sections randomly. If the selected area is still too large, subdivide it again into two or more equal section and select one section at random. It is continued until one small section with less than or equal to thirty households. Then, draw a map of the section becomes with the help of key informant and number each household in the selected section on the map or door to door visit. Then use random number table and select the first household. Annex 11 Nepal LIBON Project – Final Operations Research Report 9 Household selection: assigning numbers IF: THEN: A complete household list is available (from census, or map) -) Assign a number to each house … work is done! If the community size is about 30 households or less -) Make a household list or map with the location of each household with the help of a key informant from the community -) And then, assign a number to each house … work is done! If the community size is more than about 30 households -) Subdivide the community into 2-5 sections with about the same # of households in each section -) Select one section at random -) Make a house list or map with the location of each household with the help of a key informant -) Then, assign a number to each house … work is done! Household selection • Once all households are numbered, pick a random number (using random tables) and select the first household in the selected community • If more than one house is needed in the selected community, pick another random number to select the second household in the selected community After the selection of household they visit that house and knock at the door of selected house and share the objective of survey to the family member(s) and ask whether they have a child age 0-11 and 0-5 months with mother or not. If there is a single child of 0-11 and 0-5 months then ask question and take information with mother after getting permission. If there are two or more children of 0-11 and 0- 5 months then randomly select one child by using random table. If the house does not meet criteria then they move to next-nearest front door until they get a child aged 0-11 and 0-5 months with mother. If the respondent of the household is located far way for more than 30 minutes walking distance, then they visit the next-nearest front door. Selecting a respondent If the type of respondent you are looking for: THEN: Is at the household you selected Interview that person IF she consents Does not live at the household selected They go to the next-nearest household from the front entrance and check the next-nearest household … continue this process until they find the respondent type you they looking for Lives at that household, BUT is absent and far away (more than 30 minutes away) They leave that house and select the next house. If the type of respondent you are looking for: THEN: Lives at that household, is absent BUT is nearby (within 30 minutes) They go find the respondent with the help of a guide from the community … IF they cannot find the person in the next 30 minutes, then GO to the next-nearest household from the front entrance of the household of the person they cannot find Questionnaires were completed during the interview. At every end of the day interviewers themselves checked the filled questionnaires for quality of data. The Director Family Health Dr. Naresh Pratap Annex 11 Nepal LIBON Project – Final Operations Research Report 10 Rana, Prof. Chitra Kumar Gurung from IOM, Project Coordinator-LIBON project, Monitoring and Evaluating Officer and Health Coordinator, Plan Nepal also visited some of the study areas to supervise the fieldwork. The data were collected during June to July 2011. 2.10 Data cleaning and analysis Filled-in questionnaires were brought to central office of RUCODES. Each filled questionnaire has been edited and coded for data entry. Data was entered and processed using Statistical Package for the Social Sciences (SPSS) software packages. Data entry was done directly from the completed questionnaires. The data was validated by a computer processing team consisting of a computer programmer and data entry personnel. The computer programmer constantly supervised and monitored the data entry activities. The data set was cleaned and prepared for output generation. Data has been analyzed using simple frequency tables and cross tabulations. Tables were designed and finalized in consultation with the Technical staff of LIBON project of Plan Nepal. Data are presented in the form of tables, pie charts and bar graphs. 11 Chapter 3: Characteristics of the Respondents This chapter deals with the information regarding the socio-demographic and economic characteristics of the recently delivered women RDW. Table 3.1: Percent distribution of RDW by level of education Level of education RDW having 0-5 months child Parsa (n=247) 2011 July No schooling 68.8% Informal education 3.6% Primary 14.6% Class VI to X 12.6% Class XI and above 2.8% Chapter 4: Umbilicus Care Practices of Newborns: This chapter deals with the utilization clean delivery kit by RDW during their last pregnancy. There is 82.9% of RDW used clean delivery kit in the their last child birth either in home or institutional delivery. (Table # 4.1 and Figure 4.2). Table 4.1: Percent distribution of RDW who used of Clean Delivery Kit (CDK) during their last child birth Figure 4.2: Percent distribution of RDW who used of Clean Delivery Kit (CDK) during their last child birth Used CDK Frequency Percent Yes 402 82.9 No 62 12.8 Don't Know 21 4.3 Total 485 100.0 CDK use in Parsa N=485 82.9 12.8 4.5 .0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 Yes No Don't Know 12 The mean time of umbilicus cord cut after the newborn birth is 19 minutes, median is 15 minutes and mode is 30 minutes and the standard deviation is 14.7 minutes. The mean time for CHX applied after birth is 33 minutes. Table 4.3: The time period of umbilicus cord of newborn Time period of cord cut after birth (in minute) Time period of CHX applied after birth (in minute) Mean 19.2 33.0 Median 15.0 30.0 Mode 30.0 30.0 Standard Deviation 14.8 28.6 Among the 489 RDW, 417 (85.3%) said that they applied something for the newborn umbilicus stump after the cord cut. Among the 417 RDWs, 82.7% of RDW applied chlorhexidine, 12.2% applied some short of ointment or powder and 1% oil. There are still one case applied cow dung which is very harmful to newborn. (Table 4.4 and 4.5 and figure 4.6) Table 4.4: Percent distribution of RDW by who applied something in umbilicus stump after cutting cord of their newborn in last child birth Frequency Percent Yes 417 85.3 No 41 8.4 Don't Know 31 6.3 Total 489 100.0 Table 4.5: Percent distribution of RDW by type of things applied in umbilicus stump after cutting cord of their newborn in last child birth Things applied after cutting cord Frequency Percent Oil 4 1.0 Ointment/powder 51 12.2 Cow Dung 1 .2 Turmeric Powder 1 .2 CHX 345 82.7 Others 14 2.6 Don't Know 7 1.0 13 Figure 4.6: Percent distribution of RDW by type of things applied in umbilicus stump after cutting cord of their newborn in last child birth Things applied after cord cut (N=417) In Parsa, 89% of newborn applied the CHX on the umbilicus stump and its surroundings areas. Only 3.1% newborns were applied only on the stump whereas 6% applied around the stump. (Table 4.7 and Figure 4.8) Table 4.7: Percent distribution of RDW by areas of application of CHX in their last chid. Frequency Percent Only Stump 12 3.1 Around Stump 22 6.0 Both 307 89.0 Don't know 5 1.4 Total 345 100.0 Figure 4.8: Percent distribution of RDW by areas of application of CHX in their last chid. Series1, Oil, 1.0, 1% Series1, Ointment/pow der, 12.2, 12% Series1, Cow Dung, .2, 0% Series1, Turmeric Powder, .2, 0 Series1, CHX, 82.7, 83% Series1, Others, 2.6, 3% Series1, Don't Know, 1.0, 1% Oil Ointment/powder Cow Dung Turmeric Powder CHX Others Don't Know Total 417 100.0 14 About 94.4% RDW washed their hand before applying CHX to the newborn in Parsa districts. (Table # 4.9) Table 4.9: Percent distribution of RDW who wash hand before applying CHX Washing hand by birth attendants before applying CHX Frequency Percent Yes 328 94.4 No 1 .3 Don't Know 16 4.5 Total 345 100.0 Among 345 newborns who were applied CHX, 99.3% were applied CHX within 2 hours of newborn births. It is a standard time to apply the CHX. Table 4.10: Percent distribution of newborns as of the time period of CHX applied before applying CHX Frequency Percent CHX applied within 2 hours of birth 342 99.3 CHX applied after 2 hours of birth 3.0 0.7 Total 345 100 Among the 345 newborns who were applied the CHX, 53% (182) was applied by health workers, 34% (116) by FCHVs, 7% (23) by family members, 3% (12) by TBA and 2% (8) by mother. Figure 4.11: Percent distribution of newborns who applied CHX Areas of CHX applied 3% 6% 90% 1% Only Stump Around Stump Both Don't know 15 The Chlorhexidine hydrochloride ointment 4 gm in a tube is supplied the program pilot districts of Nepal. It is a product of Lomus Pharmacuticals of Nepal and brand name is “Kawach”. “Kawach” means a protecting device from defensive armours against the attack by enemies during the war in ancient time in Nepali language. The 4 gm (full tube) should be used in one time after cutting of cord within 2 hours. In the Parsa district, out of 345 CHX users, 97% used full tube of CHX and only 2% used partial tube. The reasons for partial tube used 2 respondents said the tube is more than enough and one respondent reported being unaware to use full content of the tube. Figure 4.12: Percent distribution of newborns as of amount of CHX applied Almost 100 percent applied the CHX one time only (see table 4.5). It is the protocol to apply the CHX only one time on the umbilicus stump and then keep it dry and clean as of WHO recommendation. Table 4.13: Percent distribution of newborns as of times of CHX applied How many times CHX applied Times of CHX applied Frequency Percent Person who applied CHX (n = 345) 2% 7% 34% 53% 3% 1% Mother Family Member FCHV Health Worker TBA Others Amount of CHX used (n = 345) 97% 1% 2% Full tube Partial tube Don't Know 16 1 343 99.5 5 1 .2 8 1 .2 Total 345 100.0 Among 345 respondent who said their newborns where applied CHX, 331 (96.1%) said that they kept the umbilicus stump without touching the cloths (see table 4.14). Table 4.14: Percent distribution of newborns as of keeping umbilicus stump without touching cloths after CHX applied After CHX applied stump was kept without touching with cloths Frequency Percent Yes 331 96.1 No 9 2.7 Don't Know 4 1.2 Total 345 100.0 Among 481 RDWs, 83% (399) received the CHX during their last pregnancy (table 4.15). Table 4.15: Percent distribution of RDWs who received CHX in their last pregnancy Did you get or buy CHX in last pregnancy Frequency Percent Yes 399 83.0 No 82 17.0 Total 481 100.0 Among 399 RDWs who received CHX in their last pregnancy, 314 (78.6%) received from FCHVs followed by health facilities 69 (17.3%). Table 4.16: Percent distribution of RDWs from whom/where did they receive or buy the CHX in their last pregnancy Where did you get the CHX Frequency Percent FCHV 314 78.6 Health Facility 69 17.3 Shop - CHX separately 7 1.8 Shop - CHX with CHDK 4 1.0 Others 4 1.0 Total 399 100.0 The FCHV and health workers explained the importance of CHX to pregnant women during the supply of CHX in their last pregnancy. Out of 494 RDWs, 76.5% (378) reported that CHX prevents umbilicus stump infection and 19.6% (97) said it prevents newborn deaths. Table 4.17: Percent distribution of RDWs who received advices from health workers and FCHVs on the importance of CHX application during in their last pregnancy orientation 17 Why advises were you told to apply CHX Reasons Frequency Percent Prevent umbilicus stump infection 378 76.5 Prevent Death 97 19.6 Others 7 1.4 No any reason told 4 0.8 Don't remember 8 1.6 494 100 Among 399 RDWs receiving CHX in their last pregnancy where asked when did you get the CHX. The 65.2% (260) reported that they got CHX in the 8th month (mode and median) of pregnancy period. The mean is 8.18 month with standard deviation of 0.849 months (23 days). The CHX should be given to pregnant women during the 8th months gestation as per CHX guidelines. 29.6% (118) RDW received the CHX in 9th month of gestation in their last pregnancy. (table # 4.18) Table 4.18: Percent distribution of RDWs as of time period of CHX received during in their last pregnancy When you received the CHX during pregnancy N 399 Mean (months) 8.18 Median (months) 8 Mode (months) 8 Standard deviation (months) .849 When you received the CHX during the last pregnancy Pregnancy period Frequency Valid Percent 1 1 .3 3 2 .5 4 2 .5 6 8 1.9 7 6 1.6 8 260 65.2 9 118 29.6 10 1 .3 Total 399 100.0 Among the 345 RDWs whose newborns were applied with CHX, 99.2% reported washing hand before applying the CHX to newborn, 86% applied by fingers, 85.2% kept the CHX applied stump without touching cloths and 66.2% applied nothing in the umbilicus stump except CHX and kept it clean and dry. Table 4.19: Percent distribution of RDWs as of process of CHX application during in their last pregnancy The Process of CHX application 18 n=345 (multiple answers) Frequency Percent Hand washing before applying CHX 342 99.2 Apply CHX on and around the stump by finger 297 86.0 After CHX applied stump was kept without touching with cloths 294 85.2 Nothing to apply anything except CHX then kept clean and dry 228 66.2 Among the 488 newborns, only 2.7% (13) had some problem on the umbilicus. 11 have umbilicus infections where as 2 have delay fall down of stump. After infection of the umbilicus stump, the newborn reapplied the CHX in one case, 7 visited to health facility or health workers, 4 took advices from medical shop and one treated at home. Figure 4.20: Percent distribution of newborns whose umbilicus stump has some problem Any problem in stump within 28 days of child birth n = 488 Frequency Percent Yes 13 2.7 No 475 97.3 Total 488 100.0 Figure 4.21: Number distribution of RDWs action taken after newborns’ umbilicus stump has some problem Problem on Umbilicus Stump within 28 days 3% 97% Yes No 19 The application of CHX to newborn’s umbilicus stump of member of pregnant women group (PWG) is 87.3% where as in non PWG members it is only 79.2%. The PWG members did not practise harmful application on umbilicus stump like cow dung, oil and turmeric. Figure 4.22: Percent distribution of newborns applying various things on umbilicus stump among PWG and Non PWG Out of 486 RDWs, there 31.5% are pregnant women group (PWG) members while 68.5% are not the members of PWG as shown in the table below. Table 4.23: Percent distribution of RDWs by member of PWG Things applied on Umbilicus Stump (PWG and Non PWG) 1.4 12.7 0.4 0.4 79.2 0 4.2 1.8 10.4 00 87.3 1.5 0.7 0.0 20.0 40.0 60.0 80.0 100.0 Oil Ointment/powder Cow Dung Turmeric Powder CHX Others Don't Know Percent Non PWG Percent PWG Percent Action after Umbilicus Stump problem 1 7 4 1 CHX reapplied Visited Health facility or HW Taken advice from Medical shop Treated at Home 20 Are you member of pregnant women group? Yes 153 31.5 No 333 68.5 Total 486 100.0 Table 4.24: Comparison between Pregnant Women Group (PWG) member and CHX applied: CHX applied Yes No Total PWG member Yes 36 12 48 No 87 38 125 Total 123 50 The table is shows that odd ratio is 1.3 which means 1.3 times more CHX is applied among the newborns of PWG members than non-PWG members in Parsa. Conclusion: Within one year of application of chlorhexidine ointment on umbilicus stump of newborns pilot programming in Parsa district, the coverage is 82.7% (345/417). The compliance (application of whole tube of Kawach at single event in the cord stump and surrounding areas of newborn within 2 hours of cord cut among those who applied Kawach) is almost to coverage 66.4% (229/345). The cost can be minimised by integrating the training of CHX with CBNCP training. The distribution can be increased through joint collaboration by supplying from health facilities, hospitals and birthing centres and at community by FCHVs in the pregnant women group meeting. Recommendation: The application of chlorhexidine ointment on umbilicus stump of newborns programming should be scaled up to other districts of Nepal by integrating other programs by existing government health system and scaling up the pregnant women groups approach for high coverage among marginalized communities. 21 Annex‐1: Sample frame of Parsa district Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 1 286 Thori 1 Nirmal Basti 1 1 287 Thori 2 Nirmal Basti 2 1 288 Thori 3 Nirmal Basti 3 1 289 Thori 4 Nirmal Basti 4 1 290 Thori 5 Nirmal Basti 4 1 291 Thori 6 Nirmal Basti 5 1 292 Thori 7 Nirmal Basti 6 1 293 Thori 8 Nirmal Basti 6 1 294 Thori 9 Nirmal Basti 6 1 295 Thori 10 Nirmal Basti 7 1 296 Thori 11 Nirmal Basti 8 1 297 Thori 12 Thori 1 1 298 Thori 13 Thori 1 1 299 Thori 14 Thori 3 1 300 Thori 15 Thori 5 1 301 Thori 16 Thori 6 1 302 Thori 17 Thori 7 1 303 Thori 18 Thori 8 1 304 Thori 19 Thori 9 2 305 Sedhwa 1 Bijbaniya 3 2 306 Sedhwa 2 Bijbaniya 7 2 307 Sedhwa 3 Jeetpur 2 2 308 Sedhwa 4 Jeetpur 6 2 309 Sedhwa 5 Jeetpur 9 2 310 Sedhwa 6 Mahadev patti 2 2 311 Sedhwa 7 Mahadevpatti 5 2 312 Sedhwa 8 Mahadevpatti 7 2 313 Sedhwa 9 Pidari Guthi 1 2 314 Sedhwa 10 Pidari Guthi 6 2 315 Sedhwa 11 Pidari Guthi 8 2 316 Sedhwa 12 Sankarsaraiya 3 2 317 Sedhwa 13 Sankarsaraiya 6 2 318 Sedhwa 14 Sedhwa 1 2 319 Sedhwa 15 Sedhwa 6 2 320 Sedhwa 16 Subarnapur 2 2 321 Sedhwa 17 Subarnapur 6 2 322 Sedhwa 18 Supauli 1 2 323 Sedhwa 19 Supauli 7 3 324 Nichuta 1 Auraha 5 3 325 Nichuta 2 Auraha 9 3 327 Nichuta 4 Gaadi 3 3 328 Nichuta 5 Gaadi 7 3 329 Nichuta 6 Kauwabankataiya 4 3 330 Nichuta 7 Lakhanpur 1 3 326 Nichuta 7 Dewarbana 3 3 331 Nichuta 8 Lakhanpur 7 3 332 Nichuta 9 Mahuwan 2 3 333 Nichuta 10 Mahuwan 8 3 334 Nichuta 11 Masihani 3 22 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 3 335 Nichuta 12 Masihani 8 3 336 Nichuta 13 Nichuta 4 3 337 Nichuta 14 Nichuta 8 3 339 Nichuta 16 Paterwa Sugauli 6 3 340 Nichuta 17 Sonbarsa 1 3 341 Nichuta 18 Sonbarsa 5 3 342 Nichuta 19 Sonbarsa 8 3 388 Nichuta 115 Paterwa Sugauli 3 4 343 Bagahi 1 Bagahi 2 4 344 Bagahi 2 Bagahi 6 4 345 Bagahi 3 Basdilwa 1 4 346 Bagahi 4 Basdilwa 5 4 347 Bagahi 5 Basdilwa 8 4 348 Bagahi 6 Belwa Parsauni 2 4 349 Bagahi 7 Belwa Parsauni 4 4 350 Bagahi 8 Belwa Parsauni 7 4 551 Bagahi 9 Belwa Parsauni 9 4 352 Bagahi 10 Birwaguthi 1 4 371 Bageshwori 10 Harpur 8 4 353 Bagahi 11 Birwaguthi 2 4 505 Bagahi 11 Maniyari 1 4 354 Bagahi 12 Biruwaguthi 3 4 355 Bagahi 13 Biruwaguthi 5 4 356 Bagahi 14 Biruwa Guthi 8 4 357 Bagahi 15 Chorni 3 4 398 Bagahi 16 Chorni 7 4 359 Bagahi 17 Chorni 8 4 360 Bagahi 18 Chorni 9 4 361 Bagahi 19 Lal Parsa 5 5 362 Bageshwori 1 Bagbana 4 5 363 Bageshwori 2 Bagbana 7 5 364 Bageshwori 3 Bagbana 9 5 365 Bageshwori 4 Bageshwori Tritona 2 5 366 Bageshwori 5 Bageshwori 6 5 367 Bageshwori 6 Bahuwari Pidari 1 5 368 Bageshwori 7 Bahuwari Pidari 5 5 369 Bageshwori 8 Bahuwari Pidari 9 5 370 Bageshwori 9 Harpur 4 5 372 Bageshwori 11 Madhuban Mathal 1 5 373 Bageshwori 12 Madhuban Mathal 4 5 374 Bageshwori 13 Madhuban Mathal 7 5 375 Bageshwori 14 Panchrukhi 2 5 376 Bageshwori 15 Panchrukhi 6 5 377 Bageshwori 16 Sakhwa Parsauni 1 5 378 Bageshwori 17 Sakhwa Parsauni 4 5 379 Bageshwori 18 Sakhuwa Parsauni 7 5 380 Bageshwori 19 Sakhuwa Parsauni 9 6 381 Bishrampur 1 Bahuawra Bhatta 1 6 382 Bishrampur 2 Bahuawra Bhatta 4 6 383 Bishrampur 3 Bahuawra Bhatta 7 6 384 Bishrampur 4 Bairiya Birta Da.Pu 3 23 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 6 385 Bishrampur 5 Bairiya Birta Da.Pu 6 6 386 Bishrampur 6 Bairiya Birta Da.Pu 9 6 387 Bishrampur 7 Bishrampur 4 6 388 Bishrampur 8 Bishrampur 6 6 389 Bishrampur 9 Gamhariya 1 6 390 Bishrampur 10 Gamhariya 6 6 391 Bishrampur 11 Nagardaha 3 6 392 Bishrampur 12 Nagardaha 9 6 393 Bishrampur 13 Ramnagari 7 6 394 Bishrampur 14 Udayapur Ghurmi 3 6 395 Bishrampur 15 Udaypur Ghurmi 6 6 396 Bishrampur 16 Udaypur Ghurmi 9 6 397 Bishrampur 17 Bahuratar 3 6 398 Bishrampur 18 Bhauratar 6 6 399 Bishrampur 19 Bhauratar 8 7 400 Bhikhampur 1 Bhikhampur 1 7 401 Bhikhampur 2 Bhikhampur 3 7 402 Bhikhampur 3 Bhikhampur 5 7 403 Bhikhampur 4 Bhikhampur 6 7 404 Bhikhampur 5 Bhikhampur 9 7 405 Bhikhampur 6 Ghoddaur Pipra 2 7 406 Bhikhampur 7 Ghoddaur Pipra 5 7 407 Bhikhampur 8 Ghoddaur Pipra 8 7 408 Bhikhampur 9 Ghoddaur Pipra 9 7 409 Bhikhampur 10 Jagarnathpur Sira 1 7 410 Bhikhampur 11 Jagarnathpur Sira 2 7 411 Bhikhampur 12 Jagarnathpur Sira 4 7 412 Bhikhampur 13 Jagarnathpur Sira 6 7 413 Bhikhampur 14 Jagarnathpur sira 7 7 414 Bhikhampur 15 Jagarnathpur sira 8 7 415 Bhikhampur 16 Janaki Tola 1 7 416 Bhikhampur 17 Janaki Tola 4 7 417 Bhikhampur 18 Janaki tola 6 7 418 Bhikhampur 19 Janaki tola 8 8 419 Langadi 1 Vishwa 3 8 420 Langadi 2 Vishwa 8 8 421 Langadi 3 Dhobini 3 8 422 Langadi 4 Dhobini 8 8 423 Langadi 5 Hariharpur 3 8 424 Langadi 6 Hariharpur 8 8 425 Langadi 7 Jaymangalapur 2 8 426 Langadi 8 Jaymangalapur 6 8 427 Langadi 9 Langadi 2 8 428 Langadi 10 Langadi 7 8 429 Langadi 11 Mirjapur 3 8 430 Langadi 12 Mirjapur 8 8 431 Langadi 13 Mudali 3 8 432 Langadi 14 Mudali 7 8 433 Langadi 15 Sambhauta 1 8 434 Lan gadi 16 Sambhauta 5 8 435 Langadi 17 Sambhauta 8 24 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 8 436 Langadi 18 Tulsibarba 3 8 437 Langadi 19 Tulsibarba 8 9 438 Pokhariya 1 Basantapur 2 9 439 Pokhariya 2 Basantapur 4 9 440 pokhariya 3 Basantapur 6 9 441 pokhariya 4 Basantapur 8 9 442 Pokhariya 5 Bairiya Birta Na. Ta.Ja 2 9 443 Pokhariya 6 Bairiya Birta Na. Ta.Ja 5 9 444 Pokhariya 7 Govindapur 1 9 445 Pokhariya 8 Govindapur 7 9 446 Pokhariya 9 Hariharpur Birta 3 9 447 Pokhariya 10 Pokhariya 1 9 448 Pokhariya 11 Pokhariya 3 9 449 Pokhariya 12 Pokhariya 5 9 450 Pokhariya 13 Pokhariya 7 9 451 Pokhariya 14 Sibarba 1 9 452 Pokhariya 15 Sibarba 4 9 453 Pokhariya 16 Sibarba 7 9 454 Pokhariya 17 Sibarba 9 9 455 Pokhariya 18 Srisiya Na Ta Ja 4 9 456 Pokhariya 19 Srisiya Na Ta Ja 9 10 457 Pakaha 1 Bhedihari 3 10 458 Pakaha 2 Bhedihari 6 10 459 Pakaha 3 Bedihari 9 10 461 Pakaha 5 Dhore 1 10 460 Pakaha 6 Biranchi Barba 4 10 462 Pakaha 6 Dhore 5 10 463 Pakaha 7 Dhore 9 10 464 Pakaha 8 Lahawar Thakri 6 10 664 Pakaha 8 Lahawar Thakri 6 10 465 Pakaha 9 Lahawar Thakri 9 10 465 Pakaha 9 Lahawar Thakri 9 10 466 Pakaha 10 Pakaha Mainpur 6 10 467 Pakaha 11 Prasauni Bhatta 1 10 468 Pakaha 12 Prasauni Bhatta 4 10 469 Pakaha 13 Prasauni Bhatta 7 10 470 Pakaha 14 Parsurampur 4 10 471 Pakaha 15 Sabaithwa 1 10 472 Pakaha 16 Sabaithwa 5 10 473 Pakaha 17 Sabaithwa 9 11 476 Srisiya 1 Alau 1 11 477 Srisiya 2 Alau 4 11 478 Srisiya 3 Alau 6 11 479 Srisiya 4 Alau 9 11 480 Srisiya 5 Amar Patti 5 11 481 Srisiya 6 Amar Patti 9 11 482 Srisiya 7 Bindabasini 6 11 483 Srisiya 8 Bindabasini 9 11 484 Srisiya 9 Harpatgunj 4 11 485 Srisiya 10 Harpatgunj 9 11 486 Srisiya 11 Jhauwa Guthi 4 25 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 11 487 Srisiya 12 Jhauwa Guthi 7 11 488 Srisiya 13 Ramgadwa 1 11 489 Srisiya 14 Ramgadwa 6 11 490 Srisiya 15 Srisiya Kahlwa Tola 2 11 491 Srisiya 16 Srisiya Kahlwa Tola 6 11 492 Srisiya 17 Srisiya Khalwa Tola 9 11 493 Srisiya 18 Sugauli Birta 4 11 494 Srisiya 19 Sugauli Birta 6 12 495 Birgunj 1 Bhawanipur 2 12 496 Birgunj 2 Bhawanipur 4 12 497 Birgunj 3 Bhawanipur 5 12 498 Birgunj 4 Bhawanipur 7 12 499 Birgunj 5 Bhawanipur 9 12 500 Birgunj 6 Lipnibirta 2 12 501 Birgunj 7 Lipnibirta 3 12 512 Birgunj 8 Prasauni Birta 6 12 502 Birgunj 8 Lipni Birta 5 12 513 Birgunj 9 Prasauni Birta 8 12 503 Birgunj 9 Lipni Birta 6 12 504 Birgunj 10 Lipni Birta 8 12 506 Birgunj 12 Maniyari 3 12 507 Birgunj 13 Maniyari 5 12 508 Birgunj 14 Maniyari 7 12 509 Birgunj 15 Maniyari 8 12 510 Birgunj 16 Prasauni Birta 1 12 511 Birgunj 17 Prasauni Birta 3 13 514 Birgunj NP 1 Birgunj U.M.N.P 1 13 515 Birgunj NP 2 Birgunj U.M.N.P 2 13 516 Birgunj NP 3 Birgunj UMNP 3 13 517 Birgunj NP 4 Birgunj U.M.N.P 4 13 518 Birgunj NP 5 Birgunj U.M.N.P 6 13 519 Birgunj NP 6 Birgunj UMNP 9 13 520 Birgunj NP 7 Birgunj UMNP 10 13 521 Birgunj NP 8 Birgunj UMNP 11 13 522 Birgunj NP 9 Birgunj UMNP 13 13 523 Birgunj NP 10 Birgunj UMNP 13 13 524 Birgunj NP 11 Birgunj UMNP 14 13 525 Birgunj NP 12 Birgunj UMNP 14 13 526 Birgunj NP 13 Birgunj UMNP 15 13 527 Birgunj NP 14 Birgunj UMNP 16 13 528 Birgunj NP 15 Birgunj UMNP 16 13 529 Birgunj NP 16 Birgunj UMNP 17 13 530 Birgunj NP 17 Birgunj UMNP 18 13 531 Birgunj NP 18 Birgunj UMNP 19 13 532 Birgunj NP 19 Birgunj UMNP 19 26 Annex‐2: Survey instrument – questionnaire for Chlorhexidine (CHX and brand name in Nepal is Kawach) To be used for confidential interview only A SURVEY ON COVERAGE OF CHX AND OTHER MNH ACTIVITIES AT COMMUNITY LEVEL-2011 QUESTIONNAIRE FOR RECENTLY DELIVERED WOMEN WITH LESS THAN 6 MONTHS (MOHP/ PLAN NEPAL) FA no. LQAS Record no INTRODUCTION AND CONSENT Namaste! My name is _____. I am from DPHO, Parsa or Plan Nepal, which is conducting a study for the Ministry of Health and Population/Government of Nepal. The MOHP has been helping pregnant women, mothers, and newborns in this district with the objectives of improving maternal, and child health status. We are here to find out about the health of mothers and newborns to help you and your community to keep mothers and children healthy. We would very much appreciate your participation in this survey. This information will help the MOHP to improve its program in the districts. The survey usually takes around one hour. I assure you that your name will not be shared with anyone else and your answers to my questions will be combined with answers from many other people so that no one will know that the answers you give me today belong to you. Your privacy is protected, and I assure that your answers will be kept confidential. Your participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important. May I proceed with the questions? RESPONDENT AGREES TO BE INTERVIEWED…………………… 1 → START INTERVIEWING RESPONDENT DOES NOT AGREE TO BE INTERVIEWED…... 2 → THANK THE RESPONDENT & END INTERVIEW 1) District:__________________________________…… 2) Name & code of VDC: _________________________....... 3) Ward Number ……………………………………........ 4) Village/ Town name:______________________________ 5) LQAS number. …………………………………....... 6) Household Number............………………………….. 7) Name of the household head:____________________ 8) Name of the respondent:________________________ Interview Visits 1 2 3 Date [DD/MM/YY] / / / / / / Interviewer's Name: Result Next Visit : DATE [DD/MM/YY] / / / / 27 TIME *Result Codes: 1 = Interview completed 2 = Respondent refused to be interviewed 3 = Time and date set for later 4 = Respondent not at home 5 = Other (specify): _________________________ a) Section 9: Immediate Newborn Care Interviewer: “Now, I would like to ask you about less than 6 months child’s related questions about the care of your child after delivery.” Q. # Question Codes Go to Q. 901 Check Q A and circle the appropriate response below: The recent delivery resulted in a live birth………………………………………………..1 The recent delivery resulted in a still birth………………………………………………..2  End Interviewer: “Now, I would like to ask you some specific questions pertaining to the baby immediately following the delivery.” 902 Was a Clean Home Delivery Kit used during delivery? (Show CHDK) Yes ........................................................ 1 No ......................................................... 2 Don't know ............................................ 8  907 903 What instrument was used to cut (name)’s umbilical cord? New Blade ............................................. 1 Boiled Blade ......................................... 2 Unboiled used blade............................... 3 Knife ...................................................... 4 Grass Cutter (hansiya) .......................... 5 Weapon (khukuri) ................................. 6 Scissor .................................................... 7 Other (specify) ________________............96 Don’t know ......................................... 98 904 Was the instrument used to cut the cord boiled prior to use? Yes ......................................................... 1 No .......................................................... 2 Do not know/ cannot remember ............. 8 905 What was used to tie the cord? New string or thread ............................. 1 Boiled string or thread .......................... 2 Unboiled used string or thread .............. 3 Other (specify)_________________............6 Don’t know ........................................... 8 906 On what surface was the cord cut on? Plastic disc ............................................... 1 Metal coin ................................................ 2 Wood........................................................ 3 Other (specify)__________________...........6 Nothing. ................................................... 7 Don’t know .............................................. 8 907 How long after the birth of the baby the cord was cut? Minutes.................................. . Don't remember....................................998 908 Did the person who handled the baby, assisting Yes ......................................................... 1 28 Q. # Question Codes Go to Q. with the delivery, washed hands with soap and water first? No .......................................................... 2 Don't know ............................................. 8 909 Did anybody apply anything on the stump after the baby’s cord was cut? Yes ......................................................... 1 No .......................................................... 2 Don't know ............................................. 8 911 910 What did they apply after the cord was stumped ? Prompt: Anything else? (CIRCLE ALL RESPONSES GIVEN) Oil ........................................................... 1 Ash .......................................................... 2 Sindoor .................................................... 3 Powder .................................................... 4 Animal dung ........................................... 5 Turmeric/turmeric powder ................. .....6 Ghyu ...................................................... 7 Kawach...................................................... ...8 Other Ointment-------------------------------- --9 Other (specify) _________________ ..96 Don’t know ........................................... 98 912 911 After the cord of your baby was cut was Chlorhexidine (CHX and brand name in Nepal is Kawach) applied on the umbilical cord stump? SHOW KAWACH TUBE Yes ...………………………...……..…. 1 No ……………………………...……... 2 Don't Know.............................................8  920  920 912 How long after the cord cut, was Kawach first applied? Immediately after cord was cut............996 Minutes ………...................... Don't Know..........................................998 913 Who applied Kawach on the umbilical cord stump of your baby? Mother…….............................................1 Family member........................................2 FCHV…………………….......................3 Health worker..........................................4 TBA……………......................................5 Other (specify)_______________............6 914 Did the person applying Kawach wash hand with soap and water before applying Kawach? Yes ...……………………………....…. 1 No ………………………………..…... 2 Don't Know.............................................8 915 Was Kawach applied on stump only or also in the surrounding area of the stump? Stump only ...……………………....…. 1 Surrounding area only…………....…... 2 Both in stump and surrounding area......3 Don't Know............................................8 916 Was the whole amount of the Kawach in the tube applied at a time on your baby's stump or only some amount from the tube applied? Whole content of the tube......................1 Part of the content of the tube........ .......2 Don't Know............................................8  918  918 917 Why was the whole amount of Kawach in the not applied at a time? Probe: Any other reason? (CIRCLE ALL RESPONSES GIVEN) Tube cream is more for one application...1 Thought more than one application is effective.........................................2 Did not know that whole content of the tube has to be applied once.....3 Other (specify)_______________..........6 Don't Know............................................8 918 How many times Kawach was applied on umbilical stump of your baby? Times............................................. . Don't Know...........................................8 919 After applying Kawach, was the cord stump kept untouched by clothes for some time? Yes ...……………………………....…. 1 No …………………………………..... 2 29 Q. # Question Codes Go to Q. Don't Know............................................8 920 During your last pregnancy, were you given or did you buy Kawach? Yes …………………………………….. 1 No …………………………….………. 2  925 921 Where did you obtain Kawach from? FCHV.....................................................1 Health facility.........................................2 Bought from a shop separately...............3 Bought from a shop in a CHDK.............4 Other (Specify)______________...........6 922 What reasons were you told for using Kawach? Probe: Any other reason? (CIRCLE ALL RESPONSES GIVEN) To prevent infection of umbilical cord.....1 To reduce risk of death..............................2 No reason was told.....................................3 Other (specify)________________...........6 Don't remember.........................................8 923 At what month of pregnancy did you receive Kawach? Months......................................... (currently running month) 924 Did the person giving you Kawach tell you the following while giving you Kawach ? YES NO Told to wash hand with soap and water before applying Kawach 1 2 Told to spread Kawach by finger 1 2 Told to, keep the stump untouched by clothes for sometime after applying Kawach 1 2 Told not to apply anything on the cord stump other than Kawach but keep it dry and clean 1 2 925 Check Q 910, 911, 922 and 923: Received Kawach but did not apply…......1 Received Kawach and applied..................2 Not received Kawach and not applied.......3 Not received Kawach but applied.............4 927 926 You had received Kawach from ...... (source from Q 921) but you did not apply on the cord stump of your baby. Why did not you apply Kawach on your baby's stump? Delivered at a health facility...................1 Family members/others were against of it.........................................2 Forgot to apply........................................3 Lost Kawach...........................................4 Did not think it was useful or necessary.5 Other (Specify)________________........6 Don't know..............................................8. 