Attachment II to .alaria Control PAR Serial No. 76-3

Report of the Situation Analysis

Tearr, - 1976 of the

Nepal Malaria Eradication Organization

Jan-..ary - febru.:u-y 1976

A. ~. n 86:('01'011C(I C

'0 ont61"l .~OOUl 1658 NS

Kathmandu, Nepal

TABLE OF CONTENTS

I. Introduction

:u. Current Status of the NMEO Program

IIT.

IV.

v.

A.

D.

C.

D.

E.

F.

Gcmeral

Erldemiolob'Y

Man.qgeri

ANNEX

I

II

III

IV

'7

VI

VII

VIII

IX

x

XII

Xln

V-'T "' .L.

~,V

XVI

XVII

XVIII

LX

GRAPH

1

2

3

TABLE OF ANt'lEXES

Organizational Chart .... ... Positive Malaria Cases ~ Far Western Region

Positive Malaria Cas~s - Western Regi~

Positive M-ilaria Cases - Central Region .... Positive l1alaria Cases - Eastern Region .0. ~dical Treatment Time Lag

Affected Villages

r~borat~ry Perform~.ce 0

ii

iii

iv

v

vi

vii

v1i1

SUJll.T'Iar'Y" of Administratioo - Western Regien 1.x

Summary of Adminintration - Far Western Regirm x:11

Summary of Adm1nistr.:ttion - Central and Eastern xv Region

Spraying Operations 1975

Fopulatiol1 protected by sprayillg 1975

Focal spraying 1974 and 1975 .... Integrated Districts MOnthly Surveillance

Fbdical T "catment and Ca:58 Investigation Time lag in Integrated Districts

L1.boratnrr l'erf~ce - Bara District

L1.b~r~to~1 Perf~ce - Parsa District

C03t Estimates Spraying Operations in the Zastern Hills

..

..

....

...

xix

Jed

xxiii

xxiv

xxv

xxvii

Kaski District Surveillance monthly pcsiti vus J'...cv11i

Rqra District ~rveillance monthly p~itives xxix

farHa Di;trict Surveillance monthly positives xxx

I. Introdtlctie~

Nepal Malarin Eradication Organizati~1

Report ~f the Situation Analysis - 1976

A. !PI) Nepal M3.1aria E!oadicati~ BeaN (MIill) :in H. l.3 __ -ih mee-i:1ng held

en 7 ec-wber 1975 u.eterm:med 'ihat a .it.ation Analy-.is of the Nepal

Ma1Tr:i .. a l::radicatien ~rganizc:rUon (NMEJ) be held during thQ i'Sriec;,

~rul'.w.ary to rnid-Febrt1a.rr, 197". The Siwation hlal,.-siB was la"ber

scheduled by the Chairman, HEB '\0 ae held dmng "\.he ~ried frll!ffi

Jcmuary 26 - Februarr 17, 1976. ThQ MEB reqtleuted the assisi,an6:c

of the World Henl~h erganization (WHO) and "\'he U~S. Aggn~T for

International Development (A~) to p~ticipate wi\h HMG officerJ

in this Sltu~tion Analysis. These assisting agen~ies agreed with the

request and a8signed personnel. 'l'he Chief Officer of the NMEO was t",

S.:.I~C f.S Ch~irman for the 1976 S:ltuation Analysis.

B. The Tenns of RefoJ'ence provided for this Situation Analysis are as

follow"8 :

1. T,., evaluate the present ei->idemi{tJ.Ggical s;t tua tililil concerning

malaria In the ceuntry.

2. To 7,ry to find "ut re3.S'-"Tl." f!3I' difficultieg in Irv;ter and timely

8X&'Y'..ltion ~f scheduled activities in MEJi.

3. To rec~mmend ways and mean~ to rectify the;e difficulties.

~. T" study ,-:'.uu,civif'c r8g:lrding the pr"rer type of activities in

the eastern hills now under .full NMEO activities.

5. To b ring ad any pt1iat/pdn1.s which mRy have faJ"-reagfrl..ngr~

em the ov'croll efficiency of the program,.

The MEB, recognizing the importance of proper managerial

pract1 ,~e5 within the NNEO, requested that more emphasis be placed

during this analysis en thiJ aspect beth at NIOO National Headlluartera

3nd in Regional field areas.

00 The mElllberR of the Situation AnalY'lis - 197. are ~ followsl

l.. f.T K.H. DiXit, Chief Officer, NMEO

2.. Dr Y.N. Sharma" Halaria Consultant, NMEO

3. Dr H .. tJ. Uprety, Ministry of Health, HMG

~. Dr G.l1. Sakya, Epidemiologist, N?1m

5. Dr F.F. Beales, l,tlO/Thailand

6. Mr A. Davidson, USAID/Washington

7. Mr L. '!'. Gowper, USAIDtdashington

8. Dr A.Q. B. Rnhman, HHO - Nepal

9. Dr A. V. Kondras:lin, WHO - Nepal

10. Mr S. Tarkojosopurc, 'I/HO - Nepal

The memb(~!'0 of the Situ3.tion Analysis were divided into three

work teams to u'lrr"y out the T~;rm.'3 of Reference in the field areaB ..

1. I

(RBr;iC)ll'~l UfficUI3 jn EirgtUlj and Biratnagar)

2. Te3Jll ~.,.

.J.. ... Dr H.N. Jpr\;~y, Dr G.l1. Snk;n, YlI' A. Davidson

3. Team III Dr K .. ,\. frixlt, IJr; ,.'1. lCenciraah:1n, Mr L.T. Owper

(HDg::i..On.'ll Ofnc(' in !JUpc1.1G

Page 3.

D. The wcrk activities af the Situatton Analysis Teams in additim t.

review and analysis .f the four Regional ~fices and related

~lected District and Unit Offices during the perled 28 January

9 February als" included one day of review jn the Matern Hillr

on February 12 studying the problem of' malaria incidence in hill

areas where spraying has buen c:lrrled out for a nur. 7>er of years ..

Hill aJ'!?as visiter were Okhaldhlmga, Rumjatar, Khotang and Bhojpur.

The Tea;,l visi tin~! t.he inter,rClt cd di stricts was a} so requested to

pre:::ent its vioH on the rresent h'vd of development of these areas

in regards to malaria controL The Tea.m presented its report to the

Chairman, Nepal Nalaria r..radic c tion Board on February 17 J 1976.

II. Current Status of the NMN rrogr~~

A. Gener.'l.l

The Ikpal flJ3.1ario. Eradication Org:ll.ization (NMEO) is a natilal.

health activity, c~vering Lhe assigned nalaria areas of the country.

The Organization is under t.l18 3uth01'i ty of the Nepal Malaria

Eradlcatior. Board (NEB). The N,~ tior:al Headquarters of the NMEO is

located in Kathmandu and h:iCl under its juri:3dictior.. fo'ln'" Regiooal

Officeo (Bir~tn~g~r, Birgunj, Bhair~awa, Nepalganj), 3- District

Offices, 156 U'1it or:'ic88 rtnd fJ27 Localities. The Organizat:!.on

hilS l.pproximatcly 3 :;00 employees with special temporary personnel

hi!'ed dUj'in~ spra)' cycles.

The prcs~~nt lJopulati on sttltus ~f the pro~ in 1975 ia as

1'0110'.-1s:

Fage h.

The present populat~.on stptus of the program in 1975 is as

follows:

Activities

Sprllyi.i1g and Surveillance

Surveil~ance

T~tal

Population

2 8)0 186

2 329 124

5 15, 31ft

TherE is also 1.5 million ~opulatian in integr~ted districts

:in the malarious areas for which NHEO is responsible for the

provisien ,=,1' specific imported items.. The total po}rulatian :in

Ncp..1.1 ::8ceiving malaria ServiC(~3 :1.s apprC'vimately }067 nrlllicno

A Tahle of' Orp,anizaticn 1s 9.ttr1.ched (Ann.,x )

During the period 19?2-71[ a steady incI'lJ9.se in malaria incidence

has been obSCrVl-'L .:.n Nop:1l. In 1975 it appeared that a le'W81ing of

the incidnncc occurred in tot'll munbers, but the reasons for this

lev(~linf! must be reviewed caref'llly as large areas hRa :incomplete

Rurveill.:mce. Previous E.:ituiltion analysis/evaluation reports 1974

and 1975 on this rise, together wi th the recommendations of these

r!!ports havt~ b(~en considerl~d by tltl: t;r-,nal Malaria Eradication Boord

ann a nei" !'itr::.tq:y has been d(;\T~lored for the .cf-~duction of malaria

tn suitabl; control lev816. The basi~ technical objectives of the

plannc:d progr:.un is to lower the ineidL:1lc;e of malaria tv apprax:1ma~ly

,.r-J 0aS(-:S p.:r million popY.lati~ O'IH the next five years. Je1nt ~grcc:mcnt:3 bc.;tween HMO and AID, \'1110 and UNDl" will enable HMG to receive

required progr

Page 5.

malaria l F1an af Oper-ati ons) 1s nOl. re!!.d~t far HID far::::ll appr.vnl.

The fi.rst majar ('('(leI'S fer drup.s, sprayers and insecticides have

been placed and are beginning to be mabilized. Considerable

attention is ueine given in the Praject FormuJn tion l"lan to. improve

the mallngerial :md administr:ltive .1D[.:ctS af the pragram in ternlS

of full ut iliza ti on of manpower, ord.::...r ly an d timely receipt of

supplies and the :tvaibbility of adeqUOlte funds at tho time ref!,uired.

In ordGI' far V,r~ progr.:lm to mav\;) forward on n planned basis farmal

HMG nppravnl of thu Project Farmulntion Plan is required.

ThE: jlroblems fac:l1l1!, the NMSO C.1Il be categorized into. three

main areas - TfCchn1cal, Uperntional

Page 6.

of L'1 Li:t,l'Glting the malaria orp;anization intu the bashl health

services in siX Districts of Nepal are outl.ine d in Part II-5

of this report.

