Control of Diarrhea Diseases
1 BACKGROUND
Recognizing diarrhea diseases as one of the major public health problems among children under five in Nepal, the National Control of Diarrhea Diseases Program (NCDDP) has been accorded high priority status by GON and is an integral part of Primary Health Care.
Improvement in diarrhea case management has been used as a primary strategy for the reduction of mortality due to diarrhea among children under five years of age. Standard diarrhea case management are provided in the health institutions by establishing Oral Rehydration Therapy (ORT) corners in all Hospitals, Primary Health Care Centers, Health Posts and Sub Health Posts throughout the country. All health facilities and community health volunteers serve as the primary health service providers in the treatment of Diarrhea with Oral Rehydration Solutions (ORS) which is free of cost.
1.1 OBJECTIVES
The main objective of the National Control of Diarrhea Diseases Program (NCDDP) is to reduce mortality due to diarrhea and dehydration (from the estimated 30,000 deaths per year in the past) to a minimum, and to reduce morbidity from 3.3 episodes per child per year to a minimum.
1.2 TARGETS
1.2.1 To reduce the under-five mortality rate due to diarrhea by 50 percent by 2005/2006;
1.2.2 To reduce the under-five morbidity rate due to diarrhea by 20 percent by 2005/2006;
1.2.3 To increase the accessibility of Oral Rehydration Solution (ORS) to 100 percent of the population by 2005/2006;
1.2.4 To raise public awareness about the correct preparation and use of Oral Rehydration Solution in the treatment of diarrhea, and increase use of ORS by 20 percent by 2005/2006; and
1.2.5 To increase the proportion of caretakers that provides ORT for children with diarrhea to 40 percent by 2005/2006.
1.3 Indicators
| Main Indicators | Numerator and Denominator |
| 1. Morbidity rate due to diarrhea | Total diarrhea new cases in specified time x 1000 |
| Target population (under-fives) | |
| 2. Mortality rate due to diarrhea | Total number of diarrhea-related deaths x 1000 |
| Target population (under-fives) | |
| 3. Case fatality rate from diarrhea | Total diarrhea deaths per year x 1000 |
| Total diarrhea new cases in same period |
1.4 STRATEGIES
General Strategies
- 4.1 Establish functioning ORT Corners and replenish ORT Corner sets in each health facility in order to educate mothers/caretakers, to demonstrate proper ORS preparation, and to treat children suffering from diarrhea;
- 4.2 Increase access to Oral Rehydration Solution packets through FCHVs, SHPs, HPs, PHCCs, hospitals and commercial outlets;
- 4.3 Raise public awareness;
- 4.4 Promote specific preventive measures through communication and information activities;
- 4.5 Involve Community Health Workers including the volunteers (VHWs, MCHWs and FCHVs), District Development Committee (DDC) and VDC members, local NGOs and local decision-makers;
- 4.6 Apply an integrated child health package including the CDD, EPI, Nutrition, Acute Respiratory Infection (ARI) and Malaria programs; and
- 4.7 Emphasize program management at all health facilities.
Strategies for Tenth Five Year Plan
- 4.8 Train all levels of health workers including VHWs/MCHWs/FCHVs/community leaders;
- 4.9 Orient community opinion leaders, VDC members, faith healers;
- 4.10 Supply Oral Rehydration Solution to all health institutions;
- 4.11 Supply Oral Rehydration Solution to all FCHVs;
- 4.12 Develop health education materials (including development and printing of IEC materials) to be used by mothers, FCHVs, and through channels of radio and TV communication;
- 4.13 Promote supervision and monitoring at all levels; and
- 4.14 Promote "Knowledge, Attitude and Practice" (KAP) on CDD among health workers, mothers and FCHVs
2 ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES
2.1 ACTIVITIES CARRIED OUT IN FY 2062/63 (2005/2006)
2.1.1 Planning
- District-level planning and orientation was conducted for District Health Officers (DHOs), Public Health Officers (PHOs), and other health personnel including DDC members and local decision makers in Sankhuwasabha, Sindhuli, Udayapur, Gorkha, Parbat, Kapilvastu, Surkhet and Jumla districts.