927 Was there any problem on the cord stump of your baby within 28 days of birth? Yes ...……………………………..…... 1 No …………………………………..... 2  930 928 What type of problems were seen? Probe: Any other problem? Infection on the cord stump....................1 Delay in cord fall....................................2 Other (Specify)______________...........6 929 What did you do when the baby had problem in cord stump? Used Kawach again................................1 Visited a health facility/health worker...2 Consulted a pharmacy............................3 Home remedy.........................................4 Other (Specify)______________...........6 Did nothing..............................................7 930 How many days after the cord was cut, it fell? Days........................................... Don't Know…………………..…..…..98 931 In your opinion why Kawach should be applied To prevent infection of 30 Q. # Question Codes Go to Q. on the baby's stump after cutting the umbilical cord? Probe: Any other reason? (CIRCLE ALL RESPONSES GIVEN) umbilical cord....................................1 To reduce risk of death.........................2 FCHV/health worker advised to apply...3 Other (specify)________________.........6 Don't know.............................................8 932 Are you member of PWG during pregnancy? Yes ......................................................... 1 No .......................................................... 2 Thank you for your time and cooperation in answering my questions. The information that you have provided will help us to improve the health of women and children throughout Nepal. 31 Annex‐3: Chlorhexidine operational Research Time Line of Parsa district Activities Date Remarks Approval from Nepal Health Research Council (NHRC) for program piloting of the CHX Jan 22, 2009 Development of concept paper Jun 30, 2009 Approval from USAID Nepal July 17, 2009 E-mail of Deepak Paudel USAID Nepal District selection letter from Child Health Division (CHD) to Plan Nepal July 29, 2009 CHX TWG recommend for program piloting to Department of Health Services (DoHS) for approval August 4, 2009 (20 Shrawan 2066 ) CHX TWG MOHP approved for piloting for four districts including Parsa (other districts are Banke, Bajhang and Jumla) Nov 4, 2009 (18 Kartik 2066) approved by Director General of DoHS, MOHP CHX orientation 13 Oct 2009 CHX – TOT 14 Oct 2009 CHX training to hospital staff 19, 20 and 22 Nov 2009 CHX distribution 19 Nov 2009 onwards CHX training to HW Jan 2010 CHX training to VHW/MCHW Nov & Dec 2009 CHX training to FCHV (integration with CB-NCP training) 25 Jan 2010 – 1 Sept 2010 CHX social market in CHDK in Parsa by CRS 8 to 16 Feb 2010 In 100 Outlets as per attached file list CHX data collection for final evaluation 494 RDWs July 2011 CHX data finding sharing at national level stakeholders Sept 23, 2011 Final evaluation report Oct 2011 32 Annex‐4: Leaflet for Chlorhexidine operational Research in Parsa district Sep 2011 Major findings of Chlorhexidine (Kawach) coverage and compliance study 2011, Parsa district Background: urrent neonatal mortality rate of 33 per 1000 live births in Nepal translates to around 23,000 neonatal deaths per annum. Studies have shown that immediate cleansing of umbilical cord with 4 per cent Chlorhexidine (CHX) reduces the cord infection and reduces neonatal mortality by about 23 per cent. After the results of a study to compare efficacy of Chlorhexidine lotion versus aqueous and another study to examine acceptability and case in the use of two different CHX formulations (liquid or lotion) for prophylactic application on freshly cut umbilical cord stumps in Nepal the Department of Health Services (DoHS) endorsed a pilot CHX program in four districts (Banke, Bajhang, Jumla and Parsa).   In Parsa district, program was initiated through district level orientation on Oct 2009 and continued provide trainer of training to district supervisors and health facility staff as well as training to Village Health Worker and Maternal and Child Health Worker separately. The CHX training program is aligned with Community Based Newborn Care Program training package at Female Community Health Volunteer has completed on September 2010. Study objectives and methods: The overall objective of the study was to measure the coverage and compliance of Kawach at community level in Parsa district. The data was collected through Lot Quality Assurance Sampling (LQAS) technique. Total 494 (13 SAs X 38) recently delivered women (RDW) defined as married women of age group 15‐49 who had given a live birth and were living in the family with the baby were interviewed using a structured questionnaire in the district. Systematic random sampling design was used through LQAS methods by dividing the areas into 13 supervision areas (SAs) where 38 RDWs were interviewed per supervision area in July 2011. Major findings: Antenatal and delivery care: 98 per cent RDW of Parsa district were immunized against tetanus toxoid vaccine, and similar 78 per cent of RDW had taken iron/folic acid tablets during their most recent pregnancy. More than 60 per cent of the RDW of Parsa had delivered by skilled provider (doctor or nurse or HA or AHW or ANM). About 88.2 per cent person had washed their hand by birth attendant before touching new born. Similarly, 94.4 per cent had washed their hand before apply CHX and 96.4 per cent full tube of Kawach is apply to newborn baby. Umbilical cord care: About 83.0 per cent RDW of Parsa district reported to have their newborns’ umbilical cord cut with safe instruments Child Delivery Kit (CDK). RDWs reported 78.6 per cent got CHX by Female Community Health Volunteer (FCHV), 17.3 per cent by health facilities, 1.8 per cent from shop‐CHX separately, 1.0 per cent from shop‐CHX with CDK and remaining 1.0 per cent by others.   The large volume of pregnant women 65.2 per cent were received CHX in eight months of her pregnancy period and 29.6 per cent in nine months. Coverage and compliance of Kawach: The application of Kawach in the stump of newborns was 82.7 per cent in Parsa district. The compliance (application of whole tube of Kawach at single C Table: other findings of Kawach Indicators (as percent of) Parsa Person who applied Kawach on the umbilical cord stump Health worker 52.8 FCHV 33.7 RDW (2.2)/family members (6.8) 9.0 Others (TBA 3.4) 4.6 Person applying Kawach (CHX) washed hand (among home deliveries) 94.4 Newborn who received Kawach application both in stump and surrounding area 89.0 Newborn who received full tube of Kawach application 96.4 Newborns who received Kawach application on time only 99.5 33 event in the cord stump and surrounding areas of newborn within 2 hours of cord cut among those who applied Kawach) is almost to coverage 66.4%. Comparison between Pregnant Women Group (PWG) member and CHX applied: CHX applied Yes No Total PWG member Yes 36 12 48 No 87 38 125 Total 123 50 The table is shows that odd ratio is 1.3 times more CHX applied by PWG member than non‐PWG member. Conclusion: Within one year of application of chlorhexidine ointment on umbilicus stump of newborns pilot programming in Parsa district, the coverage is 82.7% (345/417). The compliance (application of whole tube of Kawach at single event in the cord stump and surrounding areas of newborn within 2 hours of cord cut among those who applied Kawach) is almost to coverage 66.4% (229/345). The cost can be minimised by integrating the training of CHX with CBNCP training. The distribution can be increased through joint collaboration by supplying from health facilities, hospitals and birthing centres and at community by FCHVs in the pregnant women group meeting.   Recommendation: The application of chlorhexidine ointment on umbilicus stump of newborns programming should be scaled up to other districts of Nepal by integrating other programs by existing government health system and scaling up the pregnant women groups approach for high coverage among marginalized communities.   Annex 12 Nepal LIBON Project – Special Reports Annex 12: Nepal LIBON Project – Special Reports and Presentations Nepal LIBON Project’s Pregnant Women’s Groups (PWG) approach was presented at: (a) Global Health Conference (GHC) in 2009 and (b) American Public Health Association (APHA) in 2011. An article on PWGs was also published in the Indian Journal of Medical Research (IJMR) in January 2011. In addition, Plan Nepal created documents on the impact of the project for publicity and dissemination purposes. (a) GHC 2009 Plan Nepal Pregnant Women’s Groups and the Impact on Newborn's Mortalities in Bara District, Nepal Presented at the 36th Annual International Conference on Global Health “New Technologies + Proven Strategies = Healthy Communities” May 26-30, 2009, Washington DC, USA Bhagawan Das Shrestha, MPH, Project Coordinator Local Innovation for Better Outcomes for Neonates (LIBON) Project, Plan Nepal Web link http://www.globalhealth.org/conference_2009/view_top.php3?id=954 "D5: Better Beginnings: Improving Neonatal Outcomes / Bhagawan Das Shrestha Presentation" http://www.globalhealth.org/conference_2009/presentations/d5_shrestha.pdf Background Nepal’s under-five, infant and neonatal mortality rates are 61, 48 and 33 per 1,000 live births, respectively (DHS 2006). Over 80% of women in the Bara District, central Terai region, deliver at home without a skilled birth attendant. In 2001 Plan Nepal began a USAID-funded Child Survival project in partnership with the Nepal Ministry of Health and Population (MOHP) and Non-Governmental Organizations in Bara District to reduce the maternal and under-five child mortality rates in all 98 Village Development Committees (VDC). This impact study was conducted in June 2006. That project had 4 components: 1. Behavioral: Mothers of CU5 will be practicing healthy behaviors and seeking medical care from trained providers. The vehicle for this IEC/BCC component was Pregnant Women’s Groups or PWG’s (there were over 430 by 2006). 2. Increased access to services: Communities and families will have increased access to health education, quality care and essential medicines. 3. Quality of care by service providers (MoH and FCHV’s) will be practicing appropriate integrated management of sick children, deliver quality family planning and maternal and newborn preventive care. 4. Institutional strengthening. Annex 12 Nepal LIBON Project – Special Reports Intervention The objective of this sub-study on Component 1 was to examine the relationship between Pregnant Women’s Groups (PWG) members and non-members on maternal and under￾five child mortality rates in the perinatal (from 28 weeks of gestation to 7 days of birth), neonatal (0-28 days), and infant period (1 year). The PWG are led by a cadre of respected and trained Female Community Health Volunteers (FCHV) who are officially recognized by the Nepal MOHP. Consenting pregnant women joined a PWG nearest to their home and met monthly to learn about maternal and newborn care and danger signs of newborn, during pregnancy, delivery and post partum. Mothers who joined the PWG received iron and folic acid tablets, two TT injections, and developed a birth delivery plan (transportation, money and 3 persons for blood transfusion) that encouraged antenatal visits and delivery in a health clinic with a skilled birth attendant. In some PWGs, members of the PWG voluntarily contributed to a fund for transportation to a clinic in which members could borrow in emergencies. Pregnant women in the district who did not join a PWG were compared to pregnant women who attended PWG meetings prior to delivery. Methodology The design was a cross-sectional comparative study and the data were collected by the Motherhood Method – a variant of Participatory Community Survey (Maskey and DesChene, 2005). The study population was 110,000 women of reproductive age and 80,000 children under-five. The data were collected for 2 years from July 2003 to July 2005. The 2001 Nepal National Demographic and Health Survey report was used for baseline mortality data. 2001 NDHS national mortality rates 2006 NDHS national data mortality rates IMR 61 /1000 live birth IMR 48 /1000 live birth NMR 39 /1000 live birth NMR 33 /1000 live birth MMR 539 /100,000 total birth MMR 281 /100,000 total birth Results There was a 50–60 percent statistically significant reduction in the maternal, infant, neonatal, and early neonatal mortality rates over a 5-year period (2001-2006) in members of PWG compared to non-members in Bara District. PWG members that are linked with a referral network to health facilities have better health outcomes compared to pregnant women who did not attend PWG meetings. Comparison of Mortality Rates in PWG and Non-PWG Members: Mortality rates PWG Non-PWG Odds Ratio (95% CI) p-value IMR / 1,000 LB 25.2 57.9 2.38 (1.92-2.95) <0.0001 NMR / 1,000 LB 18.9 39.6 2.14 (1.67-2.74) <0.0001 ENMR/ 1,000 LB 16.8 34.8 2.10 (1.63-2.75) <0.0001 Annex 12 Nepal LIBON Project – Special Reports PMR/ 1,000 LB 26.1 53.4 2.11 (1.71-2.60) <0.0001 MMR / 100,000 279.7 608.7 2.18 (1.14-2.93) <0.02 ENMR: Early neonate mortality rate – First week of life (0-7 days) PMR: Perinatal Mortality Rate –28 week of gestation to 7 days of life Conclusion: The simultaneous empowerment of Pregnant Women Groups and the upgrading of the health facilities, both linked to the monthly data analysis and planning meetings at local levels, was very successful to reduce infant and neonatal mortality rates. These results contributed to the design (by the Nepalese government) of a nationwide Community Based Newborn Care Package. Moreover, Plan was awarded a follow-up project from USAID to expand this approach in the districts of Sunsari and Parsa of the Eastern and Central Terai respectively. Recommendation: • Repeated monthly dissemination of the key Child Survival messages directly to Mother’s Groups with group support • Pregnant women self-monitoring of the utilization of the health services by using a Behavioural Mapping • Replicate in similar areas with high home birth rates Success Factors In sum the real lessons learned from this activity have been: 1) The importance of regular monthly review meetings at the sub-district and district health facilities to keep the staff motivated and maintain updated health status records and; 2) The effectiveness of targeted group - pregnant women’s groups (PWG) education and pregnant women self monitoring at behavioral mapping. Challenges  To replicate the PWG approach to scattered community is a challenge. Outcomes 1) The results from Bara influenced the Nepal MOHP to develop a Community Based Newborn Care Package. 2) The Nepal MOHP and Plan Nepal are currently working to reduce neonatal mortality in Parsa and Sunsari Districts with the support from USAID and Plan USA through the Local Innovation for Better Outcomes of Neonates (LIBON) project 2008 -2011. and 3) Plan is currently working with JHU and NFHP to look at community-distributed chlorhexidine for neonatal sepsis; Operational Research will begin in June 2009. Annex 12 Nepal LIBON Project – Special Reports (b) APHA 2011 Plan Nepal Peer-support groups and community volunteers improve newborn care in rural communities Bhagawan Das Shrestha, MPH, Project Coordinator Sher Bahadur Rana, Health Coordinator Local Innovation for Better Outcomes for Neonates (LIBON) Project, Plan Nepal BACKGROUND. In Nepal, neonatal mortality has remained high and stagnant. THE PROJECT. Since 2007, Plan International, a child-centered humanitarian organization, has implemented a USAID-funded Child Survival project in the Sunsari and Parsa districts (tot pop 1,200,000) to reduce the morbidity and mortality among neonates. One project strategy was to link female community health volunteers (FCHVs) with the formal government health system through the Pregnant Women's Group (PWG). PWGs are peer-support organizations comprising 8-15 neighboring pregnant women who meet monthly with the facilitation of the FCHV and the government front-line health worker; they discuss their pregnancies, danger signs, how to prepare for delivery and basic newborn care. FCHVs raise awareness on immediate care and danger signs of newborns, carry out home visits to newborns, and provide early case management and referral of sick newborns to government health workers. RESULTS. The project helped organize 361 PWGs and a similar number of FCHVs. In three years (2007 to 2010), the project achieved (1) an increase of 22 percent points in skilled birth delivery (from 45 % to 67%); (2) an increase of 17 percent points in detection and treatment of neonates with possible bacterial infection (from 36% to 53%); (3) an increase of 24 percent points of pregnant women with four prenatal visits (from 29% to 53%). CONCLUSIONS. Based on this and similar experience, the Ministry of Health has expanded a community-based newborn program to thirteen more districts. LEARNING OBJECTIVES. To discuss the importance of peer support groups and community volunteers to prevent maternal and neonatal mortality in developing countries. Session 4126: Working with Communities in Low Income Countries to Improve Maternal and Child Health: Using Local Resources and Technology (ID=33528) Please contact Bhagwan Das Shrestha (bhagawan_das.shrestha@plan￾international.org) for copies of the presentation Annex 12 Nepal LIBON Project – Special Reports Indian Journal of Medical Research January 2011 (page # 68): Indian J Med Res 133, January 2011, pp 64-69 Field test results of the motherhood method to measure maternal mortality Mahesh K. Maskey1, Kedar P. Baral2, Rajani Shah3, Bhagawan D. Shrestha4, Janet Lang5,* & Kenneth J. Rothman6 1Nepal Public Health Foundation, Kathmandu, 2Patan Academy of Health sciences, 3CTEVT, Bharatpur, 4Plan Nepal, Nepal, 5Watson Institute for International Studies, Brown University, Providence RI, USA & 6RTI Health Solutions, Research Triangle Park, NC & Boston University School of Public Health, USA Received March 31, 2010 Background & objectives: Measuring maternal mortality in developing countries poses a major challenge. In Nepal, vital registration is extremely deficient. Currently available methods to measure maternal mortality, such as the sisterhood method, pose problems with respect to validity, precision, cost and time. We conducted this field study to test a community-based method (the motherhood method), to measure maternal and child mortality in a developing country setting. Methods: Motherhood method was field tested to derive measures of maternal and child mortality at the district and sub-regional levels in Bara district, Nepal. Information on birth, death, risk factors and health outcomes was collected within a geographic area as in an unbiased census, but without visiting every household. The sources of information were a vaccination registry, focus group discussions with local health workers, and most importantly, interview in group setting with women who share social bonds formed by motherhood and aided by their peer memory. Such groups included all women who have given birth, including those whose babies died during the measurement period. Results: A total of 15161 births were elicited in the study period of two years. In the same period 49 maternal deaths, 713 infant deaths, 493 neonatal deaths and 679 perinatal deaths were also recorded. The maternal mortality ratio was 329 (95%CI:243-434)/100000 live birth, infant mortality rate was 48(44-51)/1000LB, neonatal mortality rate was 33(30-36)/1000LB, and perinatal mortality rate was 45(42-48)/1000 total birth. Interpretation & conclusions: The motherhood method estimated maternal, perinatal, neonatal and infant mortality rates and ratios. It has been field tested and validated against census data, and found to be efficient in terms of time and cost. Motherhood method can be applied in a time and cost-efficient manner to measure and monitor the progress in the reduction of maternal and child deaths. It can give current estimates of mortalities as well as averages over the past few years. It appears to be particularly well-suited to measuring and monitoring programmes in community and districts levels. Annex 12 Nepal LIBON Project – Special Reports Key words Maternal mortality - millennium development goal - motherhood method - Nepal - sisterhood method *Present address: Balsillie School of International Affairs, Waterloo, Ontario, Canada 64 The current estimate of global maternal deaths is 3429001. Almost all of these occur in developing countries. Among the six countries accounting for more than 50 per cent of all maternal deaths, two South Asian countries, India and Pakistan occupy 1st and 3rd position1. Over the past decade, reduction in maternal deaths has attained a high priority in global health movements. The fifth Millennium Development Goal (MDG5) of improving maternal health has set a target of reducing the maternal mortality ratio by 75 per cent between 1990 and 20152. The most widely used measure of maternal mortality is the maternal mortality ratio, which is the ratio of the number of maternal deaths to the number of live births. It reflects (but is not identical to) the risk of maternal death once a woman has become pregnant. The 10th Revision of the International Classification of Diseases (ICD-10) defined a maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”3. Maternal deaths are divided into direct and indirect obstetrical deaths. In practice the distinction between an accidental and incidental death or a direct and indirect death is problematic, and a precise cause of death may not be known despite knowledge of pregnancy. ICD-10 has, therefore, introduced an alternative definition of maternal death, the pregnancy related death, which emphasizes timing of death rather than the cause to which the death is attributed3. Many maternal mortality surveys, such as the sisterhood method4 typically measure pregnancy-related deaths as maternal deaths, since the cause of death is not elicited in such surveys. The methods for measuring maternal mortality can be grouped into two categories: empirical and analytical.. A vital registration system, a facility-based health services records, and a census can be regarded as routine opportunity empirical measurement while population based surveys like sisterhood method and demographic surveillance systems can be considered as special opportunity empirical measurements3. Main analytical approaches are Birth and Death Record Linkage, Capture-recapture methods for correcting under-reporting of maternal deaths, and statistical modeling used by UN systems3. There could be composite approaches also such as Reproductive Age Mortality Study (RAMOS) and the Motherhood Method. In most developing countries, vital registration of medically-certified births and deaths is non￾existent or incomplete, and validity or feasibility of other purely records-based approaches is questionable. A reproductive age mortality study (RAMOS) uses multiple sources such as records from hospital, police, public-health department and vital data registries to identify and investigate the cause of deaths for each woman of reproductive age in a defined population. Interviews with household members and health care providers provide a basis to classify the deaths as maternal or otherwise. The RAMOS approach is considered to be the most complete estimation of maternal mortality, but it can be complex, because information regarding the number of births must come from separate sources4. RAMOS is generally less expensive than population based surveys or a complete census. All these types of studies are subject to under-ascertainment problems, despite their intensive use of resources5,6. The sisterhood method is either indirect or direct. In recent years, the direct sisterhood method has been used for calculating the maternal mortality ratio (mmr) over a time reference of 0-6 or 0- 13 years ration7. This approach uses 11 questions and more respondents. Surveyed participants provide information about their sisters – the number who reach adulthood, the number that have died, the age at death, the year in which the death occurred, and whether the death was during pregnancy, childbirth or shortly afterwards. Maternal mortality estimates from the sisterhood method have been useful in situations in which there is no other reliable measurement of the level Annex 12 Nepal LIBON Project – Special Reports of maternal mortality and limited resources hinder other approaches for measuring maternal deaths. But, it has many limitations. Although the direct method does not rely on assumptions about the patterns of fertility, it is less appropriate for settings with low fertility (total fertility rate <3) or a high level of migration; insufficient precision renders it less effective in comparing geographic areas (i.e. comparing sub-national estimates), studying trends, evaluating programme impact or allocating resources. Its use for measuring and monitoring the progress of intervention programmes aimed at reducing maternal mortality is particularly constrained owing to the fact that it cannot provide current estimates. Some of these limitations can be overcome with the motherhood method. It is a direct technique for deriving local population-based estimates of maternal mortality, which can also be used as multi-stage cluster-sample estimates for larger populations. The method involves estimating the same information within a geographic area as would be collected in a census, but without visiting every household. It is a targeted census of births and deaths within a defined study period. It is an evolutionary variant of the Participatory Community Survey method, which was developed to measure neonatal tetanus and the perinatal mortality rate in rural Nepal8,9. It shares features with the Boerma and Mati’s “networking” approach10 of eliciting maternal deaths and MIMF (Maternal death from Informants and Maternal death Follow-on review)11, which relies on interviews with individual mothers. It differs, however, in eliciting deaths through group discussion of listed mothers and community health care providers. It derives information about the numerator and denominator of the measure of interest directly from groups of women within the study area who share motherhood status by virtue of having given birth. To implement the method, the local health volunteers assist in facilitating group discussions related to maternal and child health. Information on total births and maternal death during pregnancy, childbirth or puerperium is elicited through immunization registries, group discussions (FGD), peer memory, memory aids and interview-based diagnosis (verbal autopsy). In this study we field tested this method to measure maternal and child mortality in a district in Nepal. Material & Methods After pretesting the method in a small, relatively well-off community of about 8000 population12 which gave an estimate of MMR 140/100000, the method was tested in a larger sample of 15161 births in the Bara district of Nepal, where a child survival programme impact study was being conducted13. The sample size was expected to provide estimate of MMR within 30 per cent of margin of error. This study employed the pregnant women group (PWG) approach as a means to improve the maternal and child health status of the community14. The aim of the PWG approach is to empower the group in such a way that members are able to demand quality basic health services from governmental and non-governmental health care providers. The volunteers and participating women make all the decisions required to form and operate the group. The PWG comprised 7-15 pregnant women living in the same village or wards. They met once a month to discuss issues related to mother and child health. The female community health volunteers (FCHVs) facilitated these meetings. Bara district is located in central terai plain of Nepal adjoining border with India. It has 98 village development committees and one municipality with one district hospital, three primary health care centers, 11 health posts and 84 sub-health posts. The total population projected for 2005 (based on 2001 census) was approximately 615,933. Of these, 130,578 were women of reproductive age (15-49 yr) and 98,241 were infants and children under five. It is a low human development index (HDI) district and has poor health indicators. The literacy gap between females and males was substantial, 14 and 42 per cent respectively. Muslims are second largest ethnic group in Bara15. Annex 12 Nepal LIBON Project – Special Reports For the implementation of project, the district was divided into seven sectors. From each sector, seven Village Development Committees (VDCs), the administrative units having on an average six thousand population, were randomly selected making a total of 49 VDCs (50% of all VDCs in the Bara district, a total of 441 wards). Information regarding births, maternal death, infant death and PWG status over a study period of 2 yr from 17 July 2003 to 16 July 2005, was collected retrospectively from these VDCs in a survey period of approximately 12 wk. The data were checked every day for omissions and errors and corrected in the field by revisits when necessary. In this study, a sub-sample of 49 wards was randomly selected, one from each VDC, to conduct a census to validate the information obtained from the motherhood method. Two days training was provided to supervisors and enumerators, and pre-testing and practice was done outside the study location to enable them to elicit required information from BCG and TT vaccination registries and from the group discussion. The study team prepared a list of mothers who had given birth in the study period by collecting information from local BCG and TT vaccination registries. BCG vaccination is given in the first week of birth to immunize against tuberculosis. In rural areas the vaccination may be delayed by a month or more, so some babies who die early in the neonatal period may not be listed in the registry. Because hospitals may vaccinate babies with BCG without recording the information in the local BCG registry, and because some deliveries take place at the homes of relatives, local BCG registries may have incomplete information about local births. These limitations of BCG registries were partially compensated for by augmenting the list from TT vaccination registries. Mothers who had taken even a single dose of TT in pregnancy were included in the list because the objective was to identify the pregnancy status of the study subjects. To capture most of the births that would fall within the study period, TT vaccination information was collected from 17 April 2003 through 16 July 2005, three months before the study period. Mothers who received in these three months their first dose of TT while they were in the last trimester of pregnancy were likely to complete their pregnancy at the beginning of the study period, whereas those receiving vaccine during the first or second trimester were likely to complete their pregnancy later during the study period. The augmented list was given to the female community health volunteers to pass on to the mothers. The study objectives were explained to each mother, and those who gave consent to participate were asked to assemble at a fixed time and place for the group discussion. The typical group comprised 10-15 mothers and the local health workers. The focus group discussion with the mothers and local health workers emphasized the pregnancy outcomes of these mothers and checked whether they were within the study period. Deliveries outside the study period were excluded from the list of counted pregnancies. At the group discussion, the mothers on the list were asked the date of birth of their baby or babies. Most could recall the exact birth date, although some could remember only month and year. The listed information was considered correct if mother’s information corroborated it. The group discussion also elicited information about maternal deaths, infant deaths, stillbirths and abortions. Some mothers had better recall about these events than others. Any conflict in group’s opinion was resolved by interviewing the woman in question or another household member. Those who could not come to the group discussion were visited in their own household. For mothers who had died within the study period, a close relative (mother, mother-in law, or husband) was interviewed to ascertain whether the death was a maternal death. The results were validated by conducting a census of remaining households not included in the list of study births. The census data were used to estimate the sensitivity and specificity of the Annex 12 Nepal LIBON Project – Special Reports method for ascertaining births and deaths. Overall it took 6 wk to collect data from 49 VDCs, including FGD and census in 49 wards. There were seven groups, each with four data collectors with 3 enumerators and one supervisor. On an average one group took five days to cover one VDC. The total cost of the evaluation was $ 10,896. The allowance for FCHV was $ 905 (Rs 2.05 x 49vdc x 9 wards x 1 day). It was found that doing a census was 10 times more costly than collecting data from motherhood method, (per unit cost $ 50.5 and $ 4.4). Results Of the 15,161 births (14,916 live births, 245 still births), there were 97 twin births, one triplet birth and 128 births from mothers who had given birth previously during the study period. Seven hundred thirteen babies died in infancy, of whom 493 (69%) died in the neonatal period and 434 (61%) in the early neonatal period. The number of maternal deaths was 49. Table I presents the distribution of births and deaths in all the 441 wards of the sampled 49 VDCs, the validation data of the