The .... e are no detailed d8scriptioos of Nepal in this .r:eport~

in terms of gene r;tl geography" background inforna tion in rebarcis

to ec.)nomic, poll tical or socicll structure" ani other generalized

infornation. These pointe, arc ad8qua tsly covered in previous

reports of Situation Analysis or EvulBtion T63Jl1B in p9.st years

or b)r nthcr reports readily aV!1ila blc in Nepal. There is also

no attempt in this report to n.ccl)unt the historical develor:ment

or operations of the NMEO as this descript,ian is well documented

in tht HMG Situatic~ Analysi~ Rpports of 1974 and 1975.

B~. Epidemiology

., J... The epidemiolopical St1tUS of malaria in 1975 can be :teilealed

from the folluwin~ t~hle. The epidemiolo~cal data of 1'73

and 1~'(4 artj als 0 gi.. v']n in thE: t,"ble in order to see 'the

current status in its p~rspectiv8:

SrI> Y B A R S No. ItGm 1973 1974 197~

1. Tot11 hpulation 12 046 4.10 12 300 000 12 550 ~ 2. Pop'.1l3.tion Covered 6 3u? 9211 !) ('84 075** 5 15~ O~

by NHE(? 3. l'opul;: tlon in 342 007 1 )174 ~54 1 531 615

Integrntul ~J'l~a.s It. Popula.t1on in Att..'\ck + 1 "73 h42 2 202 5~5 2 787 032

R~vert(;d Attack areas 5. Popu11t:l.on in Ccnsoli- 5 375 31C 2 881 551 2 372 0:!4

d

'Sr" 'No.

ft.

8.

9.

10.

Item

No. of Slides Cul10cted in Integrated artJ.J.s

No. of Positives in Intep:rat~.'d

Sr. No.

A. Ba.rll B. Parsa C. Ra.utnhnt Do Siraha E. Saptari F. Y.aski

22. Total Positi ves A. N.M.E.O arpas B. Intogr~t~~ areas

23. A.P.I. A. N. M. E. O. area B. Integrated areas

YEll 1973

8479 R479

1.33 1.33

Page 8.

R S

1974 1975

1.~7 0.25 * 2.09 2.86 * 0.9 0.19 * 0.09 0.003* 0.08 0.03 * 0.7 0.46

14 647 13.507

1140

1.6 2 06 0.49

11 856 10 942

914

0.73 1.59 0.52

---_.----_. __ .- - ... -- ._-------------* *

** Population excludin~ integration areas

*'H

2 .~egionwise Epidemiological Data

2.1 Far Western Regi on

The Annual Parasite Incidence in 1975 was 1.1 per thousand

in 1975 compare~ with 0.94 in 1974. The slide collection

through Mass Blood SurvE1YS has remained at the same level

as in 1974, but the number of positi yes cletected has

decreased by 4.6%. ~. ~ is the predominant species

constituting more than 9t% of the total positives in the

regian. The proportion of untraced rases has a~st

uoubled (~.5% in 1975 compared with 8.3% in 1974) due to

the movement of population workinc for the Road Project.

The number of relapse cases recorded is low (Annex II).

~.2 Weotem Region

The Annual Blood Examination Rate has increased every year

for the last three years 16.82, 19.3 and 20.99 in 1973,

1974 and 1975 respectively, while the API has decreased

(Annex III). The redllction of the case incidence has

occurred m~inl y in the Kapilvastu District where all

anti-malaria measures were strengthened and larviciding

and a weekly survei11.:mce mechanism were implemented in

FJaluhawa Unit in 1~)75. The caSes of ~.falcj.parum

constituted 5.7% of the total, although the n.mbor of

imported cases from abroad has slightly increaied.

2.3 Cerriral Region

The API in 1975 in this Region has remained almost at the

same level as in 19'(. (0.,8 and 1.37 rerpective1y). The

propori.ion of Mas. Blood Sur\-ey slides io rather high (33.7%)

though the number of p08itives detected by MIS is only

8.1% of the total positives. The nwnbol of .!:.falciparum

cases has dacreased whilst the importation of cases from

abrt.1Ud has remajned a~ th~: same level. The number of

. ~ relapsBs':in the region continuf.'s to bE: rather h

high (14.9%) due to the inadequate treatment especially

in M9.kwanpur ctistri ct (Annex IV).

2.4 Eastern Regi~

The API has slightly increased from 1.77 in 1974 to

1. 79 in 1975. The imported ~.falciparum cases have come

from I\ssam awl other states of Inni~, where strains of

res istnnt E. faldlXlrum are prevalent.. T1.e number of

~. ~ relapses recorded have also increased due to the

Game reasons as mentioned above (Annex V).

3. Radical Treatment TilID L:..g

The time la~ uetween case detection and treatment in 1975

continues to be the srune as in previous years. Chly 39.1% of

the totnl cases were tr8ated within one week. The percentage

of patients treated by Halaria Field Workers (MFW) is very high,

42.8% in the Western Region Md 28.4% in the Easten. Region

(Annex VI) ..

4. Malaria Foci in NHFX") HerioTls

The n1Jl7lbf'r of affectrJd villMes (43.5% of total villages) is

hif,h in the 81stern Re~ion but the number of positive villages

with only indip;enous cases (24.1% of total villages) is not so

high when compl1l'ed wi th thr~ Far Western Region (96.7% of total

villages). It appears that the high number of affected

Page lL

\,9.J: villages in the Eastern Region is due to imported cases

(Annex VII).

The epidemiological si tualiion in the Frtr Western Region is

characterized by ~ncreasinr, numbers of foci every year with

lecal transmisRion. On the contrary, Westr~:rn and Central

Regions have decreasinr numbers of foci with local transmission

and increasinr numbers of imported cases. Tne number of COlTDllon

vi Hages with indigenous casps i!1 1973-74 and 1974-75 have

increa~ed in all Hep,ions especially in the Central Reeion.

It means that antimlaria measures taken are not adequate and

timely.

5. Lab0ratory Performance

During 1975 the output of laboratory technicians was not up to

eXfK:ctations in all Regions. This was mainly due to the 10ft.

days cc.'~mcctcd with leave, As a result, ~nding slides wer.,

rather high especially in the Far Western and vlestern Region)

('fJ1eX VIII).

6. F.Iltomology

In view ()f the chnnr,inr- cpirlemir.lor;icai situation whereby

high numbers of cases have been reported from the plain Ter~l,

the entom()loF~j c-11 pror,ram has been concent.rating its efforts

on these casel>, as recommended by the provious Situation Analysis

Teo.m. Work is in prop,r(:ss in the forested Terni urea to study

the role of i1..annularis in the r..ransnlission of IT.alaria. So far

there is no evidence thcJ.t this 3pecies :i..s a vector in the

i'onsU:!c Terai.

!.annularis, 'Which has been prcved entomologically as n vector

Page l! ..

in the plain t~rai Rreao of Lumbini Anchal, is highly resistant

to nIJ:' and Dieldrin. Therefore: change of insecticides to

malathion has been recommC'nded. Since July 1975, the entomological

wcrk has been decentralized by provi0ing entomological teams

t') each Region whilst the National Headquarters Entomological

Section provideo technical guidance.

C. Managerial Problems at National Headquarters and Regional Levels

The Malaria Eradication Board at its 134th Board Meeting recognized

the impo.riaT'lc of the Hanagerial asp8~ts of t}le NMEO campaign and

has accordint:ly l'e4.ucsted t.hat in Uis rearls Situation Analysis

carriod out from January r:6 - Febru.'lry 17, emphasis be placed on

management. In pursuing tha~ objective, at least one memb~r of each

of the field teams was given primary responsibility for lookw.g into

managemor.t problelTlB and procodures in those Regions he was to visit.

To aSSUl'e consistency of approach and relevancy of supporting data

it was decided "'",0 examine the areas of Reporting, T.'iscal Operations,

Supply, Transport and Personnel Management, utilizing uniform

types of data and quostionnaires. However, t.hese basic points

could be expander] or supplemented to cover any aspect of management

that loTas -::onsirlered rf'levant to the prol3ram.

ThE: combinGd teams visited four regions, 17 districts ami

8 unitH in their respective areas. The Eastern Hills were not

covered for administrative purpu~0S. Since the field aspects of

th.:: prog:t:llIl1 'Hcre entered inunediately after arrival, Headquarters

operations were not anblyzed in depth and in most cases only those

heaciqunrter~ operu.Gions that immecliatel,f affect the fie~d are

referred to.

Page 13.

In general, the situati0n analysis teams found the basic

NMEO organization intact and viable. Its major organizational

problems result from some confusion as to the long range

management effects of integration (treated in anot':er section

C'f this rep0.i.-t) and the present status of the new regionalization

concept which is now beine implemented. In the latter case the

team found that there is no complete clarity an the roles of

the Regional 'ffices ill relt.tion to the District Offices and

tho relationship of beth these organizational units to

Headquarters. Is the Regional Ofnce to be primarily a

coorrlinat:inf~ unit 01' a supervising tmti? ;..t supervisory,

what o~erations does it supervise? Is it (the Regional Office)

in the line of commanrl between District and Headquarters?

These and other orr,anizational questions need to be carefully

considered, orr;anized, and documented so that ench of the

administrati va units involved has a clear organization frame

for its program responsibilities. When decisions have been

made ccncerning thest::: authorities, it is essential that the

fcnctions, responsibilities and relationships be carefully

de"ia:'lcd in wri"iten in~tNction6 ,aild .. regulations whioh should

beo'JIl8 ~art of a rlanual of iYrganiza"iion. The Mmual should

be conslianUy updat.c:i to rcfle:c\. current. administrative decisions

and used as a basic reference and instr~ction~ document.

The present Manual has not been revised since 1963.

The other major threat to management continuity of the

NMEO is the disproportionately large turn over of key

?age 110

personnel at top and middle management levels. In the past,

two years approximately 99 senior, and middle level employees

have been transferr~r resigned posi tioni. 'J.'his is reflected

in the unc~rtainty in exorcisins managem~mt responsibili t.ies t.Jy

some of the new incumbents of Senior Officer positions. The

change~ at the top have in turn affected the 1 owe l' positions

where promotions and transfers have resulted in new employees

l.m~lertaking duties for which they are not trained and with which

they are not familiar.

