assessment of the integration of family planning...

i

Assessment of the Integration of Family Planning

& Expanded Programme of Immunization (EPI)

in Selected Districts of Nepal 2017

Final Report

Submitted to:

Ministry of Health

Department of Health Services

Family Health Division

Teku, Kathmandu

By:

Population, Health and Development (PHD) Group Pvt. Ltd

Ring Road, Sanepa, Lalitpur

Post Box 3108

Kathmandu, Nepal Phone: 01-5184063

Email : [email protected], [email protected]

Asar 20, 2074 (July 4, 2017)

mailto:[email protected]

mailto:[email protected]

i

Acknowledgements

Population, Health and Development (PHD) Group would like to thank Dr. Naresh Pratap K.

C., Director, Dr. Sharad Sharma, Senior Demographer, Mr. Dilli Raman Adhikari, Senior

Public Helath Administrator, Mr. Sameer Adhikari, HMIS Section, Dr. Rajendra Gurung,

NHSSP and other staffs of the Family Health Division (FHD), Ministry of Health for

entrusting this work to us. On behalf of the PHD Group, I wish to thank DHOs/DPHOs, EPI

and FP focal persons/supervisors of Parbat, Rukum, Bajhang and Doti districts for their active

participation in consultative meetings with PHD Group field researchers in respective district

offices. In addition, health facility in-charges, staff nurses, HAs, AHWs, ANMs and FCHVs of

four PHCCs and four HPs of the four districts spared their time to sit with the PHD Group field

researchers in their localities and amicably discussed issues related to FP/EPI integration

programme implemented in the four districts. The PHD Group would like to thank them for

their time and patience. Furthermore, mothers visiting FP/EPI static clinics and FP/EPI ORCs

with their young children for immunization patiently sat with PHD Group field researchers and

cooperated well in discussing the pros and cons of the integrated model and the benefits and

difficulties they faced. This report would be incomplete without thanking them.

In the end the PHD Group would like to express heartfelt thanks to all experts who provided

written as well as oral comments on the draft report. Their views, comments and cooperation

are highly appreciated.

PHD Group

Study Team

ii

CONTENTS

Page

ACKNOWLEDGEMENT i

TABLE OF CONTENTS ii

STUDY TEAM MEMBERS iv

ABBREVIATIONS v

EXECUTIVE SUMMARY vi

Chapter I

1 Background and rationale ………………………………………….................................................... 1

2 Programme description ........................................................................................................................ 2

3 Objective ............................................................................................................. ................................ 2

4 Scope of assessment ............................................................................................................................ 2

Chapter II

2.1 Methodology and Approach .............................................................................................................. 3

2.1.1 Desk review ......................................................................................................................... 3

2.1.2 Field work for quantitative and qualitative data collection ................................................ 3

2.1.3 Respondent selection criteria ............................................................................................... 3

2.2 Assessment tools ................................................................................................................................ 4

2.3 Data collection, processing and analysis ............................................................................................ 5

2.3.1 Training of field researchers and data collection ................................................................. 5

2.3.2 Data processing .................................................................................................................... 5

2.3.3 Data analysis ......................................................................................................................... 7

2.4 Ethical considerations ......................................................................................................................... 7

2.5 Fieldwork and study duration ............................................................................................................. 7

2.6 Limitations and constraints of the study .............................................................................................. 7

Chapter III

3.1 Results ................................................................................................................................................ 8

3.1.1 FP and EPI integration and change in FP and EPI outcomes ............................................. 8

3.1.2 FP EPI integrated programme implementation in four districts ......................................... 10

3.1.3 Reaching out to marginalized population group ................................................................. 13

3.2 Adherence of the FP & EPI integration intervention activities ............................................ 14

3.3 Client, provider and programme manager’s perspectives on the integrated service delivery process 16

3.3.1 Sociodemographic characteristics of women interviewed ................................................... 17

3.3.2 FP EPI Integration and mothers’ behaviour and perspectives ............................................. 19

3.3.4 Providers’ perspectives ........................................................................................................ 23

3.3.5 Volunteer providers’ perspectives ...................................................................................... 23

3.3.6 Programme manager’s perspectives .................................................................................... 24

3.3 Challenges and areas for adjustment to help institutionalize FP and EPI integration ......................... 24

Chapter IV

4 Conclusion and recommendations ........................................................................................................ 27

4.1 Conclusion .................................................................................................................................... 27

4.2 Recommendations ........................................................................................................................ 27

Appendix I ........................................................................................................................................... 30

References ........................................................................................................................................... 31

iii

List of Table and Figures

Table 1 Types and size of study populations by district and facility ................................................... 4

Table 2 Number of children immunised in 2072 and 2073 from Kattik to Chait, EPI

registers, 8 health facilities ........................................................……………………………..

14

Table 3 Distribution of clients by type and by district, 4 districts, Nepal 2017 ................................... 17

Table 4 Distribution of clients by district and VDC, 4 districts, Nepal 2017 ...................................... 17

Table 5 Age of mothers attending EPI ORC by whether accepted FP or not, 4 districts,

Nepal 2017 ..............................................................................................……………………

18

Table 6 Age of mothers attending EPI ORC, 4 districts, Nepal 2017 ................................................. 18

Table 7 Education of mothers attending EPI ORC, 4 districts, Nepal 2017 ....................................... 19

Table 8 Caste/ethnicity of mothers attending EPI ORC, 4 districts, Nepal 2017 ................................ 19

Table 9 Counselling on FP of mothers attending EPI ORC, 4 districts, Nepal 2017 ........................... 20

Table 10 Reason for not accepting FP method at 1st visit by mothers attending EPI

ORC, 4 districts, Nepal 2017 ........................................................................................………..

20

Table 11 Distribution of mothers by type of contraceptive method in use and source of

methods, 4 districts, Nepal 2017 .....................................................................................……..

21

Table 12 Distribution of mothers mentioning benefits of FP/EPI integration model, 4 districts,

Nepal 2017............................................................................................................................. ....

21

Table 13 Distribution of mothers commenting on partition at FP/EPI integration site,

4 districts, Nepal 2017 ......................................................................................……………….

21

Table 14 Distribution of mothers commenting on the use of FP method by mothers,

4 districts, Nepal 2017......................................................................................................…….

22

Table 15 Percentage of mothers talking to their friends/family members about the integrated

FP/EPI model, 4 districts, Nepal 2017 .....................................................................................

22

Table 16 Percentage of mothers giving their opinions on vaccinators, 4 districts, Nepal 2017 .......... 22

Figure 1 Flow of FP clients in 8 facilities of 4 district, 7/072- 12/73 ..............................................…… 11

Figure 2 Per cent share of FP clients since Saun 2073 to Chait 2073 ..............................................…… 12

Figure 3 Monthly spacing methods (Depo and pills) uptake in 8 facilities of four districts,

7/072- 12/73........……………………………………………………………………………..

13

Figure 4 Percentage of FP Dalit clients as against the total FP clients, Saun 2073 to Chait 2073...……. 13

iv

STUDY TEAM MEMBERS

Dr. Yagya Bahadur Karki - Team Leader

Ms. Upasana Shakya - Research Officer

Mr. Khadaga B. Karki - Research/ Field Manager

Data Processing Staffs

Mr. Rajendra Karki - Programme Officer/Data Manager

Ms. Sabina Thakuri - Data Processor

Mr. Kiran Karki - Data Processor

Field Researchers

Mandeep Sharma

Dadiram Poudel

Mohan Neupane

Ram Chandra Poudel

Babu Ram Roka

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ABBREVIATIONS AND ACRONYMS

AHW Auxiliary Health Worker

ANM Auxiliary Nurse Midwife

CBS Central Bureau of Statistics

CHD Child Health Division

CPR Contraceptive Prevalence Rate

DHO District Health Officer

DPHO District Public Health Officer

DoHS Department of Health Services

EPI Expanded Programme of Immunization

FCHV Female community Health Volunteers

FHD Family Health Division

FP Family Planning

FY Fiscal Year

GoN Government of Nepal

HA Health Assistant

HC Health Centre

HFOMC Health Facility Operation and Management Committees

HMIS Health Management Information System

HP Health Post

HTSP Healthy Timing and Spacing of Pregnancy

IEC Information, education and communication

IPC Inter-personal Communication

IUD Intra Uterine Device

KII Key Informant Interview

MOH Ministry of Health

MOHP Ministry of Health and Population

NDHS Nepal Demographic and Health Survey

NGO Non-Governmental Organisation

NHSSP Nepal Health Sector Support Programme

OIC Office in-Charge

ORC Outreach Clinic

PHCC Primary Health Care Centre

PHD Population, Health and Development (PHD) Group

RH Reproductive Health

TOR Terms of Reference

UNICEF United Nations Children Fund

USAID United States Agency for International Development

VDC Village Development Committee

WHO World health Organization

vi

Executive summary

WHO recommends a two-year interval between births as a means to reduce the risk of adverse

maternal and child health outcomes (WHO 2005). In order for mothers to space births at least

two-year apart, they need to practice some form of birth control measure. The Family Health

Division, Ministry of Health (MoH), Government of Nepal in line with WHO (2005)

recommendations underscores the importance of strengthening the provision of family

planning and counselling for healthy timing and spacing of births, particularly for mothers in

the first year after child birth. The available evidence in Nepal, however, indicates that 21% of

births occur within the two-year period and 50% within less than 36 months (MOH, New ERA

and ICF Intl, 2012). Only 8.5% of women who had a live birth in the past 5 years were found

being counselled on family planning during postpartum check-up (ibid, p.109). As per Dr.