census and motherhood method in 49 wards and the findings in the remaining 392 wards. In the 49 wards, the Census recorded 1,995 live births, 25 stillbirths, 93 infant deaths, 77 perinatal deaths and 6 maternal deaths. The motherhood method elicited 1,990 live births, 25 stillbirths, 93 infant deaths, 77 perinatal deaths and 6 maternal deaths in the same wards. The only discrepancy was five live births recorded from the census that were missed by the motherhood method. Among the 392 remaining wards, there were 12,921 live births, 220 still births, 620 infant deaths and 43 maternal deaths during the same period. Mortality rates were computed for mothers who were and were not part of the PWG, with 95 per cent confidence intervals (Table II). Overall, the maternal mortality ratio (MMR) was 329/100000 live births (LB), the infant mortality rate (IMR) was 48/1000 LB, the neonatal mortality rate (NMR) was 33/1000 LB, and the early neonatal mortality rate was 29/1000 LB. The perinatal mortality rate (PMR) and stillbirth rate (SBR) were calculated with total births in the denominator and were 45/1000 TB and 16/1000 TB respectively. The results compared well with national data. A comparison with the census results in 49 wards showed 100 per cent agreement with MM in detecting maternal and child deaths. There was about a 0.25 per cent under-reporting of births. The maternal, infant, neonatal and perinatal indicators in PWG women were lower than the non-PWG women and the national statistics. Discussion Field-testing of the motherhood method in a district with a population of about 600,000 demonstrated that maternal mortality can be directly measured if the BCG and TT vaccination registers are in place and local health workers or volunteers and the mothers themselves in the wards are properly mobilized and supervised for data collection. The possibility of missing maternal deaths in early pregnancy and those related to abortion being reported as non maternal deaths cannot be ruled out, but such under-reporting can be reduced by collecting the information about all female deaths and then using a careful verbal autopsy in the group settings. Proper motivation of community key informants, health volunteers, and mobilizers is crucial for the accuracy of data. The findings show that the motherhood method can be applied in a time and cost-efficient manner to measure and monitor the progress in the reduction of maternal and child deaths. It approximated census-based measurement while at the same time remaining relatively immune to the problem of omission and misclassification of numerator and denominators in census studies. It can give current estimates of maternal mortality as well as averages over the past few years. It appears to be particularly well-suited in measuring and monitoring programmes in sub-national regions and districts. Annex 12 Nepal LIBON Project – Special Reports The mix of ‘outsider’ field assistants and ‘insider’ local health volunteers used appears to have been able to keep information errors down, thus improving accuracy of information and increasing time efficiency of interview. It appeared that the group discussion effectively counteracted the disinclination of mothers to talk about the death of their child, and enhanced collective memory for recalling details related to maternal and child mortality. Where confidentiality was indicated, interviews were conducted with mothers or family members in absence of local health workers. The motherhood method also appears to be robust regarding problems induced by migration. The group discussion could elicit which mothers migrated to the village to live or came to their mother’s home for delivery. The method has its limitations. It requires proper training of field assistants to moderate the group discussion among mothers and health volunteers. Motivation of key community informants and health volunteers is crucial to the accuracy of data, and mothers need to be aware of the need for accuracy. Although the method is efficient, the effort in collecting data depends on the duration of the study period, the longer the study period, the greater the potential for inaccurate recall. It is likely that some maternal deaths related to ‘hidden pregnancy’, particularly among teens be missed. Reporting of maternal deaths in early pregnancy and those related to abortion as non￾maternal deaths may occur. Collecting information about all female deaths and the careful application of verbal autopsies in the group setting may reduce such misclassification. The method would need further adaptation to measure births and deaths in urban areas. The International Conference on Population and Development +5 program of Action (1999) “calls upon United Nations and donors to support developing countries in undertaking census and surveys and to develop innovative and cost effective solution for improving estimates of maternal mortality”16. For economically poor countries, measuring maternal mortality has been viewed as “notoriously difficult and complex” and characterized as nearly hopeless by agencies such as the WHO, who maintained that “the problem of measuring maternal mortality is most acute precisely where it is least likely to be accurately measured17”. Our experience in Nepal needs more refinement, and validation at the national level. The present results provide the ground to take initiatives for development and validation of similar methods, and ultimately for the development of a commonly agreed upon methodology in other developing countries, especially in South Asia. Acknowledgment Authors are grateful to Plan Nepal for granting permission to use motherhood method to assess the impact of Pregnant Women Group Approach in the Child Survival Project in Bara district, Nepal. References 1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Mengru W, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375 : 1609- 23. 2. Government of Nepal and United Nations Country Team. Progress Report 2002 Millennium Development Goals, Nepal; 2002. Available from: www.searo.who.int/LinkFiles?MDG_Report_nep.pdf, accessed on January 3, 2009. 3. Graham WJ, Ahmed S, Stanton C, Abou-Zahr CL, Campbell OMR. Measuring maternal mortality: An overview of opportunities and options for developing countries. BMC Med 2008; 6 : 12. 4. Graham W, Brass W, Snow RW. Estimating Maternal Mortality: The Sisterhood Method. Stud Fam Plann 1989; 20 : 125-33. 5. WHO (2007). Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Available from: http://www.unfpa.org/upload/lib_pub_file/717_filename_mm2005.pdf, accessed on May 5, 2009. 6. House of Commons International Development committee (HCIDC) Maternal health. Fifth Report of Session 2007- 08, vol. 1, London: HCIDC; 2008. Annex 12 Nepal LIBON Project – Special Reports 7. WHO/UNICEF. The sisterhood method for estimating maternal mortality: guidance notes for potential users. Geneva : WHO/UNICEF; 1997. p. 9. 8. Maskey M, Des Chene M. A method for detecting unreported neonatal tetanus cases in the developing countries (Abstract). Am J Epidemiol 2000; 15 : S69. 9. Maskey M. Preventable risk factors of perinatal mortality in Nepal, D.Sc. thesis, Boston University, Boston, USA; 2001. 10. Boerma, JT, Mati JKG. Identifying maternal mortality through networking: Results from coastal Kenya. Stud Fam Plann 1989; 20 : 246-53. 11. Fikree F, Worley H, Sines E. Delivering Safer Motherhood, Sharing the Evidence, IMPAACT Policy briefs, Population Reference Bureau, Washington, USA, 2007. Available from: www.prb.org., accessed on June 8, 2009. 12. Shah R. Utilization of skilled attendant at delivery by women in Divyanagar village development committee of Chitwan district, MPHthesis, Tribhuvan University Institute of Medicine, Kathamandu, Nepal; 2005. 13. Plan Nepal. Report on impact assessment of pregnant women group approach. Kathmandu: Nepal, Plan Nepal; 2006. 14. Baral, KP. Concept and approach of pregnant women’s group: An approach to increase coverage of maternal health services in rural Nepal, Kathmandu: Nepal. 2006. 15. Statistical book of Bara district, Kathmandu Nepal. Kathmandu, Nepal: Government of Nepal. 2005. 16. Stanton C, Hobcraft J, Hill K, Kodjogbé N, Mapeta WT, MuF. Every death counts: Measurement of maternal mortality via a census. Bull World Health Organ 2001; 79 : 657-64. 17. WHO. Reduction of maternal mortality: a joint WHO/UNFPA/UNICEF/World Bank statement, Geneva: World Health Organization; 1999. 18. MOHP/New Era/ USAID, Nepal demographic and health survey 2006, Kathamandu, Nepal; 2007. 19. Ellis M, Manandhar DS, Manandhar N, Wyatt J, Bolam AJ, Costello AM. Stillbirths and neonatal encephalopathy in Kathmandu, Nepal: an estimate of the contribution of birth asphyxia to perinatal mortality in a low-income urban population. Paediatr Perinat Epidemiol 2000; 14 : 39-52. Pregnant Women’s Groups and Their Impact on Newborn Mortality Rates in Bara District, Nepal Background epal’s under‐five, infant and neonatal mortality rates are 61, 48 and 33 per 1,000 live births, respectively1 . Over 80% of women in Bara District in the central Terai region, deliver at home without a skilled birth attendant. In 2001, Plan Nepal began implementing the USAID‐funded Child Survival Project in partnership with the Nepal Ministry of Health and Population (MoHP) and non‐ governmental organisations (NGOs) to reduce the maternal and under‐five child mortality rates in all 98 villages int hat district. The impact study described here was conducted in June 2006.   The project had four components: 5. Promoting behaviour change communications: At meetings of over 430 pregnant women’s groups (PWGs), mothers of children under the age of five learned to practice healthy behaviors and seek medical care from trained providers.   6. Increasing access to services: Target communities and families had greater access to health education, good‐quality care and essential medicines. 7. Improving quality of care by service providers.   The MoHP and female community health volunteers (FCHVs) practiced appropriate integrated management of sick children and delivered good‐quality family planning and maternal and newborn preventive care. 8. Strengthening institutions. Intervention The objective of this study of the first component was to examine the relationship between membership in a PWG and mortality rates in the perinatal (from 28 weeks of gestation to 7 days), neonatal (0‐28 days), and infant (0 days to one year) period.   PWGs are facilitated by a cadre of respected and trained FCHVs who are officially recognised by the MoHP.   Interested pregnant women joined the PWG nearest to their home and met monthly to learn about maternal and newborn care and to recognise danger signs in neonates as well as during 1 Nepal Demographic and Health Survey 2006 pregnancy and delivery and the post‐partum period. Mothers who joined a PWG received iron/ folic acid tablets and two tetanus toxoid injections, and developed a delivery plan (outlining transportation, money, and three possible blood donors) that encouraged antenatal visits and delivery in a health clinic with a skilled birth attendant. Some PWGs established a transportation fund from which members could borrow in emergencies.    Methodology The design was a cross‐sectional comparative study and the data were collected by the “motherhood method,” a variant of the participatory community survey (Maskey and DesChene, 2005). The study population consisted of 110,000 women of reproductive age and 80,000 children under the age of five. Data was collected for two years, from July 2003 to July 2005. The 2001 Nepal Demographic and Health Survey (NDHS) report was used as a baseline for mortality data (see the table below).   Results In comparison with non‐members, members of PWGs saw a 50–60%, statistically significant reduction in maternal, infant, neonatal, and early neonatal (0 to 7 days) mortality rates over the five‐ year period from 2001 to 2006.   PWG members who are linked via a referral network to health facilities have better health outcomes than non‐ members (see the graphs and table below).   N National Mortality Rates (number  of deaths per 1000 live births) Rate 2001 HDHS 2006 NDHS Infant 61 48 Neonatal 39 33 Maternity (per 100,000 live births) 539 281 Mortality indices of PWG members and non‐members in Bara District compared with national estimates (number of deaths per 1000 live births) Mortality rate PWG Non‐PWG Total (95% Confidence Interval) National average Maternal  (per 100,000 live births) 9/4334=208 40/10,582=378 329 (243‐ 434) 281* Infant 108/4334=25 605/10,582=57 48 (44 ‐ 51) 48* Neonatal 81/4334=19 412/10,582=39 33 (30 – 36) 33* Early neonatal   72/4334=17 362/10,582=34 29 (26 ‐ 32)   Perinatal 113/4375=26 566/10,786=52 45 (42 ‐ 48) 45* Still birth 41/4375=9.4 204/10,786=19 16 (14 ‐18) 8.5** *Nepal Demographic and Health Survey 2006; **Estimate of Kathmandu population Conclusion The simultaneous empowerment of PWG members and upgrading of health facilities through monthly data analysis and planning meetings at the local level was very successful in reducing infant and neonatal mortality rates. The success induced the government to design the Community‐Based Newborn Care Programme for nationwide implementation and USAID to award Plan a follow‐up project to expand the approach in the districts of Sunsari and Parsa in the eastern and central Terai regions respectively. Plan formed a total of 383 PWGs, each with about eight members, in those two districts (see Table 1). Recommendations  Disseminate key child survival messages directly to PWGs every month  Teach PWG members behavioral mapping so that they can monitor their own utilisation of health services    Replicate the PWG approach in similar areas with high rates of home deliveries Lessons learned: Success factors 3) It is important to hold regular monthly review meetings at sub‐district and district health facilities in order to keep staff motivated and to update health status records and;   4) Educating a narrow target groups (PWGs) and teaching them to use behavioural mapping to monitor themselves is effective.   Challenges Replicating the PWG approach in widely dispersed communities with small populations will be difficult. Outcomes 4) The positive results in Bara district convinced the MoHP to develop and launch the Community‐Based Newborn Care Programme   5) The MoHP and Plan Nepal are currently working to reduce neonatal mortality in Parsa and Sunsari districts with the support from USAID and Plan USA through the Local Innovation for Better Outcomes of Neonates (LIBON) Project (2007 ‐2011).   6) Plan is currently working with Save the Children, Care Nepal, UNICEF, NFHP and other international non‐governmental organisations to promote the community‐level distribution of chlorhexidine to reduce neonatal sepsis. Publications and acknowledgements Versions of this article have been presented on the American Public Health Association (2011), Global Health Conference (2009). Nepal Public Health Association Journal (2010) and Perinatal Society of Nepal (2010) and published on the Indian Council of Medical Research (2011).  In 2011 Plan International HQ listed the PWG approach the status of “success stories” and will be shared globally in February 2012. LIBON project site FCHV is selected as a “Health Hero” on web page http://healthheroes.eu/en/hero_chandrawati_ram.php Table 1: PWG formation in Sunsari and Parsa districts District No. of PWGs No. of members Literacy Ethnic group Differently abled Yes No Dalit Janajati Muslim Others Sunsari 260 2,055 942 1,113 488 615 0 952 0 Parsa 123 857 93 764 233 492 55 77 2 Total  no. 383 2,912 1,035 1,877 721 1,107 55 1,029 2 Total %         36% 64% 25% 38% 2% 35% 0.01% Note: Follow‐up in Bara District has been done with 84% (362 of 430) PWGs and is continuing. 15 Findings of the final evaluation of Plan Nepal’s LIBON Project in Bara, Parsa and Sunsari districts Background In 2007 Nepal’s under‐five, infant and neonatal mortality rates were 61, 48 and 33 per 1000 live births, respectively,2    a considerable improvement over the comparable rates of 91, 64, and 39 found in the 2001 Nepal Demographic and Health Survey. The least decrease, just 15%, was in the neonatal rate, which currently accounts for two‐thirds of the infant mortality rate. The LIBON Project To tackle the high neonatal rate, the Ministry of Health and Population (MoHP), in coordination with other collaborating organisations, has been implementing the Local Innovation for Better Outcomes for Neonates (LIBON) Project in Parsa and Sunsari districts since 30 September, 2007.   This project is funded under a USAID Child Survival and Health Grant allocated to improve child and maternal health through the implementation the Community‐Based Integrated Newborn Care Programme.  It will draw to a close on 29 September, 2011.   Before LIBON, Plan had already implemented two other USAID‐ Child, Survival Projects: round CSXII (1997‐2001), which covered 50 villages in Rautahat and Bara districts and round CSXVII (2001‐ 2006). Beneficiaries The project covers a total of population of 1.97 million, or 7.34% of the country’s population.   About 51% (1,003,056) are male and 49% (963,721) are female. There are 52,214 infants aged 0‐11 months; 2 ORC Macro. 2007. Nepal Demographic and Health Survey 2006. Calverton, MD: ORC Macro. 54,519 children aged 12–23 months; 161,609 children aged 24‐59 months and 374,819 women of reproductive age. The LIBON project will target all these age groups, reaching a total beneficiary population of 643,161. Goals and Results   The goal of the LIBON project is to assist the MoHP in reducing neonatal mortality rates and improving the health status of women of reproductive age in the two target districts.   This goal will be realised by achieving the following results:    Result 1: Increased access to neonatal health services in Sunsari and Parsa Result 2: Increased demand for neonatal health services in Sunsari and Parsa Result 3: Increased quality of neonatal health Services in Sunsari and Parsa Result 4: Strengthened support for neonatal mortality reduction in Nepal 2 © Plan Map of Nepal and LIBON project sites: Central Region Eastern Region Mid-Western Region Far-Western Region Western Region Humla Darchula Baitadi Dadeldhura Kanchanpur Kailali Doti Bajhang Bajura Achham Bardiya Mugu Dolpa Mustang Manang Rasuwa Kalikot Dailekh Surkhet Jumla Jajarkot Banke Rukum Salyan Dang Rolpa Pyuthan Myagdi Baglung Gulmi Kapilvastu Arghakhanchi Parbat Kaski Syangja Rupandehi Palpa Lamjung Tanahu Gorkha Chitwan Dhading Nuwakot Makwanpur Nawalparasi Parsa Bara Rautahat Taplejung Solukhumbu Sankhuwasava Sindhupalchowk Sarlahi Mahottari Dhanusha Siraha Saptari Sunsari Sindhuli Kavre Dolakha Ramechhap Okhaldhunga Udayapur Morang Jhapa Ilam Khotang Bhojpur Panchthar Tehrathum Dhankuta K L B N Bara: 652,286 Sunsari: 733,919 Parsa: 580,572 16 Strategy The following strategies inform the project’s design:  Community‐based service delivery  Community mobilisation through PWGs  Health systems strengthening    Stakeholder sharing and collaboration    Social inclusion Methodology In close collaboration with government health and line agencies, local partners and Plan Nepal, a final evaluation of the current health status of newborns, pregnant women, and mothers was carried out by an external consultant in May, June, and July 2011 in Sunsari, Bara and Parsa districts respectively.   Using LQAS, the survey set out to fulfill three main objectives: 1) to obtain information about the level of knowledge of newborn health among pregnant women, mothers of newborns, and mothers of children under two years of age; 2) to identify existing household‐level health care practices which affect newborn health; and 3) to assess coverage of health services affecting maternal and newborn health. Under the LIBON project, Plan Nepal provided technical support and transferred skills in LQAS to the health personnel of the district public health office (DPHO), to the Ilaka3 ‐in‐charge, and to its own staff and those of its partners. The questionnaire was developed using the guidelines of the Knowledge, Practice and Coverage (KPC) Survey 2000+ Field Guide and in consultation with partners and stakeholders so that it would meet the specific objectives and context of the project. Different versions were developed for mothers of children aged 0‐5 months and mothers of children aged 0‐23 months to assess ante‐natal visits, initiation of breastfeeding, and knowledge and practices related to newborn health such as recognition of newborn danger signs and use of 3 An ilaka is an administrative area smaller than a district and larger than a village development committee. chlorhexidine on the umbilicus. Other versions were developed for three other populations:   mothers of children aged 0‐11 months, mothers of children aged 12‐23 months and women of reproductive age (15‐49 years). Mothers of children 0‐23 months were asked about feeding practices, immunisation coverage and practices related to childhood illnesses, including ARI, diarrhea and malaria. Women of reproductive age were asked about their knowledge of HIV/AIDS, child spacing and family planning. The training covered LQAS methodology and its application.   Since the majority of participants had taken basic LQAS and developed questionnaires for CSXII (1997‐2001), they were able to actively develop and pre‐test the LIBON questionnaire, translate it from English to Nepali, sample respondents, and collect and analyse data.        17 Sampling Frame: To facilitate sampling for the survey, Sunsari District was divided into 15 supervision areas (SAs) (the 12 Ilakas of Sunsari DHO and the three district municipalities), Parsa into 13 SAs (the 12 Ilakas of Parsa DPHO and the sole district municipality, and Bara into seven SAs based on CSXVII (2001‐2006). A sample size of 19 households per SA was selected as any smaller sample would have yielded unacceptably high  and  errors (greater than 10%) and any larger sample would have created more work but not necessarily reduced the margin of error.  The samples form each SA in each district were then aggregated in order to obtain a large enough sample size to estimate the proportion of coverage in each population sub‐group.  Thus, Sunsari, with 19 households in each of 15 SAs, had a total sample size of 285; Parsa of 247 (19 x 13) and Bara of 133 (19 x 7). Findings of LQAS survey of mothers with children aged 0‐5 months   Antenatal care visits In Sunsari District, the percentage of mothers who made four antenatal care visits and were checked by health workers up to the auxiliary nurse‐midwife increased by 43.9%, from 29.1% to 74.04 %.   In Parsa District, the corresponding increase was 37.6%, from 24.7% to 62.3%. The percent of mothers who were counseled on at least one aspect of antenatal cares during an antenatal care visit increased 22.1% and 29.2% in Sunsari and Parsa districts respectively (from 71.6% to 93.7% in the former and from 69.2% to 98.4% in the latter district).   Tetanus toxoid The percentages of mothers who had received a second dose of tetanus toxoid vaccine increased by 11.5% (from 83.5% to 94%) in Sunsari and by 9.3% (from 88.7% to 98.0 %.) in Parsa District.   Micronutrients 4 The results of the 2011 survey are compared with the baseline findings of a survey conducted in 2008. The percentage of mothers who had consumed six months of iron‐folate tablets or capsules during pregnancy increased by around 38% (47.7% to 85.6%) in Sunsari and around 52% (25.9% to 78.1%) in Parsa..   De‐worming The percentages of mothers receiving a single 400‐mg tablet of albendazole in the fourth month of their last pregnancy were increased by 12.6% (62.8% to 75.4%) in Sunsari and by around 50% (37.7% to 87.9%) in Parsa. 29.1 43.5 71.6 83.5 47.7 62. 74 8 86.3 93.7 94 85.6 75.4 24.7 30 69.2 88.7 25.9 37.7 62.3 81.4 98.4 98 78.1 87.9 0 20 40 60 80 100 ANC 4 visit upto ANM ANC 4 visit upto MCHW Counseled at least one - ANC TT2+ 6M Iron Table Albendazole Sunsari_BL Sunsari_Final Parsa_BL Parsa_Final 18 Delivery Care  The percentage of mothers whose birth was attended by a skilled provider (a doctor, a nurse, a health assistant, an auxiliary health worker, or auxiliary nurse‐midwife) increased by around 37% (from 45.3% to 82.5%) in Sunsari and around 22% (from 38.5% to 60.3%) in Parsa.    The percentage of mothers who knew at least two danger signs during delivery increased by 66.4% (from 27.1% to 93.5%)   in Sunsari and around 65% (from 17.2% to 82.1%) in Parsa.  The percentage of newborns who, immediately after birth, were dried off and exposed to a source of heat (including the mother’s own body heat in the case of kangaroo care) and not bathed for 24 hours increased by 51.6% (from 36.8% to 88.4%) in Sunsari and 52.2% (from 29.6% to 81.8%) in Parsa.   Post‐natal care  The percentage of mothers who know at least two danger signs regarding their own condition after delivery increased by around 66% (from 20.4% to 86.7%) in Sunsari and 69.3% (27.5% to 96.8%) in Parsa.    The percentage of mothers who know at least two danger signs among newborns increased by 21.9% (from 75.7% to 97.6%) in Sunsari and by 31.6% (from 62.8% to 94.4%) in Parsa.    The percentage of mothers who received vitamin A capsule single dose (400,000 international units) after delivery increased by around 26% (from 60.4% to 86.3%) in Sunsari and by 34% (from 47.8% to 81.8%) in Parsa. Newborn care  The percentage of children who were breastfed within one hour of birth increased by 51.6% (from 36.8% to 88.4%) in Sunsari and by 57.9% (from 17.4% to 75.3%) in Parsa.  The percentage of children who were fed colostrums increased by 12.9% (from 84.6% to 97.5%) in Sunsari and by 13.8% (from 84.6% to 98.4%) in Parsa.  The percentage of mothers who, with their newborn received a check‐up by a skilled provider within the first two days increased by around 44% (from 29.5% to 73.7%) in Sunsari and 24.4% (from 23.9% to 54.3%) in Parsa. Progress in Post‐Natal Care Sunsari Parsa Indicator Baseline Final Baseline Final Knowledge of at least 2 danger signs among post‐delivery mothers 20.4% 86.7% 27.5% 96.8% Knowledge of at least 2 danger signs among newborns 62.8% 94.4% 75.7% 97.6% Consumption of post‐ natal vitamin A 60.4% 86.3% 47.8% 81.8% 36.8 84.6 29.5 88.4 97.5 73.7 17.4 84.6 23.9 75.3 98.4 54.3 0 20 40 60 80 100 Breast-fed w ithin one hour Colostrums fed First check-up by skill prov ider Sunsari_BL Sunsari_Final Parsa_BL Parsa_Final 19 Findings of survey of maternal and newborn care among mothers with children aged 0‐ 23 months The table below compares the baseline data collected in January 2008 (Base) with that collected during the mid‐term evaluation (MTE) of January 2010 and that collected in the final evaluation (FE) of May in Sunsari District and July 2011 in Parsa District.  All data is given in percentages. SN Indicator (in percentage) Sunsari District Parsa District Base (Jan 08) MTE (Jan 10) FE (Jun 11) Base (Jan 08) MTE (Jan 10) FE (Jun 11) 1 Tetanus toxoid: Mothers with children aged 0-23 months who received two tetanus toxoid vaccinations before the birth of their youngest child 89.8 93.7 90.2 95.1 96.8 95.5 2 Skilled delivery assistance: Children aged 0-23 months whose births attended by skilled personnel 47.4 70.2 83.5 36.4 47 70.0 3 Post-natal visit to check on newborn: Children aged 0-23 months visited by a trained health worker within three days after birth 43.2 66.3 78.6 27.9 35.6 61.5 4 Exclusive breastfeeding: Children aged 0-5 months exclusively breastfed during the last 24 hours 67.7 90.6 74.7 80.7 84.5 89.2 5 Feeding of infants and young children: Children aged 6-23 months fed according to appropriate feeding practices 69.6 77.4 69.2 32.5 75.6 75.6 6 Vitamin A supplementation: Children aged 6-23 months who received a dose of Vitamin A in the last 6 months (card verified or mother’s recall) 87.3 91.3 96.3 70.7 67.7 78.9 7 Measles vaccination: Children aged 12-23 months who received measles vaccine (card verified or mother’s recall) 85.9 89.0 90.2 77.6 81.1 84.1 7a Measles vaccination: Children aged 12-23 months who received measles vaccine (card verified) 21.7 40.7 41.5 10.3 19.8 17.5 8 Access to immunisation services: Children aged 12-23 months who received DTP1* (card verified or mother’s recall) 94.6 91.2 95.1 87.9 89.6 95.2 8a Access to immunisation Services: Children aged 12-23 months who received DTP1 (card verified) 31.5 44.0 47.6 18.7 23.6 22.2 9 Health systems performance regarding immunisation services: Children aged 12-23 months who received DTP3* (card verified or mother’s recall) 88.0 86.8 92.7 80.4 79.2 84.1 9a Health systems performance regarding immunisation services: Children aged 12-23 months who received DTP3 (card verified) 30.4 42.9 47.6 15.9 21.7 20.6 10 Treatment of fever in malarial zones: Children aged 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 44.4 40.7 69.4 45.3 56.3 79.3 11 Use of oral rehydration therapy: Children aged 0-23 months with diarrhea in the last two weeks who received oral rehydration therapy and/or recommended home fluids 39.3 63.6 87.5 29.4 53.5 68.0 12 Appropriate care seeking for pneumonia: Children aged 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 46.0 87.0 82.5 36.0 50 31.4 13 Clean drinking water: Households of children aged 0-23 months that treat water effectively 34.7 56.8 21.1 6.1 6.9 19.8 14 Appropriate hand-washing practices: Households of children aged 0-23 months with soap available at hand-washing sites 73.0 77.9 84.6 57.5 57.1 74.9 15 Use of mosquito netting: Children aged 0-23 months who had slept under an insecticide-treated bed net the previous night 0 0 0.0 0 0 0.0 16 Malnutrition: Children aged 0-23 months who are underweight** 13.0 6.3 8.4 10.5 9.5 4.9 *DTP1, DPT3. The first and third dosages respectively of the diphtheria, tetanus, and pertussis vaccine **Two standard deviation below the median weight for age, according to the reference population of the World Health Organisation and the National Centre for Health Statistics 20 Progress in the CATCH (rapid core assessment tool for child health) indicators of Bara district   The table below compares the results of three LQAS studies conducted in Bara district, a baseline survey in June 2006, a mid‐term evaluation in December 2009, and a final evaluation in June 2011.   S N Indicator (in percentage) Base Jun 06 MTE Dec 09 FE Jun 11 Sentinel measures of children’s health and wellbeing         1 Underweight children: Children aged 0‐23 months that are underweight   29 13.2 6.0 2 Birth spacing: Children aged 0‐23 months that were born at least 24 months after the previous surviving child 69.4 62.5 64.3 3 Delivery assistance: Children aged 0‐23 months whose births were attended by a skilled health worker up to the level of a maternal child health worker 42.1 45.9 59.4 4 Maternal tetanus toxoid: Mothers with children aged 0‐23 months that received at least two tetanus toxoid injections before the birth of their youngest child. 