Sooner or later, every man in Australia runs into problems with impotency buy viagra australia like other bodily functions, must be in order.

Microsoft word - lab assessment report,final.doc


Comprehensive Capacity Assessment of Health Laboratory Services in Nepal National Public Health laboratory and WHO-Nepal Page 1 of 62
Comprehensive Capacity Assessment of Health Laboratory Services in Nepal Dr. Palpasa Kansakar, Ph.D. (Microbiology) Mr. Binod Kumar Yadav, M.Sc (Biochemistry) Mr Krishna Rijal, CMLT Page 2 of 62
ACKNOWLEDGEMENT
National Public Health Laboratory
Dr. Geeta Shakya, Chairperson, Director, NPHL and all staff at NPHL WHO Nepal
Dr Lin Aung, WR, WHO-Nepal Dr. Nihal Singh, Medical Officer, CDS unit, WHO-Nepal and his team Dr. Prakash Ghimire, National Professional Officer Malaria & BLT, WHO-Nepal Mr Sushil Shakya for developing database platform for data entry and analysis All the laboratories that provided information for the study All those who provided valuable inputs during field visits and finalize and accomplish this Page 3 of 62
ACRONYMS
-Academic Organization Based - Central Development Region - Central Hospital Based - District Hospital - District Public Health Office - Eastern Development Region - Enzyme Linked Immuno-adsorbent Assay - External Quality Assurance Scheme - Far-Western Development Region - International Health Regulation - Immunization Preventable Disease - Internal Quality Control - International Organization for Standardization -Laboratory Information Management System - Millenium Development Goal - Ministry of Health and Population - Mid-Western Development Region -National Influenza Center - National Public Health Laboratory -National Reference Laboratory - National Tuberculosis Center - Out-Patient Department -Private Hospital Based - Primary Health Care - Quality Assurance - Quality Control - Quality Management System - Regional Hospital Based - Sub-regional Hospital Based - Standard Operating Procedures - Walter Reed Afrims Research Unit Nepal - Western Development Region - World Health Organization - Zonal Hospital Based Page 4 of 62
CONTENTS
Particulars
1. Introduction and background 7. Recommendations Page 5 of 62
LIST OF TABLES
Table 1: Number and Types of Government laboratories assessed……………………… 14
Table 2: Number and Types of Private laboratories assessed……………………………. 15
Table 3: Types of Government labs assessed in the five development regions….……….16
Table 4: Types of Private labs assessed in the five development regions……………….16
Table 5: Number and categories of Staff at different levels of Government laboratories.19
Table 6: Number and categories of Staff at different levels of Private laboratories…….19
Table 7: Comparison between Private and Government Laboratories…………………. 26
Page 6 of 62
1. Introduction and Background
Nepal remains among the least developed countries in the world with almost one-third of its population living below the poverty line (Ministry of Finance, 2006) of its 29.3 million populations. The per capita income is around $427 (World Bank, FY 2009) in 2009 per year. The life expectancy rate for male and female is 60.1 and 60.7 respectively (Census 2001). The highest risk group for poor health are children under five (particularly girls) and females of reproductive age. Three main factors that impact state of health in Nepal are its high rate of poverty, illiteracy, and its physical geography. Literacy of the people contributes to the health status of a population as preventive health care measures, control of communicable diseases, and nutritional programs are based on the education levels of a population. Other major problem with health issues in Nepal is the geography and lack of infrastructure in Nepal. With 80% of the people living in rural areas, there is a lack of distribution not only of medicine and medical supplies, but other health-care needs also. Millions of people are at risk of various infections and thousands die every year due to communicable diseases, malnutrition and other health-related factors, especially people living in rural areas. Diagnostic Laboratories hold an important role in any health care system. Laboratory diagnosis is essential for generating evidence based data for diagnosis and treatment of diseases, in the surveillance works at public health level and disease management at institutional or central level. Nepal's healthcare system consists of laboratories involved in diagnostic services as well as those involved in public health activities (surveillance, research, regulatory). The history of diagnostic laboratory services in Nepal is nearly half a century old. In a developing country like Nepal, owing to limited resources and economic constraints, laboratory services used to be considered of less priority resulting into inadequate infrastructure, human resource capacity and technologies. However, with time as per the growing need, now services have been expanded from National and Central level reference laboratories to Primary Health Care (PHC) level laboratories in the Government sector. At present, there are 198 PHC based laboratories, 68 District Hospital based laboratories, 11 Zonal Hospital based laboratories, 2 Sub-Regional Hospital based laboratories, 3 Regional Hospital based laboratories, 8 Central Hospital based laboratories and 1 National level laboratory in the Government sector. In addition, there are approximately 1500 Page 7 of 62