Scott Radloff, Director of the USAID Office of Population and Reproductive Health,

postpartum family planning may be the biggest missed opportunity (http://fhi.org/en/Research/Projects/Progress /GTL/Mtgs/PPFPmeetingJuly2012.htm).

In Nepal, immunization programme has the highest coverage rate and the GoN/FHD initiated a

pilot to integrate FP into routine EPI in Kalikot in 2012. Finding the pilot programme

successful, FHD expanded the programme to Bajhang in FY 2071/72 and further to Doti,

Parbat, Bajhang and Rukum in FY 2072/73.

This quick assessment of the integrated model selected one PHCC and one HP from Doti,

Parbat, Bajhang and Rukum districts. The rapid evaluation used a mix of quantitative and

qualitative methods including semi-structured questionnaires and discussion guidelines.

Findings

In the four districts studied the integrated model successfully increased access to family

planning.

In the 8 health facilities of the four districts studied the number of FP clients has

increased after the intervention compared to the period before intervention.

With the introduction of FP/EPI programme, increasing number of women is utilizing

FP services from EPI outreach and EPI static clinics than static regular clinics. The

share of FP clients of regular Health Facility static clinics is increasingly declining

since the FP/EPI intervention.

Method mix is more balanced after the introduction of integrated model.

The uptake of pills, implant and IUD has also improved and thus method mix has

balanced after the integration.

http://fhi.org/en/Research/Projects/Progress%20/GTL/Mtgs/PPFPmeetingJuly2012.htm

vii

The integrated model has allowed an opportunity for marginalized population group to

benefit from FP.

Of the total clients who received family planning methods, a little over a quarter (27%)

are Dalits and this proportion of Dalit FP users is more than the actual proportion of

Dalits population of 22% in four districts combined.

The total number of EPI users increased in 2073 during programme intervention period

(six months data) compared to the six months before the intervention with some

fluctuations of service in the last two months of comparison.

All study sites were found adhering to the FP & EPI integration intervention activities.

They had initial training, FP registers updated at least partially, and FP/EPI clinics

implemented the model as per MOH, FHD guidelines

Clients’ perspectives

Mothers who attended FP/EPI integrated clinics were overall happy with the model.

They see a lot of benefits in it as they say they can get two services from one place.

Women who did not go for FP service to FP/MCH static clinic now are easily

accessing FP services because of close vicinity of the service delivery point (referring

to EPI ORCs or EPI static clinics)

Most mothers accept FP service during their 2nd visit to the EPI/ORC

Those who do not accept FP at first visit is mainly because of no resumption of

menstruation.

Mothers who do not accept FP at 2nd visit mainly do so because of absentee husbands.

A fair number of mothers cannot accept FP at second visit because they cannot decide

on their own after getting FP counselling; they need to ask their husbands.

Challenges

In this study challenges of the programme were mentioned mainly by programme managers

and service providers. The challenges included shortage of staffs, time constraints, lack of

space for service provision at FP/EPI ORC, updating of registers, lack of equipment and some

mentioned lack of contraceptive supply.

The challenge for mothers was that they could not decide on their own when they wanted to

adopt a FP method. They needed to consult with their husbands and/or family members.

Recommendations

1. Strengthen staffing

2. Strengthen infrastructure for the FP/EPI outreach centre

3. Ensure uninterrupted adequacy of contraceptive commodities

4. Ensure adequate supply of FP counselling materials

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5. Train health personnel on special skill of conducting FP counselling

6. Revise and improve FP register

7. Regularise monitoring and supervision

8. Scale up the provision of integrated FP/EPI services

9. Create a supportive environment at the local level

10. Establish a strong referral service at integrated clinics

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Chapter I

1. Background and rationale

Giving women access to family planning (FP) during the first year of postpartum provides an

opportunity to prevent unintended pregnancies and promote healthy birth spacing. Pregnancies

spaced less than 18-24 months apart have been associated with an increased risk of preterm

birth, low birth weight, foetal, neonatal and infant death, childhood malnutrition and stunting

and adverse maternal health outcomes. More than 90 per cent of women during their first year

postpartum indicate a desire to delay the next pregnancy for at least 2 years, or desire not to get

pregnant at all, yet there is substantial unmet need for family planning during their period. The

Expanded Program on Immunization (EPI) provides routine immunization to children in their

first year of life, which corresponds to the extended postpartum period of their mothers.

Routine immunization services are one of the most used and equitable health services; global

coverage for third dose of vaccine containing diphtheria, tetanus, and pertussis (DPT3) was

estimated at 84 per cent.

The contraceptive prevalence rate (CPR) for all methods (modern and traditional) has

increased form 24 per cent in 1991 (MOH, 1993) to 49.6 per cent in 2014 (CBS and UNICEF,

2015) in Nepal. However, the wide variations in health services availability and utilization of

FP services across different socio-economic and geographical population groups indicate that

there are challenges of access and equity. While there has been a significant increase over time

of the contraceptive prevalence rate for modern methods among married women- from 35 per

cent in 2001 (MOH, New ERA and ORC Macro, 2002) to 43 per cent in 2011(MOH, New

ERA and ICF Intl, 2012) and 47.1 in 2014 (CBS and UNICEF, 2015), there are significant

variations in FP service use by age, ethnicity, geographic location, wealth quintile and spousal

separation. Data vary from 79.9 in Parsa (Terai) to 15.7 in Kalikot (Hill) (HMIS 2014/15).

Disparities exist not only between districts but also within. Likewise, use of modern

contraception among the lowest and the highest wealth quintiles is 35.6 per cent and 48.9 per

cent, respectively (MOH, New ERA and ICF Intl, 2017).

The Government of Nepal, under the Family Health Division of the Ministry of Health, has

emphasised the need to strengthen quality of family planning counselling and services to

postpartum women. The 2011 Nepal Demographic Health Survey (NDHS) found only 8.5 per

cent of women who had had a live birth in the five years preceding the survey had been given

information or counselled on family planning during their postpartum period (MOH, New

ERA and ICF Intl, 2012). Various studies have demonstrated a substantial unmet need and

demand for family planning information and services at all stages of pregnancy, delivery and

in the postpartum period.

Given that the time frames for EPI and postpartum family planning services overlap,

integrating these services provides an opportunity to leverage existing contacts with the health

system to offer women a more comprehensive package of services. Such integration of

services has been recognized as a promising high-impact practice for improving access to

family planning. Furthermore, the global vaccine Action Plan for 2011-2020 recognizes that

strong immunization systems are an integral part of a well-functioning health system and states

that immunization service delivery should continue to serve as a platform for providing other

priority public health interventions.

2

2. Programme description

Given that the immunization programme has the highest coverage rate, GoN/FHD initiated a

pilot to integrate FP into routine EPI in Kalikot in 2012. An assessment carried out one year

later showed increased clients for FP services. Of the total clients who received FP services 58

per cent were new users. Learning from the Kalikot pilot, UNFPA supported FHD/DHO to

integrate FP/EPI in Bajhang from 2015 following an orientation in the district. UNFPA had

also provided technical support to initiate the FP-EPI integration in Rukum in 2015. In

addition, NHSSP had supported implementation of FP-EPI integration in Doti and Parbat

during fiscal year 2072/73 (2015/16). Up to the last fiscal year (2072/73), FP-EPI integration

program has been implemented in 5 districts including Kalikot, Doti, Parbat, Bajhang and

Rukum. During current fiscal year 2073/74, this program will be implemented in additional

two districts (Parbat, Rukum, and Doti— as follow up, Sindhuli and Salyan as new districts).