The short range and current management problems of NMEO

continue to be in these areas of manap:emcmt noted in previous

reports. In some cases such as transportation, the situation

has further doteriorated and the arrival of new vehicles will

no~ ameliorate the worst situations. Training, supplr

manaeemCTl"T:., ,mCe and fiscal problems and personnel manaeement

eontlnue "':,r) hamper tt3chnical operations, but are sUBceptible

to correctioI'. by bett'~r m.:maEement. These problema are treated

in some detail ~n thiH report. Where possible, manaeement

solutions ar0 propoaect. In a few cases only changes in basic

law ani! practice wil:'" ch::U-.ge tho situation o

1.. Reporting

The team r(:view of repJl'tinr time laps8s between despatch

an:} T' ccei}:>t of communi~ations showE:;d extreme variation.

Time between Rer-ional a:rices and Headquarters, depending

on distance and means ri: transportation, as studied particularly

sinCe very often key imtl'uctions were involved. The

Page 15.

conclusions reached were that in the Central and Eastern

Rog1

!tags 16.

0-6 ]}9.ys 7-10 Days 11 +Days Comments

Western (actual numbers)

Reg. Office 4h 40 12 From Hea.dquarters

Kapi::.vnstu 20 22 1.4

Nawalparasi IAI 33 17 10

Nawalparasi t}1 r 11 19 10 + 3 over 13 days 1 over 90 days

There 1s some quest! on as to whethur tlJ.ese time lapses al"3

justified. It would seem not. The nature of the correspondence

should dictate its method of despatch - telegraphic, air or

courier. Even in those cases where urgency is not essential, a

correspondence control both by initiating affice am receiving

offices requiring ackno~ledgellBl!t of receipt after a stated

period of dc>..ys sh()uld be installed.

Correspondeilcc should be clas~1fied according to urgency,

anc. a system established for e~ch category.

2. BUOf::et and F1sct!1 Opt-!raticms

The teams' examination of budRet and fiscal problems centered

primarily in the field. Where field ot=erations reflected

headquarters decisions, the headquarters function was

tl1alyzed. This section will examine these main fiscal

areas:

1. Budget Formll].a ti on

2~ Expendit~re Patterns and Allotment Schedules

3. TA/DA h. The Auctit Ftnx!tion

Page 17.

2.1 Budget Formuh.tion

The budp,et procedure in Nepal theoretically require~ the

budget to be built from the bottom up, That is, the

operational and program units in the field determines

needs, formulate the local plan and have their requirements

incorporated in the larger program budget, subject of

course, to executive decision at the national level. In

practice it appears that RBgions and Districts are not

ablE: or do not make the initial budget plan. The planning

is done centrally based on Headquarters! estimates of

field needs. The budget is then sent to L~e various units

in the field for review with little time for change~

In s::nne cases the budget allocation is unrealistio, and

difficult to adjust after the fact.

It w::luld seem more in keepinf, with planning from the

bottom to the top for sufficient tiI:le and consideratiqn

to be F.i ven to field estimate in makinv. up the budget

before final approval by headquarter~. This would serve

two purposes. First, a more realistic plan ... based on

local conditior.s - would result. Secondly, the peopll3

who execute too operation would have a ser.se of participa-

tion in planning their own programs. The ~udget should

follow the plrm. of action ann the Regionf3 and Districts

know best how the plan affects their owr. areac.

2.2 Expenditure Pattern and Allotment Schedules

In beneral, the team 10ur.d that expenditures were on

schedule and that in the past year the greater proportion

Page 18.

of the allotments were spE'nt,. In the Far West 84-97% of

the funds were spent. No problem existed in either the

Central or Eastern Region on total expenditures. In the

Western Region combined budget of the Regi~ and

Rupandehi District made it difficult to plan the rea::ective

expenditure for Region and District. Next year separate

allot;,lent8 will be issued.

Although a satisfactory annual expenditure pattern waB

shown, complaints were numerous ~oncerning the method

of quarterly allotments.

In the Central and Eastern Re~ons visited in the third

week cf the 3rd quarter, not a single region or district

had received its third quarter allotment. A few Districts

had been told that mop-ey was in t he bank but could not

be dr8wn. Similar cumplainto in the Westel'll Regia:r.

were heard. No complaintg "Iere JJi3.de in 1.'1e Far West.

The team is cC the opinion that the effect of late

allotments can fue corrected. The Headquarters fiscal

office could make the allotm:lnts inunediately after

receivin~ notification of availability of funds from

the Treasury, or if there appears to be an unuqual dela1

HJ;?adquarters could flotify the Regions and D1.stricts

by televraph that there would be some delay. Thls would

relieve the anxieties of delayed wagl3 and bill paj'Illents.

Page 1',

A more serious administrative problem is the delay in 4th quarter

allotments so th~t it becomes impossible to spend the money before

the end of the fiscal year even though bi)ls may be outstanding.

T'lhile, "the I.ational budget E'-ystem /?'.ves little chance to correct this

situation, some consideration should be given to making larger

allotments in the third q.l arter :n'lCi reduce 4th quarter allotments.

This "'ould not change the annual budget, but would allow greater

flexibili ty in 4th quarter operations.

The team also heard compla:i nts on the ril!idi ty of the budget

expenditure pattern. It apDears th'lt even though the law all:Ns

SC:;'.8 flex:i bility in transfer of funds betl-leen codes (except for personrlel)

the headquarters fiscal office reQ,l ire th:~t even the smallest transfer

of money from one code to another in thf! field must be approved

an:! cleared (;oj he:loQ.l art r5 b:!fore permission is given. This often

take~ [lome tirle. Field units are irritated Hhen, for instance, they

lack Rs .2GO for forms and stationery, but have a surplus of funds

in another code and can do nothiI1JS about it wjthout a long delay in

"eceiving headquarters I ~rmission.

It is the oplnion of the team that within the Fiscal Laws of HID

a dela!~a tinn of authority to transfer a lim:" ted amr,lInt of Money

from ona ccx:le to another (except persormel) could re gi ven to the field,

which \'lould -':,he r. notify headquarters to make the npl')ropriate

change in tne fiscal records.

Page 20.

The most seriouo fi.nancial problem encountered by tile tec:m Has the

problem of the wage!,; of sprayre::m and daily workers. I1alaria workers

do not receive Travel Allowance. other government emplvyees receive

mileage allQvTClnces. In some Districts competi ti ve allowance for both

other government workers and private enployees is much higher than

that of rralaria workers. This 10'Vl allowance for malaria field workers

has resulted in frequent turnover and has interrupted the effectivene3s

and continuity of the program. At his level of educaticn, the sprayrr.an

can \-lork jn factories, ar:rictlU1Jrc and road labor and receive hip-her pay.

The problem is fairly widespread pspf'cially in the Eastern Region anc

Hest('rn Rer:ion, "here recrui t!TI~nt. is h(')comi nr rli fficult .

The ~;~jEO should propose to the tropr.r HMG authorities or,

if possible, under its own authority, in~reasc wlges on 0 selective

hasis in those arenn where the present a.J..::'o\-lance for maLU'ia workers

makt; them non-competitive .'lith other work. l'hese wage differentials

,!ould be based on area cunditions ::nd need n0t be Ln a national basis.

2.3 TA/Dlt

Th

Page 21.

.. , .'1'1

sufficient to cover claims. In at lea3t 2 Districts (NawalparaLJi

rAt and t8 1) only 77% of la.t year's budget was spent for

TA/DA. A/:,ain the solution to this problem appears to be to

r,rant the Regional and District Offict'Js more participation

in the planning of TA/DA and greater flexibility in utilizing

c..ther fun.Js as discussed above.

2..4 Audit

All audits of the internal aOOi tor appear to have been performe.1

on time durinp the past year. The external audi t for last

year han not been completed in a few ~istr.icts. The financial

audits are actually perfQrmed in NMEO Headquarters rather

than in the field. The fieln units send their accounts and

sUFportinr- papers to Headquarters. If changes are made they

are often made without conferrine wi th the originating field

unit. As a rule there is no report directly to the field

a5 the result of the audit unless there are flagrant errors

or vil)l3.tions. The J.udit docS not generally review

acmrlnistrative probl(ms but confines its work to fiscal

oper.:t ti ons

A recent trend in mrulagemen~ has been the establishment of

a "Management Audit" to review management activities and

problems anel to advise th c operating heads of offices or

field units on how to corrdct such problems. !t is not a

secret nr surprise allrlit but rather serves as an arr} tp th~

supervisor in performinp bis manap:ement responsibiUt1ef1

The function of internal manasement audit can either be

Page ~.

combined wit.h .f'i..scal audit or be established sos a separate

unit at National Headquarters.

The NMEe could very well add the function of management audit

either to the present duties of the financial auditor who

would requi.i.'e additional training in management functi ons

or a minimum of two management specialists could be added

to the staff of the Senior Adminis t,rati ve Officer who is

soon to be appointed.

3. Supply Managemont

The team founn that in the field of ~up~ly management some of

the greatest weaknessos in the ~rorram occur.

There are a number uf aspects of supply managememt which should

be discussed and for purposes of clarity the subject will be

treated under four sub headings: Procurement, storage, inventor,y

control and B'IlPl)ly management training.

3.1 Procurement

In the National Mala ric. Eradication Program procurement is

of twc types. Importation and local purchases. Procurenl;)nt

from abroad, based on the schedule of required dates for

use ::-,f cr)mmodities, in the program and the lead time required

for shipment is usually handled by HMG anrJ the donor within a prt:.sc:,ihed schedule of months when the commodities must be ordered

agencies /to arrive on time. It :i.s o~:ecterJ that funds will

be roleasen on time hy the contributing a~encies to meet

the schedule. Local ~urchases are made from budget

lllrJtments under the apprl.1pria te heading of the NHEO

aCC01lnts. Money for local purchase and other operations

are disbursed to the Regh,ns and Districts and funds in

Page 23.

turn are disbursed from districts to units by the District

Accountant. It was found that in some cases procurement was

made locally at much greater cost than would orderin~ from

abroad. It was done only '\o]hen urgently required or in the

case of spare parts. To avoid costly local procurements, it

should be emphasized in the program that all needs for

imported conunodities be planned in advance and made part of

the regular WHO Or UNDP procurement requirement. Perhaps

one reason that local procurement is r8sorted to in

emergencies is the long time lag in some instances for

procuring: supplies from N. Hq.. It must be stated here that

in general, the team heard few complaints of long time lags"

but the records show that the delays in the Far West Region

frcm Regiun to District ranged up to cO days. The fact that the Regional concept i~ still not fully implemented also

a'Jcounts for delay. The District and .tho Region often have

trouble in distinguishing where distribution of commodities

is to come from - the Repion or NHq. (except drugs where

procurement is centralized).