diagnostic laboratories operating in the private sector. Along with rapid increase in the number of health laboratories in the country, the demand for the need for quality services has also been increasing. For laboratory services to be valuable, they must be easily accessible and able to provide accurate and reliable results in time. The current threat of emergence of various infectious diseases in Nepal and its neighboring countries also demands for improving laboratory capacity to allow accurate and reliable diagnosis and epidemic preparedness. Laboratory service has also been identified as the 8th core capacity of International Health Regulations (IHR) that countries must develop for the implementation of IHR. While developed countries easily adapt their well organized routine laboratory services to the international standards, resource-limited countries need considerable capacity building to meet the requirements. As part of Government commitment towards IHR 2005, for which the Government of Nepal is a signatory, it demands upgrading the existing health-care services in Nepal and making them accessible and reliable to those in need. Accurate and appropriate diagnostic testing is also recognized as a strategic need to improve global health and to reach Millennium Development Goals (MDG). The current state of laboratories in Nepal face challenges for functional and quality laboratory services in terms of human capacity, physical infrastructure and lack of well established norms for laboratory policy. There is no specific legislation for registration, renewal, quality monitoring, and regulatory authority for health laboratories in Nepal. National Public Health Laboratory (NPHL) under Department of Health Services has been nominated by ministry of Health and Population (MoHP) in accordance with the eighth five year plan and the health policy of Nepal (1991), as a national nodal/ coordinating laboratory in Nepal. NPHL has been acting as a referral center for various specialized laboratory services and a focal point to coordinate laboratory related activities throughout the country. The strategies of the NPHL are to establish health laboratory services upto PHC level of health care facilities, strengthening of Zonal Hospitals, District Hospitals, and PHCCs laboratories; introduction of new tests according to the needs of clinicians, to improve overall quality control of all health laboratory services; to ensure sufficient laboratory supplies according to the requirement of health institutions; to ensure that sufficient mid-level manpower has been selected and trained for laboratory work. NPHL under the directives of MoHP is also involved in taking initiatives for development and implementation of Page 8 of 62
necessary program for enabling laboratories in disease diagnosis and surveillance in the Health Laboratory service needs constant upgrading and modernization to meet international standards, to comply with international health regulations and to meet the emerging needs to tackle diagnostic issues for emerging and re-emerging diseases. For a developing and resource limited country like Nepal directly targeting to achieve the international standard may be easier said than done. Hence the capacity building efforts should first promote to achieve a basic national level standard that must be met mandatorily by each level of laboratory which would subsequently aim to better meet the milestones of international standards and implementation of the 2005 IHR. In Nepal, though the number of diagnostic laboratories has increased with time, a comprehensive baseline data covering their organizational, managerial and technical aspects is still lacking. In order to upgrade the capacities of diagnostic laboratories, it becomes important to assess the existing laboratory capacities for their basic infrastructures, technical competency, existing human resources and the diagnostic services offered. Information on the baseline status of these diagnostic laboratories will help to categorize the laboratories and ultimately guide to set up a national standard for each level of laboratories. This will eventually help to identify the existing gaps to meet the set national level standards and devise capacity building strategies accordingly. Moreover, it is also important to ensure that the recommendations and the minimum standard are fulfilled by all levels of laboratories so that individuals and communities will benefit from improved laboratory services. This calls for establishment of appropriate regulatory and legal support structures that gives rights to the relevant stakeholders and a firm commitment by Government to effectively implement strategies for strengthening health laboratory services. This includes developing a national laboratory policy and strategic plan; defining managerial and regulatory mechanisms; and establishing the required support services within the context of each country. In Nepal, there is no national laboratory policy and many issues including laboratory licensing procedures, authorized regulatory body in laboratory system etc remain unclear. The approach to establishing an effective national health laboratory service also requires addressing essential services at each level, including clinical and public health needs, required resources, staffing, equipment and supplies. A detailed countrywide capacity analysis to determine the current status of the health laboratory services and requirements will also provide a basis for establishment of a national health laboratory policy and Page 9 of 62
development of a long-term national health laboratory plan outlining priorities and timelines. NPHL thus proposes to assess the capacities of diagnostic laboratories in Nepal. For this, NPHL targets to assess information from laboratories in the Government sector and private sector located in major cities of all the five development regions of Page 10 of 62
2. Objectives

The study was carried out with the following objectives:
a. To conduct need assessment for the major diagnostic laboratories as of 2012. b. To compare health care laboratories from both Government and private sectors. c. To devise a national standard for each category of lab and identify the existing gaps d. To devise recommendations for fulfillment of the existing gaps and support strengthening of diagnostic laboratory capacity in the country. Limitations of the study
1. The study collected questionnaire based data from 203 Laboratories situated in 16 major cities of the five development regions of Nepal. Laboratory selection in the study was based on to represent all levels of laboratories in both Government and Private sectors. But due to limitation of resources and time constraint, and the abrupt mushrooming of health care laboratories throughout the country in absence of a proper regulating mechanism, the study could not encompass all the laboratories providing diagnostic services. 2. Responses to some questions in the questionnaire such as sufficiency of necessary equipments, staffs for operation were entirely based on perception of respondents and the interviewers. 3. Supporting literature in relation to the study was not properly available. 4. Responses to some questions could not be produced by respondents due to lack of proper documents or records. Page 11 of 62