This assessment of the implementation of Family Planning programme and its integration with

immunization programme is carried out at the request of DoHS, Family Health Division in this

current fiscal year 2073/74.

3. Objective

The overall objective of the assessment is to document the feasibility and possibility of scaling

up the programme of integrating FP and EPI in Nepalese setting. Specific objectives of the

assessment include;

To explore if the FP and EPI integration associate with the change in FP and EPI

outcomes;

To examine the extent to which the FP & EPI integration intervention activities adhere

with the proposed plan;

To understand client, provider and programme manager’s perspectives on the

integrated service delivery process and

To document the challenges and areas for adjustment so as to institutionalize FP and

EPI integration.

4. Scope of assessment

The assessment, as mentioned in the TOR, covered the time period between FY 2072/73 and

FY 2073/74. The assessment analysed how efficiently the planning and implementation of FP

and EPI integration programme was carried out. This includes the coordination mechanisms

and timeliness, technical and financial support to this initiative. The assessment provides

timely feedback and recommendations to inform policy makers and programme managers.

3

Chapter II

2.1 Methodology and Approach

Population, Health and Development (PHD) Group was awarded this short and quick

assessment using multiple methods approach for data collection to address the objectives

mentioned above. The assessment has adhered to the principle of triangulation and stakeholder

consultation and engagement.

2.1.1 Desk review

A number of documents/reports are available on FP and EPI integration and therefore attempts

have been made to critically review them and their gist was useful in formulating study tools.

In Nepal policy documents, immunization and family planning registers with HMIS reports are

available which were reviewed and cross-verified. Also implementation process was reviewed

so as to document usefulness of guidelines, area of improvement and need of supportive

supervision. FHD provided PHD Group with some relevant documents mentioned in the TOR.

On the basis of initial desk review and secondary data analysis, PHD Group, in consultation

with FHD, finalized the assessment methodology, tool and assessment framework.

2.1.2 Field work for quantitative and qualitative data collection

In order to document facility and community level activities, a team of field researchers from

PHD Group visited 4 districts (Doti, Parbat, Bajhang and Rukum). District Health Offices and

selected PHCCs, HPs EPI static clinics and FP/EPI outreach clinics were visited in those four

districts. One PHCC and one HP from each of the four districts were selected for assessment.

2.1.3 Respondent selection criteria

Respondents for the assessment were purposively sampled according to the respondent

categories (District: DHO/DPHO, FP and EPI Focal persons, below district: Office in-charge,

FP and EPI service providers and FCHVs). At the district Headquarters level, DHO/DPHO, FP

and EPI Focal Persons were interviewed. At the sampled facilities, one EPI Service Provider or

vaccinator, one FP provider, and one Officer-in-charge (OIC) were interviewed. One FCHV

each from each of two health facilities was also interviewed. In all, 8 FCHVs were

interviewed.

From each study site four mothers who came to EPI centre for their children’s immunization

and also accepted a family planning method were interviewed. Similarly another four mothers

who came to EPI centre for their children’s immunization but did not accept any FP method

were also interviewed. The following Table 1 summarizes the types and size of study

populations by district and facility.

4

Table 1 Types and size of study populations by district and facility

Districts Types

District, PHCC/HP Level Qualitative

Respondent Types PHCC/HP Level Quantitative Respondent Types

District

Level

PHCC/HP Level Qualitative

Respondent

EPI static

clinics

EPI outreach

clinics

EPI static &

outreach

clinics FP

users & none

users: Total

KII:

DHO,

FP and

EPI

focal

persons

KII: In-

charge, FP

and EPI

Service

Provider

(outreach)

FCHV

(HFM

C

Memb

er)

KII

Total

EPI

clinic

FP

user

EPI

clinic

FP

none

user

EPI

outreac

h clinic

FP

user

EPI

outreac

h clinic

FP

none

user

Bajhang

District 3 - - 3 - - - - -

PHCC -1 - 3 1 4 2 2 2 2 8

HP -1 - 3 1 4 2 2 2 2 8

Total 3 6 2 11 4 4 4 4 16

Doti

District 3 - - 3 - - - - -

PHCC -1 - 3 1 4 2 2 2 2 8

HP -1 - 3 1 4 2 2 2 2 8

Total 3 6 2 11 4 4 4 4 16

Rukum

District 3 - - 3 - - - - -

PHCC -1 - 3 1 4 2 2 2 2 8

HP -1 - 3 1 4 2 2 2 2 8

Total 3 6 2 11 4 4 4 4 16

Parbat

District 3 - - 3 - - - - -

PHCC -1 - 3 1 4 2 2 2 2 8

HP -1 - 3 1 4 2 2 2 2 8

Total 3 6 2 11 4 4 4 4 16

Total 12 24 8 44 16 16 16 16 64

2.2 Assessment tools

Qualitative Tools

Key Informant Interview (KII) guideline

Key Informant Interviews were employed to gather information from DHO/ DPHO and other

relevant district level stakeholders, Health Workers and FCHVs. Therefore, KII guidelines

were developed to get information from them.

Quantitative Tool

Structured Quantitative Survey Questionnaire

A questionnaire was used to gather information on demographic characteristics of clients who

accepted a FP method after sitting in FP group counselling session. The questionnaire included

questions on key areas of assessment as mentioned in the objectives. FHD was consulted in

this respect. The final questionnaire was translated into Nepali.

5

2.3 Data collection, processing and analysis

2.3.1 Training of field researchers and data collection

Prior to field mobilization of field researchers they were given intensive training for two days

by FHD, HMIS, MOH and NHSSP personnel and PHD Group senior staff. The researchers

were oriented on the integrated model by the FHD and NHSSP personnel and HMIS personnel

explained about data system at health facilities. PHD Group staff gave basic training on

research ethics, interpersonal communication, interview techniques, ethical consideration and

organization and management of field work in districts.

Once the review of relevant literature was conducted, tools were developed and they were

finalized in consultation with FHD. The quantitative questionnaire and qualitative tools were

used to train field researchers. The trained field researchers were mobilized to the 8 selected

health facilities (one PHCC and one HF in each district) of four study districts for data

collection.

Field data collection was of high quality. In order to ensure that the collected data were valid

and of high quality monitoring and supervision of the field work was carried out at following

three levels:

Interviewer Level: The interviewer in each site checked whether the questionnaire or

key informant interview was filled in completely and correctly before terminating each

interview with respondents and discussion at each level;

Supervisor Level: The supervisors of each team were trained to ensure proper sampling

and interviewing through daily periodic spot checks and observation of the interviews

being conducted by the interviewers. The main responsibility of the field supervisor

was to arrange for all necessary logistics including travel and accommodation,

administering questionnaire to respondents to ensure data quality and smooth

functioning of fieldwork. He was also responsible for contacting local authorities,

communicating between the team and head office and checking all completed

questionnaires and information collection tools every day. They checked all completed

work at the end of each day comprehensively.

Core Team Level: In course of the monitoring and supervision visits, the core team

members reviewed all information collection tools to ensure that the correct number of

interviews were conducted; and checked the completed questionnaire to ensure that the

questionnaire and information collection tools were completely filled up as required.

The observation, comments and feedback of the senior level personnel further helped

the survey teams to maintain the quality of field work.

2.3.2 Data processing

Upon completion of the field activities, secondary checking of the quantitative survey

questionnaires was performed at the PHD Office in Kathmandu. The edited questionnaires

were coded for computer entry, entered in the computer and the entry of data was validated.

The quantitative data were computer entered and a “cleaned” SPSS data set has been

generated. The initial output included the frequency distribution for each of the variables

included in the questionnaire.

6

The qualitative data were transcribed in Nepali. Information collected through key-informant

interviews was manually processed.

The HMIS data that were collected from 8 study health facilities of 4 districts were also

computer processed. This was a challenging task as the types of HMIS data that were

examined were Main Register (Mool darta), FP register and immunization register. A big pile

of such data (see photo below) in the form of photocopies from 8 health facility sites were

brought to Kathmandu, screened and computer entered for data analysis purposes.