63.2 14.3 9.8 5 Exclusive breastfeeding: Children aged 0‐5 months that were exclusively breastfed during the last 24 hours   100.0 82.9 70.4 6 Complementary feeding: Children aged 6‐9 months that received breast milk and complementary foods during the last 24 hours   95.7 91.9 90.2 7 Full vaccination: Children aged 12‐23 months that are fully vaccinated (against five vaccine‐preventable diseases) before their first birthday 66.9 19.5 45.1 8 Measles: Children age 12‐23 months that received a measles vaccine   72.2 21.1 45.1 9 Bed nets: Children aged 0‐23 months living in malarial areas that slept under an insecticide‐treated net the night before the survey 1.5 97.7 3.4 10 HIV/AIDS: Mothers with children aged 0‐23 months that cited at least two ways of reducing the risk of HIV infection 51.1 29.3 48.9 11 Hand‐washing: Mothers with children aged 0‐23 months that reported that  they wash their hands with soap or ash before preparing food or feeding children and after defecating or attending to a child who has defecated 63.2 33.1 47.4 Management and treatment of illness      12 Danger signs: Mothers of children aged 0‐23 months that knew at least two signs of childhood illness that indicate the need for treatment   99.6 93.2 99.6 13 Sick child: Sick children aged 0‐23 months that received increased and continued feeding during an illness in the past two weeks 94.5 75.3 98.5 14 Sick Child: Sick children aged 0‐23 months that received increased fluids during an illness in the past two weeks 92.7 44.2 93.8 **Two standard deviations below the median weight for age, according to the reference population of the World Health Organisation and the National Centre for Health Statistics 21 Child Survival and Health Grants Program Project Summary Dec-23-2011 PLAN International (Nepal) General Project Information Cooperative Agreement Number: GHN-A-00-07-00006 PLAN Headquarters Technical Backstop: Harpreet Anand PLAN Headquarters Technical Backstop Backup: Field Program Manager: Bhagawan Das Shrestha Midterm Evaluator: Rose Schneider Final Evaluator: Mahesh Kumar Maskey Headquarter Financial Contact: Harpreet Anand Project Dates: 10/1/2007 - 9/30/2011 (FY2007) Project Type: Standard USAID Mission Contact: Naramaya Limbu Project Web Site: Field Program Manager Name: Bhagawan Das Shrestha (LIBON Project Coordinator) Address: Plan Nepal Country Office Lalitpur Nepal Phone: +977 1 460 2046; +977-1-5535580 ext 107 Fax: +977-1-5536431 E-mail: bhagawan_das.shrestha@plan-international.org Skype Name: bhagawanshrestha Alternate Field Contact Name: Sher Bahadur Rana (LIBON Project Coordinator) Address: Lalitpur Nepal Phone: +977-1-5535580 ext 125 Fax: +977-1-5536431 E-mail: Sherbahadur.Rana@plan-international.org Skype Name: sher.rana Grant Funding Information USAID Funding: $1,494,337 PVO Match: $543,737 General Project Description Plan USA, a 2007 Standard category grantee, is implementing the Local Innovation for Better Outcomes for Neonates Project (LIBON) in Sunsari, Parsa and Bara Districts, Nepal. The project goal is to sustainably reduce the burden of neonatal mortality through increased access to, demand for, and quality of neonatal health services and strengthened support for neonatal mortality reduction. Plan will (1) contribute to the development and roll out of the government’s Community-based Neonatal Care Package (CB-NCP); (2) facilitate community mobilization and information, education, communication (IEC)/behavior change communication (BCC) efforts; (3) build capacity at the central, district and village levels to make data-driven decisions; and (4) generate and disseminate neonatal health information to stimulate national level policy dialogue on scaling LIBON’s innovative interventions. Project Location Latitude: 26.82 Longitude: 87.28 Project Location Types: (None Selected) Levels of Intervention: (None Selected) Province(s): -- District(s): Bara, Sunsari, and Parsa Districts Sub-District(s): -- Operations Research Information OR Project Title: Performance Coverage of Chlorhexidine (CHX) Study Cost of OR Activities: $68,000 Research Partner(s): -- OR Project Description: Trials have shown great promise for chlorhexidine (CHX) to dramatically reduce neonatal sepsis (up to 24%), even in home deliveries. Clinical efficacy and consumer preference testing have been completed, and final formulation, branding and packaging preparations are due to finish in the year. A population-based trial of how CHX performs in the community (as opposed to a clinical setting) remains. If proven successful in the community (uptake and adherence), it is poised to be endorse as an evidence-based product for both institutional and home births in Nepal and potentially all low-resource settings. Plan Nepal is conducting a two pronged study in Parsa District to determine chlorhexidine (CHX) uptake by the community at large and to assess the functionality of various delivery channels. Plan Nepal is working closely with USAID's Nepal Family Health Program (NFHP)-II in this endeavor, from design to execution to analysis. Partners The Institute of Medicine (IOM) of Tribhuvan University (Subgrantee) $10,362 Government of Nepal, Ministry of Health and Population (CHD and FHD) (Collaborating Partner) $0 Community Welfare Center (CWC) (Collaborating Partner) $0 Integrated Mother and Child Health Organization (IMCHO) (Collaborating Partner) $0 Resource Center for Sustainable Development (RCSD) (Collaborating Partner) $0 Ramgun’s Youth Club (RYC) (Subgrantee) $250,693 District Public Health Office (DPHO) - Parsa (Subgrantee) $67,669 Strategies Social and Behavioral Change Strategies: Community Mobilization Group interventions Interpersonal Communication Mass media and small media Health Services Access Strategies: Addressing social barriers (i.e. gender, socio-cultural, etc) Health Systems Strengthening: Quality Assurance Supportive Supervision Strategies for Enabling Environment: Create/Update national guidelines/protocols Stakeholder engagement and policy dialogue (local/state or national) Tools/Methodologies: Sustainability Framework (CSSA) LQAS Capacity Building Local Partners: Local Non-Government Organization (NGO) Dist. Health System Health Facility Staff Other National Ministry Health CBOs Interventions & Components Immunizations IMCI Integration CHW Training HF Training Nutrition IMCI Integration CHW Training HF Training Vitamin A IMCI Integration CHW Training HF Training Micronutrients CHW Training HF Training Pneumonia Case Management IMCI Integration CHW Training HF Training Control of Diarrheal Diseases IMCI Integration CHW Training HF Training Malaria IMCI Integration CHW Training HF Training Maternal & Newborn Care (100%) - Emergency Obstetric Care - Neonatal Tetanus - Recognition of Danger signs - Newborn Care - Post partum Care - Child Spacing - Integation. with Iron & Folic Acid - Birth Plans IMCI Integration CHW Training HF Training Healthy Timing/Spacing of Pregnancy IMCI Integration CHW Training HF Training Breastfeeding IMCI Integration CHW Training HF Training HIV/AIDS CHW Training HF Training Family Planning IMCI Integration CHW Training HF Training Tuberculosis IMCI Integration CHW Training HF Training Operational Plan Indicators Number of People Trained in Maternal/Newborn Health Gender Year Target Actual Female 2010 1734 Female 2010 2061 Male 2010 425 Male 2010 71 Female 2011 40 Female 2011 0 Male 2011 0 Male 2011 40 Female 2012 0 Male 2012 0 Female 2013 0 Male 2013 0 Number of People Trained in Child Health & Nutrition Gender Year Target Actual Female 2010 0 Female 2010 0 Male 2010 0 Male 2010 0 Female 2011 0 Female 2011 0 Male 2011 0 Male 2011 0 Female 2012 0 Male 2012 0 Female 2013 0 Male 2013 0 Number of People Trained in Malaria Treatment or Prevention Gender Year Target Actual Female 2010 0 Female 2010 0 Male 2010 0 Male 2010 0 Female 2011 0 Female 2011 0 Male 2011 0 Male 2011 0 Female 2012 0 Male 2012 0 Female 2013 0 Male 2013 0 Locations & Sub-Areas Sunsari District 733,919 Parsa District 580,572 Bara District 652,286 Total Population: 1,966,777 Target Beneficiaries Sunsari District Parsa District Bara District Total Children 0-59 months 94,908 81,847 91,587 268,342 Women 15-49 years 139,344 110,422 125,053 374,819 Beneficiaries Total 234,252 192,269 216,640 643,161 Rapid Catch Indicators: DIP Submission Sample Type: LQAS Maternal TT Vaccination Description -- Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Numerator: Enter the number of mothers with children age 0-23 months who received at least two tetanus toxoid vaccinations before the birth of their youngest child Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 222 285 77.9% 4.8 Parsa District 231 247 93.5% 3.1 Bara District 0 0 0.0% 0.0 Skilled Birth Attendant Description -- Percentage of children age 0-23 months whose births were attended by skilled personnel Numerator: Enter the number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxiliary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 140 285 49.1% 5.8 Parsa District 92 247 37.2% 6.0 Bara District 0 0 0.0% 0.0 Post-Natal Visit to Check on Newborn Within the First 3 Days After Birth Description -- Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within three days after birth Numerator: Enter the number of children age 0-23 months who received a post-natal visit within three days after birth by an appropriate health worker Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 116 285 40.7% 5.7 Parsa District 64 247 25.9% 5.5 Bara District 0 0 0.0% 0.0 Exclusive Breastfeeding Description -- Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Numerator: Enter the number of children age 0-5 months who drank breast milk in the previous 24 hours AND did not drink any other liquids in the previous 24 hours AND was not given any other foods or liquids in the previous 24 hours Denominator: Enter the total number of children age 0-5 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 95 126 75.4% 7.5 Parsa District 75 88 85.2% 7.4 Bara District 48 48 100.0% 0.0 Infant and Young Child Feeding Description -- Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Numerator: Enter the number infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 110 159 69.2% 7.2 Parsa District 50 159 31.4% 7.2 Bara District 0 0 0.0% 0.0 Vitamin A Supplementation in the Last 6 Months Description -- Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A in the last 6 months (mother’s recall or card verified) Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 138 158 87.3% 5.2 Parsa District 111 157 70.7% 7.1 Bara District 132 133 99.2% 1.5 Measles Vaccination Description -- Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 66 93 71.0% 9.2 Parsa District 58 107 54.2% 9.4 Bara District 96 133 72.2% 7.6 Access to Immunization Services Description -- Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received a DTP1 at the time of the survey according to the vaccination card/child health booklet or mother’s recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 75 93 80.6% 8.0 Parsa District 87 107 81.3% 7.4 Bara District 95 133 71.4% 7.7 Health System Performance Regarding Immunization Services Description -- Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of the survey according to the vaccination card/child health booklet or mother’s recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 70 93 75.3% 8.8 Parsa District 75 107 70.1% 8.7 Bara District 92 133 69.2% 7.8 Treatment of Fever in Malarious Zones Description -- Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began Numerator: Enter the number of children age 0-23 months with a febrile episode in the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti-malarial drug Denominator: Enter the total number of children age 0-23 months with a febrile episode in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 4 75 5.3% 5.1 Parsa District 4 52 7.7% 7.2 Bara District 0 0 0.0% 0.0 ORT Use Description -- Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with diarrhea in the last two weeks AND who received oral rehydration solution (ORS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 21 58 36.2% 12.4 Parsa District 11 34 32.4% 15.7 Bara District 33 55 60.0% 12.9 Appropriate Care Seeking for Pneumonia Description -- Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Numerator: Enter the number of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Denominator: Enter the total number of children with chest-related cough and fast and /or difficult breathing in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 54 69 78.3% 9.7 Parsa District 33 88 37.5% 10.1 Bara District 24 30 80.0% 14.3 Point of Use (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 108 285 37.9% 5.6 Parsa District 17 247 6.9% 3.2 Bara District 0 0 0.0% 0.0 Appropriate Hand Washing Practices Description -- Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live in households with soap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 180 285 63.2% 5.6 Parsa District 144 247 58.3% 6.1 Bara District 104 133 78.2% 7.0 Child Sleeps Under an Insecticide-Treated Bednet Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night Numerator: Enter the number of children age 0-23 months who slept under an insecticide-treated bednet the previous night Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 0 285 0.0% 0.0 Parsa District 0 247 0.0% 0.0 Bara District 4 266 1.5% 1.5 Underweight Description -- Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) Numerator: Enter the number of children 0-23 months with weight/age -2 SD for the median weight for age, according to the WHO/NCHS reference population Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 32 285 11.2% 3.7 Parsa District 29 247 11.7% 4.0 Bara District 76 266 28.6% 5.4 Rapid Catch Indicators: Mid-term Sample Type: LQAS Maternal TT Vaccination Description -- Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Numerator: Enter the number of mothers with children age 0-23 months who received at least two tetanus toxoid vaccinations before the birth of their youngest child Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 267 285 93.7% 2.8 Parsa District 239 247 96.8% 2.2 Bara District 19 133 14.3% 5.9 Skilled Birth Attendant Description -- Percentage of children age 0-23 months whose births were attended by skilled personnel Numerator: Enter the number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxiliary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 200 285 70.2% 5.3 Parsa District 116 247 47.0% 6.2 Bara District 61 133 45.9% 8.5 Post-Natal Visit to Check on Newborn Within the First 3 Days After Birth Description -- Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within three days after birth Numerator: Enter the number of children age 0-23 months who received a post-natal visit within three days after birth by an appropriate health worker Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 189 285 66.3% 5.5 Parsa District 88 247 35.6% 6.0 Bara District 0 0 0.0% 0.0 Exclusive Breastfeeding Description -- Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Numerator: Enter the number of children age 0-5 months who drank breast milk in the previous 24 hours AND did not drink any other liquids in the previous 24 hours AND was not given any other foods or liquids in the previous 24 hours Denominator: Enter the total number of children age 0-5 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 154 170 90.6% 4.4 Parsa District 109 129 84.5% 6.2 Bara District 63 76 82.9% 8.5 Infant and Young Child Feeding Description -- Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Numerator: Enter the number infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 89 115 77.4% 7.6 Parsa District 96 127 75.6% 7.5 Bara District 34 37 91.9% 8.8 Vitamin A Supplementation in the Last 6 Months Description -- Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A in the last 6 months (mother’s recall or card verified) Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 95 115 82.6% 6.9 Parsa District 86 127 67.7% 8.1 Bara District 121 133 91.0% 4.9 Measles Vaccination Description -- Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 81 91 89.0% 6.4 Parsa District 86 106 81.1% 7.4 Bara District 28 133 21.1% 6.9 Access to Immunization Services Description -- Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received a DTP1 at the time of the survey according to the vaccination card/child health booklet or mother’s recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 83 91 91.2% 5.8 Parsa District 95 106 89.6% 5.8 Bara District 30 133 22.6% 7.1 Health System Performance Regarding Immunization Services Description -- Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of the survey according to the vaccination card/child health booklet or mother’s recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 79 91 86.8% 7.0 Parsa District 84 106 79.2% 7.7 Bara District 29 133 21.8% 7.0 Treatment of Fever in Malarious Zones Description -- Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began Numerator: Enter the number of children age 0-23 months with a febrile episode in the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti-malarial drug Denominator: Enter the total number of children age 0-23 months with a febrile episode in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 22 54 40.7% 13.1 Parsa District 27 48 56.3% 14.0 Bara District 0 0 0.0% 0.0 ORT Use Description -- Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with diarrhea in the last two weeks AND who received oral rehydration solution (ORS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 21 33 63.6% 16.4 Parsa District 23 43 53.5% 14.9 Bara District 18 77 23.4% 9.5 Appropriate Care Seeking for Pneumonia Description -- Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Numerator: Enter the number of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Denominator: Enter the total number of children with chest-related cough and fast and /or difficult breathing in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 47 54 87.0% 9.0 Parsa District 40 80 50.0% 11.0 Bara District 60 99 60.6% 9.6 Point of Use (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 162 285 56.8% 5.8 Parsa District 17 247 6.9% 3.2 Bara District 0 0 0.0% 0.0 Appropriate Hand Washing Practices Description -- Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live in households with soap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 222 285 77.9% 4.8 Parsa District 141 247 57.1% 6.2 Bara District 41 133 30.8% 7.8 Child Sleeps Under an Insecticide-Treated Bednet Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night Numerator: Enter the number of children age 0-23 months who slept under an insecticide-treated bednet the previous night Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 0 285 0.0% 0.0 Parsa District 0 247 0.0% 0.0 Bara District 35 266 13.2% 4.1 Underweight Description -- Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) Numerator: Enter the number of children 0-23 months with weight/age -2 SD for the median weight for age, according to the WHO/NCHS reference population Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 18 285 6.3% 2.8 Parsa District 23 241 9.5% 3.7 Bara District 35 266 13.2% 4.1 Rapid Catch Indicators: Final Evaluation Sample Type: LQAS Maternal TT Vaccination Description -- Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Numerator: Enter the number of mothers with children age 0-23 months who received at least two tetanus toxoid vaccinations before the birth of their youngest child Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 257 285 90.2% 3.5 Parsa District 236 247 95.5% 2.6 Bara District 13 133 9.8% 5.0 Skilled Birth Attendant Description -- Percentage of children age 0-23 months whose births were attended by skilled personnel Numerator: Enter the number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxiliary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 238 285 83.5% 4.3 Parsa District 173 247 70.0% 5.7 Bara District 79 133 59.4% 8.3 Post-Natal Visit to Check on Newborn Within the First 3 Days After Birth Description -- Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within three days after birth Numerator: Enter the number of children age 0-23 months who received a post-natal visit within three days after birth by an appropriate health worker Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 224 285 78.6% 4.8 Parsa District 152 247 61.5% 6.1 Bara District 63 133 47.4% 8.5 Exclusive Breastfeeding Description -- Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Numerator: Enter the number of children age 0-5 months who drank breast milk in the previous 24 hours AND did not drink any other liquids in the previous 24 hours AND was not given any other foods or liquids in the previous 24 hours Denominator: Enter the total number of children age 0-5 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 133 178 74.7% 6.4 Parsa District 140 247 56.7% 6.2 Bara District 38 54 70.4% 12.2 Infant and Young Child Feeding Description -- Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Numerator: Enter the number infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 74 107 69.2% 8.8 Parsa District 68 90 75.6% 8.9 Bara District 55 61 90.2% 7.5 Vitamin A Supplementation in the Last 6 Months Description -- Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A in the last 6 months (mother’s recall or card verified) Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 103 114 90.4% 5.4 Parsa District 71 90 78.9% 8.4 Bara District 131 133 98.5% 2.1 Measles Vaccination Description -- Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 74 82 90.2% 6.4 Parsa District 53 63 84.1% 9.0 Bara District 60 133 45.1% 8.5 Access to Immunization Services Description -- Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received a DTP1 at the time of the survey according to the vaccination card/child health booklet or mother’s recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 78 82 95.1% 4.7 Parsa District 60 63 95.2% 5.3 Bara District 60 133 45.1% 8.5 Health System Performance Regarding Immunization Services Description -- Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of the survey according to the vaccination card/child health booklet or mother’s recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 76 82 92.7% 5.6 Parsa District 53 63 84.1% 9.0 Bara District 60 133 45.1% 8.5 Treatment of Fever in Malarious Zones Description -- Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began Numerator: Enter the number of children age 0-23 months with a febrile episode in the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti-malarial drug Denominator: Enter the total number of children age 0-23 months with a febrile episode in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 34 49 69.4% 12.9 Parsa District 23 29 79.3% 14.7 Bara District % ORT Use Description -- Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with diarrhea in the last two weeks AND who received oral rehydration solution (ORS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 28 32 87.5% 11.5 Parsa District 17 25 68.0% 18.3 Bara District 32 65 49.2% 12.2 Appropriate Care Seeking for Pneumonia Description -- Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Numerator: Enter the number of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Denominator: Enter the total number of children with chest-related cough and fast and /or difficult breathing in the last two weeks Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 33 40 82.5% 11.8 Parsa District 11 35 31.4% 15.4 Bara District 32 72 44.4% 11.5 Point of Use (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 60 285 21.1% 4.7 Parsa District 49 247 19.8% 5.0 Bara District % Appropriate Hand Washing Practices Description -- Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live in households with soap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 241 285 84.6% 4.2 Parsa District 185 247 74.9% 5.4 Bara District 113 133 85.0% 6.1 Child Sleeps Under an Insecticide-Treated Bednet Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night Numerator: Enter the number of children age 0-23 months who slept under an insecticide-treated bednet the previous night Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 0 285 0.0% 0.0 Parsa District 0 247 0.0% 0.0 Bara District 9 266 3.4% 2.2 Underweight Description -- Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) Numerator: Enter the number of children 0-23 months with weight/age -2 SD for the median weight for age, according to the WHO/NCHS reference population Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits Sunsari District 24 285 8.4% 3.2 Parsa District 12 247 4.9% 2.7 Bara District 16 266 6.0% 2.9 Rapid Catch Indicator Comments 2) Percentage of mothers with children age 0-11 months who received at least two Tetanus toxoid vaccinations with card confirm before the birth of their youngest child in BARA district; Numerator is 19 and Denominator 133 and percentage is 14%. 3) Percentage of children age 0-11 months whose births were attended by skilled personnel in BARA district, Numerator is 61 and Denominator 133 and percentage is 46%. 4)Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within 3 days after the birth of the youngest child has not collected information in BARA district. 6) Percent of infants and young children age 6-9 months fed according to a minimum of appropriate feeding practices in BARA district, Numerator is 34 and Denominator 37 and percentage is 92%. 11) Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began has not collected information in BARA district. 14) Percentage of households of children age 0-23 months that treat water effectively has not collected information in BARA district. Annex 14 Nepal LIBON Project – Grantee Plans to Address Final Evaluation Findings Annex 14: Nepal LIBON – Grantee Plans to Address Final Evaluation Findings With the closing of the LIBON project, Plan Nepal does not have resources in the immediate future to continue programming; however, the country team is actively seeking further funding to scale up the best practices related to the LIBON project not only in Bara, Parsa and Susari but also in other Program Unit (PU) areas. Annex 15: Nepal LIBON – Grantee Response to Final Evaluation Findings (optional) Annex 15: Nepal LIBON – Grantee Response to Final Evaluation Findings (optional) Not Applicable (N/A) Annex 16 Nepal LIBON Project – Social Mapping Mat Annex 16: Nepal LIBON Project – Social Mapping Mat Annex 17 Nepal LIBON Project – “Mother’s Card” Annex 17: Nepal LIBON Project – “Mother’s Card” The “mother’s card” (referred to in Nepal as “Jeewan Suraksha Action Card”) has educated mothers about the Birth Preparedness Package (BPP) and danger signs. The card is used by the Government in all (75) districts of Nepal. The card is an A4 size pictorial card that is green in color on one side and red in color on the other side. On the green side are the illustrations of antenatal care, birth preparedness plan, post natal care and neonatal care; the red side has illustrations of danger signs during the pregnancy, at birth, after delivery and for neonates. Annex 17 Nepal LIBON Project – “Mother’s Card” Annex 18: Nepal LIBON Project – CB-NCP Endline Report Annex 18 Nepal LIBON Project – CB-NCP Endline Report Community Based Newborn Care Program (CB-NCP) End Line Report Sunsari & Parsa Districts Local Innovation for Better Outcomes for Neonates Project (LIBON) Plan Nepal Child Survival Project XXII Funded by United States Agency for International Development Child Survival and Health Grants Program (CSHGP) Grant No. GHN-A-00-07-00006-00 Bureau for Global Health Office of Health, Infectious Disease, and Nutrition Submitted by Hari Bhakta Khoju Rural Community Development Society Submitted to Plan Nepal August, 2011 Acknowledgement We acknowledge and express our gratitude to Plan-Nepal especially to Mr. Donal Keane, Country Director and Mr. Subhakar Baidya, Program Support Manager for offering us to prepare a report to Community Based-Newborn Care Program (CB-NCP) of Sunsari and Parsa Districts, Local Innovation for Better Outcomes for Neonates Project (LIBON), Plan Nepal Child Survival Project XXII. Mr. Bhagawan Das Shrestha, Project Coordinator-LIBON and Mr. Sher Bahadur Rana, Health Coordinator, Plan Nepal deserves our heartfelt sincere thanks for their constant accomplishment and assistance in field work for data collection, data analysis and report preparation. We would like to appreciate Mr. Dipak Dahal, Monitoring and Evaluation Officer for his endless commitment, enthusiasm and effort in convincing, building capacity and confidence of health supervisor and officials to conduct the survey for data collection without being bias to subjective judgment and data fabrication. Mr. Parasuram Shrestha, Chief, Community Based-Integrated Management of Childhood Illness (CB-IMCI), Child Health Division, Ministry of Health and Population (MoHP), Mr. Indra Dev Yadav, District Public Health Office (DPHO) Parsa, Dr. Surendra Prasad Chaudhary, District Health Office (DHO) Bara and Dr. Indra Narayan Das, District Health Office Sunsari are also thankful to us, who provided information and inputs for report preparation. We extend our heartfelt thanks to field based staff Mr. Deo Ratna Chaudhary, District LIBON Coordinator (DLC) Bara/Parsa, Mr. Diwakar Mishra, Assistant District LIBON Coordinator (ADLC) Bara, Mr. Krishna Bahadur Achhami, ADLC Parsa, Ms. Meena Kumari Singh, Admin and Finance Assistant and Ms. Srijana Rai, Office Assistant, Parsa for supporting the enumerators during data collection field work. Further, we should appreciate and express heartfelt thanks to Ms. Kalawati Changbang, Health Program Coordinator-Sunsari Program Unit (PU), Mr. Hari Dev Shah, ADLC, Sunsari and Ms. Muiya Rai, Office Assistant, Sunsari for supporting and guiding enumerators during data collection field work. We should not forget to appreciate and thank to Mr. Ram Khoju Shrestha and Mohan Prasad Adhikari, who dedicated to coding, entering and cleaning data during data processing work of this project. At last but not least, we are thankful to the survey respondents for their valuable time and patience in cooperating and providing information. Authors Hari Bhakta Khoju Rural Community Development Society LIST OF ACRONYMS AHW Auxiliary Health Worker (HP, Sub-HP) ANC Antenatal Care ANM Auxiliary Mid-wives BCC Behavioral Change Communication CB-NCP Community Based – Neonatal Care Package CDK Clean Delivery Kit CHDK Clean Home Delivery Kit CS Child Survival CSSA Child Survival Sustainability Assessment DDC District Development Committee DHO District Health Office DPHO District Public Health Office FCHV Female Community Health Volunteers GoN Government of Nepal HA Health Assistants (HP, SHP) HF Health Facility HH Household HP Health Post IEC Information Education and Communication IOM Institute of Medicine KPC Knowledge, Practice and Coverage LBW Low Birth Weight LIBON Local Innovation for Better Outcomes for Neonates LQAS Lot Quality Assurance Sampling MCHW Maternal and Child Health Worker (SHP) MINI Morang Innovation for Neonatal Intervention MoHP Ministry of Health and Population, Government of Nepal NGO Non Governmental Organization NNH Neonatal Health NNM Neonatal Mortality PHCC Primary Health Care Center PNC Postnatal Care PWG Pregnant Women Group RDW Recently Delivered Women RUCODES Rural Community Development Society SA Supervision Area SBA Skilled Birth Attendant SHP Sub-health Post SPSS Statistical Package for the Social Sciences TBA Traditional Birth Attendants TT Tetanus Toxoid VDC Village Development Committee VHW Village Health Worker (SHP) Content, Tables and Figures | i CONTENTS EXECUTIVE SUMMARY ....................................................................................................................................... 4 Chapter 1: Introduction .............................................................................................................................................. 5 Chapter 2: Methodology ............................................................................................................................................ 7 2.1. Concept and Use ............................................................................................................................................ 7 2.2. Purpose of LQAS ........................................................................................................................................... 7 2.3. Sample Size .................................................................................................................................................... 7 2.4. Sampling Frame ............................................................................................................................................. 7 2.5. Threshold and Decision Rule ......................................................................................................................... 8 2.6. Survey Questionnaire ..................................................................................................................................... 8 2.7. Team Composition and Field Plan ................................................................................................................ 8 2.8. Training of Enumerators and Supervisors ..................................................................................................... 8 2.9. Data Collection ............................................................................................................................................... 8 2.10 Data cleaning and analysis .......................................................................................................................... 10 Chapter 3: Characteristics of the Respondents ........................................................................................................ 11 Chapter 4: Antenatal Care and Birth Preparedness ................................................................................................. 11 4.1 Birth preparedness ......................................................................................................................................... 12 Chapter 5: Delivery Services ................................................................................................................................... 15 5.1 Experiencing danger signs during delivery .................................................................................................. 15 5.2 Utilization of delivery services ..................................................................................................................... 17 5.3 Exposure to measures related to delivery services ....................................................................................... 17 Chapter 6: Postpartum Care ..................................................................................................................................... 19 6.1 Early postnatal care visit ............................................................................................................................... 19 Chapter 7: Immediate Newborn Care and Newborn Care ...................................................................................... 19 7.1 Immediate newborn care ............................................................................................................................... 20 7.2 Exposure to messages related to immediate newborn care .......................................................................... 22 Annex-1a: Sample frame of Sunsari district ........................................................................................................... 24 Annex-1b: Sample frame of Parsa district ............................................................................................................... 29 Annex-2: Survey instrument – questionnaire is an attached file............................................................................. 34 Content, Tables and Figures | ii TABLES Table 4.1: Percent distribution of RDW by persons consulted for antenatal services during their last pregnancy (qm302) .................................................................................................................................................. 11 Table 4.2: Percent distribution of RDW by source of antenatal services during their last pregnancy .................. 12 (qm305) 12 Table 4.3: Percent distribution of RDW by type of antenatal care received during their last pregnancy, among those who received ANC at least once (qm308) ................................................................................... 12 Table 4.4: Percent distribution of RDW by type of antenatal and postnatal care counselling received during their last pregnancy (qm312) ......................................................................................................................... 12 Table 4.5: Percent distribution of RDW who reported making specific preparations for the delivery of their last child (qm402) ......................................................................................................................................... 13 Table 4.6: Percent distribution of RDW by type of person they discussed about plan for their recent delivery (qm404) .................................................................................................................................................. 