The role of the Rer-ion in storing and dlabur~ing commodities

must he more clearly spelled out - optimally in the Administrative

Manual. As it is, a district can order the same item

from bnth HearJquarters and the Region ... and receive from

both of chern; fer lnstance, spray pumps. Headquarters has

records of its distribution to the field, but has no

knowledge of the field inventories. Thus it can not make

a judgement as to whether a procurement request is reasonable.

Page 24.

As a re3ult, Hq. Supply Office sometimes cuts a procurement

order arhitra~ily on the assumption that the requesting field

unit is inflatinp- its demp.nd.

The above situation indicates that a comprehensive procurement

and distribution system be installed which would assume

balanced distribution to all field units on the basis of

n~ed. It is the opinion of the tean that the Region could

plLiY a IiItrong role in the system by maintaining a record

system of inventories in all its Districts and informing

Headquarters periodically of its supply situation. This

system would, of course, have to be supplemented by visual

inspection and checking of inventory records by the Regional

Off:Lce.

3.2 storage

In all the Regions and Districts some problems in storage

were found. In the Far West Region there was a problem of

outside storqge at Kailali and in l);mr, t.he D'1T was several

yp.!'.rs old. In t.he Central and Eastern Regions the storage

of DUT was generally poor, and in some cases DDT was

exposed to rains and westher. In the Western Region in

several districts, the physical facilities were cramped and

dirty, with somo older DDT buried under trash.

CamoqwU\ tablets were often stored in bottles intended for

other drugo, and in one instance over 2((0 tablets had been

destroyed by ratl:l (Western Region). In t.he East primaquin

tablets were diB~olored or were stuck together. A problem

frequently encountered is the hck of storage space

Pc..ge 2~.

(for Dm') but in 11I'05t cases lack of training of the

supply clerks accounted for storage problems. The fact

that supervisory District und Regional Personnel oid

not check these facilities may account for the continuation

of the problem.

3r3 Inventory Controls

The team noted that in many instancus the inventory

rocords did not agree with the actual supply of the

product in stogage. In the Far West most of the

inventory aheeta checked 'tiere incorrect. In the

Western Rep1 on, receip-c of druf,s in one unit 'Tltls'!not

posted until some time after receipt. In the same post

several thousand tablets of camoquin had been found

stolen after a shinment of 16000 tablets had been

rEceived. In three districts in the Western Region

the record showed a total number of spray pmnps withOll.t

no~ing tha~ almos~ 1/3 of ~hem were no~ repairable.

fther ins~ance~ of inven~or1 discrepancies were noted.

Almo:;o~ invariably two conditions existed: stock

clerks were ~ct trained in supply procedures and supervisors

did not check the rp.Go!"ds.

Again the question of the r.esponsibility of the

Region in kee',)lng posted on the inventories 01' the

DistrictlJ com"lS up. Are the Regions respOJlsible for

knowlecgt:; of all adrl'linistrative matt~rs in their areas?

The unanimous cunc)usi('n li1' tho team iH that training is

needed in supply mp..nageroont. Further that supervisors up to

the rank of D,O, should periodically (monthly) eheck stocks

a.."ld inventorles and initial the records. The HMO should

alSo spot check when he visits the District. It is felt

that distribution should be based on demand and should not

be automatic. Particularly in tho case of chloroquine tablets,

automatic distrihution leads tn waste.

3.4 Supply Manarerrent Training

As noted ahove, turnover in pe:rs:'nncl and lack of training

in supply management has led to widespread deficiencie; in

control anci storat~e of supplies. Good management require.

trained r:ersor.nel n.nd an efficient system. Both of these

conditiuns could bl~ fuliilled bi a t;erie. of training

programs for sUPFly clerks. The training sesson~ could be

given perinc1it.ally in Kathmandu or other Centers under

superTi;oior. of a supply expert on temporary assignment.

The problem L: probably- so wido[;Vread that consideration

m~ght be given to initia~ine a Ministry wide training

:>rogrrun.

4. Transport

Perhaps the major managorial problem in the NMEO is that of

transport. The situation hns even worsened since last July

(Project Formulation Document). In distri(.;t after district

visited by the team, transporlation deficiencies were found.

In th6 Far West H6~~ion only ~wo working vehiclef: were found

Page 27.

and ~wo-.were- bE.1'uI1ti-repair-_ In--the Western Regon Dne ~d Rever

for supervision is on the road, two others are irreparable. No

load carrying vehicle :s available. In the East and Central Region

all types of transport were searoe and in the Regions the vehities

lacked s'[lare parts and are off the roan.

As for\.repp.ir shops and .. facilities, o:11y one region, the East..

Region he.s a .re?air facility. The other regions and districts.

are provided for by either the Headquarters repair shop for

mC'.;or repairs, or the 'periodic visits of the senior mechanicr.-

and helpers to t11e field. otherwise, repairs have to be made

where few f~cilitieo arc a~J.i12.blQ. The team lias informed that

fully manned regiunal repair shops are not now being contemplated.

The rletedoratis>n of a once excellent fleet of vehicles is

dua to a number \)f factor:., mos t of which can be traced to

manaGement deficiencies.

(1) Many of the vehicles ordered are not suited to the

road and land condition!;; of Nepal.

(2) Inadequate repair parts were ordered, often not in

time or in the quantity necessary.

(3) Inventory controls were not always ade~uate (especially

in the field) to indicate reoDdera of parts on tim~.

(4) Inadequate driver trainins in basic repairs and

preventi ve maintenance.

(5) Unavailability of even small repair part~ on the local

market.

(6) Lack of funds.

(7) The availability of mechanics to work full time on a

sustained basis.

Page 28.

(8) PlanninG of replacement of vehicles and parts long

eno~gh in advance to prevent breakdown of transport

in ,'my PRrt of the country.

(9) HiGh price of petrol prevent~ use of many vehicles.

All of these deficiencies are correctable with the possible

ex~eption of #6 and #9.

The status of the vehicle fleet at present (February 1976)

is as follows:

6 Land Hovers are on the road and operating.

3 other Land Rovers require major o,erhauls.

1 Unimog truck is operating in the Far Wes~.

3 7rucku are available and in good contition.

However, many of these vehicles cannot be. used because :f

of high cost of petrol. There are l~ vehic~ea funded by

HMG Clvor the last 12 years which are not ope::-able. The

greatest need is for load carrying trucks and pick-~ps.

The use of fO\r-wheelod vehicles for "dumping" wou.:::l

increase the efficiency of the spray operation cons~derablY'

by rlistributing DIJI' quickly to many places that othErwise

must be reached by porters or dum?ed ia central locaiions

and then carried by porter, ".:ith all the; consequent

problems of day labor, tardy payment of wages and sometmes

unreJ iability of the labor supply. The vehicles neede~

for this type of work in rough terrain are four-wheel

drive trucks and piQk-ups.

Page 29.

Unf nrtun,q,t ely, the vehiclus on order for load carrying which

have n0W arri veri in C3.1cutta are two-wheel riri ve l>I".azda trucks.

Eif:,ht of th em wi 11 be delivered to NMEO in the next few weeks.

It, is the C('l1sidered opinion of the team th;=tt these will be

completely ir,arlequate for "the job to he done. Money would have

heen spent more effectively if fewer trucks with four-wheel

drive had been ordered at the same cost. If the situation can

be retrieved by trade or :purchase it should be done immediately.

HUh the limite,! number of vehicles and with the tremendous

need for traruoport allover the country, it would seem appropriate

fur a new .urvoy of transport needs to be made over the entire

field ol'ganizc:ttiOT. and Headquarters, perhaps with the employment

of a UNICEF tr,:ion::l nn~ rerhaps even Districts where feasiClle.

In any case, the continuation of CI. post for Transport Advisor

is essenUal in view of the above conditions. It would be false

econorr.y to cancel the post tion at this time, as is contemplated.

5. nepair and I'Jaj ntenance

Even if all nece.sary vohicles were available, their usefulness

would depend on adequate repair and maintenance faciUtie .. and

training. At present the major facility i. at Headquarters.

While the equipment appear:. adequate, the 0UtPUt of the facili~y

ha. not c.Jme up to its potential. It was noted that lung and

frequent absences of the Seuior and I-laster Mechanics may have

detracted from the efficiency of the operation. As stated above.

Page 30.!.

only the Eastern Region ha~ a functioninf, repair facility. Major

rep~ir jobs are broupht bac~ to Kathmandu m1 d other repairs are

taken care of by a mohile team that periodically visits the diotricts

and re~ions. Ohviously this ~as not been satisfactory.

A "new lac-k" At trans~ort needs including a five-y~r plan for

rrl)CUrement of vehicles and spare parts, repair facilities, and

training is needed. The survey suggested here would serve that

purpose. The team has noted l:hat prccurement program ha. been

planned by HMG and contriLutinv ar:encies, but feel. that a survQy

by an (?xpert team would verify and establish a comprehensive

The \erum feels strongly that even with the prenent fleetof

vehiclec ~d espedally wi ti: the acquisition of new vehicles,

it is most imI10rtant to establish a system of preveniive

~lilt8n~ce. The key to a successful maintenance program is

the driver. :::t is urged th'lt driver training and refresher

traini n~ be c,")JTI.rnenced as early as possible to include minimal

rer-lir s kil::'s for the dri v0r, and a requ iremant that vehicles

1e tested a: least once a month for all routine maintenance

requirements.

