Nawa Raj Subba* and Gagan Gurung
To cite the article: Nawa Raj Subba, Gagan Gurung. (2007). A study of public health indicators of Morang Nepal by Lot Quality assurance sampling method.Nepal Medical College Journal; Vol.9, No.2, June 2007 pp117-119.
Corresponding author:  Nawa Raj Subba. Email id: firstname.lastname@example.org
This article is the result of findings of Lot Quality Assurance Sampling that present and compares the findings of Public Health status indicators of Morang district over 2004 and 2006. Surveys’ findings are also been compared with data that come from Health Management Information System. This study aimed to see the trend of status of coverage of public health services in the district. Contraceptive Prevalence Rate (CPR) has slightly been increased from 41.0% in 2004 to 42.0% in 2006. Percentage of women having 4 ANC by Health Workers increased from 42.0% in 2004 to 46.0% in 2006. Proportion of mothers who received iron tablets during last pregnancy increased from 70.0% in 2004 to 80.0% in 2006. Similarly, proportion of mothers who received Vita A during last pregnancy also increased from 45.0% in 2004 to 55.0% in 2006. Percentage of mother who fed breast milk within 1 hour during last natal period increased from 24.0% in 2004 to 31.0% in 2006. Percentage of delivery conducted by health workers has been also increased from 52.0% in 2004 to 57.0% in 2006.
Keywords: LQAS, HMIS, PHC, Trend over two years, Data Analysis, Morang, Nepal.
Morang is one of the Terai district located in Eastern Development Region comprising of 65 VDCs where 66 governmental health institutions are providing Primary Health Care services. According to the UNDP report 2001,1 Human Development Index of the district is in better position among the districts in Eastern Development Region. Health Management Information System (HMIS) has reported the coverage and achievement of the district which is in increasing trend. But, these data mainly include service indicators which are collected by service providers and volunteers. Some indicators which are necessary for planning process do not come from the HMIS.2 Different studies and review reports noted that both over reporting and under reporting in the programmes are still remained.3 Errors are found in the recording and reporting which begins right from the service providers while recording and reporting to health institutions. A descriptive cross sectional study is helpful to evaluate the situation of services and reporting status as well. Lot Quality Assurance Sampling (LQAS) method with random sampling has its own methodology to collect, analysis and interpretation of data. It gives us overall situation of a district as well as it indicates poor supervision areas in the district. The objective of survey is to assess the behavior as well as practice level of community regarding health related issues. Specific objectives are to assess the ANC/NC/PNC service status, assess immunization status of children and mother, assess utilization status of family planning services, assess the current status of primary health care out reach clinic (PHC-ORC), assess current status of health facility management committee (HFMC), and assess the Infection prevention practice status of health facilities.
Study design: It is a descriptive study of cross-sectional type. Primary data collection by interviews with mothers, health workers, members of committees from randomly selected sites using questionnaires. Structured questionnaire were filled up by enumerator after having training. All data collected from questionnaire were entered into computer and processed using SPSS software. All precaution measures to prevent data entry errors were undertaken.
A defining characteristic of LQAS uses a sample size of 19 for each SA. In this LQAS described by Joseph J. Valedez, Willium Weiss, Corey Leburg, Robb Davis state that randomly selected 19 samples from divided supervision areas is sufficient to distinguish between high and low coverage.4 Samples were taken as- 1. Married women having children of 12 to 23 months (n= 133), 2. Members of PHC-ORC (n=55), 3. Members of HFMC (n=63), 4. Health facilities staff for infection prevention practices (n=63).
Supervision Areas (SA)
As per described by LQAS method district has been divided into seven supervision areas. The total number of 65 VDCs divided into 6 supervision areas as 1, 2,3,4,5, and 6. Biratnagar Sub metropolitan city has been taken as a supervision area 7. SAs are-
Supervision Area A: Urlabari, Pathari, Sanischare, Rajghat, Hoklabari, Keraun, and Bayarban VDCs.
Supervision Area B: Itahara, Amardaha, Govindapur, Jhurkia, Sijuwa, Bardanga, Mahadewa, Hasandaha, Takuwa, amgachi, and Dainia VDCs.
Supervision Area C: Jhorahat, Bhaudaha, Indrapur, Belbari, Haraicha, Dangihat, Kaseni, Bahuni, Sidraha, Thalaha, Banigama and Motipur VDCs.
Supervision Area D: Sundarpur, Dulari, Mrigaulia, Hattimudha, Siswani Badahara, Baijanathpur, Tanki, Lakhantari, Dangraha, Katahari and Siswani Jahada VDCs.
Supervision Area E: Budhnagar, Darbesa, Babiabirta, Sorabhag, Bhatigach, Dadarbairia, Kadmaha, Amahi, Majhare, Nocha, Pokharia and Rangeli VDCs.
Supervision Area F: Letang, Jante, Bhogateni, Warangi, Kerabari, Pati, Yangsila, Singhadevi, Madhumalla, Tandi, and Ramite VDCs.