Mool darta, FP, EPI and Gaunghar Registers

7

2.3.3 Data analysis

HMIS data collected from 8 health facilities of 4 districts were analysed to see whether the

client flow of new acceptors of FP has increased in 2073/74 (first year of integration)

compared to 2072/73 when the programme was not implemented.

Similarly new clients accepting family planning methods from EPI static clinic, EPI outreach

clinics and regular outreach (Gaunghar) clinics have been analysed to see whether the flow of

clients has changed since the implementation of the FP-EPI integrated programme.

In addition, quantitative data of 62 mothers who went to EPI static and EPI outreach clinics

with their children for immunization who were counselled on FP have been analysed. Also

qualitative data collected by conducting KII with district level relevant personnel such as

DHO/DPHO, EPI and FP focal persons, below district health personnel like health facility in-

charges, EPI and FP focal persons and FCHV have been analysed and triangulated with the

information and research findings from quantitative HMIS data, mothers visiting EPI outreach

clinics – some accepting FP and some not and other reports and documents.

2.4 Ethical considerations

Prior to conducting interviews the interviewers obtained informed consent from the

respondents. Every respondent was told about the purpose of the study and convinced about the

confidentiality of the data. The participants were explained about the purpose of the study and

their consent to participate in it was sought. During the training the client rights issues such as

right to share or not to share personal information, emotional problems, etc. were discussed and

the field researchers were instructed to act accordingly.

2.5 Fieldwork and study duration

Field work was started soon after the training of the research team members. Two teams were

responsible for covering 2 districts each. Each team comprised of 2 field researchers. FHD

central office and PHD Group central office maintained regular communication among them to

ensure uniformity of data collection and sharing of field experiences. Field researchers spent

32 days for field work. Despite the local election time, the field work was completed as

planned.

2.6 Limitations and constraints of the study

There are no major limitations in the study that affected the quality and outcomes of the study

considerably. However, there were few minor limitations. One limitation of the study was that

the field work was conducted during the local election time in Parbat. HMIS data from study

sites was collected which was large in size and also the local health facility in-charges also

mentioned that they did not have all the data particularly before the intervention as some of

them were not properly recorded and some pages were missing. However, local election did

not affect the study results at all but HMIS data may have affected the flow of clients for the

period prior to programme intervention.

8

Chapter III 3.1 Results

3.1.1 FP and EPI integration and change in FP and EPI outcomes

As mentioned earlier, following a successful operational research on FP and EPI integration in

selected health facilities in Kalikot in 2012, the Ministry of Health with support from external

development partners expanded this integrated programme in four additional districts namely

Doti, Parbat, Bajhang and Rukum by the fiscal year 2072/73. The aim of FP EPI integration is

to increase the uptake of family planning among women during the extended post-partum

period (up to one year after child birth). The Government of Nepal, Ministry of Health,

prepared a 6-step guideline on the implementation of the integrated model as follows and also

shown diagrammatically in the flow chart in the next page.

Pre-method choice stage: Steps 1 - 4

Step 1: Before the immunisation session begins, all EPI clinics have to provide a group health

education session on healthy timing and spacing of pregnancy (HTSP) using a four page flex

chart specifically designed for this model. The objectives of this session are:

to make women aware of HTSP, its advantages and disadvantages; and

to provide information about the family planning methods available at the

integrated service so they can make an informed choice about the family

planning method most suited to their needs.

Step 2: After the group health education session, each participant (mother) is asked informally

during vaccination of her child whether she needs FP based on her child’s age, and engaged in

conversation about family planning and birth spacing. She is also reminded once again to talk

with health workers individually if she wants to know more about family planning or to use

some of the methods available.

Step 3: If women are interested in using family planning, further information and individual

counselling is to be provided using the ‘need identification flowchart’ and ‘family planning flip

chart’ developed to support the integrated service.

Step 4: Based on the informed choice of mothers, family planning methods including

injectables (Depo Provera), pills and condoms will be provided to clients.

Method choice stage: step 5

Step 5: If women’s pregnancy status is not confirmed, women is referred to the nearest health

facility for pregnancy testing and provided with a supply of condoms for fifteen days. At the

same time, women wanting long acting methods (Implant, Copper-T, permanent sterilisation)

are referred to a nearby static clinic.

9

Post method choice stage: step 6

Step 6: All the family planning services provided are to be recorded in a primary health care

outreach clinic (PHCC/ORC) register provided to each health institution. Uptake of family

planning methods need to be recorded in the family planning service register and reported

monthly in the HMIS.

Flowchart: EPI family planning Integrated Service Delivery model

At all EPI clinics

While vaccinating the

child to all mothers

After vaccination of the child

1. Group health education on healthy timing

& spacing of pregnancy (TSP) to persons

accompanying the child to the EPI clinic

2. Ask clients what they think of spacing and family

planning after participating in group health education;

and remind again to talk with provider individually if

willing to take device

3. Women willing to get family planning device and

further information

4. Need identification and individual counselling of women

Willing to use available

family planning devices

at the EPI clinic:

Provide services

Discuss about next

service at the most

accessible place

Recording

Reporting

Willing to use the

methods that are not

available at the EPI

clinics:

Refer to nearest

health facility for

long term methods

(location & timing

of service), and

follow for service

Willing to use the

methods, but HW

could not confirm

pregnancy status:

Refer to

nearest health

facility for

pregnancy test

Undecided:

Continue

health

education and

counselling in

next visit

10

3.1.2 FP EPI integrated programme implementation in four districts

All district level personnel viz., DHOs/DPHOs, EPI and FP focal persons/supervisors during

their consultative discussions with PHD Group field researchers said that before implementing

the integrated programme in the four districts training was organised for health service

providers including EPI and FP service providers, health facility in-charges and district

supervisors.

“Training was organized about this programme which made it necessary that condoms should

be distributed to mothers of children coming for vaccination of children and if needed Depo

injection should also be given”, Acting DPHO of Bajhang district.

“A two-day training event was organised for district level focal persons by the Regional

Directorate and later we provided 2-day training to health service providers of the district. We

conducted the training in two sessions – morning and evening”. FP focal person Rukum

District Health Office.

“In order to implement integrated FP/EPI programme in this district, first, a two-day training

was conducted and after that all EPI ORCs are providing integrated services.” EPI supervisor,

Parbat District Health Office.

In all four districts integrated programme implementation began effectively from Saun, 2073

(16/07/2016). In, principle, therefore, all health facilities are conducting integrated FP/EPI

services in all EPI ORCs and EPI static clinics. FP service utilisation data available from

health facility registers which are composed of FP acceptor cases from FP/EPI outreach

clinics1, PHC/ORCs (Gaunghar clinics) and static clinics indicate that there is an increase in

the number of clients using FP methods. EPI/ORC and ORC (Gaughar clinic) services are

provided on certain fixed dates in a month. Every PHCC or HP fixes dates for these outreach

clinics (see Appendix I for details). The FP/EPI interventions began in Saun 2073 (mid-July

2016 — vertical line on Figure 1). Figure 1 shows total use of family planning methods (FP

data from health facility FP registers including FP from FP/EPI ORCs) in 8 study sites of four

districts during the period of 18 months – 9 months before the intervention began and 9

months after the intervention. It is clear that the number of FP clients has increased after the

intervention compared to the period before intervention.

1 FP/EPI/ORC does not have a separate FP register but the health worker makes a list of FP clients and when

he/she is back at the static clinic the data are entered in the FP register and it was found that in some clinics they

marked “I” for clients from FP/EPI/ORC.

11

In principle, with the introduction of FP/EPI programme, increasing number of women should

be utilizing FP services from EPI static and EPI/ORC clinics. This phenomenon was examined

by looking at the HMIS data. It is seen from Figure 2 that the share of FP clients using Depo

and pills of regular static clinics is increasingly waning since the FP/EPI intervention because

the proportions of FP clients at FP/EPI ORCs and EPI static clinics are continually rising.

Intervention begins

12

Figure 3 shows monthly family planning methods – pills and Depo uptake at 8 health facilities

of four districts studied. This data suggests a considerable contribution to increased uptake of

two spacing methods during the period of 18 months (9 months before intervention and 9

months after intervention) especially after the intervention.

Depo was the most popular family planning method among FP method users before the

intervention and it has become even more so after the intervention. The uptake of pills has

also improved.