The team will not further comment on the need for Regional

repair fricilitic~, 18;wm!~ that to any rcc,:ml!ncndation of the

survey team referred to above. The same is true of whether

vehicles ;ho'uld be located onq in the ReEional Offices or also

L~ key Jistricts where transport is most eQsentiAl. The team

will, however, urge that the list of spare paxts for existing

vehicles be dispa~chcd for procurement as soon as possible.

Page 31.

~. PerDonnel MP.nagement

Personnel m~~agement in the NMEO ha~ been characterized primarily

by the lar~o turnover in pE:rsonnel in the past two years. As a

result of integrat,ion and other changes in the Hinistry the staff

has been somewhat reduced. But reductiLn alene is not the major

change. In the senier ~d middle management positions a number

of changes have taken place which affect management stability

and efficiency. Some of the chanp,es noted are the following:

1974 - Two Deputy Chief (Medical Officers) have been

tr&nsferred to the ncpartmont of Health. Also in 1974

two l'-10's (Epidemiology) Here newly transferred to NMEO.

Two arlministrative officer::; (1 supply) were: transferred.

A Grade 3 acting accountant was transferred to the Ministry

of Health

~ Sflnior malaria a~iOi .. tants were transferred in 1974 to the

Inte~rated Health Sorvl~e~.

2 Grade 1 A.si.tant Malaria l'Jffl"ft."if were ~ran.fgrred

out of NMEO.

1975 - One Malaria Offi~er in ~harge of opera\ion.

tran.ferred to ano\her po.ition in NMEO.

One Sr. Health Educator and 2 Malaria Officers 'vere

tran~ferred to the Ministry of Health.

In the same year 2 Senior Officers resigned and one was

transferred to Pokhara (Integration Region)

Also in 1974-75 a total of 75 lower grade personnel left

the Organization as follows:

Page 32.

48 Senior Hilaria Inspectors~

15 Senior Lab. Technici~s ) transferred )

4 Malaria Assist~nts ) )

8 Resignations )

Even if some of these posts were ref:i.l1ed, the turnover of

99 positions, ma'1Y of them senior and midnle supervisory posit-ions,

mus~ affect the continuity of management and supervision.

The Team did find tl1.!t at present most authorized positions were

filled with the exception of Regional personnel in West and F3.r West

vlhich are still considerably understaffed. The implementation

of the Hegional Organization plan is not yet complete and no

doubt these positions will gradually be occupied.

Tho Team has concluded thA.t excessive turnover in t,he cause of

many of the manflf~ement pr0blems in the field and :in the

Organizntinn as a whole. Every effort should be rrr:lde to stAbilizQ

the present st.qff tr) assure a smooth continuity of operations.

The Director of NMEO should inrlicate the consefluences of turnover

to the Hinistry of Health and Puhlic Services Commission.

The teams o~~~ed in most of the Ref-ions ann Distric:s that the

Senior Officers spent varying portions of their time in the

field. In Central and Eastern Regions it was noted that the

senior staff had a low percentage of time in the field, only

the malaria inspector:; and :;;enior malaria ins[,ctors spent a.t

least 5i% of their time in the field. In the Far Wes~ field

t~e rangQu frem 33% ~o 55%. In \he WQS~ k8-~8%. However,

'\,he 1.ime in ~he fie Id did no'\, :llwayi represen'\, adequate supervision.

Page 33.

Only iJ" a very few cases was there any evi nence that HMOs or DOs

had checked personnel records, supply records or any other

adminifltro.t i ve data. For instance it war; noted that several senior

staff mctnl'(~r!} rf some I1istric ts Offices had been on leave at the

same tjmf: durinG thE: hei;::rht of the spraying season. This fact

had not L(:c:n noted or 'crouvht to the attention of the RMO. In

almost no case was any Cl)rrecti ve action taken.

It is 1I1d~rst::mdable that the Regional and District Officers were

more involved in tel,;hnir.~l than administrative. interests. However,

their responsibilities as sUlJervisors require them to note

adlnini"trati VG pr.:)blem .:mel put~ntial breakdcwns.

The t"mm recommends that senior fiegional and District t;rficers

receive training in supervisory management in seminars or special

cl:tsses conducted for that purpose under management personnel.

It is also recommended that all ru10[s and DOs check adminis~rative

rec,~rcls on a srot rasis when they visit the field. They should

ini tial the records they h:we reviewed.

In order to facilit.1te manaRerrent chan(l'es .and to assure continuity

of efficient practices the team urges that a Manual of Procedures

be ini~jated to reflect the pra~tices and standards required for

good admini~tratibn. The present Manual has not been revised

.in"c 19'3 and is compl~tely LlUt of date. A!;ency-wide attention

.hould be ~alled to new issuances or amendments to the

The ~~am wa~ impreD;ed with the general enthusiasm and dedication

of ~he .~a.ff of ~he Organization at all le"elg. The NMEO is a

well ~on~eiTed and well planned Organization whlch is known and

http:tec.:hnic.al

Page 34

respected throughout the country. It is important that its

mission not deteriorate as a result of bad management and

slipshod practices. This report attempts to point out some cf

those areas that require attention.

D. Operational Accomplishments and Problems

1. Insecticide cover~

DDT was mainly used except in tr.e four localities of Baluhawa Unit

in Kapilvastu district which had :received one round of BHS. In

addition, 'ABATE' (larviciding agent) was used in two of the

above localities in the same Unit (Annex XII).

1.1 According to the plan of action for the F.Y. 1914-15, a

population of 1.9 million was to be rrotected with DDT

Rpraying during the Feb/March cycle cf 1915. However,

because of limited stocks of DDT. Selective spraying had

to be carried out very cautiously ke~ping in mind both the

DDT in stock and the epidemiolo~ical situation. A targeted

population of 165,000 was selected. But during spraying a

population of only 155,000 ~LS covered.

1.2 Similarly during the May/June spray cycle 960,000 persons were

protected out of the targeted population of 1 million

(on a selective basis) against the planned population of

2.2 million. Due to the various administrative difficulties

in some places, the spraying operation had to be started

late.

1.3 The Aug/S~pt. cycle on a very selective basis due to the

same reason was targeted to cover 1 million as against

Page 35.

the planned 1.5 million. However, actually 423 108 persons

were protected. Ill." some places spraying started late and

had to be terminated without completion because of variouii

administrative difficulties and of time factors. During this

round a tJtal of 47 001 population in Baluhawa Unit were

prut.ected by BHC (58%) wdp at a dosage of 0.5 gm/sqm.

(Annex XIII).

1.4 Five rounds of larviciding with 'ABATE I were used between

A]')ril and Jlme 1975 in the ponds and other lftter collections

considered ideal for anopheline breeding, in localities

3 and L. of the !laluh:.lwa Unit. The whole operation was planned

,:mrl inj tially executed tmrer the tii rect Ir,tlidance and supervision

by the HHO ReF'ional Sanitary ~f_~ineer and ne~ional Entomologist.

However, the results could not be thoroughly reviewed and

analysed because of improper collection of data after the

derarture (.If the reGional WHO tgam.

2, Focal sprayinK

Due t.o insufficient Di)T, focal srJrayings had to be re:otrioted

on many o~casions. On the whole epidemiological factors determined

t.he rriori"y for such spraying. It was observed that in some

area~ selection of the houses round a focu. wa. ve~ unrealisti

Unwarr~ted del~ys have aiso been noted in carr}~ng out su.h

srernti MS in some placelJ (Annex XIV).

3. Surveillante

3.1 Throur-~hout 1975 schedulon AC n rounds were maintained.

Depending on the epidemiological situation the time interval

be~ween AC[l rcnnds was adjusted. In some of the difficult

areas like r.a.luhawa, Ast.trcd.na, Belatnri., Lumbini and Jhapa,

11100d slides were collected every tenth day during house

to house visitinG' In other areas, lC' was restricted to

15 days interval. The remainder of the country had monthly

visitini" vrith the exception of project areas usually dra1.nng

larp,e com;rer;aUon of labour....whre twic-e-1llonthly visiting

was r.ecessary.

There is a tendency to visit the same h~use at each visit

in some of the Units. It appeared that age and ~exwise

coverage was not uniform and special attention must be paid

to infants and children.

MI3S had to be res',ricted in a number of places, e~pecially

lihere there was a huge backlog of slides. Examination of

slides obtained throuGh Ml~ clearly indicated that-ACD needeu

to be improved.

3.2 FCD produced only 0.9% of the total slides collected during

1975 from all sources. However, the positivity rate amongst

Fe:r slides lvaS h.7%. Cooperation from all medi~al/health

services units is neede1 to improve the rate of slide

collt:ct ion.

'I'reatr.1E:nt

4.1 Drugs were readily available throughout the year for both

f-'res~ptive and radical treatment. Proper acrutinization

during issuance of drugs at all levelu could help in the

reduction ofjmisu~e. The higher initial dOBe of

k-amin0quinoline group ,.,f drugs and the use of long acting

sulpha drugs a. subceque.t recrudescence of resistant

~. falciparum have not been st.rictly adhered to in seme

places. DiBtr.tbution of drugs by persons entrusted with

other duties have in some places created doubt.ful situations

about relapses. 'rhe persoas employed to gi VI3 radical

treatment, should be the only persons entrusted to treat

cases, as far as possjb1e. This will not only Ansure proer

proper taking of drup.s by the patients, but also interfer

less with the t:chedu1ed activities of other personnel such

as the MFWs.

4.2 Because of the d~tection of large numbers of imported

posi ti ve cases (1082) in persons residing outside the

NMEO o~rations area i..'1 the Eastern Region, treatllEnt had

to be arranged. But with the present resources of the

NMEO, it is not possible to do so effectively. In this

connection close liaison wi.th Ministry of Health is needed.

3 Three rounds of MDA using 6&0 mgm of camoquine and 45 IfIga

of primaquine were re~ommended in the Asuraina Unit. Only

-ihe first round was given under proper supervision and t.he

resu1-i was inadequate coverage during the other two rounds.

In the resettlement area of ~h'andragarhi Unit in Jhapa

nistrict, a sin~le round of 600 rng carnoquine and 50 mgm

of pyrimethamine p.1ven during the mon,ce of September

produced very good results (116 cases de~ected between

September - Detember 1975 compared with 913 cases during

the same period in 197_).