13 Table 4.7: Percent distribution of RDW by place where they had planned for the delivery of their last child (qm504) .................................................................................................................................................. 13 Table 5.1: Percent distribution of RDW by opinion regarding the persons to be present at birth to help deliver the baby safely (qm512) ........................................................................................................................ 15 Table 5.2: Percent distribution of RDW experiencing danger signs during the delivery of their last child (qm557) ................................................................................................................................................................ 15 Table 5.3: Percent distribution of RDW by persons consulted for the management of problems experienced during the delivery of last child (qm558) .............................................................................................. 16 Table 5.4: Percent distribution of RDW by places they were referred for the complications appeared during last delivery .................................................................................................................................................. 16 Table 5.5: Percent distribution of RDW persons who accompanied them while going to the health facility for delivery (qm507) ................................................................................................................................... 17 Table 5.6: Percent distribution of RDW by source of information on maternal and newborn health services qm553..................................................................................................................................................... 17 Table 5.7: Percent distribution of RDW by perception on the trusted sources of information on maternal and newborn health services qm556, denominator qm 555) ....................................................................... 17 Table 5.8: Percent distribution of RDW by sources from where they got messages on attendance of a trained health worker during delivery qm563, denominator qm561) ............................................................... 18 Table 6.1: Percent distribution of RDW by persons who checked them before they were discharged or left their house qm606 .......................................................................................................................................... 19 Table 6.2: Percent distribution of RDW by type of services received from the health service providers ............. 19 Qm607 and denominator is qm605) ........................................................................................................................ 19 Table 7.1: Percent distribution of RDW by placement of their newborn immediately after delivery (qm514) .... 20 Table 7.2: Percent distribution of RDW whose baby cried or breathed easily immediately after birth and type of help provided for crying or easy breathing the baby qm517 for denominator (did not cry code 2) and qm518..................................................................................................................................................... 20 Table 7.3: Percent distribution of RDW by knowledge about the timing of initiating the breast milk to the newborn qm 551 .................................................................................................................................... 21 Table 7.4: Percent distribution of RDW by persons who checked their baby before the health professional, FCHV or TBA left their house or before they were discharged from the health facility following the birth of their last child qm 706 .............................................................................................................. 21 Table 7.5: Percent distribution of RDW by number of times and type of provider who checked their newborn within four weeks after birth, among RDW whose newborn was either still alive or survived at least one month after birth (Q 704 and 706) .................................................................................................. 22 Table 7.6: Percent distribution of RDW by opinion regarding the size of their child at birth (Q 716) ................. 22 Table 7.7: Percent distribution of RDW by number of times their newborn got sick during neonatal period (Q 804) ........................................................................................................................................................ 23 Content, Tables and Figures | iii FIGURES Figure 7.1: Percentage of RDW who reported that their infant had experienced at least one danger sign or symptoms within one month following birth, among RDW whose child was still alive or survived at least one month (n=285, 247) ................................................................................................................ 23 Introduction | 4 EXECUTIVE SUMMARY Local Innovation for Better Outcomes for Neonates (LIBON) project aims to reduce neo￾natal mortality rate and maternal mortality ratio. It is believed that child and maternal mortality is caused due to lack of knowledge, information and skill to take care of pregnant mothers during their pregnancy, at birth, after delivery and the newborn. The objective of this study was to assess the factors associated with antenatal care, birth preparedness, delivery services, post-partum care and newborn care services. A total of 285 recently delivered women (RDW) of Sunsari and 247 RDW of Parsa, who were selected by lot quality assurance sampling were interviewed using structured questionnaire. The types of antenatal and postnatal care counselling received during the last pregnancy have increased in both districts in the end line survey in July 2011 than in baseline in March 2010. Over all, more than 80% of the RDW reported that they had made some kind of preparations for their delivery in Sunsari and Parsa. The higher percentage of RDW reported making arrangement for money (Sunsari-100%, Parsa-99%) and arrangement of clean cloths (Sunsari-89%, Parsa-85%). There is remarkable increase in arrangement for health delivery kit (CHDK), clean instruments for cord cutting, Health Facility (HF)/Skill Birth Attendant (SBA) identification in end line survey in both districts. RDW experienced having no any danger signs during the delivery with decrease from 29.5% to 14.8% in Sunsari and from 24.3% to 18.2% in Parsa. Among referred RDWs, 75% of Sunsari and 60.73% of Parsa consulted hospital which has increased than baseline. Regarding the level of exposure of RDW to maternal and newborn health information, 82% RDW of Sunsari and 91% of Parsa mentioned that they had heard that a newborn should be breastfed within one hour after birth form FCHV. In response to the place of keeping the newborn immediately after delivery, majority of newborn (71% in Sunsari and 79% in Parsa) were placed on the mothers’ abdomen which is increased than baseline in both districts. Among RDWs with live birth, 95% of both districts reported that their baby cried or breathed immediately after birth. However, about 3% RDW of both the districts reported that their baby did not cry immediately after birth. Regarding taking help to cry or breathe the baby easily for newborn who did not cry, majority were rubbed or massaged which is increased from baseline (Sunsari- from 29.4% to 66.7%, Parsa￾from 68.8% to 76.9%). In the conclusion, all the indicators are increased from baseline survey in March 2010 to end line survey in August 2011 because of full implementation of community based newborn care programme in Sunsari and Parsa under the local innovation for better outcomes of neonates (LIBON) project. Introduction | 5 Chapter 1: Introduction Plan Nepal has been implementing Child Survival XX-III project called “Local Innovation for Better Outcomes for Neonates (LIBON)” in collaboration with the Ministry of Health and Population (MoHP) and Institute of Medicine (IOM), Tribhuvan University in Sunsari and Parsa districts to support to implement Community Based Newborn Care Program (CB-NCP) and supports Bara district to maintain the health service status of 2006 Final Evaluation Results. These districts are located in the Eastern and central parts in the Southern Terai belt, the lowland plain areas, along the border of India, starting from September 2007. It is a four year project to cover up-to 2011 September. LIBON project is designed to address the complex issues to reduce neo-natal mortality rate which is caused due to lack of knowledge, information and skill to take care of pregnant mothers during their pregnancy, at birth and after delivery and newborn dangers sings. To address these complex issues, LIBON project proposed following goals, results, strategies, interventions and activities which are in line with MoHP, Government of Nepal (GoN) policies and programs. The main Goal of the project is “To Sustainably Reduce the Burden of Neonatal Mortality in Nepal” The goal will be achieved through the implement of the following results: Result 1: Increased Access to Neonatal Health (NNH) Services in Sunsari and Parsa Result 2: Increased Demand for NNH Services in Sunsari and Parsa Result 3: Increased Quality of NNH Services in Sunsari and Parsa Result 4: Strengthened Support for Neonatal Mortality (NNM) Reduction in Nepal Strategies:  Community-based Service Delivery to increase ACCESS to meet Result 1  Community Mobilization to increase DEMAND to meet Result 2  Health Systems strengthening to increase QUALITY to meet Result 3  Stakeholder sharing and Collaboration to increase SUPPORT to meet Result 4  Social Inclusion to increase EQUITY to meet Result 1 The LIBON project will contribute:  To the development and roll out of the MoHP’s CB-NCP and its seven program components; facilitate and promote community mobilization and information, education, communication (IEC)/behaviour change communication (BCC) efforts including those that proved successful in Plan’s previous child survival (CS) projects.  To build capacity at the central, district and village levels to make data-driven decisions using information collected from knowledge, practice and coverage (KPC) questionnaires through the application of Lot Quality Assurance Sampling (LQAS) methods, and through application of the Child Survival Sustainability Assessment (CSSA), and  To generate and disseminate NNH information to stimulate national level policy dialogue on nationwide implementation of LIBON’s innovative interventions through its partnership with the MoHP and IOM. Activities: Reduce neonatal mortality through local organizations such as Pregnant Women’s Groups (PWGs), a model transferred from Plan’s previous child survival project, partner with Village Development Committees (VDCs) and District Development Committees (DDCs) to support appropriate health service delivery at each level, assist with training and organization at the local level, work with local non-governmental organizations (NGOs) such as the Community Welfare Center and the Integrated Introduction | 6 Mother and Child Health Organization, staffs from both of these were involved in the implementation of previous CS projects. All seven components of community-based neonatal care package along with implementing and integration of Bara CS-XVII Project and Morang Innovation for Neonatal Intervention (MINI) experiences are covered under this Project. Based on the selection criteria, the following seven components were identified for inclusion in the package: 1. Behaviour change communication 2. Promotion of institutional delivery and clean delivery practices in case of home deliveries 3. Postnatal care 4. Community case management of pneumonia/Possible Severe Bacterial Infection 5. Care of low birth weight (LBW) newborns (<2,500 grams) 6. Prevention and management of hypothermia 7. Recognition of asphyxia with initial stimulation and resuscitation of newborn baby Methodology | 7 Chapter 2: Methodology A Lot Quality Assurance Sampling (LQAS) technique was applied to conduct survey in Sunsari and Parsa districts on May and July 2011 respectively. 2.1. Concept and Use LQAS was developed in the 1920s for quality control of industrial production goods. The basic principle is that a line manager/supervisor takes a small random sample of a recent batch, or lot, of goods from a production unit such as an assembly line. If the number of defective goods in a sample exceeds a pre-determined number, then the lot is rejected; otherwise it is accepted. The pre￾determined (allowable) number is called the “decision rule.” This allowable number is based on a production standard and the sample size. Recently, the industrial monitoring experience was transferred to monitor the quality of health indicators and to improve supervision of the field area. 2.2. Purpose of LQAS The LQAS sampling method was used in the LIBON project to collect baseline data on project￾relevant health indicators, to determine whether the supervision areas were above or below average coverage on specific indicators, to determine the indicators that were well performing and those that were not within a given supervision area, and to determine how supervision areas within the total project area compared with another area. 2.3. Sample Size Sample sizes were calculated with the following formula: n = z2 (pq)/d2 ; where n = sample size; z = statistical certainty chosen; p = estimated prevalence/coverage rate/level to be investigated; q = 1-p; and d = precision desired. The value of p was defined by the coverage rate that requires the largest sample size (p= 0.5). The value of d was dependent on the precision, or margin of error, desired (in this case d=0.1). The statistical certainty was chosen to be 95% (z=1.96). Given the above values, the necessary sample size turns out to: n = (1.96x1.96) (0.5x0.5)/(0.1x0.1) = (3.84)(0.25)/0.01 = 96 As the value of “p” is not known, we took a conservative approach and set p=0.5. The estimate of confidence limits for the survey results was calculated using the following formula: 95% confidence limit = p ± z (square root of pq/n); where p = proportion in population found from survey; z = statistical certainty chosen (for 95% certainty, z = 1.96); q = 1-p; and n = sample size. 2.4. Sampling Frame For the purpose of the LQAS Survey, Parsa district was divided into 13 SAs (12 Ilakas of Parsa DHO and 1 district municipality - Birgunj). Likewise, Sunsari district was divided into 15 SAs (12 Ilakas of Sunsari DHO and 3 district municipalities namely Dharan, Itahari and Inaruwa). A sample size of 19 households (HH) was selected per SA for this assessment. The reason for choosing 19 is that any sample that is less than 19 will have  and  errors greater than 10%, which is not desired. Similarly, increasing the sample size to greater than 19 creates more work and does not necessarily reduce the margin of error. In assessing coverage, we have aggregated all the samples taken from each SA in order to obtain a large enough sample size as required to estimate the proportion in each population subgroup. Methodology | 8 In the case of Parsa, the total sample size was calculated as 247 mothers (19 HHs x 13 SAs that is MoHP’s Ilaka). Similarly, in Sunsari, total sample size was 285 mothers (19 HHs x 15 SAs). 2.5. Threshold and Decision Rule Initial thresholds/benchmarks for assessing the indicators were selected using the average proportion obtained by aggregating the data of all 13 SAs in Parsa and 15 SAs in Sunsari districts. 2.6. Survey Questionnaire The survey questionnaire were used from Child Health Division, CB-NCP secretariat which was used by Save the Children, UNICEF, and CHD itself during the baseline data collection in 7 CB-NCP districts namely Dhankuta, Bardia, Chitwan, Dang, Kavre, Palpa and Morang. The questionnaire was already tested in different districts. The questionnaire is attached in the annex. 2.7. Team Composition and Field Plan The district teams were requested to select the supervisors and enumerators ensuring that they would include an CB-IMCI focal person, a statistician, an EPI supervisor, a FP supervisor, and/or those in charge in Ilakas of concerned District (Public) Health Offices - D(P)HOs. From the pool of representatives from D(P)HO, NGO, and Plan Nepal teams consisting of two persons (one from each group) were formed. The team is mixed with Government staff and NGOs/Plan staff to minimize the vested interests and subjective errors. 2.8. Training of Enumerators and Supervisors The three-days training was conducted for D(P)HO, NGO/partner and Plan Staff of Sunsari and Parsa districts which included dummy practice of the questionnaire filling including real field practices in the ward which is not included in the real sample. There was sharing of the field practice and misunderstanding and make consensus in the plenary for common understanding among all the team members and supervisors. 2.9. Data Collection A standard procedure was applied for data collection. First, a sampling frame was constructed for each field area consisting of 2-9 VDCs, their 9 wards with population sizes. Secondly, dividing the total population size of a field area by the LQAS sample size of 19 created a sampling fraction. Third, a random number between 1 and the sampling fraction was selected by standard random table. The ward having the corresponding person in the sampling frame’s cumulative population column was selected as the first sample. Adding the sampling fraction to the selected sample identified the next ward. All remaining samples were selected by continuing the addition of the sampling fraction to the preceding sum. Identifying locations for interview: Step 1: List communities and their total population Step 2: Calculate the cumulative population Step 3: Calculate the sampling interval Step 4: Choose a random number Step 5: With an initial random number and the sampling interval, identify communities for the 19 sets of interviews After the selection of community; interviewers visit that area and take the information from the key informants or self assessment in that location. If there are more than 30 households, they are subdivided into two or more (almost equal HHs) groups which is manageable to clearly identify the location. Then select one location of these sections randomly. If the selected area is still too large, subdivide it again into two or more equal section and select one section at random. It is continued until one small section with less than or equal to thirty households. Then, draw a map of the section Methodology | 9 becomes with the help of key informant and number each household in the selected section on the map or door to door visit. Then use random number table and select the first household. Household selection: assigning numbers IF: THEN: A complete household list is available (from census, or map) -) Assign a number to each house … work is done! If the community size is about 30 households or less -) Make a household list or map with the location of each household with the help of a key informant from the community -) And then, assign a number to each house … work is done! If the community size is more than about 30 households -) Subdivide the community into 2-5 sections with about the same # of households in each section -) Select one section at random -) Make a house list or map with the location of each household with the help of a key informant -) Then, assign a number to each house … work is done! Household selection • Once all households are numbered, pick a random number (using random tables) and select the first household in the selected community • If more than one house is needed in the selected community, pick another random number to select the second household in the selected community After the selection of household they visit that house and knock at the door of selected house and share the objective of survey to the family member(s) and ask whether they have a child age 0-11 months with mother or not. If there is a single child of 0-11 months then ask question and take information with mother after getting permission. If there are two or more children of 0-11 months then randomly select one child by using random table. If the house does not meet criteria then they move to next-nearest front door until they get a child aged 0-11 months with mother. If the respondent of the household is located far way for more than 30 minutes walking distance, then they visit the next-nearest front door. Selecting a respondent If the type of respondent you are looking for: THEN: Is at the household you selected Interview that person IF she consents Does not live at the household selected They go to the next-nearest household from the front entrance and check the next-nearest household … continue this process until they find the respondent type you they looking for Lives at that household, BUT is absent and far away (more than 30 minutes away) They leave that house and select the next house. If the type of respondent you are looking for: THEN: Lives at that household, is absent BUT is nearby (within 30 minutes) They go find the respondent with the help of a guide from the community … IF they cannot find the person in the next 30 minutes, then GO to the next-nearest household from the front entrance of the household of the person they cannot find Methodology | 10 After selecting the respondent, questionnaire consisting of one screening section and 8 sections (Annex 2) was administered in face to face interview with selected respondent. Questionnaires were completed during the interview. At every end of the day interviewers themselves checked the filled questionnaires for quality of data. The Director Family Health Dr. Naresh Pratap Rana, Prof. Chitra Kumar Gurung form IOM, Project Coordinator-LIBON project, Monitoring and Evaluating Officer and Health Coordinator, Plan Nepal also visited some of the study areas to supervise the fieldwork. The data were collected during June to July 2011. 2.10 Data cleaning and analysis Filled-in questionnaires were brought to central office of Plan Nepal. Each filled questionnaire has been edited and coded for data entry. Data was entered and processed using Statistical Package for the Social Sciences (SPSS) software packages. Data entry was done directly from the completed questionnaires. The data was validated by a computer processing team consisting of a computer programmer and data entry personnel. The computer programmer constantly supervised and monitored the data entry activities. The data set was cleaned and prepared for output generation. Data has been analyzed using simple frequency tables and cross tabulations. Tables were designed and finalized in consultation with the Technical staff of LIBON project of Plan Nepal. Relationships between the selected variables have been established using Chi-square test. Data are presented in the form of tables and bar graphs. Antenatal Care and Birth Preparedness | 11 Chapter 3: Characteristics of the Respondents This chapter deals with the information regarding the socio-demographic and economic characteristics of the recently delivered women RDW. Table 3.1: Percent distribution of RDW by level of education (result from qm105) Level of education District Sunsari (n=285) Parsa (n=247) 2010 March 2011 July 2010 March 2011 July No schooling 42.1 46.2 67.2 66.4 Informal education 3.5 4.0 3.6 1.2 Primary 15.4 10.5 14.2 10.9 Class VI and above 38.6 39.4 15.4 21.5 Chapter 4: Antenatal Care and Birth Preparedness This chapter deals with the utilization of antenatal services by RDW during their last pregnancy and the kind of preparations made for the delivery of their last child. Information related to the use of antenatal services including number and timing of Antenatal Care (ANC) visits, source of antenatal services and type of advice and services received from health service providers were collected in the survey. Information related to arrangement of money, transport, food and safe delivery items and skilled health providers for the delivery of their last child was also collected in the survey (Table # 4.1). Table 4.1: Percent distribution of RDW by persons consulted for antenatal services during their last pregnancy (qm302) Person consulted Sunsari (n=276) Sunsari (n=257) Parsa (n=224) Parsa (n=228) 2010 March 2011 July 2010 March 2011 July Doctor 34.0 33.1 41.1 50.9 Nurse 25.0 26.1 33.5 32.9 ANM 30.7 43.6 25.9 27.2 HA/AHW 19.2 14.0 13.4 19.7 MCHW 21.4 33.1 16.5 33.8 VHW 2.8 6.6 0.8 7.0 FCHV 19.0 26.1 11.7 26.3 TTBA 2.5 0.8 0.8 2.6 TBA 1.8 0.4 - 0.4 Ayurved 3.1 3.0 The proportion of the RDW of both the districts received antenatal check up from skilled providers, health worker and FCHV has increased from baseline to end line. Regarding the health institution for ANC services, the majority of the RDW in both the districts attended hospital and sub health posts. The proportion of the RDW receiving ANC services from SHP has increased than baseline may be due to birthing centre establishment and more demand of sevices. (Table 4.2). Antenatal Care and Birth Preparedness | 12 Table 4.2: Percent distribution of RDW by source of antenatal services during their last pregnancy (qm305) Source of antenatal services Sunsari (n=276) Sunsari (n=257) Parsa (n=224) Parsa (n=228) 2010 March 2011 July 2010 March 2011 July Hospital 34.9 33.9 39.2 49.6 PHCC 7.3 12.8 15.0 9.6 Health post 14.9 18.3 13.2 15.8 Sub-health post 24.7 43.2 16.3 43.4 PHC/ORC 12.7 23.7 4.4 11.0 Private clinic/nursing home 14.9 14.8 26.4 18.4 Pharmacy 0.4 0.4 - 4.4 Own home 3.3 1.6 2.7 1.8 TBA home 1.1 - 7.2 0.4 Others (family planning) 3.0 - 0.8 - Table 4.3: Percent distribution of RDW by type of antenatal care received during their last pregnancy, among those who received ANC at least once (qm308) 2010 March 2011 July 2010 March 2011 July Type of antenatal care received Sunsari (n=276) Sunsari (n=257) Parsa (n=224) Parsa (n=228) Weight measurement 92.7 97.0 77.4 93.3 Blood pressure measurement 89.4 94.7 90.3 96.0 Urine sample examination 57.3 57.9 52.2 55.1 Blood sample examination 52.9 59.8 45.1 45.3 The type of antenatal care services received their last pregnancy has a small increase in both districts than in baseline. But weight measurement in Parsa is increased from 77.4% to 93.3%. Table 4.4: Percent distribution of RDW by type of antenatal and postnatal care counselling received during their last pregnancy (qm312) 2010 March 2011 July 2010 March 2011 July Types of counselling received Sunsari (n=276) Sunsari (n=257) Parsa (n=224) Parsa (n=228) Tetanus toxoid vaccination 76.8 92.9 68.3 83.5 Danger signs during pregnancy 55.1 77.4 40.2 75.4 Using a skilled birth attendant/trained health worker 47.6 71.0 27.2 50.0 Breastfeeding immediately after birth 63.0 78.6 44.2 74.1 Financial preparation for your delivery 67.0 79.4 52.7 81.3 Wrapping the newborn 52.9 69.4 33.0 55.8 Preparation of CHDK 46.4 65.5 25.0 51.3 Essential newborn care 31.5 44.0 12.1 29.9 Family planning 28.3 44.4 18.8 30.4 Identifying emergency transport options 34.8 50.8 34.8 33.9 Arranging for blood in case of emergency 25.0 43.7 9.8 21.9 The types of antenatal and postnatal care counselling received during the last pregnancy have increased in the both districts in the end line survey. 4.1 Birth preparedness The information about the preparations made by the RDW or their families for the delivery of their last child was collected. Overall, more than 80% of the RDW reported that they had made some kind Antenatal Care and Birth Preparedness | 13 of preparations for their delivery and it was also higher in Sunsari than Parsa. The higher percentage of RDW reported making arrangement for money (Sunsari-100%, Parsa-99%), making provisions for food (Sunsari-75%, Parsa-86%) and arrangement of clean cloths (Sunsari-89%, Parsa-85%). There is remarkable increase in crucial preparations affecting the newborn such as arrangement for clean health delivery kit (CHDK), clean instruments for cord cutting, Health Facility (HF)/Skill Birth Attendant (SBA) identification in end line survey in both districts (Table 4.5). Table 4.5: Percent distribution of RDW who reported making specific preparations for the delivery of their last child (qm402) 2010 March 2011 July 2010 March 2011 July Kind of preparations Sunsari (n=238) Sunsari (n=271) Parsa (n=168) Parsa (n=198) HF/SBA identification 69.3 80.1 50.0 85.9 Transport arrangement 72.3 78.8 57.2 90.9 Money 94.1 100.0 93.4 99.0 Food 71.5 80.5 75.0 86.4 Clean delivery kit 55.9 64.8 36.9 70.7 Clean instrument for cord cutting 44.1 47.9 35.1 55.1 Clean cloths 76.1 89.8 64.0 85.4 Overall, 96% of the RDW reported that they had discussed about planning for delivery with at least one person (either a family member or outsider) during their last pregnancy. A majority of them discussed it with husbands followed by with mother in law. 67% RDW of both districts reported that they had discussed it with FCHVs. It indicates that family communication on planning for delivery was more prominent than communication with health workers. The end line values are increased than in baseline in both districts (Table 4.6). Table 4.6: Percent distribution of RDW by type of person they discussed about plan for their recent delivery (qm404) 2010 March 2011 July 2010 March 2011 July Persons with whom they discussed Sunsari (n=230) Sunsari (n=228) Parsa (n=153) Parsa (n=194) Husband 86.9 96.1 85.6 95.9 Mother in law 73.9 82.9 73.8 85.6 Friends/relatives 40.4 46.5 19.7 56.7 Mother 52.2 41.7 34.6 44.3 FCHV 54.8 66.7 35.3 67.5 Other health care worker 14.3 18.9 11.1 21.7 Other family members and relatives 0.9 6.1 2.0 2.1 RDW were also asked whether they had pre-identified the place for the delivery of their last child. Overall, 75% RDW of both districts reported that they had pre-identified the place for delivery. Among those who pre-identified the place for delivery, most of them pre-identified hospital to deliver their baby. Table 4.7: Percent distribution of RDW by place where they had planned for the delivery of their last child (qm504) Description 2010 March 2011 July 2010 March 2011 July Sunsari Sunsari Parsa Parsa Planning for place for delivery (n=285) (n=281) (n=247) (n=241) Yes 68.1 75.1 53.0 75.7 Antenatal Care and Birth Preparedness | 14 No 31.9 24.9 47.0 21.9 Places pre-identified for delivery (n=195) (n=131) Hospital 71.1 68.3 58.8 66.3 PHCC 2.1 10.0 3.8 3.2 Health post 3.6 3.6 6.1 10.5 Sub-health post 5.7 8.6 1.5 4.7 Private clinic/nursing home 3.6 3.6 14.5 5.3 Own home 13.9 4.5 15.3 10.0 Delivery Services | 15 Chapter 5: Delivery Services One of the objectives of the survey was to assess the perceptions and household behaviour regarding delivery at a health institution and in the presence of skilled birth attendants. Information on different aspects of delivery care such as knowledge about sources of delivery services, danger signs associated with delivery, utilization of delivery services and exposure to various behaviour change communication messages related to delivery were collected from RDW. Table 5.1: Percent distribution of RDW by opinion regarding the persons to be present at birth to help deliver the baby safely (qm512) Persons to be present at birth (multiple response) 2010 March 2011 July 2010 March 2011 July Sunsari (n=285) Sunsari (n=285) Parsa (n=247) Parsa (n=247) Doctor 57.1 47.5 46.9 35.2 Nurse 42.4 43.1 51.4 30.5 ANM 20.7 21.6 13.3 14.8 HA/AHW 3.5 3.5 7.2 11.4 MCHW 5.9 3.1 5.6 9.3 VHW - 0.0 0.4 2.1 FCHV 32.2 25.1 20.2 33.1 TTBA 8.4 1.6 14.5 11.0 TBA 10.8 3.5 11.7 9.3 Relatives/friends 31.2 34.9 45.7 38.1 Family members 5.2 3.2 5.1 Experiencing danger signs during delivery RDWs were asked regarding danger signs during the delivery of their last child if they had experienced any. Among four pronounced major danger signs, 6.7% of Sunsari and 6.9% of Parsa reported having experienced prolonged labour. Similarly, 2.1% RDW of Sunsari and 8.1% of Parsa reported excessive bleeding, 1.8% of Sunsari and 8.1% of Parsa reported convulsions. Very few mothers reported mal presentation. RDW experienced having no any danger signs during the delivery decreased from 29.5% to 14.8% in Sunsari and from24.3% to 18.2% in Parsa. Table 5.2: Percent distribution of RDW experiencing danger signs during the delivery of their last child (qm557) 2010 March 2011 July 2010 March 2011 July Type of danger signs experienced Sunsari (n=285) Parsa (n=247) Total Total Prolonged labour (>8 hours) 17.9 6.7 13.0 6.9 Excessive bleeding 7.7 2.1 9.3 8.1 Convulsions 6.7 1.8 5.2 8.1 The baby’s hand, leg or cord came out first (mal presentation) 1.8 1.4 3.2 2.4 Others 7.3 1.4 4.0 1.6 No problems 70.5 84.2 75.7 81.8 Delivery Services | 16 Prolonged labor (>8 hours) Heavy bleeding Convulsions The baby's hand, leg or cord came out first Other No problem Sunari Parsa 8.1 8.1 6.9 2.4 0.0 74.5 6.7 2.1 1.8 1.4 1.4 86.7 % Problem during delivery Jul 2011 RDW who reported having experienced danger signs during the delivery of their last child were then asked about the persons whom they consulted for the management of such problems. For this, consultation with doctors has decreased in both districts than in baseline whereas the consultation with FCHV has increased in case of complications during delivery. Table 5.3: Percent distribution of RDW by persons consulted for the management of problems experienced during the delivery of last child (qm558) 2010 March 2011 July 2010 March 2011 July Persons consulted Sunsari (n=84) Sunsari (n=45) Parsa (n=60) Parsa (n=) Doctor 48.8 34.8 45.0 24.8 Nurse 25.0 18.2 23.4 17.1 ANM 6.0 9.1 5.0 8.6 HA/AHW 10.8 3.0 11.6 8.6 MCHW - 1.5 - 4.8 VHW 1.2 0.0 - 1.0 FCHV 15.5 19.7 10.0 16.2 TTBA 3.6 0.0 1.7 5.7 TBA 3.6 1.5 3.3 3.8 Other HW 3.6 3.0 - 2.9 Traditional healers - 3.0 - 1.0 Relatives/neighbour/friend 8.4 0.0 6.7 2.9 Pharmacist 2.4 3.0 - 1.9 Given medicine at home 1.2 0.0 - 1.0 Others 2.4 0.0 - 0.0 Among referred RDWs, 75% of Sunsari and 60.7.3% of Parsa consulted hospital has increased than baseline. The proportion of RDW consulting PHCC, health post and sub-health post has increased in both districts than in baseline except in health post in Sunsari (Table 5.4). Table 5.4: Percent distribution of RDW by places they were referred for the complications appeared during last delivery 2010 March 2011 July 2010 March 2011 July Places consulted Sunsari (n=46) Sunsari (n=32) Parsa (n=30) Parsa (n=28) Total Total Delivery Services | 17 Hospital 67.4 75.0 43.3 60.7 PHCC 2.2 12.5 6.7 14.3 Health post 8.7 3.1 10.0 42.9 Sub-health post 8.6 31.3 3.3 25.0 Private clinic/nursing home 15.2 6.3 30.0 28.6 Own home 8.7 6.3 3.3 14.3 TBA home - - 3.3 7.1 5.2 Utilization of delivery services RDW who had an institutional delivery for their last child were further asked about the persons who accompanied them to the health facility for delivery. In Sunsari, 70.8% and in Parsa 80.5% of RDW were accompanied by their husbands followed by Mother in law 54.2% in Sunsari and 69.2% in Parsa. Accompanied by FCHV is increased in both districts in the end line than in baseline. Table 5.5: Percent distribution of RDW persons who accompanied them while going to the health facility for delivery (qm507) Persons (Multiple response) 2010 march 2011 August 2010 march 2011 August Sunsari (n=155) Parsa (n=102) Husband 76.7 70.8 77.4 80.5 Other relatives 46.4 22.4 37.2 45.1 Mother in law 52.2 54.2 65.6 69.2 Father in law 24.5 20.3 28.4 27.1 Mother/father 29.6 20.8 23.5 26.3 FCHV 14.1 19.3 4.9 27.1 Others (friends/neighbours, sister) 4.5 3.9 5.3 Exposure to measures related to delivery services Regarding the level of exposure of RDW to maternal and newborn health information, 82% RDW of Sunsari and 91% of Parsa mentioned that they had heard that a newborn should be breastfed within one hour after birth form FCHV. Table 5.6: Percent distribution of RDW by source of information on maternal and newborn health services qm553 Source of information Sunsari (n=285) Parsa (n=247) 2010 march 2011 August 2010 march 2011 August FCHV 71.7 82 61.6 91 Other health personnel 32.8 42 36.6 48 Radio 63.7 40 32.2 27 Posters/pamphlets 12.8 13 4.5 09 TV 44.6 36 23.3 32 TBAs 4.4 04 8.9 13 BPP flip chart 12.8 15 5.4 31 Friends/relatives/neighbours 16.8 25 18.7 37 NGO workers 7.6 8 4.5 20 Street dramas 0.4 2 0.9 2 Others (teachers, books, mothers group) 4.8 5 6.2 2 A large proportion of the RDW in both the districts perceived FCHVs as trusted sources for getting information on maternal and newborn health services. Similarly, radio, television, health personal other than FCHVs were also reported as trusted sources for getting information on maternal and newborn health services. Table 5.7: Percent distribution of RDW by perception on the trusted sources of information on maternal and newborn health services qm556, denominator qm 555) Delivery Services | 18 2010 march 2011 August 2010 march 2011 August Opinion on the trusted sources of information (multiple response) Sunsari (n=285) Parsa (n=247) Other health personnel 35.1 50 39.0 49 FCHV 73.6 85 67.8 92 Radio 57.7 45 32.1 28 TV 43.3 12 24.1 28 Posters/pamphlets 10.1 5 8.0 11 TBA 6.3 5 10.3 15 NGO workers 7.7 12 3.4 22 BPP flip chart 15.9 18 3.4 29 Friends/relatives/neighbours 23.1 30 17.2 29 Street dramas 1.0 2 2.3 0 Others (newspaper, family members) 4.3 2 4.5 0 None 1.4 0 5.7 0 FCHVs, were commonly mentioned sources, who provided information about attendance of a trained health worker during delivery. Similarly, radio, television, health personnel other than FCHVs were also the sources for getting messages on attendance of a trained health worker during delivery. Table 5.8: Percent distribution of RDW by sources from where they got messages on attendance of a trained health worker during delivery qm563, denominator qm561) 2010 march 2011 August 2010 march 2011 August Source of information Sunsari (n=285) N=165 Parsa (n=247) N=140 Total Total FCHV 68.9 72 59.3 84 Other health personnel 36.6 37 27.2 50 Radio 62.9 35 25.3 28 Posters/pamphlets 15.6 12 2.9 10 TV 47.3 33 17.5 23 TBAs 6.0 4 6.8 13 BPP flip chart 14.4 17 3.9 19 Friends/relatives/neighbours 25.3 26 21.3 28 NGO workers 8.4 14 2.0 28 Others (magazine, mothers group) 9.5 1 8.8 0 None/no where 1.1 0 9.8 0 Annex-1a | 19 Chapter 6: Postpartum Care One of the objectives of the CB-NCP Program is to inform and encourage mothers in the program areas to utilize postnatal health services. The current status of use of postnatal health services among women who delivered babies 12 months prior to the survey. Information regarding the utilization of postnatal health services, such as source of postnatal services, timing of first and subsequent postnatal check ups, and type of services received from health facilities and providers were collected. 