13

3.1.3 Reaching out to marginalized population group

Of the total clients who received family planning methods, around 60 per cent were from the

Bahun/Chhetri (Bahun, Chhetri, Thakuri and Sanyashi) and a quarter were Dalits (Figure 4).

The proportion of Dalit FP users is more than the actual proportion of Dalits (22%, CBS.

2012) in the four districts (Dalit proportion among the total population 21.5% and users in

Chaitra 2073 was 27.1%), suggesting that Dalits were not excluded from the service.

Intervention begins

14

Because of concern that adding family planning services to the EPI services might slow down

the delivery of childhood immunization, the effect on the functioning of the immunization

programme of providing FP services has been examined by analysing the number of EPI users

during the six months before the intervention and six months after the intervention. The results

are presented in Table 2.

Table 2 Number of children immunised in 2072 and 2073 from Kattik to Chait, EPI registers, 8 health facilities

YEAR Kartik Mangsir Poush Magh Fagun Chait TOTAL

2072 (No FP/EPI

integration) 39 28 57 67 97 63 351

2073 (FP/EPI

integration) 49 68 70 77 59 48 371

% change in 2072-

2073 due to

integration

25.6 142.9 22.8 14.9 -39.2 -23.8 5.7

The total number of EPI users (children date of birth registered in EPI registers) increased in

2073 during programme intervention. However, there were fluctuations of service use from

month to month in 2073 with use declining in the last 2 months of the year, i.e. Fagun and

Chait. This study is not able to verify this as the evaluation had been completed by that point.

3.2 Adherence of the FP & EPI integration intervention activities

In all four districts, FP/EPI integrated programme implementation has begun in Saun 2073

following initial training of relevant staff of the districts. During the training, it was also

instructed to mark any FP client accepting FP method. It was also instructed that each health

facility should develop FP/EPI register to keep records of family planning users because prior

to the integration the register was called only FP register. Bajhang, Deulekh PHCC wrote on

the cover page of the Register “FP Service Register with EPI services” as shown in the

picture below.

15

Bajhang, Sunkoda HP also did about the same thing by putting a sticker on the cover page of

the regular FP regiter.

Doti DHO, however, prepared a printed copy of FP/EPI Integrated FP register as shown below.

16

During the FP/EPI training the trainees were also instructed to mark in the FP register with

letter “I” if the woman accepted FP method at EPI ORC. The field researchers of PHD Group

looked for such forms and found some forms marked as “I” if a woman accepted FP method

from EPI ORC as shown below for a client (Sharda BK is marked “I” in the following

photocopy).

3.3 Client, provider and programme manager’s perspectives on the integrated service

delivery process

In order to understand the perspectives of clients, i.e., mothers visiting EPI Outreach Clinics

for vaccination of their children on the integrated model a small scale client survey was

conducted. For study purposes, sample was drawn from all 4 districts. Of these, Bajhang is

located in Far-western high mountain region; it is regarded as a very remote district. Other

three districts are also located in Western region of Nepal but they are mid hill districts. Parbat

is perhaps the most accessible of the four districts. Rukum is almost like a high mountain

district bordering with Dolpa to the north. Doti lies in the Far western region bordering with

Bajhang to the north. As shown in Table 1 above, from each study health facility site both

17

types of mothers who accepted FP method after immunization of their children and those who

did not have been interviewed to get their perspectives on the programme. Distribution of

sample respondents by type and district is shown in Table 3 below. It is seen that from both

types of health facilities equal number of clients of each type were interviewed. Also equal

number of FP acceptors and non-acceptors was interviewed.

Table 3 Distribution of clients by type and by district, 4 districts, Nepal 2017

Type of client Name of District Total

Parbat Rukum Bajhang Doti

FP acceptor

Type of Health

facility PHCC 4 4 4 4 16

HP 4 4 4 4 16

Total 8 8 8 8 32

FP non

acceptor

Type of Health


HP 4 4 4 4 16

Total 8 8 8 8 32

Total

Type of Health


HP 8 8 8 8 32

Total 16 16 16 16 64

Table 4 displays names of VDCs of each of four districts where assessment study was

conducted. Each VDC health facility conducts EPI clinic at static facility and EPI ORC every

month and since Saun 2073 FP education and services are also provided to mothers visiting

clinics for children’s immunization.

Table 4 Distribution of mothers visiting FP/EPI clinics by district and VDC, 4 districts, Nepal 2017

Name of district

Health facility VDC Parbat Rukum Bajhang Doti Total

PHCC Deaulekh 0 0 8 0 8

Saraswoti Nagar 0 0 0 8 8

Kotjahari 0 8 0 0 8

Thulipokhari 8 0 0 0 8

Total 8 8 8 8 32

HP Sunakoda 0 0 8 0 8

Chhatiwan 0 0 0 8 8

Bejyaswori 0 8 0 0 8

Tilahara 8 0 0 0 8

Total 8 8 8 8 32

All total 16 16 16 16 64

NOTE: As shown in Table 1 above, from each selected site for study equal number of mothers accepting and not

accepting FP method was selected

3.3.1 Sociodemographic characteristics of women interviewed

Table 5 shows mean, median, minimum and maximum ages of mothers attending EPI outreach

clinics by whether they accepted FP method at the facility. Younger mothers are more likely to

accept FP method than their older counterparts.

18

Table 5 Age of mothers attending EPI ORC by whether accepted FP or not, 4 districts, Nepal 2017 All mothers

District Mean N

Std.

Deviation Median Minimum Maximum

Parbat 25.4 16 4.241 26 18 35

Rukum 23.6 16 4.588 23 15 35

Bajang 23.5 16 6.000 22 18 40

Doti 24.1 16 3.492 23 20 30

Total 24.1 64 4.618 23 15 40

Mothers accepted FP at EPI ORC

Parbat 23.8 8 3.732 25 18 29

Rukum 22.4 8 4.719 22 15 30

Bajang 24.4 8 4.809 22 21 35

Doti 23.9 8 3.182 23 20 30

Total 23.6 32 4.031 23 15 35

Mothers did not accept FP at EPI ORC

Parbat 27.0 8 4.309 26 23 35

Rukum 24.9 8 4.390 24 21 35

Bajang 22.6 8 7.230 21 18 40

Doti 24.3 8 3.991 23 21 30

Total 24.7 32 5.146 23 18 40

It is seen from Table 6 that nearly 10% of all mothers attending EPI ORCs are adolescent

mothers regardless of whether they are accepting FP method or not. Over 55% of all mothers

belong to age group 20-24.

Table 6 Age of mothers attending EPI ORC, 4 districts, Nepal 2017 All mothers District

Age Parbat Rukum Bajang Doti Total

15-19 1 2 3 0 6

20-24 6 9 10 11 36

25-49 9 5 3 5 22

Total 16 16 16 16 64


15-19 1 2 0 0 3

20-24 3 4 6 6 19

25-49 4 2 2 2 10

Total 8 8 8 8 32


15-19 0 0 3 0 3

20-24 3 5 4 5 17

25-49 5 3 1 3 12

Total 8 8 8 8 32

The mothers interviewed in this study apparently are more educated than the mothers in

general in the country because only 6% mothers reported as having no education (Table 7) at

all compared to 33% for the country as a whole (MOH, New ERA and ICF. 2017). However,

the survey mothers are selective women than women in general.

19

Table 7 Education of mothers attending EPI ORC, 4 districts, Nepal 2017 District

Education Parbat Rukum Bajhang Doti Total

No education 1 0 2 1 4

Primary 3 5 4 10 22

Some secondary 9 9 8 4 30

SLC & above 3 2 2 1 8

Total 16 16 16 16 64

FP users


Primary 3 4 3 3 13


SLC & above 0 1 0 1 2

Total 8 8 8 8 32

FP non users


Primary 0 1 1 7 9


SLC & above 3 1 2 0 6

Total 8 8 8 8 32

The mothers interviewed belong mostly to Bahun/Chhetri/Sanyashi category (69%) while there

is a fairly large proportion (27%) of Dalit mothers (Table 8). Mothers who accepted family

planning methods at the EPI outreach clinics are overwhelmingly (81%) of

Bahun/Chhetri/Sanyashi category.