2.1.2 Supply of ORS
- 2,500,000 sachets ORS purchased and distributed to the districts.
2.1.3 Communication and Training Materials
- Revised and finalized training materials and printed through WHO and GoN.
2.1.4 Transportation
- Supply of IEC materials regarding CDD to districts as requested.
2.1.5 Monitoring and Supervision
- Supervision from center and region to districts accomplished
- Supervision from district to PHCC, HP/SHP as per schedule done
2.1.6 Epidemic Control
- Financial support to all districts provided where epidemic occurred
2.2 TARGETS vs. ACHIEVEMENT, FY 2062/63 (2005/2006)
| S.
No. |
Activities | Unit | Targets | Achievement | Targets vs.
Achievement (percent) |
| 1. | Purchase of ORS | Pkts. | 2,500,000 | 2,500,000 | 100 |
| 2. | Printing of IMCI Register | Pcs. | 1,500 | 1,500 | 100 |
| 3. | Printing of Mothers' Card | Sheets | 10,000 | 10,000 | 100 |
| 4. | Printing of CB-IMCI Training Materials | Pcs. | 2,800 | 2,800 | 100 |
| 5. | CB-IMCI Drugs | freq | 1 | 1 | 100 |
| 6. | Counselling Service (CB-IMCI Program for 10 Districts) | freq | 2 | 2 | 100 |
| 7. | Treatment of <5 Diarrhea Cases | Cases | 628,573 | 739,915 | 100 |
Source: HMIS/MD & IMCI Section/CHD, DoHS
As can be seen from the above table, all CDD targets were achieved satisfactorily during FY 2062/63. The overall achievement was 100 percent.
Table 2c.1 ORS Supply, Three-Year Comparison, FY 2060/61 to 2062/63
| Year | Targets | Achievement | Achievement percent |
| 2060/61 2003/2004 | 2,000,000 | 2,000,000 | 100% |
| 2061/62 2004/2005 | 2,000,000 | 2,000,000 | 100% |
| 2062/63 2005/2006 | 2,500,000 | 2,500,000 | 100% |
Source: IMCI Section/CHD, DoHS
Table 2c.1 shows the trend of Oral Rehydration Solution supply to the districts from FY 2060/61 to 2062/63. The CDD program provided ten packets of ORS to each FCHV according to the CDD National Policy. Those ten packets were replenished whenever FCHVs used all on treatment of diarrhea in under-five children. During the FY 2060/61, 2061/62 and 2062/63 the target vs. achievement was 100 percent. Figure 2c.3 and Table 2c.1 for FY 2062/63 is based on the report received from the Finance Section, DoHS.
2.3 ANALYSIS OF SERVICE STATISTICS
Table 2c.2 below shows the decreasing trend in the number of diarrhea visits for the last two years compared to FY 2060/61. In FY 2062/63, the total number of diarrhea visits decreased remarkably in comparison to FY 2060/61 and 2061/62. Diarrhea deaths in FY 2062/63 have decreased by 66.4% in comparison to FY 2061/62 and 57.7% to 2060/61. The national reported incidence of diarrhea per 1,000 among children under five years also decreased in FY 2062/63 in comparison to FY 2060/61 and 2061/62. The reported incidence of diarrhea at the regional level also decreased in all the development regions. At national level, the case fatality rate has decreased significantly (0.11/1,000) in the FY 2062/63 compared to FY 2060/61 and 2061/62. The reason for this decreasing trend in the visits for diarrhea, deaths and incidence and case fatality rate may be due to rapid expansion of CB-IMCI Program.