Supervision Area G: Biratnagar sub metropolitan ward No. 1, 2, 4, 5, 6, 7, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, and 22.
Table 1. Comparison Table of Major Indicators between LQAS 20045 and 2006
|SN||Indicators||LQAS 2004||LQAS 2006||Trend|
|1||Monthly Meetings (within last 3 months)||49.1||96.4||+|
|2||Addressed at least three health management issues||41.8||73.1||+|
|3||Having updated financial records and reports||88.5||92.2||+|
|4||Presence of above 1, 2,3||42.0||64.1||P=0.0029|
Table 1 indicates that the trend of monthly meetings held has been increased from 49.1% in 2004 to 96.4% in 2006. Similarly, committees addressing at least three health management issues also increased from 41.8 in 2004 to 73.1% in 2006. Health institutions having updated financial records and reports increased from 88.5% in 2004 to 92.2% in 2006. Proportion of PHC-ORC those met all three criteria viz monthly meetings within last 3 months, addressing at least three management issues and having updated financial records and reports have significantly been increased from 42.0% in 2004 to 64.1% in 2006 that is also statistically significant. Reactivation of PHC-ORC management Committee has been successfully concluded in entire district with the support of SCF.6
Table 2. Primary Health Care-Out Reach Clinic
|SN||Indicators||LQAS 2004||LQAS 2006||Trend|
|1||ORC running on schedule||87.8||91.6||+|
|2||Meeting with minute (within last 3 months)||9.5||36.1||+|
|3||Provided all essential services as per protocol||41.9||56.2||+|
|4||ORC functioning with 1, 2,3||9.0||18.1||P=0.0978|
Table 2 shows that clinics running on schedule increased from 87.8% in 2004 to 91.6% in 2006. Similarly, ORC management committee’s meeting with taking minute has remarkably been increased from 9.5% in 2004 to 36.1% in 2006. All essential services provided by ORC as per protocol also been increased from 41.9% in 2004 to 56.2% in 2006. Proportion of those PHC-ORC who met all three criteria viz clinics which are running on schedule, meeting held with recorded minutes, and clinics providing all essential services package as per protocol has been improved from 9.0% in 2004 to 18.1% in 2006.
Table 3. Infection Prevention (%)
|SN||Indicators||LQAS 2004||LQAS 2006||Trend|
|1||Sterilization using functioning or boiling pot with cover||70.9||92.1||+|
|2||Disposal of sharp instruments and medical wastage properly||46.2||94.2||+|
|3||Having Puncture proof container||90.9||97.0||+|
|4||Wash hands with soap and water||92.6||94.1||+|
|5||IP Functioning with above 1, 2,3||46.1||68.3||P=0.0027|
Table 3 shows that practice of sterilization using functioning or boiling pot with cover is increased from 70.9% in 2004 to 92.1% in 2006. Similarly, disposal of sharp instruments and wastage properly remarkably increased from 46.2% in 2004 to 94.2% in 2006. The proportion of health institutions having punctured proof containers also increased from 90.9% in 2004 to 97.0% in 2006. Health workers who wash their hands with soap water are slightly increased from 92.6% in 2004 to 94.1% in 2006. Proportion of those health facilities who met all four criteria viz doing sterilization using functioning or boiling pot with cover, disposal of sharp instruments and medical wastage properly, having puncture proof container and washing hands with soap and water has significantly been improved from 46.1% in 2004 to 68.3% in 2006 which is also statistically significant. Training for health workers on infection prevention and supervision of health institutions are taken place for improving infection prevention. Supervisors from supporting partners are going to visit health facilities and giving supervision report including infection prevention which allowed taking action accordingly. Supplementary logistic supply and maintenance of equipments are also being done by supporting partners.7
Table 4. Maternal and Child Health Status over LQAS 2004 and 2006
|1||Contraceptive Prevalence Rate||41.1||42.1||+|
|2||% of women having 4 ANC by Health Workers||41.9||45.7||+|
|3||% of mothers who received iron tablets during last pregnancy||70.2||80.1||+|
|4||% of mothers who received Vita A during last pregnancy||45.1||55.1||+|
|5||Complete Immunization (Card+ history)||90.3||92.9||+|
|6||% of mother who fed breast milk within 1 hr during last natal period||24.1||31.3||+|
|7||% of mothers who received iron tablets during last PN period||32.4||37.7||+|
|8||% of delivery conducted by skilled health workers||38.0||43.4||+|
|9||% of delivery conducted by HA, AHW, TTBA, VHW||17.0||13.3||–|
|10||% of delivery conducted by health workers||52.5||56.7||+|
Table 4 shows that Contraceptive Prevalence Rate had slightly been increased from 41.1% in 2004 to 42.1% in 2006. Percentage of women having 4 ANC by Health Workers increased from 41.9% in 2004 to 45.7% in 2006. Percentage of mothers who received iron tablets during last pregnancy increased from 70.2% in 2004 to 80.1% in 2006. Similarly, percentage of mothers who received Vita A during last pregnancy also increased from 45.1% in 2004 to 55.1% in 2006. Practices of breast feeding also been improved. Percentage of mother who fed breast milk within 1 hour during last natal period increased from 24.1% in 2004 to 31.3% in 2006. Percentage of delivery conducted by health workers also been increased from 52.5% in 2004 to 56.7% in 2006. It is encouraging to note that proportion of delivery conducted by skilled health workers is increasing from 38.0% in 2004 to 43.4% in 2006.