Table 8 Caste/ethnicity of mothers attending EPI ORC, 4 districts, Nepal 2017

Name of District

All mothers Parbat Rukum Bajhang Doti Total

Bahun/Chhetri/Sanyashi 75.0 75.0 75.0 50.0 68.8

Janjati 0.0 6.3 0.0 12.5 4.7

Dalit 25.0 18.8 25.0 37.5 26.6

Total % 100.0 100.0 100.0 100.0 100.0

Total n 16 16 16 16 64



Janjati 0.0 12.5 0.0 25.0 9.4

Dalit 50.0 25.0 25.0 37.5 34.4

Total % 100.0 100.0 100.0 100.0 100.0

Total n 8 8 8 8 32



Dalit 0.0 12.5 25.0 37.5 18.8

Total % 100.0 100.0 100.0 100.0 100.0

Total n 8 8 8 8 32

3.3.2 FP EPI Integration and mothers’ behaviour and perspectives

In order to understand how mothers visiting EPI static clinic and EPI outreach clinics for

immunization of their children behave with respect to FP, they were asked a series of questions

in the survey. Nearly all (97%) mothers visiting EPI clinics for the immunization of their

children for the first time were counselled on family planning (Table 9). Counselling was in

20

the form of group counselling (95%) and the rest was interpersonal counselling. Most (69%)

mothers participating in FP counselling mentioned that vaccinator conducted counselling while

the rest of counselling was done by nurse/ANM. Following the counselling on FP only 5% of

mothers accepted a family planning method at the first visit. Among the mothers (n=32) who

accepted FP, only about 9 % (n=3) accepted family planning method at the EPI site at first

visit and all three accepted Injectables.

Table 9 Counselling on FP of mothers attending EPI static clinic and EPI ORC, 4 districts, Nepal 2017

Counselling type

Person

counselling

District

% counselled

on FP during

the 1st visit to

EPI clinic Group Interpersonal Vaccinator Nurse/ANM

Accepted

FP method

at 1st visit

Parbat 100.0 87.5 12.5 68.8 31.3 6.3

Rukum 93.8 93.3 6.7 80.0 20.0 12.5

Bajhang 100.0 100.0 0.0 50.0 50.0 0.0

Doti 93.8 100.0 0.0 80.0 20.0 0.0

Total % 96.9 95.2 4.8 69.4 30.6 4.7

Total n 64 62 62 62 62 64

The mothers who did not accept FP method at the first visit were asked why they did not

accept it and in response they gave a number of reasons. The most important reason given was

that their menstruation had not started after the birth (37%) and this is obvious because the first

visit to EPI ORC is for BCG (Table 10). Another important reason was that they wanted to

discuss the matter with their husbands (22%). Third important reason was absentee husband

and the fourth reason was irregular menstruation. Some 7% mothers wanted to use FP method

later and about 2% mothers desired a son before practicing contraception.

Table 10 Reason for not accepting FP method at 1st visit by mothers attending EPI static clinic and EPI ORC,

4 districts, Nepal 2017

Reason for not accepting FP method at 1st

visit

District

Total Parbat Rukum Bajhang Doti

Because menstruation didn’t start after birth 33.3 46.2 37.5 33.3 37.3

Irregular menstruation 0.0 0.0 18.8 40.0 15.3

Decided to use FP method later 6.7 7.7 12.5 0.0 6.8

Wanted to discuss with husband 20.0 7.7 31.3 26.7 22.0

Husband in a foreign country 33.3 38.5 0.0 0.0 16.9

Desire for a son 6.7 0.0 0.0 0.0 1.7

Total % 100.0 100.0 100.0 100.0 100.0

Total n 15 13 16 15 59

Of the total mothers who accepted FP (n=32), most (n=20) accepted FP method after having

their children immunized for DPT/Polio and another 9 mothers accepted FP method even later.

In all, 32 mothers accepted FP method after visiting EPI static clinics and EPI outreach clinics.

Most (88%) of these mothers accepted injectables followed by Implant (9%) and one mother

(3%) received contraceptive pills (Table 11). Half of mothers currently using methods received

their methods from EPI static clinics and EPI/ORCs.

21

Table 11 Distribution of mothers by type of contraceptive method in use and source of methods, 4 districts, Nepal

2017

District

Methods in use Source of FP method/ service

Total

n Pills

Injectables

(Depo) Implant

Total

%

PHC

C

Health

Post

EPI

ORC Total %

Parbat 0.0 100.0 0.0 100.0 25.0 25.0 50.0 100.0 8

Rukum 0.0 100.0 0.0 100.0 25.0 25.0 50.0 100.0 8

Bajhang 12.5 87.5 0.0 100.0 25.0 25.0 50.0 100.0 8

Doti 0.0 62.5 37.5 100.0 25.0 25.0 50.0 100.0 8

Total 3.1 87.5 9.4 100.0 25.0 25.0 50.0 100.0 32

Inquiry was also made whether mothers were in a way forced to accept family planning after

FP counselling at the EPI static clinic and EPI ORC sites and in response all respondents said

that there was no such pressure form the providers. Also the mothers were asked about their

thinking about the integrated model and all said it is a good model. They said that vaccinator

can provide FP service when immunizing children. A number of benefits of the integrated

model were mentioned by mothers attending EPI static clinic and EPI ORC (Table 12).

Table 12 Distribution of mothers mentioning benefits of FP/EPI integration model, 4 districts, Nepal 2017

Benefits of integrated model (multiple

responses)

District Total

Parbat Rukum Bajhang Doti % n

Time saved/Method can be used immediately 50.0 18.8 12.5 6.3 21.9 14

Because we get FP education in a group, we

can discuss with a friend and accept a method 18.8 25.0 12.5 0.0 14.1 9

FP service along with immunization/two

services from one place/ No need to go twice 50.0 37.5 18.8 31.3 34.4 22

Good advice on birth spacing 0.0 12.5 0.0 0.0 3.1 2

It is confidential 0.0 6.3 0.0 0.0 1.6 1

After learning about the benefits, the number

of FP users will increase 0.0 6.3 0.0 0.0 1.6 1

Helps birth spacing 0.0 0.0 50.0 37.5 21.9 14

It is a way to limit the number of children 0.0 0.0 0.0 12.5 3.1 2

Health of both mother and child will be good 0.0 6.3 37.5 25.0 17.2 11

16 16 16 16 64

Of the total mothers attending EPI static clinic and EPI ORC nearly half of them mentioned

that they have seen some kind of partition done at EPI site. Their comments on this type of

partition were that it may make women think something strange (17%), women would feel it

okay to talk to the vaccinator about FP (83%) and women might accept to go to the FP service

provider when there is a partition (Table 13).

Table 13 Distribution of mothers commenting on partition at EPI static clinic and FP/EPI integration site

District

Total Comments on partition of EPI site (multiple responses) Parbat Rukum Bajhang Doti

It may make people think something strange about the

EPI services 14.3 15.4 14.3 33.3 16.7

Women would feel more or less okay to talk to the

vaccinator about FP 85.7 84.6 85.7 66.7 83.3

Women might accept to go to the FP service provider 28.6 46.2 71.4 66.7 50.0

Total n 7 13 7 3 30

22

All mothers in the study sites said that it is good to practice FP method and they mentioned a

number of advantages of FP. Nearly half (45%) of the respondents of the study think that FP

can help avoid bad effects on health/spacing helps the current child grow healthy/health of

both mother and child will improve (Table 14). Thirty eight per cent respondents think that FP

can help improve the health of both mother and child. Thirty per cent respondents think that FP

can help postpone next child/have a child only when desires/one can get pregnant only when

one wants. Other advantages mentioned included use of FP method to limit family size; current

child can take mother’s milk and grow healthy and no need to seek abortion service.

Table 14 Distribution of mothers commenting on the use of FP method by mothers, 4 districts, Nepal 2017

District

Comments on use of FP methods by mothers (multiple responses) Parbat Rukum Bajhang Doti Total

Helps postpone next child/Have a child only when desired/One

can get pregnant only when one wants 56.3 37.5 6.3 18.8 29.7

Spacing helps to be healthy/ Health of mother and child improves 37.5 37.5 68.8 37.5 45.3

FP helps space and stop child bearing 6.3 0.0 0.0 0.0 1.6

Current child can take mother’s milk and grow healthy 6.3 6.3 0.0 0.0 3.1

No need to seek abortion service 6.3 6.3 0.0 0.0 3.1

Health of both mother and child will be good 0.0 12.5 68.8 68.8 37.5

Total n 16 16 16 16 64

Over two in three respondents have talked to their friends or family members about the FP/EPI

integrated programme (Table 15) and this is similar in all four districts.