6.1 Early postnatal care visit The information about the person who checked them post delivery was collected. It was found that 61.8% RDW were checked by skilled providers (doctor, nurse, ANM) in Sunsari and 51.9% in Parsa. FCHVs involvement in post delivery check up for both districts is increased and check up from TTBA/TBA decreased. This is a good trend. Table 6.1: Percent distribution of RDW by persons who checked them before they were discharged or left their house qm606 2010 march 2011 August 2010 march 2011 August Persons Sunsari (n=87) Sunsari (157) Parsa (n=55) Parsa (110) Doctor 47.1 38.2 21.8 39.1 Nurse 8.0 11.5 9.1 7.3 ANM 13.8 12.1 7.3 12.7 HA/AHW/CMA 4.6 2.5 9.1 9.1 MCHW 6.9 .6 1.8 .9 VHW 1.1 5.7 1.8 6.4 FCHV 11.5 26.8 5.5 17.3 TTBA/TBA 5.7 .6 34.6 2.7 Relatives/friends/medical shop/medical shopkeeper 1.1 1.9 9.1 3.6 RDW reporting check up by a health care provider before they were discharged from the health facility or before the health provider left the house were also asked about the type of services they received. Majority of RDW in both the districts reported that their body was examined, check up for excessive bleeding, checked for breasts, checked for fever. Thus, it reveals that majority of RDW received the most essential check up services within few days following delivery in both districts. Table 6.2: Percent distribution of RDW by type of services received from the health service providers Qm607 and denominator is qm605) 2010 march 2011 August 2010 march 2011 August Type of services Sunsari (n=87) Sunsari (150) Parsa (n=55) Parsa (107) Total Total Examined body 86.2 98 83.7 100 Checked for excessive bleeding 75.9 82 52.8 82 Checked breasts 72.4 83 47.3 92 Checked for fever 68.9 81 56.3 70 Referred to a health center/hospital 22.1 25 12.7 18 Others (blood pressure check up, injection, check wound) 9.2 1 1.8 0 Chapter 7: Immediate Newborn Care and Newborn Care The main objectives of the CB-NCP program are to increase awareness and bring about household behavior change towards healthy newborn practices, increase utilization of the available newborn services and strengthen the quality of the preventive, promotive and curative services from the Annex-1a | 20 community to the health facility level. This chapter deals with the findings on immediate newborn care, exposure of respondents to messages related to immediate newborn care and newborn care practices during first month. 7.1 Immediate newborn care Regarding immediate newborn care, information on materials used for cord cutting, drying, wrapping and bathing the newborn, initiation of breastfeeding and health check up and counselling following the birth was collected. a) Drying, wrapping and bathing of newborn In response to the place of keeping the newborn immediately after delivery, majority of newborn were placed on the mothers’ abdomen which is increased than baseline in both districts. Table 7.1: Percent distribution of RDW by placement of their newborn immediately after delivery (qm514) 2010 march 2011 August 2010 march 2011 August Placement of baby immediately after birth Sunsari (n=285) Sunsari (n=285) Parsa (n=247) Parsa (n=247) On a cot 8.8 6.8 30.4 10.7 On the floor 11.2 3.9 17.8 3.7 With someone else 10.9 11.1 8.1 3.7 On the mothers abdomen 64.6 71.3 33.2 79.4 Other (in cabin, plastic, ventilator) 1.8 3.2 4.5 .0 Do not know 2.8 3.6 6.1 2.5 b) Crying of baby after birth Among RDW with live birth, 95% both districts reported that their baby cried or breathed immediately after birth. However, about 3% RDW of both the districts reported that their baby did not cry immediately after birth. Regarding to taking help to cry or breathe the baby easily for newborn who did not cry, majority were rubbed or massaged which is increased from baseline (Sunsari- from 29.4% to 66.7%, Parsa- from 68.8% to 76.9%). (Table: 7.2). Table 7.2: Percent distribution of RDW whose baby cried or breathed easily immediately after birth and type of help provided for crying or easy breathing the baby qm517 for denominator (did not cry code 2) and qm518 2010 march 2011 August 2010 march 2011 August Description Sunsari Sunsari Parsa Parsa Whether baby cried or breathed easily n=285 N=285 n=247 n=247 Yes 91.2 95.3 90.3 95.5 No 6.0 2.9 6.1 3.3 Do not know 2.8 1.8 3.6 1.2 Type of help provided for crying or breathing n=17 n=8 n=15 n=8 Rubbed/massaged 29.4 66.7 68.8 76.9 Resuscitation using a bag and mask 11.8 - 12.5 23.1 Mouth-to-mouth resuscitation 5.9 - - - Mouth cleared - - 6.7 23.1 Fed butter/ghee 17.6 - 12.5 Others 11.8 - 13.3 15.4 Nothing 17.6 22.2 12.5 15.4 Do not know 17.6 11.1 - 7.7 Persons helped to cry or breathe qm519 n=17 n=8 n=15 n=8 Doctor 35.2 40.0 13.3 15.4 Nurse 41.1 20.0 33.3 38.5 Annex-1a | 21 2010 march 2011 August 2010 march 2011 August Description Sunsari Sunsari Parsa Parsa ANM 11.7 10.0 - 7.7 HA/AHW 5.8 6.6 15.4 Relatives/friends 5.8 20.0 20.0 TBA 11.7 10.0 26.6 MCHW - - 7.7 FCHV 5.8 - 7.7 TTBA - 20.0 Other (breathing itself) 23.5 - 7.7 Nobody - 6.6 d) Initiation of breastfeeding It is recommended that a newborn should be breastfed immediately after birth. RDWs were asked about the timing of introducing breast milk to the newborn. About 78% of mothers of Sunsari and Parsa mentioned that a child should be breastfed immediately after birth. The proportion of mothers mentioning breastfeeding should be initiated after the placenta is expelled was significantly high in both districts (13.5%) though it is reduced from baseline value. Thus there is need of education about the appropriate timing of initiating breastfeeding. Table 7.3: Percent distribution of RDW by knowledge about the timing of initiating the breast milk to the newborn qm 551 2010 march 2011 August 2010 march 2011 August Knowledge about the timing of initiating breast milk Sunsari (n=285) Sunsari (n=285) Parsa (n=247) Parsa (n=247) Immediately after birth 65.6 77.9 32.2 78.4 After the placenta is expelled 15.4 13.5 22.4 13.5 After bathing the newborn 1.1 .7 5.3 1.2 After 24 hours after birth 3.2 1.4 18.0 2.4 Others 8.4 1.8 6.1 .8 Do not know 6.3 4.6 15.9 3.7 e)Early PNC for newborn (within 24 hours or before discharge) RDW, who reported that their baby was checked by a health care provider before they were discharged or before the provider left the house, were asked about the person checking their baby at that time. Among those newborns, 55.5% of Sunsari and 58.7% of Parsa were reported to have been checked by a skilled provider (doctor, nurse, ANM). The check up by FCHV to newborn is increased in the both districts in end line than baseline. Table 7.4: Percent distribution of RDW by persons who checked their baby before the health professional, FCHV or TBA left their house or before they were discharged from the health facility following the birth of their last child qm 706 2010 march 2011 August 2010 march 2011 August Persons checking baby’s health (Multiple response) Sunsari (n=174) Sunsari (n=155) Parsa (n=118) Parsa (n=109) Doctor 51.7 34.2 46.6 35.8 Nurse 28.2 7.1 35.6 11.0 ANM 11.5 14.2 9.3 11.9 HA/AHW 5.2 0 9.3 .9 MCHW 4.6 3.9 2.5 8.3 VHW 1.7 0 - 0 FCHV 13.2 35.5 5.9 20.2 Annex-1a | 22 2010 march 2011 August 2010 march 2011 August Persons checking baby’s health (Multiple response) Sunsari (n=174) Sunsari (n=155) Parsa (n=118) Parsa (n=109) TTBA, TBA 6.9 .6 16.9 2.8 Relatives/friends - 0 0.8 0 Other (jhole health worker) 0.6 .6 0.8 .0 7.2 Exposure to messages related to immediate newborn care This section deals with the findings related to the type of health care provided to the newborn within one month following birth. Among RDW whose newborn was checked within four weeks, majority (Sunsari-54.6%) were checked three times or more where as in Parsa only 20.4%. Skilled health care providers checking the newborn were doctors about 34% in both the districts. The involvement of FCHV was singnificantly increased in both districts than in baseline. (Table 7.5). Table 7.5: Percent distribution of RDW by number of times and type of provider who checked their newborn within four weeks after birth, among RDW whose newborn was either still alive or survived at least one month after birth (Q 704 and 706) Description 2010 march 2011 August 2010 march 2011 August Sunsari (n=77) Sunsari (n=152) Parsa (n=50) Parsa (n=107) Number of times checking newborn 1 40.3 19.1 52.0 53.1 2 33.8 26.3 26.0 26.5 3 or more 26.0 54.6 20.0 20.4 Persons checking newborn Doctor 46.8 34.2 18.0 35.8 Staff nurse 9.1 7.1 12.0 11.0 ANM 13.0 14.2 14.0 11.9 MCHW 5.2 3.9 2.0 8.3 HA - .0 4.0 .9 AHW/CMA 6.5 3.9 8.0 5.5 VHW 1.3 .0 2.0 0 FCHV 10.4 35.5 4.0 20.2 Trained TBA 5.2 .6 18.0 2.8 Untrained TBA 2.6 0 12.0 3.7 Relatives/friend - .6 4.0 0 Medical shopkeeper - 0 2.0 0 Information about perception of the mothers regarding the size of their child at birth was also collected during the survey. Among RDW with live birth, 69.6% (baseline 60.4%) of Sunsari and 68.9 (baseline 57.9%) of Parsa reported that they perceived average weight or size of the baby. Table 7.6: Percent distribution of RDW by opinion regarding the size of their child at birth (Q 716) Perception on size of the newborn 2010 march 2011 August 2010 march 2011 August Sunsari (n=285) Parsa (n=247) Very large 4.2 1.8 2.0 4.6 Larger than average 22.8 20.7 27.9 21.6 Average 60.4 69.6 57.9 68.9 Smaller than average 6.0 4.3 8.5 2.9 Very small 2.5 3.2 1.2 1.2 Do not know 4.2 .4 2.4 .8 Annex-1a | 23 a) Neonatal complications and treatment RDW with live birth whose child was alive or survived at least one month were asked about any danger signs or symptoms experienced during the first month after delivery. Overall, 19.2% (baseline23.2%) RDW of Sunsari and 7.0% (baseline 10.9%) RDW of Parsa said that their newborn had experienced at least one of the danger signs or symptoms during their neonatal period (Figure 7.7). In both districts, the prevalence of danger sign is decreased in newborns. It is may be due to proper care of newborn by CBNCP program. Fig 7.1 QNO 802 YES one danger sign or symptoms od newborn within one month following birth 23.2 10.9 19.2 7.0 0 5 10 15 20 25 Sunsari Parsa % Baseline End line Figure 7.1: Percentage of RDW who reported that their infant had experienced at least one danger sign or symptoms within one month following birth, among RDW whose child was still alive or survived at least one month (n=285, 247) The types of danger signs or symptoms experienced by their child within one month were also assessed in the survey. It was found that majority of newborn experienced fever, difficult or fast breathing, and unable to suck milk or feed. Of the 59 RDW of Sunsari and 16 RDW of Parsa who reported that their newborn had experienced danger signs or symptoms within one month after birth, a great majority in both the districts said that their babies had one episode of illness upto to the age of one month. (Table: 7.7). Table 7.7: Percent distribution of RDW by number of times their newborn got sick during neonatal period (Q 804) Number of times of getting sick 2010 march 2011 August 2010 march 2011 August Sunsari (n=66) Sunsari (n=59) Parsa (n=27) Parsa (n=16) 1 71.2 67.8 70.4 75.0 2 18.2 11.9 18.5 6.3 3+ 10.5 20.3 11.1 18.8 Average number of episodes 1.48 1.92 1.44 1.69 Annex-1a | 24 Annex-1a: Sample frame of Sunsari district Ilaka# Rec # Ilaka/MP LQA# VDC/MP Ward 1 1 Itahari 1 Aekamba 2 1 2 Itahari 2 Aekamba 5 1 3 Itahari 3 Aekamba 8 1 4 Itahari 4 Hanshposha 2 1 5 Itahari 5 Hanshposha 2 1 6 Itahari 6 Hanshposha 2 1 7 Itahari 7 Hanshposha 4 1 8 Itahari 8 Hanshposha 5 1 9 Itahari 9 Hanshposha 8 1 10 Itahari 10 Khanar 2 1 11 Itahari 11 Khanar 4 1 12 Itahari 12 Khanar 5 1 13 Itahari 13 Khanar 6 1 14 Itahari 14 Khanar 7 1 15 Itahari 15 Panchakanya 2 1 16 Itahari 16 Panchakanya 3 1 17 Itahari 17 Panchakanya 5 1 18 Itahari 18 Panchakanya 5 1 19 Itahari 19 Panchakanya 6 2 20 Chatara 1 Barahachhetra 1 2 21 Chatara 2 Barahachhetra 3 2 22 Chatara 3 Barahachhetra 4 2 23 Chatara 4 Barahachhetra 5 2 24 Chatara 5 Barahachhetra 6 2 25 Chatara 6 Bishnupaduka 4 2 26 Chatara 7 Bishnupaduka 6 2 27 Chatara 8 Bishnupaduka 8 2 28 Chatara 9 Mahendranagar 1 2 29 Chatara 10 Mahendranagar 2 2 30 Chatara 11 Mahendranagar 3 2 31 Chatara 12 Mahendranagar 4 2 32 Chatara 13 Mahendranagar 4 2 33 Chatara 14 Mahendranagar 4 2 34 Chatara 15 Mahendranagar 4 2 35 Chatara 16 Mahendranagar 7 2 36 Chatara 17 Mahendranagar 7 2 37 Chatara 18 Mahendranagar 9 2 38 Chatara 19 Mahendranagar 9 3 39 Madhuwan 1 Haripur 1 3 40 Madhuwan 2 Haripur 5 3 41 Madhuwan 3 Haripur 7 3 42 Madhuwan 4 Haripur 9 3 43 Madhuwan 5 Laukahi 3 3 44 Madhuwan 6 Laukahi 6 3 45 Madhuwan 7 Madhuwan 3 3 46 Madhuwan 8 Madhuwan 5 3 47 Madhuwan 9 Madhuwan 8 3 48 Madhuwan 10 PaschimKasuha 1 3 49 Madhuwan 11 PaschimKasuha 4 3 50 Madhuwan 12 PaschimKasuha 4 3 51 Madhuwan 13 PaschimKasuha 8 3 52 Madhuwan 14 PaschimKasuha 9 3 53 Madhuwan 15 Sripurjabdi 3 3 54 Madhuwan 16 Sripurjabdi 5 3 55 Madhuwan 17 Sripurjabdi 6 3 56 Madhuwan 18 Sripurjabdi 7 3 57 Madhuwan 19 Sripurjabdi 8 4 58 Harinagara 1 Basantapur 1 4 59 Harinagara 2 Basantapur 5 4 60 Harinagara 3 Basantapur 7 Annex-1a | 25 Ilaka# Rec # Ilaka/MP LQA# VDC/MP Ward 4 61 Harinagara 4 Basantapur 8 4 62 Harinagara 5 Harinagara 1 4 63 Harinagara 6 Harinagara 3 4 64 Harinagara 7 Harinagara 4 4 65 Harinagara 8 Harinagara 6 4 66 Harinagara 9 Harinagara 8 4 67 Harinagara 10 Madhyeharsahi 1 4 68 Harinagara 11 Madhyeharsahi 3 4 69 Harinagara 12 Madhyeharsahi 5 4 70 Harinagara 13 Madhyeharsahi 7 4 71 Harinagara 14 RajganjSenuwari 1 4 72 Harinagara 15 RajganjSenuwari 3 4 73 Harinagara 16 RajganjSenuwari 4 4 74 Harinagara 17 RajganjSenuwari 5 4 75 Harinagara 18 RajganjSenuwari 7 4 76 Harinagara 19 RajganjSenuwari 9 5 77 Satterjhora 1 Aurabarni 1 5 78 Satterjhora 2 Aurabarni 3 5 79 Satterjhora 3 Aurabarni 6 5 80 Satterjhora 4 Aurabarni 9 5 81 Satterjhora 5 Bhaluwa 1 5 82 Satterjhora 6 Bhaluwa 5 5 83 Satterjhora 7 Bhaluwa 9 5 84 Satterjhora 8 Chhitaha 3 5 85 Satterjhora 9 Chhitaha 5 5 86 Satterjhora 10 Chhitaha 6 5 87 Satterjhora 11 Chhitaha 9 5 88 Satterjhora 12 Santerjhora 1 5 89 Satterjhora 13 Santerjhora 3 5 90 Satterjhora 14 Santerjhora 6 5 91 Satterjhora 15 Santerjhora 6 5 92 Satterjhora 16 Santerjhora 8 5 93 Satterjhora 17 Tanamuna 1 5 94 Satterjhora 18 Tanamuna 4 5 95 Satterjhora 19 Tanamuna 7 6 96 Inaruwa 1 Babiya 1 6 97 Inaruwa 2 Babiya 2 6 98 Inaruwa 3 Babiya 4 6 99 Inaruwa 4 Babiya 6 6 100 Inaruwa 5 Babiya 8 6 101 Inaruwa 6 Dumaraha 1 6 102 Inaruwa 7 Dumaraha 2 6 103 Inaruwa 8 Dumaraha 3 6 104 Inaruwa 9 Dumaraha 3 6 105 Inaruwa 10 Dumaraha 4 6 106 Inaruwa 11 Dumaraha 6 6 107 Inaruwa 12 Dumaraha 6 6 108 Inaruwa 13 Dumaraha 7 6 109 Inaruwa 14 Dumaraha 7 6 110 Inaruwa 15 Dumaraha 8 6 111 Inaruwa 16 Dumaraha 9 6 112 Inaruwa 17 Madhesa 3 6 113 Inaruwa 18 Madhesa 5 6 114 Inaruwa 19 Madhesa 7 7 115 Prakashpur 1 Bhokraha 1 7 116 Prakashpur 2 Bhokraha 1 7 117 Prakashpur 3 Bhokraha 2 7 118 Prakashpur 4 Bhokraha 3 7 119 Prakashpur 5 Bhokraha 3 7 120 Prakashpur 6 Bhokraha 4 7 121 Prakashpur 7 Bhokraha 5 7 122 Prakashpur 8 Bhokraha 6 7 123 Prakashpur 9 Bhokraha 7 Annex-1a | 26 Ilaka# Rec # Ilaka/MP LQA# VDC/MP Ward 7 124 Prakashpur 10 Bhokraha 8 7 125 Prakashpur 11 Bhokraha 9 7 126 Prakashpur 12 Prakashpur 1 7 127 Prakashpur 13 Prakashpur 2 7 128 Prakashpur 14 Prakashpur 4 7 129 Prakashpur 15 Prakashpur 5 7 130 Prakashpur 16 Prakashpur 5 7 131 Prakashpur 17 Prakashpur 6 7 132 Prakashpur 18 Prakashpur 7 7 133 Prakashpur 19 Prakashpur 8 8 134 Bakalauri 1 Bakalauri 2 8 135 Bakalauri 2 Bakalauri 4 8 136 Bakalauri 3 Bakalauri 6 8 137 Bakalauri 4 Bakalauri 8 8 138 Bakalauri 5 BhadgauSinawari 2 8 139 Bakalauri 6 BhadgauSinawari 4 8 140 Bakalauri 7 BhadgauSinawari 5 8 141 Bakalauri 8 BhadgauSinawari 9 8 142 Bakalauri 9 Bharaul 2 8 143 Bakalauri 10 Bharaul 3 8 144 Bakalauri 11 Bharaul 4 8 145 Bakalauri 12 Bharaul 5 8 146 Bakalauri 13 Bharaul 7 8 147 Bakalauri 14 Pakali 2 8 148 Bakalauri 15 Pakali 4 8 149 Bakalauri 16 Pakali 9 8 150 Bakalauri 17 Singiya 2 8 151 Bakalauri 18 Singiya 5 8 152 Bakalauri 19 Singiya 8 9 153 Madhelee 1 Chandbela 4 9 154 Madhelee 2 Chandbela 7 9 155 Madhelee 3 Duhabi 1 9 156 Madhelee 4 Duhabi 3 9 157 Madhelee 5 Duhabi 4 9 158 Madhelee 6 Duhabi 5 9 159 Madhelee 7 Duhabi 5 9 160 Madhelee 8 Duhabi 6 9 161 Madhelee 9 Duhabi 8 9 162 Madhelee 10 Madhelee 1 9 163 Madhelee 11 Madhelee 4 9 164 Madhelee 12 Madhelee 7 9 165 Madhelee 13 Simariya 1 9 166 Madhelee 14 Simariya 6 9 167 Madhelee 15 Sonapur 1 9 168 Madhelee 16 Sonapur 2 9 169 Madhelee 17 Sonapur 3 9 170 Madhelee 18 Sonapur 7 9 171 Madhelee 19 Sonapur 9 10 172 Sitagunj 1 Amaduwa 1 10 173 Sitagunj 2 Amaduwa 3 10 174 Sitagunj 3 Amaduwa 5 10 175 Sitagunj 4 Amaduwa 6 10 176 Sitagunj 5 Amaduwa 9 10 177 Sitagunj 6 Amahibelaha 2 10 178 Sitagunj 7 Amahibelaha 6 10 179 Sitagunj 8 Amahibelaha 8 10 180 Sitagunj 9 Chimdi 1 10 181 Sitagunj 10 Chimdi 4 10 182 Sitagunj 11 Chimdi 6 10 183 Sitagunj 12 Purbakushaha 1 10 184 Sitagunj 13 Purbakushaha 3 10 185 Sitagunj 14 Purbakushaha 6 10 186 Sitagunj 15 Purbakushaha 8 Annex-1a | 27 Ilaka# Rec # Ilaka/MP LQA# VDC/MP Ward 10 187 Sitagunj 16 RamganjBelgachhiya 1 10 188 Sitagunj 17 RamganjBelgachhiya 4 10 189 Sitagunj 18 RamganjBelgachhiya 7 10 190 Sitagunj 19 RamganjBelgachhiya 9 11 191 Dewanganj 1 Dewanganj 1 11 192 Dewanganj 2 Dewanganj 3 11 193 Dewanganj 3 Dewanganj 3 11 194 Dewanganj 4 Dewanganj 6 11 195 Dewanganj 5 Dewanganj 8 11 196 Dewanganj 6 Ghuskee 1 11 197 Dewanganj 7 Ghuskee 3 11 198 Dewanganj 8 Ghuskee 4 11 199 Dewanganj 9 Ghuskee 5 11 200 Dewanganj 10 Ghuskee 7 11 201 Dewanganj 11 Ghuskee 8 11 202 Dewanganj 12 Kaptanganj 1 11 203 Dewanganj 13 Kaptanganj 2 11 204 Dewanganj 14 Kaptanganj 3 11 205 Dewanganj 15 Kaptanganj 5 11 206 Dewanganj 16 Kaptanganj 7 11 207 Dewanganj 17 Kaptanganj 8 11 208 Dewanganj 18 Sahebganj 2 11 209 Dewanganj 19 Sahebganj 7 12 210 Bhutaha 1 Gautampur 4 12 211 Bhutaha 2 Gautampur 9 12 212 Bhutaha 3 Jalpapur 4 12 213 Bhutaha 4 Jalpapur 7 12 214 Bhutaha 5 Narshinhatappu 1 12 215 Bhutaha 6 Narshinhatappu 2 12 216 Bhutaha 7 Narshinhatappu 3 12 217 Bhutaha 8 Narshinhatappu 4 12 218 Bhutaha 9 Narshinhatappu 5 12 219 Bhutaha 10 Narshinhatappu 6 12 220 Bhutaha 11 Narshinhatappu 7 12 221 Bhutaha 12 Narshinhatappu 8 12 222 Bhutaha 13 Narshinhatappu 9 12 223 Bhutaha 14 RamnagarBhutaha 1 12 224 Bhutaha 15 RamnagarBhutaha 3 12 225 Bhutaha 16 RamnagarBhutaha 5 12 226 Bhutaha 17 RamnagarBhutaha 7 12 227 Bhutaha 18 RamnagarBhutaha 8 12 228 Bhutaha 19 RamnagarBhutaha 9 1a (13) 229 Itahari NP 1 Itahari N.P. 1 1a (13) 230 Itahari NP 2 Itahari N.P. 1 1a (13) 231 Itahari NP 3 Itahari N.P. 2 1a (13) 232 Itahari NP 4 Itahari N.P. 2 1a (13) 233 Itahari NP 5 Itahari N.P. 2 1a (13) 234 Itahari NP 6 Itahari N.P. 2 1a (13) 235 Itahari NP 7 Itahari N.P. 3 1a (13) 236 Itahari NP 8 Itahari N.P. 3 1a (13) 237 Itahari NP 9 Itahari N.P. 4 1a (13) 238 Itahari NP 10 Itahari N.P. 4 1a (13) 239 Itahari NP 11 Itahari N.P. 4 1a (13) 240 Itahari NP 12 Itahari N.P. 5 1a (13) 241 Itahari NP 13 Itahari N.P. 5 1a (13) 242 Itahari NP 14 Itahari N.P. 5 1a (13) 243 Itahari NP 15 Itahari N.P. 6 1a (13) 244 Itahari NP 16 Itahari N.P. 7 1a (13) 245 Itahari NP 17 Itahari N.P. 8 1a (13) 246 Itahari NP 18 Itahari N.P. 8 1a (13) 247 Itahari NP 19 Itahari N.P. 9 1b (14) 248 Dharan NP 1 Dharan NP 2 1b (14) 249 Dharan NP 2 Dharan NP 3 Annex-1a | 28 Ilaka# Rec # Ilaka/MP LQA# VDC/MP Ward 1b (14) 250 Dharan NP 3 Dharan NP 6 1b (14) 251 Dharan NP 4 Dharan NP 7 1b (14) 252 Dharan NP 5 Dharan NP 8 1b (14) 253 Dharan NP 6 Dharan NP 8 1b (14) 254 Dharan NP 7 Dharan NP 9 1b (14) 255 Dharan NP 8 Dharan NP 10 1b (14) 256 Dharan NP 9 Dharan NP 11 1b (14) 257 Dharan NP 10 Dharan NP 12 1b (14) 258 Dharan NP 11 Dharan NP 13 1b (14) 259 Dharan NP 12 Dharan NP 14 1b (14) 260 Dharan NP 13 Dharan NP 15 1b (14) 261 Dharan NP 14 Dharan NP 15 1b (14) 262 Dharan NP 15 Dharan NP 15 1b (14) 263 Dharan NP s Dharan NP 16 1b (14) 264 Dharan NP 17 Dharan NP 17 1b (14) 265 Dharan NP 18 Dharan NP 18 1b (14) 266 Dharan NP 19 Dharan NP 19 6a (15) 267 Inaruwa NP 1 Inaruwa NP 1 6a (15) 268 Inaruwa NP 2 Inaruwa NP 1 6a (15) 269 Inaruwa NP 3 Inaruwa NP 2 6a (15) 270 Inaruwa NP 4 Inaruwa NP 3 6a (15) 271 Inaruwa NP 5 Inaruwa NP 3 6a (15) 272 Inaruwa NP 6 Inaruwa NP 3 6a (15) 273 Inaruwa NP 7 Inaruwa NP 4 6a (15) 274 Inaruwa NP 8 Inaruwa NP 5 6a (15) 275 Inaruwa NP 9 Inaruwa NP 5 6a (15) 276 Inaruwa NP 10 Inaruwa NP 6 6a (15) 277 Inaruwa NP 11 Inaruwa NP 6 6a (15) 278 Inaruwa NP 12 Inaruwa NP 6 6a (15) 279 Inaruwa NP 13 Inaruwa NP 7 6a (15) 280 Inaruwa NP 14 Inaruwa NP 7 6a (15) 281 Inaruwa NP 15 Inaruwa NP 7 6a (15) 282 Inaruwa NP 16 Inaruwa NP 8 6a (15) 283 Inaruwa NP 17 Inaruwa NP 9 6a (15) 284 Inaruwa NP 18 Inaruwa NP 9 6a (15) 285 Inaruwa NP 19 Inaruwa NP 10 Annex-1b | 29 Annex-1b: Sample frame of Parsa district Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 1 286 Thori 1 Nirmal Basti 1 1 287 Thori 2 Nirmal Basti 2 1 288 Thori 3 Nirmal Basti 3 1 289 Thori 4 Nirmal Basti 4 1 290 Thori 5 Nirmal Basti 4 1 291 Thori 6 Nirmal Basti 5 1 292 Thori 7 Nirmal Basti 6 1 293 Thori 8 Nirmal Basti 6 1 294 Thori 9 Nirmal Basti 6 1 295 Thori 10 Nirmal Basti 7 1 296 Thori 11 Nirmal Basti 8 1 297 Thori 12 Thori 1 1 298 Thori 13 Thori 1 1 299 Thori 14 Thori 3 1 300 Thori 15 Thori 5 1 301 Thori 16 Thori 6 1 302 Thori 17 Thori 7 1 303 Thori 18 Thori 8 1 304 Thori 19 Thori 9 2 305 Sedhwa 1 Bijbaniya 3 2 306 Sedhwa 2 Bijbaniya 7 2 307 Sedhwa 3 Jeetpur 2 2 308 Sedhwa 4 Jeetpur 6 2 309 Sedhwa 5 Jeetpur 9 2 310 Sedhwa 6 Mahadev patti 2 2 311 Sedhwa 7 Mahadevpatti 5 2 312 Sedhwa 8 Mahadevpatti 7 2 313 Sedhwa 9 Pidari Guthi 1 2 314 Sedhwa 10 Pidari Guthi 6 2 315 Sedhwa 11 Pidari Guthi 8 2 316 Sedhwa 12 Sankarsaraiya 3 2 317 Sedhwa 13 Sankarsaraiya 6 2 318 Sedhwa 14 Sedhwa 1 2 319 Sedhwa 15 Sedhwa 6 2 320 Sedhwa 16 Subarnapur 2 2 321 Sedhwa 17 Subarnapur 6 2 322 Sedhwa 18 Supauli 1 2 323 Sedhwa 19 Supauli 7 3 324 Nichuta 1 Auraha 5 3 325 Nichuta 2 Auraha 9 3 327 Nichuta 4 Gaadi 3 3 328 Nichuta 5 Gaadi 7 3 329 Nichuta 6 Kauwabankataiya 4 3 330 Nichuta 7 Lakhanpur 1 3 326 Nichuta 7 Dewarbana 3 3 331 Nichuta 8 Lakhanpur 7 3 332 Nichuta 9 Mahuwan 2 3 333 Nichuta 10 Mahuwan 8 3 334 Nichuta 11 Masihani 3 3 335 Nichuta 12 Masihani 8 3 336 Nichuta 13 Nichuta 4 3 337 Nichuta 14 Nichuta 8 3 339 Nichuta 16 Paterwa Sugauli 6 Annex-1b | 30 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 3 340 Nichuta 17 Sonbarsa 1 3 341 Nichuta 18 Sonbarsa 5 3 342 Nichuta 19 Sonbarsa 8 3 388 Nichuta 115 Paterwa Sugauli 3 4 343 Bagahi 1 Bagahi 2 4 344 Bagahi 2 Bagahi 6 4 345 Bagahi 3 Basdilwa 1 4 346 Bagahi 4 Basdilwa 5 4 347 Bagahi 5 Basdilwa 8 4 348 Bagahi 6 Belwa Parsauni 2 4 349 Bagahi 7 Belwa Parsauni 4 4 350 Bagahi 8 Belwa Parsauni 7 4 551 Bagahi 9 Belwa Parsauni 9 4 352 Bagahi 10 Birwaguthi 1 4 371 Bageshwori 10 Harpur 8 4 353 Bagahi 11 Birwaguthi 2 4 505 Bagahi 11 Maniyari 1 4 354 Bagahi 12 Biruwaguthi 3 4 355 Bagahi 13 Biruwaguthi 5 4 356 Bagahi 14 Biruwa Guthi 8 4 357 Bagahi 15 Chorni 3 4 398 Bagahi 16 Chorni 7 4 359 Bagahi 17 Chorni 8 4 360 Bagahi 18 Chorni 9 4 361 Bagahi 19 Lal Parsa 5 5 362 Bageshwori 1 Bagbana 4 5 363 Bageshwori 2 Bagbana 7 5 364 Bageshwori 3 Bagbana 9 5 365 Bageshwori 4 Bageshwori Tritona 2 5 366 Bageshwori 5 Bageshwori 6 5 367 Bageshwori 6 Bahuwari Pidari 1 5 368 Bageshwori 7 Bahuwari Pidari 5 5 369 Bageshwori 8 Bahuwari Pidari 9 5 370 Bageshwori 9 Harpur 4 5 372 Bageshwori 11 Madhuban Mathal 1 5 373 Bageshwori 12 Madhuban Mathal 4 5 374 Bageshwori 13 Madhuban Mathal 7 5 375 Bageshwori 14 Panchrukhi 2 5 376 Bageshwori 15 Panchrukhi 6 5 377 Bageshwori 16 Sakhwa Parsauni 1 5 378 Bageshwori 17 Sakhwa Parsauni 4 5 379 Bageshwori 18 Sakhuwa Parsauni 7 5 380 Bageshwori 19 Sakhuwa Parsauni 9 6 381 Bishrampur 1 Bahuawra Bhatta 1 6 382 Bishrampur 2 Bahuawra Bhatta 4 6 383 Bishrampur 3 Bahuawra Bhatta 7 6 384 Bishrampur 4 Bairiya Birta Da.Pu 3 6 385 Bishrampur 5 Bairiya Birta Da.Pu 6 6 386 Bishrampur 6 Bairiya Birta Da.Pu 9 6 387 Bishrampur 7 Bishrampur 4 6 388 Bishrampur 8 Bishrampur 6 6 389 Bishrampur 9 Gamhariya 1 6 390 Bishrampur 10 Gamhariya 6 6 391 Bishrampur 11 Nagardaha 3 6 392 Bishrampur 12 Nagardaha 9 6 393 Bishrampur 13 Ramnagari 7 Annex-1b | 31 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 6 394 Bishrampur 14 Udayapur Ghurmi 3 6 395 Bishrampur 15 Udaypur Ghurmi 6 6 396 Bishrampur 16 Udaypur Ghurmi 9 6 397 Bishrampur 17 Bahuratar 3 6 398 Bishrampur 18 Bhauratar 6 6 399 Bishrampur 19 Bhauratar 8 7 400 Bhikhampur 1 Bhikhampur 1 7 401 Bhikhampur 2 Bhikhampur 3 7 402 Bhikhampur 3 Bhikhampur 5 7 403 Bhikhampur 4 Bhikhampur 6 7 404 Bhikhampur 5 Bhikhampur 9 7 405 Bhikhampur 6 Ghoddaur Pipra 2 7 406 Bhikhampur 7 Ghoddaur Pipra 5 7 407 Bhikhampur 8 Ghoddaur Pipra 8 7 408 Bhikhampur 9 Ghoddaur Pipra 9 7 409 Bhikhampur 10 Jagarnathpur Sira 1 7 410 Bhikhampur 11 Jagarnathpur Sira 2 7 411 Bhikhampur 12 Jagarnathpur Sira 4 7 412 Bhikhampur 13 Jagarnathpur Sira 6 7 413 Bhikhampur 14 Jagarnathpur sira 7 7 414 Bhikhampur 15 Jagarnathpur sira 8 7 415 Bhikhampur 16 Janaki Tola 1 7 416 Bhikhampur 17 Janaki Tola 4 7 417 Bhikhampur 18 Janaki tola 6 7 418 Bhikhampur 19 Janaki tola 8 8 419 Langadi 1 Vishwa 3 8 420 Langadi 2 Vishwa 8 8 421 Langadi 3 Dhobini 3 8 422 Langadi 4 Dhobini 8 8 423 Langadi 5 Hariharpur 3 8 424 Langadi 6 Hariharpur 8 8 425 Langadi 7 Jaymangalapur 2 8 426 Langadi 8 Jaymangalapur 6 8 427 Langadi 9 Langadi 2 8 428 Langadi 10 Langadi 7 8 429 Langadi 11 Mirjapur 3 8 430 Langadi 12 Mirjapur 8 8 431 Langadi 13 Mudali 3 8 432 Langadi 14 Mudali 7 8 433 Langadi 15 Sambhauta 1 8 434 Langadi 16 Sambhauta 5 8 435 Langadi 17 Sambhauta 8 8 436 Langadi 18 Tulsibarba 3 8 437 Langadi 19 Tulsibarba 8 9 438 Pokhariya 1 Basantapur 2 9 439 Pokhariya 2 Basantapur 4 9 440 pokhariya 3 Basantapur 6 9 441 pokhariya 4 Basantapur 8 9 442 Pokhariya 5 Bairiya Birta Na. Ta.Ja 2 9 443 Pokhariya 6 Bairiya Birta Na. Ta.Ja 5 9 444 Pokhariya 7 Govindapur 1 9 445 Pokhariya 8 Govindapur 7 9 446 Pokhariya 9 Hariharpur Birta 3 9 447 Pokhariya 10 Pokhariya 1 9 448 Pokhariya 11 Pokhariya 3 9 449 Pokhariya 12 Pokhariya 5 Annex-1b | 32 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 9 450 Pokhariya 13 Pokhariya 7 9 451 Pokhariya 14 Sibarba 1 9 452 Pokhariya 15 Sibarba 4 9 453 Pokhariya 16 Sibarba 7 9 454 Pokhariya 17 Sibarba 9 9 455 Pokhariya 18 Srisiya Na Ta Ja 4 9 456 Pokhariya 19 Srisiya Na Ta Ja 9 10 457 Pakaha 1 Bhedihari 3 10 458 Pakaha 2 Bhedihari 6 10 459 Pakaha 3 Bedihari 9 10 461 Pakaha 5 Dhore 1 10 460 Pakaha 6 Biranchi Barba 4 10 462 Pakaha 6 Dhore 5 10 463 Pakaha 7 Dhore 9 10 464 Pakaha 8 Lahawar Thakri 6 10 664 Pakaha 8 Lahawar Thakri 6 10 465 Pakaha 9 Lahawar Thakri 9 10 465 Pakaha 9 Lahawar Thakri 9 10 466 Pakaha 10 Pakaha Mainpur 6 10 467 Pakaha 11 Prasauni Bhatta 1 10 468 Pakaha 12 Prasauni Bhatta 4 10 469 Pakaha 13 Prasauni Bhatta 7 10 470 Pakaha 14 Parsurampur 4 10 471 Pakaha 15 Sabaithwa 1 10 472 Pakaha 16 Sabaithwa 5 10 473 Pakaha 17 Sabaithwa 9 11 476 Srisiya 1 Alau 1 11 477 Srisiya 2 Alau 4 11 478 Srisiya 3 Alau 6 11 479 Srisiya 4 Alau 9 11 480 Srisiya 5 Amar Patti 5 11 481 Srisiya 6 Amar Patti 9 11 482 Srisiya 7 Bindabasini 6 11 483 Srisiya 8 Bindabasini 9 11 484 Srisiya 9 Harpatgunj 4 11 485 Srisiya 10 Harpatgunj 9 11 486 Srisiya 11 Jhauwa Guthi 4 11 487 Srisiya 12 Jhauwa Guthi 7 11 488 Srisiya 13 Ramgadwa 1 11 489 Srisiya 14 Ramgadwa 6 11 490 Srisiya 15 Srisiya Kahlwa Tola 2 11 491 Srisiya 16 Srisiya Kahlwa Tola 6 11 492 Srisiya 17 Srisiya Khalwa Tola 9 11 493 Srisiya 18 Sugauli Birta 4 11 494 Srisiya 19 Sugauli Birta 6 12 495 Birgunj 1 Bhawanipur 2 12 496 Birgunj 2 Bhawanipur 4 12 497 Birgunj 3 Bhawanipur 5 12 498 Birgunj 4 Bhawanipur 7 12 499 Birgunj 5 Bhawanipur 9 12 500 Birgunj 6 Lipnibirta 2 12 501 Birgunj 7 Lipnibirta 3 12 512 Birgunj 8 Prasauni Birta 6 12 502 Birgunj 8 Lipni Birta 5 12 513 Birgunj 9 Prasauni Birta 8 12 503 Birgunj 9 Lipni Birta 6 Annex-1b | 33 Ilaka Code Record no. Ilaka Name LQAS # VDC_Name Ward 12 504 Birgunj 10 Lipni Birta 8 12 506 Birgunj 12 Maniyari 3 12 507 Birgunj 13 Maniyari 5 12 508 Birgunj 14 Maniyari 7 12 509 Birgunj 15 Maniyari 8 12 510 Birgunj 16 Prasauni Birta 1 12 511 Birgunj 17 Prasauni Birta 3 13 514 Birgunj NP 1 Birgunj U.M.N.P 1 13 515 Birgunj NP 2 Birgunj U.M.N.P 2 13 516 Birgunj NP 3 Birgunj UMNP 3 13 517 Birgunj NP 4 Birgunj U.M.N.P 4 13 518 Birgunj NP 5 Birgunj U.M.N.P 6 13 519 Birgunj NP 6 Birgunj UMNP 9 13 520 Birgunj NP 7 Birgunj UMNP 10 13 521 Birgunj NP 8 Birgunj UMNP 11 13 522 Birgunj NP 9 Birgunj UMNP 13 13 523 Birgunj NP 10 Birgunj UMNP 13 13 524 Birgunj NP 11 Birgunj UMNP 14 13 525 Birgunj NP 12 Birgunj UMNP 14 13 526 Birgunj NP 13 Birgunj UMNP 15 13 527 Birgunj NP 14 Birgunj UMNP 16 13 528 Birgunj NP 15 Birgunj UMNP 16 13 529 Birgunj NP 16 Birgunj UMNP 17 13 530 Birgunj NP 17 Birgunj UMNP 18 13 531 Birgunj NP 18 Birgunj UMNP 19 13 532 Birgunj NP 19 Birgunj UMNP 19 Annex-2 | 34 Annex-2: Survey instrument – questionnaire is an attached file. COMMUNITY-BASED NEWBORN CARE PACKAGE (CB-NCP) SURVEY QUESTIONNAIRE: MAY-JUL 2011 (MOHP/PLAN NEPAL) SCREENING QUESTIONNAIRE – 1 Instructions to interviewer: Complete this Household Listing Form by interviewing the household head. If the household head is not present or otherwise unable to provide the required information, interview a senior member of the household and note their name in the table below. Form No. 1) Name of District _________________________________ 2) Name and code of VDC __________________________ 3) Ward Number …………………………………… 4) Village name ………………………………… 5) Cluster Number. ………………………………… 6) Household Number ……………………………… 7) Name of the household head _______________________ 8) Name of respondent:______________________________ 9) Relationship of respondent to household head (if respondent is not household head) _______ INTERVIEWER VISITS 1 2 3 DATE [DD/MM/YY] / / / / / / INTERVIEWER'S NAME: RESULT NEXT VISIT : DATE [DD/MM/YY] TIME / / / / *RESULT CODES: 1 = Interview completed 4 = Respondent not at home 2 = Respondent refused to be interviewed 5 = Other, specify:_____________ 3 = Time and date set for later Language Of Questionnaire _____________________ Language of Interview _____________________ Native Language of Respondent ____________________ Translator Used (Yes=1; No=2) …………………………. Language Codes: Nepali=1, Bhojpuri=2, Maithili=3, Tharu=4, Other=5 Q. # Question Codes Go to Q 1. How many women (all women) of age 15-49 years live in your household? | None………………………….97 If none then end the interview 2. Please give me the name(s) of the women who usually live in your household? Name__________________________ Marital status:________________ Name___________________________ Marital status:________________ Name____________________________ Marital status:________________ Supervisor Name ______ Date ______ Field Editor Name _____ Date _____ Office Editor Keyed By Annex-2 | 35 COMMUNITY-BASED NEWBORN CARE PACKAGE (CB-NCP) SURVEY QUESTIONNAIRE: MAY-JUL 2011 (MOHP/PLAN NEPAL) SCREENING QUESTIONNAIRE – 2 Form No. 1) Name of District _________________________________ 2) Name and code of VDC __________________________ 3) Ward Number …………………………………… 4) Village name ………………………………… 5) Cluster Number. ………………………………… 6) Household Number ……………………………… 7) Name of the household head _______________________ 8) Name of respondent INTERVIEWER VISITS 1 2 3 DATE [DD/MM/YY] / / / / / / INTERVIEWER'S NAME: RESULT NEXT VISIT : DATE [DD/MM/YY] TIME / / / / *RESULT CODES: 1 = Interview completed 4 = Respondent not at home 2 = Respondent refused to be interviewed 5 = Other, specify:: _____________ 3 = Time and date set for later INTRODUCTION AND CONSENT Namaste! My name is _____. I am from Plan Nepal, which is conducting a study for the Ministry of Health and Population/Government of Nepal. The MOHP has been helping pregnant women, mothers, and newborns in this district with the objectives of improving child health status. We are here to find out about the health of mothers and newborns to help you and your community to keep mothers and children healthy. We would very much appreciate your participation in this survey. This information will help the MOHP to improve its program in the districts. The survey usually takes around one hour. I assure you that your name will not be shared with anyone else and your answers to my questions will be combined with answers from many other people so that no one will know that the answers you give me today belong to you. Your privacy is protected, and I assure that your answers will be kept confidential. Your participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important. May I proceed with the questions? RESPONDENT AGREES TO BE INTERVIEWED…………………… 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED……… 2 → END INTERVIEW & THANK RESPONDENT Annex-2 | 36 101 Now, I would like to ask you about all the pregnancies that you have had in the last 3 years. By this I mean all the children born to you in last 3 years whether they were born alive or dead, whether they are still living or not, whether they live with you or someone else, and all the pregnancies in the last 3 years that did not result in a live birth. I understand that it is not easy to talk about children who have died, or pregnancies that ended before the full term, but it is important you tell us about all of them, so that the government can develop programs to improve children's health. 