5. Laboratory Services

5.1 The central cross-checking laboratoI'Y' at NHQ was decentralized

effect.i ve August 1975. The C61tral laboratory at NHQ is to bEl

used far cross-checkin~ slirles from the regional laboratories

and far basic and refresher traininr courses far the

lab. technicians. At some of the lab~ratories visited the

slide output per lab. technician was too low (about 38 ~ 40 slides

~er day), Leave of absence was noted to be a major cause

of backlog of slides} and this could be dtcreased by properly

utilizing (by temporary transfers) the laboratory technicians.

A total of 46 laboratory te8hnicians of the central and

east8rn regions (including SMA, HA + SLT) were tested usig

six different sets of six numbered slides which were provided

by NHQ lah. Only 18 (39.13%) identified all the slides

correctly, 15 (32.6%) did very badly and have been recommended

for refresher training.

5.2 The par2.sitolor:;ical orerational ma.uaLis not being strictly

follower:1 hy the SMA/MAs of the RHQ laboratories while visiting

distrjct lahoratories.

5.3 Some micr:)~'copes need Iilaintenance or replacement. The

overnip:ht safe keepine of microscopes \-lhere electricity is

available, is not being done.

E. Integrated Areas

The ~eam visited the integrated districts of Kaiki, Bara and Parsa

and in the limited tiroo available, endeavoured to evaluate the

malaria status and to i,jentify technic al and administrative prob.i.ems

both to NMEO and the Basic Health Services. Pr'wious reports

"Page ;39,

outline in detl'l.il the HMG Policy Rnd achievemants regardingtbe

intcgr.-... ti.m cf the 'bnsic health services and a comprehensive

cvalua ti0n was c2rried (\ut hy a HMG/AID/lvHO team in January/February

1975. Thus the present team marie no attempt at an in c1epth study

but prefient here an overall il'lprGssioJn 'Jf the situation based upon

statistic& "lnd inf:~rmation provided dUr'inr. the visi t.

The timinfs of integration varied 1::etween Bara and Kaski distri

Page ~.

consideration the distril.Jution and leveJ of survci1lance

activities in time and sl~ce and the coverage and level of cane

investigatiun.

The total nwnber of 98 cases detected in 1975 were found amongst

~ cunsic18r({lJly reduced nwnber of slides taken compared with

previous yo:1rs. The overall impression is that the malaria

situation hRS not improved in this d:'strict and t he situation

c(lntinues to be of major concern. It was apparent to the team

that the Il"l.sic Health S8rvices personnel responsible for the

malaria activities are ~~able to adequately cope with the

continuinl' caS0 loan. The reasons f,r t.his 2re r'rilTlA.rily

admir.istriltive interferring tTith t::ase dotpct.i'Jn, timely treatment

of cases and the implementation of remedial measures.

The actual am::mnt of allotted Ludr,e+, fer' the required level of

anti-malaria activities is insufficient particularly for TA/DA

and spraying operations. The Situation Analysis Team in 1975

visited this district and noting the risiP.[~ t.rend in malaria

caBes ann the increased A1-I, recommenc!L:d that regula!' spraying

be carried Gut in certair. areas coverin!; 36 000 population.

Hot/ever, due to an acute shortage of DDT this was not carried

out durine 1975. Supplies of DDT h'J. vo n,)w been provided to

this riistrict, but the district h'-is insufficient funds to carry

out ref!Ular or focal spraying. The team noted that the DDT was

not properly stored.

The shortage cf TA/DA funds has had the effect of reducing field

supervision v;rhich the team found to c':::lsti tute only 21% of tho

supervis0ry personnelts time. Close supervision of ~he Junior

Health Worker is essential for effective surveillance activities.

At the time uf the visit tu the Health Post buth

Jiux:Uary Health Workers W8ru "lbsent and the Senior Auxilary

Health Horker was umble ill cops with the activities norm11.1y

carri~d ~lUt by the AHW. Thi.s appnrently was a frequent

OCCUITt:mcu at this Health Post. This is one explanation for

the long delay in r,qciic.:ll t.rLa"t,ment and case detecti:m whioh

was noted hy the tee_me

The lahoratory is sufficiently staffed to copw with the

present level (If survei llance, to the point that the microscopists

were examin~n[; an averaFe of 30 malaria slirles per day. There

was no slide back-lo~.

SincL~ the ensct of intq"ration in this district malaria

activities h'lve teen r-.rriud uut from the three HCdlth Posts

at Dcui"lli, Pokhara and Batulcdwur. Since September 1975

three adJi tional Health Post~ In ve l,oen established at Majhthana

m.endabari 3l1d Sishawa. The team c onsidero this to be a

beneficial cleveloJ'loont which should result in improved case

detecti()n::;nd treatment.

2. Bara District

The team, accomp.:'mi'3d hy the Civil Surgeon of the Zone visited

the Thra District Health Services Office and tho Rampur Health Post.

statistics wore avaihble lJp i" and inclurlin~ October 1975. The

si tuation in the district :nay be briefly summarized as follows:

Blood Slides Positive Year Population examined cases

1973 2463n 34 114 26

In. 254 173 43 390 333 1975 261 152 26 34h 272 (10 months)

(Jan-Oct ober)

Page 42

Detailed statistical data is presented in annexes XV and XVI. It

shoU:.d be note~ that the reduced number of cases compared with 1974

were detected in a considerab~y lower number of slides collected.

Difficulties have been encountered in coping with the case load

to be investigated. This was revealed by 2~ of the cases detected

between April 1975 and January 1976 remaining uninvestigated and

46.57% o~ case investigations being carried out 4 weeks or more after

the blood smeaT collection. StIDilarly for the same period radical

treatment was not given to 26.67% of cases detected and was delayed

by 15 days or more in 48.23% of cases. No records were available

of follow-up of positive cases, but in the previous two years

follow-up was continued beyond 6 months in only 4 cases. The

changing epidemiological pattern reflects the above difficulties

(graph 2).

The overall level of surveillance was markedly reduced during

1975 and from January to June was below the expected 1% per month.

An examination of the records at the Rampur Health Post

indicated that the total surveillance in 1975 amongst the

population served amounted to 8.65%. At this health post blood

slides were not taken from all fever cases but from suspected cases

only which averaged less than 4% of the total attendance. In 1975

the total out-patient attendance was 11,817 and a total of 357

slides were taken for nk~laria screening.

The laboratory also had difficulty in keeping pace with

slide examination, due mainly to the low dailr examination rate

by each microscopist, until the slide back-log reached more

than 2,000, whereupon the daily output per microscopist

went up to 87 and 123 durin~ September and October 1975

respectively (Annex XVII). Only one of the three microscopists

is engnrcd in examining specimens for TB and Leprosy and these

amount to no more than 15 specimens each per month. The Team

tested the microscopists malaria diaenostic ability and

fotU1d two of them to be quite compet.ent.

TIle adnUnistrative difficulties which have affected

the m~laria activities in this distl~Ct may be briefly

surrunarizeu as C1. coordin.:'1 tion I~ap between the NMEO and the

district regarding the February rel0ular 0pray cycle; lengthy

delays in reporting to NMEO; the lack of cross coverage

between the AHW curative and AHW preventive; +':le ruutd to

ensure that the remaining S health assistant posts are

fi) len. hy !"lers onnel c.dequa tely conversant w t th the integration

activities; unsettled, TA/DA claims for the period

April 1974 - March 1975 and a similar situation developing

with outstanding TA/DA from December 1975; late arrival

of ~unds for salaries; an1 the lack of a bUdgetary

provision for the laboratory technicians.

The -I;,eam examined the supply situation and found

it to be satisfactory, with adequate stock A of

4-aminoquinoline~.

3. Par~a D:i..s "t.ric t

The team was able to visit the Par'..Ja District HeaUh

.~rvi.e. Qffi~e a"t. Birganj and the Langadi Health Post.

'l'he Uu':l.'\ion in \hi. District is cause for more conc81'll

\han Kaski or Bara and mar be simply stated as:

Pa,[e 44.

Blood slides Po~itive Year Population El%amined Cal;es

1974 211 552 34 963 459

1975 212 768 20 030 499

Detailed 6~atistical nata ts presented in annexes XV and XVI

and graph 3, An extremely low level of surveillance prevailed

il1 this r1istric t throu~hout the early part of 1975, with

improvement from July onwards.

As in B.:lra the personnpl are unable to cope with the

case load fm' investigation '. and radical treatment and details

of follow '1.41; ,,,erE: net availClLle. The lq;ontJry work output

"laS much better, the mie rose opists maintaining a regular daily

DUtput resulting in a minimum of slide backlog (.hnn8X XVIII).

It vms i't}lt that this was tht) result of better supervision.

The throe l1l.1.croscor-j.sts WEre tested for their ability to

diagnose malaria parR-sites and were all found to be thoroughly

compe"t.c:nt.

Few records were avail.'lhle a~ "t.he I.angacli HeaUh Pos",.

S~atisti on blood slides examined from patients attending

the Hertlth P')st bef!:in from September 1975. In the 9 months

April to !1eeemher In5 the patient attewlance at the Health

Post amounted t.o 6396 and from September 155 blood smears

~~I-. I-,aken and 6 positives found. The surveillance coverage

of the area served hy the health post from January to December

1975 was very satisfactury, when a total of 3706 slides were

taken and 13. positives found, in a population of 26 206.

Pae~ 45.

Radical treatm:mt and case investir-ation however, was delayed

by 15 days or more in 70.9% of cases. The administrative

difficulties encountered in this district are no different to

thoge in the other integrated areas except that at the time

of the visit the nistrict Health Servic es Office was not

officially sanctioned a nrl was opE:rating with a temporary

staffing pattern. All personnel W8re on loan.

The administrative difficulties encountered in this

district reflect the ne8ci for adequate preparation and planrmg

l.;efore effecting inteeration.