Table 15 Percentage of mothers talking to their friends/family members about the integrated FP/EPI model, 4

districts, Nepal 2017

District

Ever talked to friends or family members about

what FP/EPI integration? Total

Yes No % n

Parbat 62.5 37.5 100.0 16

Rukum 68.8 31.3 100.0 16

Bajhang 68.8 31.3 100.0 16

Doti 68.8 31.3 100.0 16

Total 67.2 32.8 100.0 64

Information was also sought from mothers about what they think of vaccinators providing FP

services. The mothers spoke highly of the vaccinators. They said vaccinators provide not only

service but also advice. In their hands children are safe (Table 16).

Table 16 Percentage of mothers giving their opinions on vaccinators, 4 districts, Nepal 2017

Opinions on vaccinators (multiple responses)

District

Total Parbat Rukum Bajhang Doti

Vaccinators give good advice 50.0 31.3 50.0 31.3 40.6

When they give vaccination to children, the

children do not cry 31.3 25.0 12.5 18.8 21.9

They explain to us in simple language 6.3 0.0 6.3 18.8 7.8

They are helpful and trustworthy 0.0 12.5 0.0 0.0 3.1

They explain to us in simple words 6.3 6.3 6.3 12.5 7.8

They explain to us about FP methods well/Due to

their advice we have accepted FP methods 0.0 18.8 25.0 18.8 15.6

They are good to us; they treat us like sisters 6.3 6.3 0.0 0.0 3.1

Counselling on birth spacing is good 0.0 0.0 6.3 6.3 3.1

Total n 16 16 16 16 64

23

3.3.4 Providers’ perspectives

FP/EPI service providers are immunization officers/vaccinators, staff nurse, AHW, ANMs and

FCHVs. FCHVs are volunteers but they also distribute condoms and pills to women in their

locality. From KII with health service providers in 4 PHCCs and 4 HPs of 4 districts the

providers’ perspective is that they provide vaccination to children and in the integrated site

they also counsel mothers on FP using information booklets and charts. Mothers who desire to

use a method are given the methods or service. If the desired method is not readily available

women are referred to another appropriate centre. Records are maintained. FP registers are

maintained.

“Women come to the EPI site to immunize their children. At that time we also inform them that

family planning service is also available and if a woman is in need of FP we provide the FP

service on the same day and some women get the service later.” ANM, Sunkonda HP,

Bajhang.

She further said, “Because clients get two services from one place it has become convenient for

them. This has helped clients save their time. Their knowledge level has also improved as they

get counselling on FP.”

“Since the implementation of EP/FP integrated model, we counsel clients about the

advantages of FP, its effectiveness and if mothers want to use a FP method we also give them

a reference card and when they get the service we list them in our registration record.” AHW,

Saraswatinagar, PHCC, Doti.

“Mothers visiting this EPI clinic are counselled on FP and then we provide FP service. At the

static PHCC permanent sterilization and Implant services are also available but in EPI ORC

we provide only Pills and Depo services.” EPI Focal Person, Kotjahari PHCC, Rukum.

“At every EPI clinic FP counselling is given. The temporary FP methods that we carry with us

are provided to clients who ask for them.” AHW, EPI Focal Person, Tilahar, HP, Parbat.

3.3.5 Volunteer providers’ perspectives

In every ward of a VDC there is at least one FCHV and she is the link person between the

health facility and local community members especially women in the areas of reproductive

health. She distributes condoms, pills and iron tablets to women of her local community. After

the FP/EPI integration model local women might prefer to go to the EPI ORC clinic for

condoms, pills and other spacing methods. This arrangement should be affecting her regular

volunteerism in the community but it appears that she is more active now after the integration.

The FCHVs who consented to talk with field researchers mentioned that the integrated model

helps local mothers to learn more about contraception, reproductive health and child health. As

local volunteers they help the local women to go for FP education and learn about FP. They

feel that now compared to the past more local mothers practice family planning.

24

3.3.6 Programme manager’s perspectives

Programme managers at the district level are DHO/DPHO, EPI and FP focal persons. Overall,

they have the opinion that the FP/EPI integrated model is good for women with young

children.

“This integrated programme is in operation in this district for nearly two years. This

programme has many benefits. Mothers who come to EPI centre for their children’s

immunization do not know that they also need to practice FP. Since this programme has been

implemented now they learn that they can practice FP for their benefit.” Acting DPHO,

Bajhang.

“Women can receive EPI services for their children and FP services for themselves from one

place. Because of counselling their knowledge increases. Health of both children and mothers

improves. Child mortality reduces. Service providers save time and coordination among staff

is established.” Acting DHO, Doti.

“This programme is implemented with the objective of addressing geographic hardships as

people have to travel difficult paths on the mountains. Why not give chance to mothers for FP

when they come for immunization of their young children. This way by visiting for fewer

numbers of times to EPI centre they get more benefits.” DHO, Rukum.

“Certainly FP/EPI integrated programme has benefits. It is easy to talk about FP when a

mother comes to EPI centre for immunization of her child. When administering vaccination the

vaccinator asks the mother about the number of children and can also talk about FP”. DHO

(Medical superintendent) Parabt.

3.3 Challenges and areas for adjustment to help institutionalize FP and EPI integration

Despite good results after implementation of FP/EPI integrated model in 4 districts, the district

level officials including DHO/DPHO, EPI and FP focal persons/supervisors, and below district

health facility level health care providers such as in-charges, immunization officers, staff

nurses, HAs, AHWs and ANMs mentioned a number of challenges while implementing the

integrated model.

a) Lack of skilled human resources

Nearly all key informants made remarks that they lack skilled human resources to manage the

programme properly and timely. At the EPI ORC except in a few health facilities, most

facilities have to manage the outreach programme single handed while they say due to

integration the number of mothers coming for immunization of their children as well as for

family planning is increasing over time. In the field it was also found that because FP service is

close by women who used to go to static clinic for FP service like to get the service form the

EPI/ORC.

“Few staffs are providing immunization service but the number of mothers coming for

immunization of their children is big. This makes it difficult to conduct FP counselling session

at the same time. The programme would be effective if there is a separate counselling staff.”

Acting DHO, Bajhang.

25

b) Shortage of space

Several health service providers expressed their concern for the lack of space at the FP/EPI

ORC. The service provider needs to gather together a number of mothers for FP group

counselling but s/he does not usually have a separate closed space for FP counselling.

“EPI outreach clinic is conducted in a school building and there is no separate room for FP

counselling. In addition, there is no room to put equipment.” ANM. EPI focal person, Parbat.

“This programme is conducted outside the regular static clinic. There is no building, room or

equipment to conduct the programme. Several programmes are conducted under a pipal

(banyan) tree (Chautara). There is not enough staff either”. DHO, Rukum.

c) Contraceptive supply constraint

Some health care providers expressed their concern for the regular supply of contraceptives.

They said they cannot provide clients with the type of method they want on time.

“We do not have sufficient quantity of temporary methods. Right now we do not have any pills.

We requested the District Office but they say they do not have the supply either”. ANM,

Rukum (EPI focal person).

“Necessary drugs are not supplied by the centre. When I go to fetch the supply I come back

empty hand. I got two Implants but it was later found to be out-dated.” FCHV, Rukum.

d) Social/cultural, normative challenges

Interviews with mothers visiting EPI/ORC for their children’s immunization revealed that

many mothers did not accept FP method readily at the clinic following group counselling

primarily because they wanted to discuss with husband or other family members. Even the

informed choice method does not work despite the desire of individual to practice a method.

Also some health care providers reported that mothers are embarrassed to sit in group

counselling session on FP. This prevents mothers to learn about contraception and

reproductive health.

“During FP counselling session some women are embarrassed and they are hesitant. This is a

challenge for us to promote FP.” AHW, EPI focal person, Parbat.

e) Shortage of FP counselling materials

Some service providers complained about shortage of FP counselling materials while

conducting group counselling. They need flip chart, flex, posters, leaflets, fact sheets, etc. on

FP. Lack of relevant teaching/counselling materials has discouraged them to conduct group

counselling and retain mothers for group sessions.

“In our health facility we lack information and communication materials although we have a

fairly good place to keep confidentiality”. Staff Nurse, vaccinator, Bajhang.