102 First I would like to ask about all the births you have had in the last 3 years. Have you given birth in the last 3 years? Yes……………………………………..1 No……………………………………...2 107 103 Do you have any sons or daughter to whom you have given birth in the last 3 years who are now living with you? Yes…………………………………….1 No……………………………………..2 105 104 How many sons live with you? And how many daughters live with you? If NONE, RECORD '00' Sons at Home…………….…..1 | Daughters at Home………........2 | 105 Do you have any sons or daughters to whom you have given birth in the last 3 years who are alive but do not live with you? Yes…………………………………….1 No……………………………………..2 107 106 How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? If NONE, RECORD '00' Sons Elsewhere……………..1 | Daughters Elsewhere………...2 | 107 Have you given birth to a boy or girl in the last 3 years who was born alive but later died? If NO PROBE: Any baby who cried or showed any sign of live but did not survive? Yes…………………………………….1 No……………………………………..2 109 108 How many boys have died? And how many girls have died? If NONE, RECORD '00' Boys Dead………………..…1 | Girls Dead…………………..2 | 109 Women sometimes have pregnancies that do not result in a live born child. That is, a pregnancy can end in a miscarriage, or the child can be born dead. Have you ever had a pregnancy in last 3 years that did not end in a live birth including induced abortion? Yes…………………………………….1 No……………………………………..2 111 110 How many pregnancies in the last 3 years did not end in a live birth? Pregnancy Losses…………….. | 111 Sum Answers to 104, 106, 108 And 110 and Enter total. If None, record '00' Total …………………………. | 112 Check 111: Just to make sure that I have this right: you have had in TOTAL____ pregnancies during last 3 years. Is that correct? Yes ………………………………113 No Probe and Correct 102-111 As necessary. 113 Check 111: One Or More pregnancies in last 3 years ………………………………114 No Pregnancies………………………………………………………… END the interview Annex-2 | 37 Now I would like to record all of your pregnancies in the last three years, whether born alive, born dead, or lost before full term, starting with the last one you had. RECORD ALL THE PREGNANCIES IN 111. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (If there are more than 5 pregnancies, use an additional questionnaire starting with the second row;) 114 115 116 117 118 119 120 121 122 123 Think back to your last pregnancy. Was that a single or multiple pregnancy? Was the baby born alive, born dead, or lost before birth? Did that baby cry, move, or breath when it was born? What was the name of the child? Was [NAME] a boy or a girl? In what month and year was [NAME] born? Is [NAME] still alive? If Born Alive and Still Living How old was [NAME] at his/her last birthday? Record age in completed months (<1 yr.) or years. Is [NAME] living with you? 01 Single…….…….1 Multiple………...2 Do not know……8 Born alive…...1 118 Born dead…..2 Lost before full term………..3 126 Yes………1 No……….2 126 Name Boy………1 Girl………2 Month | Year Yes………1 No……….2 124 Month | Age in Years | Yes…….1 No……..2 (Next pregnancy) 02 Single…….…….1 Multiple………...2 Do not know……8 Born alive…...1 118 Born dead…..2 Lost before full term………..3 126 Yes………1 No………..2 126 Name Boy………1 Girl………2 Month | Year Yes………1 No……….2 124 Age in Years | Yes…….1 No……..2 (Next pregnancy) 03 Single…….…….1 Multiple………...2 Do not know……8 Born alive…...1 118 Born dead…..2 Lost before full term………..3 126 Yes………1 No………..2 126 Name Boy………1 Girl………2 Month | Year Yes………1 No……….2 124 Age in Years | Yes…….1 No……..2 (Next pregnancy) 04 Single…….…….1 Multiple………...2 Do not know……8 Born alive…...1 118 Born dead…..2 Lost before full term………..3 126 Yes………1 No………..2 126 Name Boy………1 Girl………2 Month | Year Yes………1 No……….2 124 Age in Years | Yes…….1 No……..2 (Next pregnancy) 05 Single…….…….1 Multiple………...2 Do not know……8 Born alive…...1 118 Born dead…..2 Lost before full term………..3 126 Yes………1 No………..2 126 Name Boy………1 Girl………2 Month | Years Yes………1 No……….2 124 Age in Years | Yes…….1 No……..2 (Next pregnancy) Annex-2 | 38 124 125 126 127 If born alive but now dead If born dead or lost before birth How old was [NAME] when he/she died? If '1 YRS' PROBE: How many months old was [NAME]? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS In what month and year did [NAME] die? In what month and year did the pregnancy end? How many months did this pregnancy last? RECORD IN COMPLETED MONTHS. Days……1 | Months....2 | Years…..3 | Month | Year (Next Pregnancy) Month | Year #Months | (Next pregnancy) Days……1 | Months....2 | Years…..3 | Month | Year (Next Pregnancy) Month | Year #Months | (Next pregnancy) Days……1 | Months....2 | Years…..3 | Month | Year (Next Pregnancy) Month | Year #Months | (Next pregnancy) Days……1 | Months....2 | Years…..3 | Month | Year (Next Pregnancy) Month | Year #Months | (Next pregnancy) Days……1 | Months....2 | Years…..3 | Month | Year (Next Pregnancy) Month | Year #Months | (Next pregnancy) Annex-2 | 39 128 Compare 111 with the number of pregnancies with the history above and mark: Number are same ………………………………..………..1 Numbers are different (Probe and reconcile)…………….2 Check: for each pregnancy: year is recorded in 120, 125 and 126  For each birth since November, 2007: month and years are recorded  For each living child: current age is recorded in 122  For each dead child: age at death is recorded in 124  For age at death at 12 months or 1 year: probe to determine the exact month of death  For age at death <1 month, probe to determine the exact day of death 129 Check 126 and 127 and enter the number of still births in November 2007 or later and The pregnancy that lasted for 7 months or more. If None, record '0' 130 Check 124 and 125 and enter the “number of deaths” at 0-30 days in November, 2007 or later, If none, record '0' 131 Check 129 and 130, if one or more read the following statement: "We would like to get more information on the circumstances around the deaths of the young children so that the government can provide services to help reduce the deaths. We would like to come back and talk with you about your child's death. Is this okay?" Yes…1 No….2 132 Check 120 and enter the number of births in November, 2007 or later, if none, record '0' The eligible women for the main questionnaire are all women who have given birth(s) from November 2007. The child born to these women can be:  Born alive but dead (124-125)  Born alive and still living (122-123)  Still born (born dead or lost before birth, pregnancy lasted for 7 months or more) (126-127) Annex-2 | 40 Confidential, information to be used for research purposes only COMMUNITY-BASED NEWBORN CARE PACKAGE (CB-NCP) SURVEY QUESTIONNAIRE: MAY – JUL 2011 (MOHP/PLAN NEPAL) MAIN QUESTIONNAIRE FOR RECENTLY DELIVERRED WOMEN Form No. Respondent: Recently Delivered Women (RDW): RDW are defined as women who have delivered within 12 months prior to the survey date (since Jan/Feb 2009) (regardless of whether the infant is currently alive or dead), including stillbirths. 1) Name of District _________________________________ 2) Name and code of VDC __________________________ 3) Ward Number …………………………………… 4) Village name ………………………………… 5) Cluster Number. ………………………………… 6) Household Number ……………………………… 7) Name of the household head _______________________ 8) Name of respondent INTERVIEWER VISITS 1 2 3 DATE [DD/MM/YY] / / / / / / INTERVIEWER'S NAME: RESULT NEXT VISIT : DATE [DD/MM/YY] TIME / / / / *RESULT CODES: 1 = Interview completed 4 = Respondent not at home 2 = Respondent refused to be interviewed 5 = Other, specify:: _____________ 3 = Time and date set for later INTRODUCTION AND CONSENT Namaste! My name is _____. I am from Plan Nepal, which is conducting a study for the Ministry of Health and Population/Government of Nepal. The MOHP has been helping pregnant women, mothers, and newborns in this district with the objectives of improving child health status. We are here to find out about the health of mothers and newborns to help you and your community to keep mothers and children healthy. We would very much appreciate your participation in this survey. This information will help the MOHP to improve its program in the districts. The survey usually takes around one hour. I assure you that your name will not be shared with anyone else and your answers to my questions will be combined with answers from many other people so that no one will know that the answers you give me today belong to you. Your privacy is protected, and I assure that your answers will be kept confidential. Your participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important. May I proceed with the questions? RESPONDENT AGREES TO BE INTERVIEWED…………………… 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED……… 2 → END INTERVIEW & THANK RESPONDENT Annex-2 | 41 Check Q114, Q118, Q121, Q122, Q124, Q127: enter in the table the line number, name and the survival status of each birth from November 2007 or later, ask questions about the last birth. QA Line number from 114 Last birth QB From 118 and 121 Name __________________ Living……………………………1 Dead……………………………..2 QC From 122 Age of [NAME] | months QD From 124 Age of [NAME] when he/she died | months QE From 127 (pregnancy loss after 7 months or more) Stillbirth SECTION 1: RESPONDENT'S BACKGROUND Interviewer: “Now I would like to ask some questions about you and your household.” Q. # Question Codes Go to Q 101 In what month and year were you born? Month [__ _ | __ _] Year [_ __ | _ __] Don’t know month ……………. 98 Don’t know year ………………..98 102 How old are you? Age in completed years . [___ | ___] Don’t know .................................................. 98 103 Have you ever attended school? Yes .................................................................. 1 No .................................................................... 2 106 104 What is the highest class you completed? Grade……………………… | 105 (Interviewer: Check Q. 104) Grade 5 or below ............................................ 1 Grade 6 and above .......................................... 2 107 106 Now, I would like you to read out loud as much of this sentence as you can. “Gharelu Upachar” (Show card to the respondents) Cannot read at all ............................................ 1 Able to read only parts of sentence ................ 2 Able to read whole sentence ........................... 3 108 107 Do you read from a newspaper or magazine almost every day, at least once a week, less than once a week or not at all? Almost every day ............................................ 1 At least once a week ....................................... 2 Less than once a week .................................... 3 Not at all ............................................ …….. 4 108 Do you watch television almost every day, at least once a week, less than once a week, or not at all? Almost every day ............................................ 1 At least once a week ....................................... 2 Less than once a week .................................... 3 Not at all .......................................................... 4 109 Do you listen to the radio almost every day, at least once a week, less than once a week, or not at all? Almost every day ............................................ 1 At least once a week ....................................... 2 Less than once a week .................................... 3 Not at all .......................................................... 4 Annex-2 | 42 Q. # Question Codes Go to Q 110 From where do you get information on maternal and newborn health services? Circle all responses which the mother mentions unprompted. Then ask, “Is there any other else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes No 1 FCHV 1 2 3 2 TBAs 1 2 3 3 NGO workers 1 2 3 4 Other health personnel 1 2 3 5 TV 1 2 3 6 Radio 1 2 3 7 Posters/pamphlets 1 2 3 8 BPP flip chart 1 2 3 9 Street dramas 1 2 3 10 Newspaper/Magazine 1 2 3 11 Other (specify):_________________ 1 97 Nowhere 7 111 Which are the trusted sources of information? (MULTIPLE RESPONSE) FCHV .............................................................. 1 TBAs ............................................................... 2 NGO workers .................................................. 3 Other health personnel .................................... 4 TV ................................................................... 5 Radio ............................................................... 6 Posters/pamphlets ........................................... 7 BPP flip chart .................................................. 8 Street dramas .................................................. 9 Newspaper/Magazine ..................................... 10 Other, specify: ................................................ 11 None ................................................................ 97 112 To which radio station do you mostly listen? (MULTIPLE RESPONSE) Radio Nepal…………………………………1 FM station ……………………………..........2 Name the station_______________________ None……………………………………….97 Don't know…………………………………98 114 113 At what time do you listen to the radio? 6-9:59 am.....………………….……………..1 10 am-1:59 pm….…………….………….….2 2-3:59 pm ……………………………….…..3 4-7:59 pm…………………………………....4 8pm-5:59 am………………………………...5 Don't know…………………………………8 114 Which TV stations do you watch the most? NTV…………………………………………1 Kantipur……………………………………..2 Nepal 1………………………………………3 Channel Nepal………………………………4 Sagarmatha………………………………….5 Avenues……………………………………..6 Image………………………………………..7 None………………………………………97 Don’t know……………………………… 98 115 What is your caste or ethnicity? (Write caste in space provided. Do not fill in the box.) Caste/Ethnicity | Annex-2 | 43 Q. # Question Codes Go to Q 116 What is your religion? Hindu………………………………………..1 Buddhist…………………………………….2 Muslim ……………………………………..3 Kirat……………………………………..….4 Christian…………………………………….5 Other, specify:_____________________ 6 Section 2: Respondent’s Background (Socio-economic status) Interviewer: “Now I would like to ask some questions about your household.” Q. # Question Codes Go to Q 201 Does your household have the following items? (READ ALL) Yes No 1 Electricity 1 2 2 Bicycle 1 2 3 Telephone 1 2 4 Television 1 2 5 Radio 1 2 202 What is the main source of drinking water for members of your household? Piped water  Piped into house/yard/plot ……….. 1  Public / neighbor’s tap …………… 2 Dug well  Well in house/yard/plot ………..…. 3  Public/neighbor’s well …………… 4 Tube well/borehole  Tube well in yard/plot ……………. 5  Public/neighbor’s tube well …….... 6 Surface water  Spring/kuwa ……………………... 7  River/stream/pond/lake ………….. 8  Stone tap/dhara ………………….. 9 Other, specify: __________________ 10 203 What type of toilet facilities does your house have? Flush toilet …………………………… 1 Traditional pit toilet …………………. 2 Ventilated improved pit latrine ……… 3 No facility / bush / field ……………… 4 Other, specify: …………………..…… 5 204 Main material of the floor Record observation Earth/mud/dung ……………………… 1 Wood planks ………………………… 2 Linoleum / carpet ……………………. 3 Ceramic tiles, marble chips ………….. 4 Cement ………………………………. 5 Other, specify: ___________________ 6 205 Main material of the roof Record observation Thatch ………………………………… 1 Metal ………………………………….. 2 Tiles/Khapada ………………………… 3 Cement ………………………………... 4 No roof ………………………………... 5 Other, specify: ___________________ 6 206 Main material of the walls a) Record observation Bamboo with mud …………………….. 1 Bamboo with cement………………..….2 Adobe …………………………………. 3 Unfinished wood ……………………… 4 Cement ………………………………... 5 Bricks …………………………………. 6 Cement blocks ………………………… 7 Wood planks ……………………….... 8 No walls ……………………………... 9 Annex-2 | 44 Q. # Question Codes Go to Q Other, specify: __________________ 10 Section 3: Antenatal Care Now I would like to ask you some questions about services you may have received during your last pregnancy Q. # Question Codes Go to Q. 301 Did you see anyone for antenatal care during your last pregnancy? Yes .................................................................. 1 No ................................................................... 2 Section 4 302 Whom did you see? Circle all responses which the mother mentions unprompted. Then ask, “Is there anyone else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No SKILL PERSONNEL 1 Doctor 1 2 3 2 Nurse 1 2 3 3 ANM 1 2 3 TRAINED PERSONNEL 4 HA/AHW 1 2 3 5 MCHW 1 2 3 6 VHW 1 2 3 OTHER PERSONNEL 1 2 3 7 FCHV 1 2 3 8 TTBA 1 2 3 9 TBA 1 2 3 10 Other (specify): ___________ 1 303 Did you discuss your pregnancy with an FCHV? Yes……………………………………………..1 No ……………………………………………..2 305 304 Did your FCHV give you specific information about where to go for ANC check up? Yes……………………………………………..1 No ……………………………………………..2 305 Where did you receive antenatal care during your last pregnancy? Circle all responses which the mother mentions unprompted. Then ask, “Is there anywhere else.” Then, read each question and circle “2” for “Yes” or “3” for “No.” If unable to determine if a hospital, PHCC or health center or clinic is private or public, write the name of the place(s) below. (Name of places) Unprompted Prompted Yes Yes No PUBLIC SECTOR 1 Hospital 1 2 3 2 PHCC 1 2 3 3 Health post 1 2 3 4 Sub-health post 1 2 3 5 PHC/ORC 1 2 3 PRIVATE SECTOR 6 Pvt. Clinic/Nursing Home 1 2 3 7 Pharmacy 1 2 3 HOME 8 Own home 1 2 3 9 TBA home 1 2 3 10 Other (specify): ___________ 1 Annex-2 | 45 Q. # Question Codes Go to Q. 98 Don’t know/don’t remember 8 306 How many months pregnant were you when you first received antenatal care for this pregnancy? Months………………………………. Don’t know…………………………………98 307 How many times did you receive antenatal care during your last pregnancy? Number of times……………  Don’t know ................................................... 98 308 As part of your antenatal care during this pregnancy, were any of the following done at least once? (READ ALL) Yes No Don’t Know 1 Were you weighed? 1 2 8 2 Was your blood pressure measured? 1 2 8 3 Did you give a urine sample? 1 2 8 4 Did you give a blood sample? 1 2 8 309 During any of your antenatal care visit(s), were you advised to use a skilled birth attendant during delivery? Yes………………………………………...1 No……………………………………..…..2 Don’t know………………….…………….8 310 During (any of) your antenatal care visit(s), were you told about the signs of pregnancy complications? Yes………………………………………...1 No……………………………………..…..2 Don’t know………………….…………….8 311 Were you told where to go if you had any of these complications? Yes………………………………………...1 No……………………………………..…..2 Don’t know………………………..…….8 312 During any of your antenatal care visits with health workers during this pregnancy, were you counseled on: (READ ALL RESPONSES) Yes No Don’t know 1 Financial preparation for your delivery? 1 2 8 2 Breastfeeding immediately after birth? 1 2 8 3 Danger signs during pregnancy? 1 2 8 4 Tetanus toxoid vaccination? 1 2 8 5 Wrapping the newborn? 1 2 8 6 Using a skilled birth attendant/trained Health Worker? 1 2 8 7 CDK 1 2 8 8 Family planning? 1 2 8 9 Identifying emergency transport options? 1 2 8 10 Arranging for blood in case of emergency? 1 2 8 11 Essential Newborn care? 1 2 8 313 During this pregnancy, were you given an injection in the arm to prevent you and the baby from getting tetanus? Yes…………………………………………....1 No…………………………………………….2 Don’t know…………………………………..8 Sec 4 Sec 4 314 During this pregnancy, how many times did you get this tetanus injection? If more than “7,” write “7.” #Times……………………………… Don’t Know………………………………….8 Annex-2 | 46 Section 4: Birth Preparedness “Now I would like to ask you some questions about how you prepared for delivery for your last pregnancy.” Q. # Question Codes Go to Q. 401 During your last pregnancy, did you make any preparations for delivery? Yes ……………………………………….1 No ………………………………………...2  403 Q. # Question Codes Go to Q. 402 If yes, what kind of preparation did you make? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” What things did you arrange? Unprompted Prompted Yes Yes No 1 HF/SBA identification 1 2 3 2 Transport 1 2 3 3 Money 1 2 3 4 Food 1 2 3 5 Clean Delivery kit 1 2 3 6 Clean instrument for cord cutting 1 2 3 7 Clean cloths 1 2 3 8 Other, specify:___________________ 1 403 Did you discuss planning for your delivery with anybody while you were pregnant? Yes .................................................................. 1 No ................................................................... 2 Section 5 404 With whom did you plan for your delivery? Circle all responses which the mother mentions unprompted. Then ask, “Is there anyone else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Husband 1 2 3 2 Mother in law 1 2 3 3 Mother 1 2 3 4 Friends/relative 1 2 3 5 FCHV 1 2 3 6 Any other health care worker, specify: 1 2 3 7 Other, specify:_______________________ 1 97 No one 7 98 Don't know 8 Annex-2 | 47 Section 5: Delivery Care and Immediate Newborn Care Q. # Question Codes Go to Q. 501 Who assisted with your most recent delivery? Circle all responses which the mother mentions unprompted. Then ask, “Is there anyone else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No SKILL PERSONNEL 1 Doctor 1 2 3 2 Nurse 1 2 3 3 ANM 1 2 3 TRAINED PERSONNEL 4 HA/AHW 1 2 3 5 MCHW 1 2 3 6 VHW 1 2 3 OTHER PERSONNEL 7 FCHV 1 2 3 8 TTBA 1 2 3 9 TBA 1 2 3 10 Relative/friends 1 2 3 11 Other (specify): ___________ 1 97 Nobody 7 502 Did your FCHV give you specific information about where to go for delivery? Yes……………………………………...1 No………………………………………2 503 Did your FCHV give you specific information to call her at the time of delivery? Yes……………………………….........1 No………………………………..……2 504 Did you plan the place for delivery during your pregnancy? Yes……………………………………1 No…………………………………….2  506 505 Where had you planned to deliver? If source is hospital, health center, or clinic, write the name of the place. Probe to identify the type of source and circle the appropriate code to the right. 2. Name of place: ___________________ Public Sector Hospital ........................................................... 1 PHCC .............................................................. 2 Health post ...................................................... 3 Sub-health post ............................................... 4 Private Sector Pvt. Clinic/nursing Home ............................... 5 Home Your home ...................................................... 6 TBA home ...................................................... 7 Other (specify)_____________ ..................... 8 506 Where did you give birth during your most recent delivery? If source is hospital, health center, or clinic, write the name of the place. Probe to identify the type of place and circle the appropriate code to the right. 3. Name of place: ___________________ Public Sector Hospital ........................................................... 1 PHCC .............................................................. 2 Health post ...................................................... 3 Sub-health post ............................................... 4 Private Sector Pvt. Clinic/nursing Home ............................... 5 Home Your home ...................................................... 6 TBA home ...................................................... 7 FCHV home………………………………..8 Other (specify)_____________ ..................... 9  509  509  509 Annex-2 | 48 Q. # Question Codes Go to Q. 507 Who accompanied you to the health facility? (Probe: “Did FCHV accompany you to the health facility?”) (Circle all responses.) Self………………………………………..1 Mother-in-law......……………..……….....2 Father-in-law......………………………....3 Husband....………….……………….…....4 Mother/father ………………………..…..5 Other relative ……………………….….. 6 FCHV…………………………………….7 Other, specify:______________________8 Don’t know.........................…......………98 508 How long after [NAME] was delivered did you stay there? IF LESS THAN ONE DAY, RECORD IN HOURS. HOURS……………………………….. 1 DAYS………………………………. 2 DON’T KNOW…………………………………….98 511 511 511 509 Why didn’t you deliver in a health facility? (Probe: “Any other reason?”) (Circle all responses) Cost too much …………………………… 1 Facility not open ……………………….… 2 Too far / no transportation …………….…. 3 Don’t trust facility / poor quality service… 4 No female provider at facility …………… 5 Husband / family did not allow ………….. 6 Not necessary ……………………………. 7 Not customary …………………………… 8 Other, specify: _____________________ 9 510 Did your FCHV give you specific information about which health worker to contact to attend a home birth if you chose to deliver at home? Yes………………………………..……….1 No …………………………………………2 511 Please tell me the name and type of health facility in your community where you can go to deliver your child as well as its location. 4. Name:____________ Location:___________________ Confirmed by supervisor:__________ Public Sector Hospital ........................................................... 1 PHCC .............................................................. 2 Health post ...................................................... 3 Sub-health post ............................................... 4 Private Sector Pvt. Clinic/nursing Home ............................... 5 Home Your home ...................................................... 6 TBA home ...................................................... 7 FCHV home…………………………………8 Other (specify)_____________ ..................... 9 Do not know ................................................. 98 512 Who should be present at birth to help deliver the baby safely? (MULTIPLE RESPONSE) Skill Personnel Doctor ............................................................. 1 Nurse ............................................................... 2 ANM ............................................................... 3 Trained Personnel HA/AHW ........................................................ 4 MCHW ........................................................... 5 VHW ............................................................... 6 Other Personnel FCHV .............................................................. 7 TTBA .............................................................. 8 TBA ................................................................ 9 Relatives/friends ........................................... 10 Other (specify)_______________ ............... 11 Nobody ......................................................... 97 Annex-2 | 49 Q. # Question Codes Go to Q. Checkbox 5.1 Interviewer: Check questions QB and QE. Which of the following conditions is true: Baby still alive……………………………………………………………………………………….1 Baby born alive, then died …………….…………………………………………………………….2 Baby stillborn………………………………………………………………………………………..3 Sec. 6 513 Was the baby wiped (dried) before the placenta was delivered? Yes…………………………….………….1 No…………………………………………2 Don’t know . . . ………………………….8 514 Where was the baby placed immediately after delivery? On the floor ………….…………….......... 1 On a cot…….…………..............…………2 On the mother’s abdomen ….….…………3 With someone else …….......... …………..4 Other, specify: _____________________5 Don’t know ………..……….... …………98 515 Was the baby wrapped with cloth before the placenta was delivered? Yes…………………………………...……1 No………………………………………….2 Don’t know . . . …………………………..8 517 517 516 What was the condition of the cloth, which was used for wrapping the baby? (Probe: “Anything else?”) (Circle all responses) Clean cloth. ……………………………… 1 Dry cloth. ………………………………... 2 New cloth……. …………………….……. 3 Used cloth……. …………………………. 4 Wet cloth…………………………………..5 Other, specify: ______________________6 Don’t know ……………………………… 8 517 Did your baby cry/breathe easily immediately after birth? Yes………………….……………..………1 No………………………………………….2 Don’t know . . . ……………………..……8 →520 →520 518 What was done to help the baby cry or breathe at the time of birth? Rubbed/massaged…………........................1 Dried. …………………………….……….2 Mouth cleared ………………………….....3 Fed Butter/Ghee. . . . …………………….4 Mouth-to-mouth resuscitation………...…..5 Resuscitation using a bag and mask…..….6 Other, specify: _____________________7 Nothing………………………............…..97 Don’t know. . ……. …………………… 98 519 Who took these measures to help the baby cry or breathe? Skill Personnel Doctor ............................................................. 1 Nurse ............................................................... 2 ANM ............................................................... 3 Trained Personnel HA/AHW ........................................................ 4 MCHW ........................................................... 5 VHW ............................................................... 6 Other Personnel FCHV .............................................................. 7 TTBA .............................................................. 8 TBA ................................................................ 9 Relatives/friends ........................................... 10 Other (specify)_______________ ............... 11 Nobody ......................................................... 97 520 Was the baby put to the breast before the placenta was delivered? Yes……………………………………….1 No………………………………………...2 Don’t know . . . ………………………….8 521 Was a Clean Home Delivery Kit used during delivery? (Show example of a CHDK) Yes…………………………..…………….1 No………………………………..………..2 Don’t know…………………………...…..8  526 Annex-2 | 50 Q. # Question Codes Go to Q. 522 What was used to cut the cord? New blade...................................................1 Blade that was used for other purposes.......2 Sickle ….....................................................3 Scissor …....................................................4 Other, Specify: ____________________5 Don’t Know/Can’t Remember…...............98 523 Was the instrument used to cut cord boiled prior to use? Yes …..........................................................1 No …............................................................2 Don’t Know/Can’t Remember….............…8 524 What was used to tie the cord? Probe: “Were the ties boiled?” New ties …………………………………. 1 Boiled string or thread …………………... 2 Unboiled used string or thread ………….. 3 Other, specify: ______________________4 Don’t know …………………….…………8 525 On what surface was the cord cut on? Plastic disc..……………………...……….1 Metal coin.. ………………………….…...2 Wood……………..…………….………....3 Other, specify: ______________________4 Nothing……………………………………7 Don’t know …………………………........8 526 Was anything applied to the cord immediately after cutting? Yes …....................…..................................1 No …............................................................2 Don’t Know/Can’t Remember.................…8 →528 →528 527 What was applied to the cord just after cutting the cord? Butter……………..…………………….…1 Ash………….…………………………….2 Ointment…….……………………………3 Animal dung……..….................................4 Oil….…………..…………………………5 Other, specify: _____________________6 Don’t know………….