This article explored mainly coverage of different services in Morang district. Coverage is the percentage of people in any given area (a catchments area or supervision area) who know of and/or practice a recommended health behavior or who receive a particular service. Measles coverage, according to DPHO/HMIS 2062/63 is reported as 91.0% which is found 93.0% in LQAS 2006. According to DPHO/HMIS 2062/63,8 CPR is reported as 69.6% which is found only 42.0% in LQAS 2006. SA 6 that is Letang, Jante, Bhogateni, Warangi, Kerabari, Pati, Yangsila, Singhadevi, Madhumalla, Tandi and Ramite VDCs are having comparatively poor CPR according to decision rule. According to DPHO/HMIS 2006, the percentage of women having four ANC by Health Workers is 41.9% which is found 45.7% in LQAS 2006. But, SA 6 has got comparatively poor coverage of fourth ANC visits as per decision rule. The percentage of mothers who received iron tablets during last pregnancy is 32.4% in LQAS 2004 which increased 37.7% in LQAS 2006. Similarly, the percentage of mothers who received Vita A during last pregnancy is 45.1% in LQAS 2004 which increased 55.1% in LQAS 2006. Complete immunization or measles vaccination is 92.9% which was traced by observing card and by taking history. SA 4 that is Indrapur, Dulari, Mrigaulia, Tetaria, Hattimudha, Siswani Badahara, Baijanathpur, Tanki, Lakhantari, Dangraha, Katahari and Siswani Jahada VDCs have got comparatively poor immunization coverage in the district. Delivery conducted by health workers is 52.5% in LQAS 2004 which increased 56.7% in LQAS. But, According to DPHO/HMIS 2062/63 it is only 23.0 percent. In Jhapa the delivery conducted by health workers was 21.8% in 20049 and 27.6% in 2006.10 In Sunsari the delivery conducted by health workers was 13.2% in 200411 and 31.0% in 2006.12
In Morang, the status of coverage of Public Health Programme is increasing year by year. The impact of the coverage has resulted positive result in child health by decreasing infant mortality rate.13 Supervision areas 4 and 6 are found comparatively weaker in achieving coverage. So, these areas draw attention of managers of district and community level institutions accordingly. Data those come from DoHS/HMIS14 and survey findings resemble regarding EPI and safe motherhood programmes. But, data remarkably varies regarding CPR and delivery conducted by health workers in district. It is often been raised some questions about under reporting of delivery conducted by health workers which is as low as 23.0% in ERHD/HMIS.15 Now, survey has discovered it as 56.7% deliveries conducted by health workers in Morang. Similarly, according to HMIS, Morang district has reported CPR as 69.6% which is also remarkably higher. But, CPR is only 42.1% found in the LQAS 2006. It might be due to proportion of CYP which is mainly occupied by VSC and of which most of the clients are coming from India and adjoining districts. However, findings of surveys have opened rooms for further assessment especially on the indicators as CPR and delivery conducted by health workers. Such type of LQAS surveys at regular interval are needed and to be institutionalized in district health system.
Authors appreciate with gratitude for the support provided by SCF (US) in conducting this study. Thanks also go to health workers from DPHO Morang and SCF District Field Office staff of Biratnagar involved in the study.
1 UNDP. Annual report on Human Development Index, 2001
2 DPHO/Morang. Report on Annual Review Meeting, 2060/61
3 DPHO/Morang. Report on EPI Micro planning in Morang district, District Public Health Office Morang, 2006
4 Valadez JJ, Weiss W, Leburg C, Davis R. A trainers Guide for Baseline Surveys and Regular Monitoring, NGO Networks, 2002
5 SCF. Lot Quality Assurance Sampling in Morang district Nepal, 2004
6 SCF. Field Report on PHC-ORC Reactivation Programme in Morang, 2005
7 NFHP. Field Report on Supervision of Morang District, 2005/2006
8 DPHO. Annual Report of District Public Health Office Morang, 2062/63
9 DPHO/Jhapa. Annual Report of District Public Health Office Jhapa, 2060/61
10 DPHO/Jhapa. Annual Report of District Public Health Office Jhapa, 2062/63
11 DHO/Sunsari. Annual Report of District Public Health Office Sunsari, 2060/61
12 DHO/Sunsari. Annual Report of District Public Health Office Sunsari, 2062/63
13 Subba NR. Assessment of Morang Innovative Neonatal Intervention, 2004
14 MoH/DoHS. Annual Report of Ministry of Health, Department of Health Services, 2061/62
15 ERHD. Annual Report of Eastern Regional Health Directorate Dhankuta, 2061/62.