26

“It is urgent to have information and communication materials at the place where counselling

is conducted. It has become difficult to explain to the people in this locality about FP due to

shortage of education materials. It would be good to have a special place for audio-visual

materials and educational materials such as posters”. AHW, Doti.

f) Staff transfers

District level as well as below district level staffs are trained on FP/EPI integration at the

beginning of programme implementation. However, the trained staffs are transferred to new

posts and new staffs are not orientated about the new programme.

g) FP records

The impression from the field and key informant interviews is that FP records in the service

sites and static clinics of FP clients are not up to date. They said the staffs involved in

administering services at FP/EPI outreach clinics have little time to keep records of FP clients

up to date. Some of them do not understand well how to keep records.

“It would be better if a separate arrangement were made to keep records of FP clients. Now

records are kept but the method is not clear. There should be a separate FP register of FP

clients receiving FP service from FP/EPI ORC.” ANM EPI focal person, Parbat.

h) Monitoring and supervision

Key informants in the study mentioned that monitoring and supervision of the integrated

model is not up to the mark.

“This programme needs to be followed-up and monitoring is urgently required”. FP

supervisor, Doti.

“Monitoring of this programme is lightly taken. Also reporting has been done lightly.” FP

officer, Rukum.

27

Chapter IV

4. Conclusion and recommendations

4.1 Conclusion

The quantitative and qualitative data collected in the field and HMIS data records from all 8

sites indicate that the integration of family planning into EPI service does contribute to

increasing access to family planning knowledge and services for mothers visiting EPI/ORC

with their young children for immunization. The quick assessment of the integrated model

implemented in four districts also identified some aspects of the model that should be

improved in order to deliver quality family planning service to the intended audience. The

provision of quality FP care is essential if the integrated approach is to be further scaled up to

the rest of the country.

4.2 Recommendations

The recommendations that follow will help address the key challenges reported in this study.

These recommendations will help strengthen the integrated FP/EPI service model which has

already been implemented in 5 districts of Nepal. The integrated model will be effective if it is

improved along the lines suggested in this report prior to expanding the programme to the rest

of the country.

1. Strengthen staffing

As noted earlier staffing is a serious problem for the successful implementation of this

model. In most sites introduction of the model has contributed to increase in FP client flow

and as a result the staffs are hard pressed for time to manage several activities at the same

time. Therefore staffing situation has to be studied before expanding the programme to a

new district. Plan should be put in place to ensure that there is sufficient number of staffs to

carry out the programme all year round.

2. Strengthen infrastructure for the FP/EPI outreach centre

In the new federal set up local bodies can be active in establishing good infrastructure for

FP/EPI service delivery. Each health facility should create an environment by talking to the

local authority so that space, equipment, local human resource and other amenities

necessary for the programme can be established.

3. Ensure uninterrupted adequacy of contraceptive commodities

Some key informants complained of irregular supply of contraceptive commodities. This

issue must be solved on time and the model should not be expanded to new districts

without regularising uninterrupted supply of contraceptive commodities. District level

officials and even central level officials should be made responsible for this mechanism to

be successful.

28

4. Ensure adequate supply of FP counselling materials

The major component of the FP/EPI integrated model is counselling. Several key

informants reported that they need teaching/counselling aids while conducting

interpersonal or group counselling on FP. Therefore, adequate quantity and types of

counselling materials need to be prepared and distributed to the FP/EPI ORCs.

5. Train health personnel on special skill of conducting FP counselling

Although prior to implementing the integrated model training is given to district level and

below district level health personnel, this gets disrupted when staffs are transferred and

untrained personnel take up the job. It is therefore necessary to put in place a training

package that ensures presence of skilled personnel to conduct FP group or individual or

interpersonal counselling. These personnel must have very good communication skills so

that potential FP users are attracted and become continuing users of FP methods.

6. Revise and improve FP register

In several sites studied, the regular FP register was given a slightly different look by

placing a sticker and only one site had actually a new cover for the integrated FP clients.

However, the format was not changed and any client receiving FP service was hand written

as “I” and several sites did not even do this. Now that the new model has been

implemented, a new format should be developed by adding a column in the record and

clients should be recorded accordingly.

7. Regularise monitoring and supervision

Several key informants, especially district kevel key informants mentioned that monitoring

and supervision is not that good enough. Many of them have not carried out this activity.

The FP/EPI integrated activities should be regularly monitored, perhaps at least, every

three months, and reports should be prepared. Based on the recommendations of the

monitoring report the programme should be continuously improved.

8. Scale up the provision of integrated FP/EPI services

Scale up the provision of integrated FP/EPI services nationally because it is found that

CPR (modern methods) has stagnated at 43 in the last 10 years (2006-2016). This will

increase use of FP methods without affecting the EPI or PHC/ORC services.

9. Create a supportive environment at the local level

In principle, every health facility should have a functioning Health Facility Management

Committee comprising of gatekeepers from different sections of the society. One member

is also an FCHV and in this study it was found that she is active in mobilizing mothers to

consider FP during postpartum. District level officials should be proactive to ensure that

HFMC is active in making the programme successful. In this way local level problems can

be overcome and every mother in need of FP service can be served.

29

10. Establish a strong referral service at integrated clinics

This study showed that only a few mothers accept FP in their first visit to FP/EPI ORC and

that too when their children are about two months or older. However, the vaccinator should

not leave any mother without involving her in group or individual counselling on FP.

Besides, FP/EPI ORC cannot provide all types of FP service there and therefore there

should be a good referral system and referral tracking system in place to meet the demand

of every mother. District authorities need to ensure the availability of long term family

planning methods at PHCCs and health posts. This can also be encouraged by

strengthening PHC/ORCs to provide regular support to women who have adopted family

planning methods from integrated clinics.

30

Appendix I

EPI/ORC Centres in Bajhang district

Deulekh PHCC ORC (Gaunghar clinic)

1. At PHCC Building on 9th of every month 1. Ward no. 6, on 11th of every month

2. At PHCC Building on 10th of every month

3. In Ward 7 on 4th of every month

Sunkoda HP

ORC (Gaunghar clinic)

1. At Janakalnyan Secondary School - on 23rd of every month 1. At Dhatti - on 12th of every month

2. At Bhabya Secondary School - on 24th of every month 2. At Belpakha - on 14th of every month

3. At Sunkhuda bazar - on 25th of every month 3. At Rahiboshi - on 15th of every month

4. At PHCC building - on 26th of every month

5. At Tingi Lower Secondary School - on 27th of every month

EPI/ORC Centre in Doti district

Chhatiwan HP ORC (Gaunghar clinic)

1. At Ward 6 - on 16th of every month 1. At Ward no. 6- on 6th of every month

2. At Ward 5 - on 17th of every month 2. At Ward no. 5 - on 7th of every month

3. PHCC Building - on 18th of every month 3. At Ward no. 7 - on 8th of every month


Saraswotinagar PHCC ORC (Gaunghar clinic)

1. At Ward no. 1 - on 16th of every month 1. At Ward no. 1 - on 6th of every month


3. PHCC Building - on 18th of every month 3. At Ward no. 7 - on 8th of every month

4. At Ward no. 7 - on 19th of every month 4. At Ward no. 9 - on 9th of every month

5. At Ward 9 - on 20th of every month

EPI/ORC Centre in Parbat district

Thulipokhari PHCC ORC (Gaunghar clinic)

1. At PHCC centre - on 12th of every month 1. At Ward no. 2- on 23rd of every month

2. At Ward 2 - on 13th of every month 2. At Ward no. 6 and 7 - on 24th of every month


Tilahara HP ORC (Gaunghar clinic)

1. At Ward no. 2 - on 12th of every month 1. At Ward no. 2 – on 25th of every month


3. At PHCC Building – on 6th, 7th, 8th , & 9th of

every month

3. At Ward no. 6 - on 27th of every month

4. At Ward no. 9 - on 28th of every month

EPI/ORC Centre in Rukum district

Bijeshwori HP ORC (Gaunghar clinic)

1. At HP building - on 11th of every month 1. At Ward no. 9- on 25th of every month

2. At Ward 6 and 7 - on 12th of every month 2. At Ward no. 8 - on 27th of every month

Kotjahari PHCC ORC (Gaunghar clinic)

1. At Ward 2 - on 11th of every month 1. At Ward no. 7 - on 22nd of every month

2. At Ward 8 - on 12th of every month 2. At Ward no. 3 - on 23rd of every month

3. At Ward 7- on 13th of every month 3. At Ward no. 9 - on 24th of every month



31

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