4. Conclusions

'The epidemiological picture in the three integrated districts

is depicted in graphs 1, 2 and 3. The situation should not

be interpreted only in terms of positive caoes foune, ag

this i~ dependent upon the number of p3tients screened, whioh

in 1975 was lOWEr than in previous years. These graphs

indicate that in 1975 transmission commeneed ea~ly in the

season indicating the presence of a sizeable reservcir of

untreated p~rasite carriers. Intensive case detection, timely

radical treatment ann case follow up throurhout the year, and

especially during the non-transmission season (October - February)

would produce the epidemiological picture seen in 197.3 ir.

Bara district. That is to say late onset of transmi~sion,

and a short, sharp transmission period. The present picture

therefore is cau~e for confiiderable conc~rn during 1jhis year

and prompt remedial measures are essential.

The team is fully aware that the problems revealed during

this evaluation nre well known and th~t efforts are beinr. rrade

to overcome them. However, the mahria situation in these areas

is such that the inter:r9.t.ed services cannot adequately contain

the dis8ase. In some localities it has reached the criteria

(lIPI ~ 0.5 %0) for the reintroductiun of r8gular spray rounds,

in keeping with the NMEO efforts in the rest of the country~

It is very apparent thut the Basic Health Services is unable

to carry out the required remedial measur8S of focal spraying

and rcn:ular sprayin!; through lack of aciequate budgetary provision,

personnel ~d transportation. S~milarly the NNEO at the

present. time, is

cases are either not being investigated prompt:.y or not at all.

Laboratory serviaes need to re maintained at a very lrlgh level

of efficiency with adequate superTision.

Numerous administrative difficultie. involving budge~,

Bupplie. and I)ersonnel exist, and require urgent attention,

The key man in the integrated areas is the Civil Surgeon and

persons fillinr such a post should be devoid of clinical

responsibilities to ensure adequate field supervision of the

integrated operaticns, and more time devoted to the administrative

diff~clllties of' such nn operation. It ia through the Civil Surr,eon

:hat the NMEO can maintain improved coorn.ination at the

operational level to the advantaf"e of the Basic Health Services

and NMEO.

Careful and r;radual phJ.std inteGration of a. complex

vertir.al programme like malaria offers the bes~ pros:p3c~ for

success. The basic oreanization needs to be establi.hed,

staffed, adequately budgeted ir.Glud~g a ~0ntingency plan,

and functiGning, bgfare the pro[;ramme begin. to be phaDed

in. Ctherwise economic gains alrc.:tdy achieved may well be

10s"8 J3efare inteGration a high level vf p9.6si ve case de'ic;lc'Uon

c auld be devol eJIX'd by th (: s ~reening cf all fevtff cases

attending outpatient clini.d at :he various heaHh institution

and Health Posts.

The] ahol"1.tory caplcility can also be develo:p3d to a high

deF-rAe of efficiency. Case invpstigation, radical treatment

and finally house visitinr, can be built on top of this in an

oPage 48. 0

orderly fashion, with the appropriate expansion of the

Health Servicea,

In the six districts already integrated containment

and eventual reduction of the disease incidence c?~ now best

be hrouf!,ht about by sharing the responsibilities for the

malqria activities between the NMEO anc the Bafic Health

Services :in a joint ecoorrlinated effort. However, it must be

emphasi~ed thnt appropriate and adequate funding muet be

provided a~ a pr~ority to both NMEO and the Basic Health Services

to enable their respective activities to be effectively carried

out.

The team anticipates that the future integration of NMEO

districtu into the Basic Health Services 'will be carried out

gradually ~nd effectively along the lines developed in the

1975 Prcj ect Fonnulation for l3asic Health Services.

F. The FEstern Hills

This area of Ne~~l presents a special problem and in accordance

\Olith the Terms of Reference the tC'3JTl visited the eastern hill

mal"lria district offices of Okhaldhunra, Khotang (fliktel) and B

!Jhojpur} nnd the malari.a Unit II of Okhalr:lh'Jnga at Rumjatar.

In this arE.J. the popul:ltion rellides on top of and along the sides

of the hills, ann farms the land in the valleys. Some families

have tHO honses, Glle on the hill and the other in the valley. There

is .onsidr-:rabJ (; movemen":. of t.his population to the N .E .. Indian Stat)s

for farmint; (1 - 2 ye3.!'g), tea planting (1 - 2 years) or wood cutting

(6 mop. ... h.). eorne\i.mes a leader will take a group of male villagers

to work outside the countr)", but generally farmers take the entire family.

Page 491~

The malaria Bi tullticm h both Okhaldhunga and Khotang-- iB--very

similar, in that it is doubtful whether any transmission is occ\l.l:"rlng

at all. Very few cases are bein~ classified as indigenous. From

60 to 70% of all cases are imported from outside Nepal, ma5nly Assam

and Nagalano. Of these imnorted cases more than 50% are ~.falciplrum

and during 1975 in Khotanf, 39 recrudescent cases were reported which

rt:sponded to tre2.tment with sulphadoxine and primaquine. In addition

m,')re tha:t1 70% of the imported cases reside outside of the operational

area. These cases aru usually detect8d when they report sick to

the malaria unit within the operational area, at winch time a blood

smear is tc?ken and presumptive treatment given. rhe patient then

returns tu his hCll8 ann if t.he blood smoar is subsequently found

to be posi ti ve then r3di.cal treatment \lecomes a problem.. Attempts

,g,re made to trace the pCitj,ent. If md when the patient is found,

radical treatment usually consists of the first dose only and the

patient carries hack home the remaining four days treatment.

Somo positive cases are referred from the check-post on the

eastern horder at Kakarvita, in which case attempts are made to

trace those parasite carriers even if they reside outside the

operatio~al arpa. In Okhaldhunga during 1975 a little more than

20% of the non-indigenous ~ases remained 1,lIltraced, and ill Khotang

6% in ~he same year.

The situation in Llhojp-.r is identical J.n every respect to that

in the o~her \WO di:;l,rt"t.s wi th one important difference.

Transmissiun is defini.tely occurring. TJuring 1975 10% of all

cases were indi~enous. However, these came mainly from two

localities in Unit I Dingla, and one locality in Unit III Dinglapu

Transmission is centred around the Arun river valley,

The team was aware of a lack of entomological data for this

area. The receptivity is not precisely known. Latest entomological

infOI'JTlation appears to pertain to a study more than 5 years ago

in Kiri village of Khotan~ district, when ~.nuviatiliB was recorded

The team felt that entomological information was neede~ in order

to make a BOu''1d judgement as to the effects of, and the need for,

residual spraying.

From the brief study of the districts visited the team had the

impression that in a significant portion of the operational area

there is Ii ttle or no transmission, whilst in the remainder

transmissicn is occurring but in pockets associated with specific

eco] ogical candi tiona conduci vo to vector breeding. Furthermore,

the villae;es are ~enerally not compact" the houses bein~ widel):

scattered over the hill side.

A l:lreakdO"m of cGm~rati vt:) costs of spraying in the terai and

the eastern hills ~ex XIX) indicated that the costs are more

than trebled for operations in the hills. In addition, due to the

difficul t terrain" alld scattered hOUl~es, the quality of spraying

and supervislon cannot be guaranteed. It therefore beccmes of

sifJ11ficilll"t importance to determin8 the precisE:::J situation .' _ :7._'

e.xisti:1f, in localitie:: at present covered by spraying operations

and to adjust these operationa accor.-dingly. Focal spraying is

proba'.ly logistlcally more ci.ifficul t than an organized regular

spray cycle since adequate superrision is virtually impoosible,

and there is an i~evitable time lag in distributing the supplieB

and equir,ment..

http:proba'.ly

l'age 51

Many of the imported. ccses-are entering through the Kalmruta

border ch~ck-post where it is estimated that 52 to 55% of cases

found are ~. falciparurn, and as can be seen from the statistics

below, 8.3% of these persons checked are parasite carriers:

Blood Smears Positives Slides positivity Year examined found rate

1972 2 193 28 1.2%

1973 7 018 455 6.4%

1974 10 490 632 6.f1'/o

1975 l327l 1 066 8.3%

Effective control at this post would offer some protection

to the population from ~. falc ip a rum , reduce the chances of a

4-aminoquinoline resistant strain of ~. falciparurn becoming

established in the country and reduce the vulnerability in the

eastern hills. Careful consideration should therefore be given

to three possibilties:

1. That ~ediate blood examinations be conducted at the

check-post and appropriate on the spot radical treatment

be given to all positive cases found, using a single dose

radical treatment in the case of ~. falciparum.

2. That a single dose presumptive or radical treatment be

given to all persons from whom blood smears are taken.

3. That a single dose presumptive or radical treatment be

given only to suspected positive cases, based upon history

of fever.

The first alternative is difficult because migrants arrive in

large groups, the second is very expensive, and the third is less

Page 52

expensive but IDay not be as effective. These considerations

should be balanced against th.; fact thllt these migrants are

often unable to provide an exact address, many never arrive at

the locality originally indicated and they invariably stop

overnight on their way to the eastern hille. Thus many parasite

carriers are probauly lost within the country, and precisely to

what extent warrants careful study.

III. Review of Present Program Policy and Planning

A. PolicY"

Support for a nntional malaria program is based primarily

on tee broad based r.a"cional health objectives of reducing

morbidi ty and mortality so as to facil:""tate the economic and

social development of Nera1. This objective has its origin in

b0th national and hC'aUh sector priori"~y planning areas.

The basic fou~dations of the HMG FIfth Development Plan

(FY 1976 - FY 1980) outline three basic principles to follow in

developing this national development pJan. These principles are

1. To maximize n'1tione 1 output for the general welfare

2. To muximize utilizotion o~ the labor force

3. To create regional balancr~ and greater inter-regional

exchanges, thereby encournging national unity.

The planned malaria activities of the NMEO meet all three

of these over-nIl national objectives by: (1) increasing improve

working conditions for Agriculture development in fOl~erly

malarious areas; (2) maintaining a healthy work force to produce

crops and materials required by the nation; and (3) allowing the

malarious regionD of t.he I;ountry to take their rightful plaCE; in

the regional development schellU::Jl of the country.

In reviewing the priority concerns of the t1iniatry of Health

for the Fifth Development Plo.n there emerges four principles areas:

1. Contr')l or eradication of malaria, smallpox, tuberculosis

and lorrcmy 0

2. Family p:anning, nutrition and related matters,

3. Environme:1tal Health and water supply.

h. General Health Services.