…………………...98 528 Check Q N. 506, (Place of delivery) Public Sector: Hospital ......................................................... 1 PHCC ............................................................ 2 Health post .................................................... 3 Sub-health post ............................................. 4 Private sector Pvt. Clinic/n. Home ...................................... 5 Home Your home ……………………….…..… 6 TBA home ……………………………... 7 FCHV home………………………………8 Other, specify: ____________________ 9 530 529 FOR BIRTHS IN WOMAN’S OWN/OTHER'S HOME: Before the Health Professional, FCHV or traditional birth attendant left your house, after [NAME] was born, did he/she check on your health? YES……………………………………… 1 NO…………………………………..... ….2 NONE OF THEM WERE PRESENT..…..3 →531 →534 →534 530 FOR ALL OTHER BIRTH LOCATIONS (PUBLIC & PRIVATE SECTOR) : Before you were discharged after [NAME] was born, did any health care provider check on your health? YES……………………………………… 1 NO…………………………………..... ….2 →535 Annex-2 | 51 Q. # Question Codes Go to Q. 531 Who checked on your health at that time? Circle all responses which the mother mentions unprompted. Then ask, “Is there anyone else.” PROBE FOR MOST QUALIFIED PERSON. Skill Personnel Doctor ............................................................. 1 Nurse ............................................................... 2 ANM ............................................................... 3 Trained Personnel HA/AHW ........................................................ 4 MCHW ........................................................... 5 VHW ............................................................... 6 Other Personnel FCHV .............................................................. 7 TTBA .............................................................. 8 TBA ................................................................ 9 Relatives/friends ........................................... 10 Other (specify)_______________ ............... 11 532 How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. HOURS……………………………….. 1 DAYS………………………………. 2 DON’T KNOW…………………………………….998 533 What did the health provider do to check on your health? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Did she examine your body? 1 2 3 2 Did she check your breasts? 1 2 3 3 Did she check for heavy bleeding? 1 2 3 4 Did she check for fever? 1 2 3 5 Did she refer you to a health center/hospital? 1 2 3 6 Other (specify)__________ 1 97 Nothing 7 534 FOR BIRTHS IN WOMAN’S OWN/OTHER'S HOME: Before the Health Professional, FCHV or traditional birth attendant left your house, after [NAME] was born, did he/she check on your baby’s health? YES……………………………………… 1 NO…………………………………..... ….2 NONE OF THEM WERE PRESENT..…..3 →536 →543 →543 535 FOR ALL OTHER BIRTH LOCATIONS (PUBLIC & PRIVATE SECTOR) : Before you were discharged after [NAME] was born, did any health care provider check on your baby’s health? YES……………………………………… 1 NO…………………………………..... ….2 →543 536 Who checked on your baby’s health at that time? Circle all responses which the mother mentions unprompted. Then ask, “Is there anyone else.” PROBE FOR MOST QUALIFIED PERSON. Skill Personnel Doctor ............................................................. 1 Nurse ............................................................... 2 ANM ............................................................... 3 Trained Personnel HA/AHW ........................................................ 4 MCHW ........................................................... 5 VHW ............................................................... 6 Other Personnel FCHV .............................................................. 7 TTBA .............................................................. 8 TBA ................................................................ 9 Relatives/friends ........................................... 10 Other (specify)_______________ ............... 11 Annex-2 | 52 Q. # Question Codes Go to Q. 537 How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. HOURS……………………………….. 1 DAYS………………………………. 2 DON’T KNOW…………………………………….998 538 What did the health provider do to check on your baby’s health? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Did she generally examine the baby’s body? 1 2 3 2 Did she weigh the baby? 1 2 3 3 Did she check the umbilical cord? 1 2 3 4 Did she observe breastfeeding? 1 2 3 5 Did she refer you to a health center/hospital? 1 2 3 6 Other (specify)_____________ 1 97 Nothing 7 98 I wasn’t there/Don’t know 8 539 CHECK 506; Before you were discharged (or before the Health care provider or traditional birth attendant or FCHV left your home), what health topics did the health provider discuss with you regarding your health or your baby’s health? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No a Breast feeding 1 2 3 b Nutritious food for mother 1 2 3 c Umbilical cord care 1 2 3 d Immunization 1 2 3 e Skin-to-skin/kangaroo method 1 2 3 f Keep baby warm (except STS or KMC) 1 2 3 g Danger signs/symptoms for newborn 1 2 3 h Danger signs/symptoms for mother 1 2 3 i Birth control/family planning 1 2 3 j Other (specify)_____________ 1 540 ASK THE FOLLOWING QUESTION ONLY IF THE MOTHER ANSWERS ‘YES’ TO 539a . What advice did the health provider give you on breastfeeding? DO NOT READ THE RESPONSES. CIRCLE ALL MENTIONED. Breastfeed immediately/as soon as possible…..1 Give colostrum…………………………..……2 Don’t give formula ……………………………3 Breastfeed exclusively……………………..….4 More frequent breastfeeding leads to more milk produced by mother…………….……..….5 Other ways to increase milk production……….6 How to breastfeed…………..………….…....…7 Mother should plan breastfeeding together with family……..………………………………8 Benefits of breast milk for newborn, “is good, the best”……………………..……..…...9 Give food/drink besides breast milk………….10 Breast/nipple care/cleaning…………………...11 Mother should eat nutritious food…………….12 Mother should eat vegetables…………………13 Other, specify: _________________________14 Not Applicable ……….………………………97 Annex-2 | 53 Q. # Question Codes Go to Q. 541 Ask the following question only if the mother answers “yes” to 539c. What advice did the health provider give you on how to treat the umbilical cord? DO NOT READ THE RESPONSES. CIRCLE ALL MENTIONED. Do not put anything on the cord………………..1 Clean with alcohol……………………………...2 Provided with microform/betadine…………….3 Clean with soap and water………………….…4 Do not cover the cord…………………………5 Other, specify: ________________________6 Not Applicable ……….………………………97 542 ASK THE FOLLOWING QUESTION ONLY IF THE MOTHER ANSWERS ‘YES’ TO 539f. What advice did the health provider give you on how to keep the newborn warm? DO NOT READ THE RESPONSES. CIRCLE ALL MENTIONED. Cover with blanket……………………..…...….1 Put on mother’s breast/abdomen……………....2 Skin-to-skin contact/kangaroo…………………3 Apply warm water compress…………………..4 Cover head with hat/cap……………………….5 Put on gloves..………… ………………………6 Put on socks.…………………………………..7 Delay bathing………………………….…..….8 Other, specify: ________________________9 Not Applicable ……….………………………97 543 When was [NAME] bathed for the first time after delivery? IF LESS THAN ONE DAY, PROBE TO RECORD THE NUMBER OF HOURS OF LIFE WHEN BATHED. HOURS……………………………….. 1 DAYS………………………………. 2 DON’T KNOW…………………………………….998 544 Did you ever breastfeed [NAME]? Yes…………………..…………………….1 No………………………..………………..2 Baby died early……………………………3  551  551 545 How long after birth did you first put [NAME] to the breast? During the first hour after delivery.……….1 More than 1 hour. ..…………………….…2 Don’t know……………………………..…8 546 Did you give [NAME] the first liquid (begauti) that came from your breasts? Yes………………………………………..1 No…………………………………………2 547 Are you still breastfeeding [NAME]? Yes………………………………………..1 No………………………………………...2  550 Annex-2 | 54 Q. # Question Codes Go to Q. 548 Interviewer: “Now I would like to ask you about liquids your baby [NAME] drank yesterday during the day or at night. Did [NAME] drink:” (READ ALL) Unprompted Prompted Yes Yes No 1 Plain water? 1 2 3 2 Honey? 1 2 3 3 Non-breast (animal) milk? 1 2 3 4 Infant formula? 1 2 3 5 Expressed breastmilk? 1 2 3 6 Fruit juice? 1 2 3 7 Daal? 1 2 3 8 Yogurt or mohi? 1 2 3 9 Tea? 1 2 3 10 Ghee? 1 2 3 11 Did you feed your baby any liquids using a bottle? 1 2 3 12 Did you give any other liquids (specify) __? 1 2 3 549 Interviewer: “Now I would like to ask you about the food [NAME] ate yesterday during the day or at night, either separately or combined with other foods. Did [NAME] eat:” (READ ALL) 13 Jaulo? 1 2 3 14 Lito? 1 2 3 15 Biscuits? 1 2 3 16 Noodles? 1 2 3 17 Fruits? 1 2 3 18 Vegetables? 1 2 3 19 Bread? 1 2 3 20 Bhaat? 1 2 3 21 Meat, fish or eggs? 1 2 3 22 Did you give any other solids (specify) __? 1 2 3 550 At how many completed months of age did you first start giving food or drink other than breast milk to your baby? # months: ____ ____ Baby exclusively breastfed until now .. 95 Don’t know ………………………….. 98 551 Please tell me when should a newborn child be breast fed for the first time after birth? Immediately after the birth……….............1 After the placenta is out.........…………...2 After bathing the new born……………...3 After 24 hours after birth.......……………4 Other (specify) _____________________5 Don’t know……………..……………….8 552 In the last three months, have you heard, seen, or read the message: “A newborn should be breast fed within one hour after birth.” Yes………………………1 No……………………..2 554 553 Please tell me where you saw or heard the message or who told you about it? “A newborn should be breastfed within one hour after birth.” Circle all responses which the mother Mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 FCHV 1 2 3 2 TBAs 1 2 3 3 NGO workers 1 2 3 4 Other health personnel 1 2 3 5 Friends 1 2 3 6 TV 1 2 3 7 Radio 1 2 3 8 Posters/pamphlets 1 2 3 9 BPP flip chart 1 2 3 10 Street dramas 1 2 3 11 Any other (specify) __________________ 1 97 Nobody 7 Annex-2 | 55 Q. # Question Codes Go to Q. 554 Please tell me when should a newborn child be bathed after the birth? Immediately after the birth.………….…......1 Within 24 hours after birth.………...............2 After 24 hours after birth...………................3 Should not be bathed....……….....................4 Other, specify: _______________________5 Don’t know……………..…………………..8 555 In the last three months, have you seen, heard, or read the message “A newborn should have their first bath delayed until at least 24 hours after birth.” Yes…………………………………………1 No…………………………………………..2 557 556 Please tell me where you saw or heard the message or who told you about it? “A newborn should have their first bath delayed until at least 24 hours after birth.” Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 FCHV 1 2 3 2 TBAs 1 2 3 3 NGO workers 1 2 3 4 Other health personnel 1 2 3 5 Friends 1 2 3 6 TV 1 2 3 7 Radio 1 2 3 8 Posters/pamphlets 1 2 3 9 BPP flip chart 1 2 3 10 Street dramas 1 2 3 11 Other, specify: ______________________ 1 97 Nobody 7 Danger signs 557 During your delivery, did you experience any danger signs? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Heavy bleeding? 1 2 3 2 Convulsions? 1 2 3 3 Prolonged labor (>8 hours)? 1 2 3 4 The baby’s hand, leg or cord came out first ? 1 2 3 5 Other, specify: 1 6 No problems 7  561 558 What did you do or whom did you consult for the problems that you stated above? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No SKILL PERSONNEL 1 Doctor 1 2 3 2 Nurse 1 2 3 3 ANM 1 2 3 CONSULTED TRAINED PERSONNEL 4 HA/AHW 1 2 3 5 MCHW 1 2 3 6 VHW 1 2 3 OTHER PERSONNEL 7 FCHV 1 2 3 8 TTBA 1 2 3 9 TBA 1 2 3 Annex-2 | 56 Q. # Question Codes Go to Q. 10 Other HW 1 2 3 11 Dhami Jhakri (traditional healers) 1 2 3 12 Consulted relative/neighbor/friend 1 2 3 13 Bought medicine from pharmacy 1 2 3 14 Given medicine at home 1 2 3 15 Other (specify): ___________ 1 97 Nothing 7 559 Were you referred for any of these problems? Yes………………………………………….1 No…………………………………………..2 561 560 Where did you go? Circle all responses which the mother mentions unprompted. Then ask, “Is there anywhere else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No PUBLIC SECTOR 1 Hospital 1 2 3 2 PHCC 1 2 3 3 Health post 1 2 3 4 Sub-health post 1 2 3 PRIVATE SECTOR 5 Pvt. Clinic/Nursing Home 1 2 3 HOME 6 Your home 1 2 3 7 TBA home 1 2 3 8 FCHV home 1 2 3 9 Other (specify): ___________ 1 561 In the past three months, have you seen, heard, or read anything about attendance of a trained health worker during delivery on the radio or television or in the newspaper or anywhere else? Yes……..………………………….………..1 No…………………………....……………..2 562 In the past three months, have you seen, heard, or read anything about attendance of a FCHV during delivery on the radio or television or in the newspaper or anywhere else? Yes……..…………….……………………..1 No…………………………………………..2 Checkbox 5.2 Interviewer: Check questions 561 and Q562 and circle below: Answered “yes” in Q561 or Q562 or both ................................................................................. 1 Answered “no” in both Q561 and Q562 ..................................................................................... 2  Sec 6 563 Please tell me where you saw or heard a message on attendance of a trained health worker during delivery or who told you about it. Circle all responses which the mother mentions unprompted. Then ask, “Is there anywhere else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 FCHV 1 2 3 2 TBAs 1 2 3 3 NGO workers 1 2 3 4 Other health personnel 1 2 3 5 Friends 1 2 3 6 TV 1 2 3 7 Radio 1 2 3 8 Posters/pamphlets 1 2 3 9 BPP flip chart 1 2 3 10 Street dramas 1 2 3 11 Other, specify: ______________________ 1 97 Nobody 7 Annex-2 | 57 Section 6: Post-natal Care for the Mother Q. # Question Codes Go to Q. 601 Check Q N. 506, (Place of delivery) Public Sector: Hospital ................................................... 1 PHCC ...................................................... 2 Health post .............................................. 3 Sub-health post ....................................... 4 Private sector Pvt. Clinic/n. Home ................................ 5 Your home …………………………… 6 TBA home …………………….…... 7 FCHV home…………………………….8 Other, specify: _________________ 9 603 602 FOR BIRTHS IN OWN/OTHER HOME, ASK: After [NAME] was born and the health care provider, FCHVor traditional birth attendant left your home, did any health care provider or a traditional birth attendant check on your health? Note: For women with a stillbirth, ask: “After you lost your baby, and the health care provider, FCHV or traditional birth attendant left your home, , did any health care provider or a traditional birth attendant check on your health? Yes………………………………. 1 No……………………………… 2 →604 →611 603 FOR BIRTHS IN HEALTH FACILITY, ASK: After you were discharged, did any health care provider or a traditional birth attendant check on your health? Yes…………………………………. 1 No.………………………………… 2 →611 604 In the first month, after [NAME] was born, how many times did a health care provider or traditional birth attendant check on your health? # TIMES MOTHER 1 605 How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. HOURS 1 DAYS 2 Don’t know….………………………….998 606 Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON. Skilled Personnel Doctor…………………….……………...1 Staff Nurse . . . ……………….…....…....2 ANM….…………...……………............. 3 Trained Personnel MCHW………………………....……..…4 HA …………………………………..…..5 AHW / CMA …………….….. …...……6 VHW........……………….………….……7 FCHV…………………………………….8 Other Personnel Trained TBA………………….……..…...9 Untrained TBA…………………..…..…10 Relative/Friend ……………….…….….11 Other, specify: ___________________12 Annex-2 | 58 Q. # Question Codes Go to Q. 607 What things did she or he do to check on your health? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Did she examine your body? 1 2 3 2 Did she check your breasts? 1 2 3 3 Did she check for heavy bleeding? 1 2 3 4 Did she check for fever? 1 2 3 5 Did she refer you to a health center/hospital? 1 2 3 6 Other (specify)_______________________ 1 97 Nothing 7 Check box 6.1 Interviewer: Check questions Q604 and circle below: More than one postnatal check for mother ................................................................................ 1 Only one visit ............................................................................................................................... 2  611 608 How long after delivery did the second check of your health take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. HOURS 1 DAYS 2 WEEKS 3 Don’t know………..…………………….998 609 Who checked on your health at that time? PROBE FOR MOST QUALIFIED PERSON. Skilled Personnel Doctor…………………….……………...1 Staff Nurse . . . ……………….…....…....2 ANM….…………...……………............. 3 Trained Personnel MCHW………………………....……..…4 HA …………………………………..…..5 AHW/CMA …………….….. ……..……6 VHW........……………….………….……7 FCHV…………………………………….8 Other Personnel Trained TBA………………….……..…...9 Untrained TBA…………………..……10 Relative/Friend ……………….……….11 Other, specify: ___________________12 Nobody ……………………………… 97 610 Where did this second check take place? PROBE TO IDENTIFY THE TYPE OF PLACE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. (NAME OF PLACE) Public Sector: Hospital ................................................... 1 PHCC ...................................................... 2 Health post .............................................. 3 Sub-health post ....................................... 4 Private sector Pvt. Clinic/n. Home ............................... .5 Home Your home …………………………..… 6 Other/TBA home …………………..… 7 FCHV home………………………..…..8 Other, specify: ___________________ 9 611 Check Box 6.2 Interviewer: Check questions B and E (page 2), and circle below: Baby still alive or baby born alive then died .............................................................................. 1 Baby stillborn ............................................................................................................................... 2  End interview Annex-2 | 59 Section 7: Post-natal Care for the Newborn Q. # Question Codes Go to Q. 701 Check Q N. 506, (Place of delivery) Public Sector: Hospital ................................................... 1 PHCC ...................................................... 2 Health post .............................................. 3 Sub-health post ....................................... 4 Private sector Pvt. Clinic/n. Home ................................ 5 Your home ………………...….……..… 6 TBAhome …………………......…........ 7 FCHV home…………………….…..…..8 Other, specify: __________________ 9 703 702 FOR BIRTHS IN OWN/OTHER HOME, ASK: After [NAME] was born and the health care provider or traditional birth attendant left your home, did any health care provider or a traditional birth attendant check on his/her health? Yes………………………………………. 1 No…………..…………………………… 2 →704 →711 703 FOR BIRTHS IN A HEALTH FACILITY, ASK: After you were discharged, did any health care provider or a traditional birth attendant check on [NAME’S] health? Yes………………………………………. 1 No………….…………………………… 2 →711 704 In the first month, after [NAME] was born, how many times did a health care provider or traditional birth attendant check on his/her health? # TIMES BABY 1 705 How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS HOURS 1 DAYS 2 WEEKS 3 Don’t know………………………….998 706 Who checked on his/her health at that time? PROBE FOR MOST QUALIFIED PERSON. Skilled Personnel Doctor…………………….……………...1 Staff Nurse . . . ……………….…....…....2 ANM….…………...…………….............. 3 Trained Personnel MCHW………………………....……..…4 HA …………………………………..…..5 AHW / CMA …………….….. …………6 VHW........……………….………….……7 FCHV…………………………………….8 Other Personnel Trained TBA………………….……..…...9 Untrained TBA…………………..…..…10 Relative/Friend ……………….…….….11 Other, specify: ___________________12 Annex-2 | 60 Q. # Question Codes Go to Q. 707 What things did she or he do to check on your baby's health? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Did she generally examine the baby’s body? 1 2 3 2 Did she weigh the baby? 1 2 3 3 Did she check the umbilical cord? 1 2 3 4 Did she observe breastfeeding? 1 2 3 5 Did she refer you to a health center/hospital? 1 2 3 6 Did she take temperature using thermometer? 1 2 3 7 Did she take temperature without thermometer? 1 2 3 8 Other, specify_____________________ 1 97 Nothing 7 98 I wasn’t there/Don’t know 8 Check box 7.1 Interviewer: Check question 704 and circle below: More than one postnatal check for baby .................................................................................... 1 Only one visit ............................................................................................................................... 2  711 708 How long after delivery did the second check of your baby’s health take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. HOURS 1 DAYS 2 WEEKS 3 Don’t know…………………………….998 709 Who checked on his/her health at that time? PROBE FOR MOST QUALIFIED PERSON. Skilled Personnel Doctor…………………….………….…...1 Staff Nurse . . . ……………….…....…......2 ANM….…………...…………….............. 3 Trained Personnel MCHW………………………....……..…4 HA …………………………………..…..5 AHW / CMA …………….….. …………6 VHW........……………….………….……7 FCHV…………………………………….8 Other Personnel Trained TBA………………….……..…...9 Untrained TBA…………………..…..…10 Relative/Friend ……………….….….….11 Other, specify: ___________________12 710 Where did this second check take place? PROBE TO IDENTIFY THE TYPE OF PLACE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. Public Sector: Hospital ......................................................... 1 PHCC ............................................................ 2 Health post .................................................... 3 Sub-health post ............................................. 4 Private sector Pvt. Clinic/n. Home ...................................... 5 Home Annex-2 | 61 Q. # Question Codes Go to Q. (NAME OF PLACE) Your home ……………………..……..… 6 Other/TBA home …………….…............ 7 FCHV home……………………….……..8 Other, specify: ____________________ 9 711 Was [NAME] weighed any time after birth? Yes………………………………………..1 No…………………………………………2 Don’t know……………………………….8  716  716 712 When was your baby [NAME] weighed the first time after birth? Within 24 hours ……………………… 1 1-2 days……..………………………….2 3 days…………………………………..3 After 3 days ……………………………4 Don’t know……………………………..8 713 Where was the baby weighed? Public Sector: Hospital ......................................................... 1 PHCC ............................................................ 2 Health post .................................................... 3 Sub-health post ............................................. 4 Private sector Pvt. Clinic/n. Home ...................................... 5 Home Your home ……………………………..… 6 Other/TBA home ………………………… 7 Other, specify: _____________________ 8 714 Who weighed the baby? Skilled Personnel Doctor…………………..………….……...1 Staff Nurse . . . ………….………..…….....2 ANM….………….……………….............. 3 Trained Personnel MCHW……………….….……....……..…4 HA ………………………….………..…..5 AHW / CMA ………….....….. ……..……6 VHW........………………..………….……7 FCHV…………………….……………….8 Other Personnel Trained TBA………………….…..…..…...9 Untrained TBA……………………...……10 Relative/Friend …………..……….….…..11 Other, specify:______________________12 715 How much did [NAME] weigh? RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE. KG FROM CARD .………………..………1 KG FROM RECALL.…………...…2 DON’T KNOW………………………..99.98 716 When [NAME] was born, was he/she very large, larger than average, average, smaller than average, or very small? Very large…………………………………1 Larger than average……………………….2 Average…………………………….….....3 Smaller than average…………….….…....4 Very small………..……………............... 5 Don’t know……………………………. 8 Sec. 8 717 Because your baby was small, did you receive extra visits from a health provider? Yes………………………………………. 1 No……………………………………… 2 Don’t know…………………….…………8 718 What advice did FCHV give when your baby [NAME] was small? Probe: What else advice? Frequent breast feeding................................1 Keep baby warm......................................... 2 Newborn danger signs................................. 3 Repeatedly weigh baby…........................... 4 Repeated visit ............................................. 5 Annex-2 | 62 Q. # Question Codes Go to Q. Other, specify:________ ______________6 FCHV not visited…………………………96 No advice.................................................…97 Don’t know.................................................98 722 719 Following your last delivery, did the FCHV talk about "keeping the baby in skin-to- skin contact with the mother?" Yes………………………………………..1 No………………………………………...2 720 Because your baby was small, was [NAME] referred to a health facility? Yes………………………………………. 1 No……………………………………… 2 722 721 Did you take the baby to health facility? Yes……………………..………………….1 No...…………………..…………………..2 722 Because your baby was small, did you give extra care to your baby? Yes………………………………………. 1 No……………………………………… 2 724 723 What extra care did you give to your baby? CIRCLE ALL MENTIONED. More frequent breastfeeding…………… 1 Skin-to-skin care……………………….. 2 Fed by cup or spoon………………………3 Other, Specify: ____________________4 724 Was the baby placed in SKIN-to-SKIN contact in the first 24 hours after delivery? Not at all ………………………………..1 A little (up to 2 hours total)……………..2 Moderate amount (between 2 to 5 hours total)………………………………3 A lot (more than 5 but less than 12 hours)………………………………..…..4 Most of the time (day & night, more than 12 hours)………………….………..5 726 725 How soon after delivery was the baby placed SKIN-to-SKIN for the first time?. Before the cord tied……………..……….1 After the cord tied, before the placenta delivered……………………………….…2 After the placenta delivered, within the first hour after birth………………..…….3 After one hour after delivery……………4 DK ………………………………..…8 726 For how many days did your baby get skin to skin contact? Number of days: | Not at all………………………………… 96 Sec. 8 727 Did your baby get skin-to-skin contact for 24 hours a day? Yes…………………………………………1 No………………………………………….2 729 728 How many days did your baby get skin to skin contact for 24 hours? Number of days: | 729 Who else did skin-to-skin contact for your baby? (Multiple Responses.) Husband………………………………….1 Mother-in-law……………………………2 Other family member…………………….3 Other, specify: ____________________ 4 No one……………………………………7 Annex-2 | 63 Section 8: Sick Newborn Care Q. # Question Codes Go to Q. 801 What are the danger signs/symptoms after giving birth indicating the need to seek health care for a baby less than a month? When she has finished answering, ask “Is there anything else?” CIRCLE ALL RESPONSES MENTIONED. . Fever………………………………………1 Unable to suckle/feed………………….….2 Difficult/fast breathing……………………3 Diarrhea…………………………………...4 Convulsions………………………………5 Persistent vomiting…..……………………6 Yellow palms/soles/eyes/jaundice………...7 Lethargy…………………………………...8 Unconsciousness…………………………..9 Red/discharging eyes..……………………10 Skin pustules………..…………...………..11 Skin around cord red……………....….......12 Pus from cord………….………………….13 Failure to pass urine……………..………..14 Shivering/cold baby/low temperature…….15 Bluish palms and soles………....................16 Very small baby/below normal weight…...17 Baby doesn’t cry at birth………………….18 Baby cries stridently………………………19 Other, specify: _____________________20 Do not know………………………….....98 802 Did [Name] experience any danger sign/symptoms during the first month following delivery? Yes……………………………………………1 No……………………………………………..2 Don’t know……………………………………8 End the interview  End the interview 803 What were the danger signs/symptoms that [NAME] experienced? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” THEN, READ EACH QUESTION AND CIRCLE “2” FOR “YES” OR “3” FOR “NO.” Unprompted Prompted Most serious episode (Q806) Yes Yes No 1 Fever 1 2 3 4 2 Unable to suckle/feed 1 2 3 4 3 Difficult/fast breathing 1 2 3 4 4 Diarrhea 1 2 3 4 5 Convulsions 1 2 3 4 6 Persistent vomiting 1 2 3 4 7 Yellow palms/soles/eyes/jaundice 1 2 3 4 8 Lethargy 1 2 3 4 9 Unconsciousness 1 2 3 4 10 Red/discharging eyes 1 2 3 4 11 Skin pustules 1 2 3 4 12 Skin around cord red 1 2 3 4 13 Pus from cord 1 2 3 4 14 Failure to pass urine 1 2 3 4 15 Shivering/cold baby/low temperature 1 2 3 4 16 Bluish palms and soles 1 2 3 4 17 Very small baby/below normal weight 1 2 3 4 18 Baby doesn’t cry at birth 1 2 3 4 19 Baby cries stridently 1 2 3 4 20 Other (specify):___________________ 1 4 Annex-2 | 64 Q. # Question Codes Go to Q. 804 How many episodes of illness did [NAME/BABY] have up to the age of 1 month? Number [___|___] 805 How many times did you seek medical help up to the age of 1 month? Number of times …...…… | Never ever examined …………97 806 CHECK BOX: 8.1 IF MORE THAN ONE EPISODE OF ILLNESS, IDENTIFY WHAT MOTHER FELT WAS MOST SERIOUS EPISODE. CHECK THE APPROPRIATE BOX IN THE LAST COLUMN IN THE TABLE FOR Q 803 807 MOST SERIOUS ILLNESS How old was [NAME] when the problem started? If less than 1 day, record hours. If less than 1 week, record days. Otherwise record weeks. HOURS 1 DAYS 2 WEEKS 3 DON’T KNOW……………………….998 808 How was [NAME] treated for this illness at home? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompte d Prompted Yes Yes No 1 By giving drugs 1 2 3 2 By giving herbs 1 2 3 3 By bringing health provider to home 1 2 3 4 By taking advice of the health provider 12 3 5 Other (specify) 1 97 No treatment 7 809 How long after illness started was care initialised at home? Hours [___|___] Days [___|___] No care given at home……………….………….96 Don’t know.......................................................... 98 810 Did you seek advice or treatment for the illness outside the home? Yes ...................................................................... 1 No ....................................................................... 2 Don’t Know ........................................................ 8 823 823 811 How much time after illness started was [NAME] brought outside the home for care? Hours [___|___] Days [___|___] Don’t know .......................................................... 998 812 Whom did you go to for the first time for the problem? Skilled Personnel Doctor…………………..………….……...1 Staff Nurse . . . ………….………..…….....2 ANM….………….……………….............. 3 Trained Personnel HA/AHW……………….….……..….…..…4 MCHW ……………………….………..…..5 VHW........………………..…………………6 Other Personnel FCHV…………………….……….……….7 TTBA………………….…..………….…...8 TBA……………………...……………..…9 Relative/Friend …………..……….….…..10 Other, specify:______________________11 Annex-2 | 65 Q. # Question Codes Go to Q. 813 From where did you seek care for the first time? Public Sector Hospital ......................................................... 1 PHCC ............................................................ 2 Health post .................................................... 3 Sub-health post ............................................. 4 Private sector Pvt. Clinic/N. Home ..................................... 5 Home TBA home ……………………………..… 6 FCHV home………………………………7 Other, specify: ____________________ 8 814 How did you take [NAME] to the hospital/clinic/care provider? (Multiple Response) Taxi………………………………………….1 Bus……………………….………………….2 Bicycle………………………………………3 Motor Cycle…………………………………4 Horse/Donkey………………………………5 Horse/Donkey Cart/Bullock cart…………….6 On foot……………………………..…………7 Other (specify) ________________….…….8 815 Was it difficult to find the transport? Yes……………………………………………1 No…………………………………………..2 Don’t Know………………………………...8 816 How much time did it take to go there? Minutes [_____]______] Hours [_____]______] Don’t Know…………………………….998 817 On your way to the health facility (other), what did you do to care for your baby? Circle all responses which the mother mentions unprompted. Then ask, “Is there anything else.” Then, read each question and circle “2” for “yes” or “3” for “no.” Unprompted Prompted Yes Yes No 1 Skin-to-skin 1 2 3 2 Kept baby bundled 1 2 3 3 Breastfed 1 2 3 4 Other (specify)_______________________ 1 2 3 7 Nothing 7 8 Don’t Know 8 Check Box 8.2 Interviewer: Check question 812 and circle below: Examined by an FCHV ............................................................................................................ ..1 Not examined by an FCHV ......................................................................................................... 2  819 818 If examined by an FCHV, did she give a referral form to call the VHW/MCHW? (Note: show referral/call form) Yes …………………………………………1 No ……………………….………………….2 819 At that time, was a pediatric tablet of Cotrimoxazole given? Yes …………………………………………1 No …………………….…………………….2 824 820 How many days did you give Cotrim? #Days ………………………………... | 821 What was the condition of your baby [NAME] at last dose of Cotrim? Improved ..................................................... 1 Worse ……………………………………….2 Same …………………………………………3 Dead………………………………………….4 Don’t’ know………………………………….8 822 Did you pay for Cotrim? Yes……………………………………………1 No…………………………………………….2 824 824 Annex-2 | 66 Q. # Question Codes Go to Q. 823 Why didn’t you seek care for your neonate outside your home? If the respondent says, respected ‘FAMILY MEMBERS DID NOT ALLOW’, probe to identify who that family member is: husband? Mother? Mother-in-law? Father? Father-in-law? Grand mother/grand father? Specify Unprompted Prompted Yes Yes No 1 Expecting self resolution of the illness 1 2 3 2 Health facility too far/no transportation 1 2 3 3 Cost of treatment service high 1 2 3 4 Don’t trust facility/poor quality of care 1 2 3 5 Respected family members did not allow 1 2 3 6 The traditional birth attendant didn’t allow 1 2 3 7 Not customary to seek care outside home after childbirth 1 2 3 8 Other (specify): _______________ 1 97 No reason given 7 824 Now I would like to know how frequently your baby was breastfed during the illness. Was he/she breastfed less than usual, about the same or more than usual frequency? Less than usual……………........................... 1 Same as usual………………..........................2 More than usual…………………………..…3 Nothing to drink ………………………....…4 Don't know . .…………….........…............... 8 Thank you for your time and cooperation in answering my questions. The information that you have provided will help us to improve the health of women and children throughout Nepal.