Table 2c.2 Incidence of Diarrhea, by Region, FY 2060/61 to 2062/63
| Indicators | Year | Region | National | |||||
| EDR | CDR | WDR | MWDR | FWDR | ||||
| Total <5 Populationfor CDD/ARI | 2062/63 | 796,079 | 1,202,989 | 725,133 | 524,860 | 384,625 | 3,633,687 | |
| Total diarrheaVisits | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
234,206
230,320 221,757 |
253,588
249,003 229,268 |
121,327
128,644 113,459 |
103,451
106,297 104,234 |
74,522
71,072 71,197 |
787,094
785,336 739,915 |
| Total diarrheaDeaths | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
23
24 11 |
50
56 20 |
26
20 3 |
63
107 39 |
32
37 9 |
194
244 82 |
| Incidence ofdiarrhea /1,000<5 yrs. Popn. | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
302
294 279 |
216
209 191 |
171
179 156 |
202
205 199 |
199
187 185 |
222
219 204 |
| Case Fatality Rate/ 1,000<5 yrs. Popn. | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
0.1
0.1 0.05 |
0.2
0.2 0.09 |
0.2
0.2 0.03 |
0.6
1.0 0.37 |
0.4
0.5 0.13 |
0.2
0.3 0.11 |
Source: HMIS/MD, DoHS
Figure 2c.4 shows the three-year trend of reported diarrhea incidence per 1,000 under-five children. At the national level during FY 2062/63, incidence of diarrhea decreased slightly, (204 per 1,000) compared to FY 2060/61 and 2061/62. At regional level also diarrhea incidence has decreased in all regions in FY 2062/63 in comparison to FY 2060/61 and 2061/62.
Figure 2c.5 shows the three-year trend of reported diarrhea deaths. In FY 2062/63 the total number of diarrhea deaths decreased by 66.4% in comparison to FY 2061/62 and by 57.7% compared to FY 2060/61. Similarly, at regional level also the diarrhea deaths decreased by more than 50 percent in comparison to FY 2060/61 and 2061/62. Amongst the five development regions the highest number of diarrhea deaths occurred in the MWDR (39) followed by CDR (20) and the lowest number occurred in the WDR (3) in FY 2062/63.
Table 2c.3 Classification of Dehydration, by Region, FY 2060/61 to 2062/63
| Indicators | Year | Region | National | |||||
| EDR | CDR | WDR | MWDR | FWDR | ||||
| Total cases | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
234,206
230,320 221,757 |
253,588
249,003 229,268 |
121,327
128,644 113,459 |
103,451
106,297 104,234 |
74,522
71,072 71,197 |
787,094
785,336 739,915 |
| No Dehydration Cases | 2060/61 | 2003/04 | 110,764
47.3% |
146,966
58.0% |
80,141
66.1% |
63,918
61.8% |
47,726
64.0% |
449,515
57.1% |
| 2061/62 | 2004/05 | 114,888
49.9% |
155,256
62.4% |
88,256
68.6% |
66,137
62.2% |
46,449
65.4% |
470,986
60.0% |
|
| 2062/63 | 2005/06 | 127,884
57.7% |
154,586
67.4% |
81,938
72.2% |
68,062
65.3% |
48,660
68.3% |
481,130
65.0% |
|
| Some Dehydration Cases | 2060/61 | 2003/04 | 118,086
50.4% |
100,715
39.7% |
38,760
31.9% |
34,921
33.8% |
24,812
33.3% |
317,294
40.3% |
| 2061/62 | 2004/05 | 111,610
48.5% |
89,176
35.8% |
38,038
29.6% |
35,144
33.1% |
22,876
32.2% |
296,844
37.8% |
|
| 2062/63 | 2005/06 | 91,701
41.4% |
72,407
31.6% |
30,199
26.6% |
33,113
31.8% |
21,297
29.9% |
248,717
33.6% |
|
| Severe Dehydration Cases | 2060/61 | 2003/04 | 5,356
2.3% |
5,907
2.3% |
2,426
2.0% |
4,612
4.5% |
1,984
2.7% |
20,285
2.6% |
| 2061/62 | 2004/05 | 3,822
1.7% |
4,571
1.8% |
2,350
1.8% |
5,016
4.7% |
1,747
2.5% |
17,506
2.2% |
|
| 2062/63 | 2005/06 | 2,172
1.0% |
2,275
1.0% |
1,322
1.2% |
3,059
2.9% |
1,240
1.7% |
10,068
1.4% |
|
Source: HMIS/MD, DoHS
Table 2c.3 shows the classification of dehydration by region over the last three years. CDD reactivation, CBAC, and IMCI programs had positive impact on the skill and knowledge of health workers, enabling them to better identify various categories of classifications and treat them appropriately. Because of their better skill and knowledge, more cases are gradually being classified as 'No Dehydration' and less cases as 'Some Dehydration'. Also because of increased awareness among caretakers, cases of diarrhea in children are brought to health facilities at an earlier stage. At the national level cases of 'Severe Dehydration' has gradually declined (2.6 percent, 2.2 percent and 1.4 percent) during the three fiscal years. This decline in severe dehydration is observed in all regions in comparison to FY 2060/61 and 2061/62.