The activities of the NHEO relate directly to the health

policy concerns (;1' the I>linistry of Health in meetine their

priority objectives.

The Nl"I;al Halaria Eradica ti011 Lloard (MEB) ws con~idered

the pre:oent maln.rJa situation through evalw. tiona reports and

fleld uhoervations. The o'iljectives of the HE~3 and the NMFD are

nl)W focused G[, the control of malaria to a level where it is no

lon,~er a public health problem and to facilitate the orderly

;levelopment cf basic health services in Nepal.

In ~uantifiecl technical terms the objecti vesaail for the

interruption of the risinr~ endcnriaity of malaria and the reduction

of its 'lnoicience to 0.5 Arumal Pare1site Incirlence (API) based

on an API calcub.t(;r1 from all the reported casc::-o minus the imported

case:: from ~l)1os.d. For Nepal Country-wide, the 0,5 API standard

translates to an incidence level where the annual number of detected

case:. under a stabilized surveillance mechanism should not exceed

J COO cases and with an adequate response mecwnism in p1:1. ce

to effecitvely handle this level of jncidence.

The Situat~on Analysj sTeam - JYi6 believes the palicy ta~c

f(,r :Jllrr,ortir.g the malaria contrul Cictivities is in accord w;:.th ":loth

national [lLci he:lltb development objectives. There are clear and.

clircct l:i.rH' (ut-l'ut V((LU80 to the activiU.es of the NHEO which

in r;,-'1'":2.. TL,' 'l't:iln lJcli8v(~s that it :ls extremely important that

pl'oj)t;r, planrkd {lnd :o.de'-lU~lte S11ppt'rt. be given to the NMEO in order

that tld.s ()rt~ani a.tien can meet its responslbill ty in the atta:1nment

of nat-lOin] olJj (~ctl vus. 'l'be Tc:m. WlS impl'l-!ss eri with the detcrminatioT'.

of' the i-1alad a Era(~icati0n noard to SU~)port a national malaria

effort. Tilt: rtLfficult d!:cL, ions :-rw.de L,v the- HE l"1o.1.rrl. to revE:n .

al'ea~1 tel ~)I'rCl?-hf:: aGtjv:t~il~S aI'(: irlriicat.ion:.> of the concern of the

ME ;lu'lr'rj fer a ~~,)und prof'ram ba~1ud on technLcal n8eds ..

Plannlng

The f)1jEC iu guided in its over-all program direction by the

Flilll of Opt::nt~i.uns which is Jet3.ilcd each :rear through annual

Plans ,1 f:.. ction" wring the pc:riud of Jmu~-..l.,.. 1975, a revisod

PrGj-Jct Furmulation Papl::r (Plan of OperA.tiC1t~) was prepared by

thL! HHG with thu [lBSistrillCt of MIO. The draft :.If this Project

FOrlrN.l'ttion Paper is Lef...,re the G(.mceIT.eJ (jfflciald in the Health

Hinist1J ;u:l i~~ r'}Cl.dy f'Jr pr('!ll!ntTLiun tu oth(:r ap)::roving

lJ.uth;'riti8[,.. Thi8 ?rojt:ct F'~rrnul;:-,tion Pap"r wan approved in

I_,rinc.;i;:,lc l

Page 55.

plf the

Plan of Acti0n with the targets in the operational portions of

http:Fi,,rmulat.io

Page> 56.

the F-la~. The oper~1,joll'j".J a.~cJJfl!,liflbmtJnts and problems of'1975

are provided in jJ3.rt. lJ-h c,r thb ne~ort awl are not repes.ted here.

Th::' late arrival of iW3 ecticide was the reason given for the

p:Jor c,'veraf;

i.e. ~i':.lministr'ltive, t'~llt()m'_)lt:,[,y, iJar;;wit!)1.oVY, ope::rations, The

Team abc felt that pant rc:c,}mrwmdaLi ons ,)f External Heview (Jr

Situut:im all,:,lYDi(3 Teams HC:l'C: :H.::inl" us.:::d hy the NHEO and the

pro,:ram wat: ",l~o~rvinf! and aclaptinc many cf the changes previGualy

rc~','Jnm0n,it-d. 1!r:\,,8ver J it is felt by the Team that more national

c:valuatic![J d'f\,rt (;hould lie made b;{ the NMEO .. .:i th more inter-related

evalu[, tiGn ;~cti vi tius ,,.nth c.;tht:!' Ministry of Hoal th personnel.

The 'h;;lJn h:l~ nc,tc:d 11 f!r 'I.'int impro':.~'ment in this intra-I1inistry

c".r,::i.n,'lt:i,n be:tHeen the int'.:f:rltc'(; health Rel'v:ic(.:s and malaria

rtnd it i[; hurc-d that tl::i.o c"'}r:!iwlti-'Jn will c(ntinue to imprc)ve

d,nc in cr'm;ult:lti(:n ...,itl, t::'J i-!inif,try 0f Ikalth and the NMEO

1"":-tlc1l11rly 1.n tlH' f](;lcci,i.on "r dist.r:icts to be intcgr'lted, time

In [~llmrr,ar'r, tr,c pelicy ~',':!.f,t~ for tho mmo apT_'L:ar(;d to the

Team t,_, ~:,,) in acccrd wjth both ;)ll.t..:i.onal and H(;altb fvlinistry planning.

'T'l!c 'fe2:n

1. Thr~ '~'.;:1rr, rcc:-;mmend~ th!1t the troj8ct Formulation Paper for

malaria l;i; i'ln:llizc-] .:tnd approved hy the concE:rned HMG

.)fficc'rt!

2. 'l'he final upprov.:ll ,.1' this docur,;cnt by hiRher HM'G authorities

roquire that the contribltions of the various assistinG

aCE:l1cics be carefully c(lcr~1irJ.3. ted in orde:r that these funds

rr,;vlrle timely and .:td('~-ilwte assistance support. The Team

rocommencis tll'l t. this a,~ Lhn b t~ carried out as promptly ao

pussiblu t.o avoid Clnr time la[;3 in t. he planned program

.3. The Team supports t.he 1975/76 NHEO {-'lan (If Action target

()i' pI'\lvid:'nl~ ~1 St:?l1~cr J\dC1inist r:ltivc Officer and an 8J

revised manual and re gul,tj ons refle:ctinv, current administrative

requirements.

6. Traininr: f'-f aclministr3.:iv8 i-'ersc,nne:l is 11adl)r needed. The findings

of the ~ituati.:n hnalysis Tfams in t hr:: riel r ] indicated th'lt well

0v,:r the tJO'':: )f th

10% frem onr; code to another fer the Dls trict (except

Dcrsc.nnel) !icc.r:~ll:t'l.rt er~ ~;')l:l~l 1-(: infe rn:('~ after thl;! fact . '

12. ;l srstun,' "n8.I1Ll"'e!1l(mt a\~dit" shl)uld be initiated, This

in Hc;:iGn, lli::;tric t, ell' Unit pcriodicall:r (twice a yenr) ,

ThL! Nanal;\JTncnt .specialist HOule. relJort his findinG to the

Rcf_:icnal or District offices and advise propP!' action. 'l'h

15. In the Far West Dist.ric:t of Dan~-neokhuri the area cover:d

by the Tllstrict off'lc(. is too l"rr~e for propAr manar-em8nt.

Thl:: Tealn rf'comrnenri:; th t a sut,-rJist.rict 'Afico Lo estahlished

at Ghoraha to c ovn' the area il1 the Deokhuri Valley ami, P10re

importantly, the !-i.R.N. Ito ad Project as this project is causing

malaria problems for th~ 0ntire area.

16. SUFerv:i.sion frarr, thE: inkrme:liatE: level shauLl be strE:n~thened

by revising thp existini; Travel a"::l lJaily ~\}_lCW-mCC8.

17. The lo~t m./1'1As of the

re gi un.:l1 1a L ora to rie s

4.. Takin,:: intv cor.sikr.'lti'Jn the approved general str.!ltegy'

of the pro ;:'7am two r:.,unds of spraying may be cJnsidered

in all common positive villages in formerly hypoendemic area.

5. Ha;;s iJrut' i,:lr.'..inistraUon UWh) ill the C(JI'II'lrJn positive

Survqr [;'11 ~l'S an'! 1.0\01 J)~;s:itivit.y rates, it is rtJ8urrunenrk:d that

t () t hc' ::hil'lren ' ... r:i i, J. '~'r \.; it h ou t. fevi"' r e:3 p:' (~i :llly i.r1 th ()

S(:)'.i us 1)'.

i) th0~c villares wJth a level of tfhnsmissirnl

precisoly l.,.h(~re transmbsion js occurring

(inside or ,-;utsirle thE; villaf~e);

http:regul.ar

Page 63

. . , ~1, the preci::;e transmission seaDon;

ill) the le vel of existinl: surveillance acti vitie.

Clnct ;

iV) the receptivity existin,' in l,hp rerlaining vlllaP'8s

~f the srrnyed 10cality, bas8~ upon simple

considerations of the: ccolo:~ic3.1 ccmditions suitable

to support the orincipal vect'::-r and/or the

demonstrated presence of the v8ct:)r.

The outcome of '~hi~ rf~cJr.;n:endatilJn should be selecti vo

re~ul.U' sprayinG Cit an appropric.te time relative '10 the

known transmission [-,,,,riorj only in thl)se villagos with

an API I!,rc:ate-:- 1;h:m ur qual to 0.5/1'J00, and in those

assistClnce over no less than OLe (r. +,ire year, in

selocted 'rillarcs where transmi ssion is c;ontin'Cling '\.0

determine}

i)

i , 1,

the precise anopheline f?Una'i

the vectorial ca):'d.c-l ty of the pr.i.ncipal,

secondary ann sus pt~cteci vcc+.ors j

iii) the soasonal variation of tho vectorial

cap3.citic:s (,f ,he \'ectors stuJies;

iT) ~he 10 vel of vt1ctodal ca;:l.ci ty Oissociated

wi t