Table 2c.4 Treatment of Diarrhea Diseases, by Region, FY 2060/61 to 2062/63
| Indicators | Year | Region | National | ||||||
| EDR | CDR | WDR | MWDR | FWDR | |||||
| Total cases | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
234,206
230,320 221,757 |
253,588
249,003 229,268 |
121,327
128,644 113,459 |
103,451
106,297 104,234 |
74,522
71,072 71,197 |
787,094
785,336 739,915 |
|
| Treated withORS | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
192,352
188,410 176,215 |
233,303
230,052 212,912 |
114,664
121,641 107,050 |
88,973
89,188 89,267 |
67,968
64,540 63,727 |
697,260
693,831 649,171 |
88.6%
88.3% 87.7% |
| Treated withIV fluid | 2060/612061/622062/63 | 2003/04
2004/05 2005/06 |
5,637
4,266 2,599 |
6,309
5,645 3,404 |
3,863
4,017 2,527 |
5,810
6,185 4,306 |
2,812
2,730 1,449 |
24,431
22,843 14,285 |
3.1%
2.9% 1.9% |
Source: HMIS/MD, DoHS
Table 2c.4 shows that, at the national level over the three fiscal years, treatment by IV fluid is gradually decreasing, whereas the percentage of ORS treatment in all three fiscal years remained almost the same. In FY 2062/63 1.4 % of cases were diagnosed as severe dehydration where as 1.9% were treated by IV Fluid. But this has been gradually improving over the years.
Figure 2c.6 shows a consistent seasonal variation in total diarrhea visits over the last three years. Increases in diarrhea incidence starts from the month of Falgun and continues till Jestha, and then starts declining gradually. This sort of seasonal variation was observed during the last three fiscal years.
2.4 Recommendations
Based on field experience, the following strategies are to be improved and should be continued for a successful and effective implementation of program.
- A) Strategies to be modified
- IMCI approach
- Extension of community-based IMCI to FCHV and VDCs
- Decentralized planning to promote district-level commitment and a feeling of program ownership and responsibility for effective program implementation
- Central level facilitators should be made available for each district-level training as well as for community-level program monitoring
- Focus on program management without neglecting case management
- B) Strategies to be improved
- Training allowances for VHWs, MCHWs, and FCHVs to be revised according to the level of status and allocated in central-level budget planning
- FCHVs to be supervised/recognized by all levels to maintain high motivation
- Motivation and follow-up mechanisms to be developed for VDCs to support FCHVs
3 PROBLEMS/CONSTRAINTS AND ACTIONS TO BE TAKEN
| S. No. | Problems/constraints | Action to be taken | Responsibilities | Deadline |
| 3.1 | Inadequate ORS in some districts | Increase budget for ORS for some districts. | CHD | As soon as possible |
| 3.2 | Inadequate budget for epidemics of diarrhea. | Strict management and discipline over proper use of epidemic budget and increase budget. | DHO/RHD and CHD | As soon as possible |
4 TARGETS FOR FY 2063/64 (2006/2007)
| S. No. | Activities | Unit | Annual Targets | Budget Rs.'000 |
| 1 | ORS purchase | Pkts. | 2,500,000 | 11,000 |
| 2 | Treatment of <5 diarrhea cases | Cases | 628,573 | 1,177 |
Source: IMCI Section/CHD, DoHS
Note: For detailed, district-specific data and analysis on this program/project, please refer to the annexes in this document.