3. Methodology
This study is a first of its kind in Nepal to encompass health care laboratories in both Government and Private facilities for their capacity assessment. The assessment team comprising three Consultants (Dr. Palpasa Kansakar, Mr Binod Yadav and Mr. Krishna Rijal) was formed to perform comprehensive assessment of the health care laboratories in Nepal. This team worked in close coordination with Director NPHL, and NPO/ BLT, WHO Nepal during the assessment period. 3.1 Pre-visit Activities:
The following activities were undertaken before on-site visits to the laboratories by the 1. Identification of major cities throughout the country: The study team after
consultation with the Director NPHL and NPO/BLT, WHO, identified 16 cities situated in 10 zones to conduct the surveillance. These comprised of 2 cities; Biratnagar and Jhapa from Eastern Development Region (EDR), 7 cities; Kathmandu, Lalitpur, Bhaktapur, Chitwan, Makawanpur, Birgunj and Janakpur from Central Development Region (CDR), 3 cities; Pokhara, Bhairahawa and Butwal from Western Development Region (WDR), 2 cities; Nepalgunj and Surkhet from Mid Western Development Region (MWDR), 2 cities; Mahendranagar, Dhangadi from Far Western Development 2. Selection of healthcare laboratories for assessment
The laboratories situated in the aforementioned locations were selected for the study to include: 1. All National level laboratories in Government Sector 2. All Central/ Regional/ Zonal/ District hospital based laboratories in Government Sector 3. 25% of Primary Health Care (PHC) based laboratories in Government sector 4. 25% of District Public Health Office (DPHO)/District Health Office (DHO) based laboratories in Government sector 5. 50% of Academic Organization based laboratories in Private Sector 6. 50% of Private Hospitals /Nursing homes with more than 50 beds 7. 25% of Private Hospitals /Nursing homes with 50 beds or less 8. 25% of Independent Private laboratories (private clinic/ polyclinic/ medical center/pharmacy based) in Private Sector 3. Development of study questionnaire: A study questionnaire tool was developed by
the consultants under the direction of Director NPHL and NPO/BLT to ensure that the Page 12 of 62
questionnaire addressed various aspects including management and organization of laboratories, basic infrastructure, and human resource, test services offered, quality assurance and management of laboratory waste (Study Questionnaire in Annex I).
3.2. Field Visit and data collection

a. The team surveyed 203 laboratories (Details in Annex II) located in 17 districts of Nepal using the aforementioned tool. The data/information from the laboratories was gathered by on-site observation visit by the consultants and verification of the filled information was done through personnel interview of the available staff. b. Three collection centers (that collect patient samples and refer to laboratories elsewhere outside the country for laboratory diagnosis) were also assessed during the study to gather qualitative information on their available facilities (such as sample storage facility, laboratory equipments), sample transport practices, registration and approval received for shipping of samples out of c. The respondents to the questionnaires were as follows: • Pathologists/Microbiologists/Biochemists • Medical laboratory technologists • Medical laboratory technician • Laboratory assistant 3.3 Data Analysis and Report writing
Data entry was done using the Access program made available by WHO Nepal and the analysis was done using SPSS program and Microsoft Excel. Analyzed data were tabulated and presented into narrative report form. Page 13 of 62
5. Findings
5.1 General Information of the laboratories assessed
There are 240 laboratories (National reference laboratory; 1, Central hospital based (CHB); 6, Regional hospital based (RHB); 3, Sub-regional hospital based (SRHB); 2, Zonal hospital based (ZHB); 10, District hospital based (DHB); 68 and PHC based; 148 in the Government sector in Nepal. The detail list of Government organization based laboratories is listed in Annex III. There are a large number of laboratories in private sector, two of which are based in Private Hospital that have been categorized as central Hospital (Patan Hospital and Tribhuvan University Teaching Hospital, TUTH). Exact numbers of private laboratories are not known. However, it is estimated to be around 2000. In Kathmandu alone, there are around 500 laboratories. A total of 203 laboratories across the country were assessed in the study. The detail list of these laboratories is tabulated in Annex II. Of the 203 laboratories, 55 (27.5%) were government and 148 (72.5%) were private facilities. The number and categories of these laboratories are tabulated in tables 1 and 2. The categories of the clinical laboratories in Nepal were leading by independent private clinic/polyclinic based laboratories followed by private hospital based laboratories. In the Government sector, in 9 laboratories the laboratory supervisors/heads were pathologists, medical technologists in 10 laboratories, laboratory technicians in 16 laboratories and laboratory assistants in 19 laboratories. Similarly in the Private sector, 34 labs were under the charge of pathologists, 59 under medical technologists, 28 under laboratory technicians and 27 under laboratory assistants. The categories of these laboratories are presented in tables 1 & 2. Table 1: Number and Types of Government laboratories assessed
No. of labs with Head/Incharge as
Laboratory Categories
Laboratory
Laboratory
Assessed
Pathologist
technician
assistant
Reference laboratory Central Hospital Army/Police Hospital Regional Hospital Sub-regional Hospital Zonal Hospital based District Hospital based Page 14 of 62
Other Govt. Facility PHC based laboratory No. of Govt. labs assessed Table 2: Number and Types of Private laboratories assessed
Number of labs with Laboratory Head/In-charge as
Laboratory Categories
Assessed
Med Technologist/
Lab assistant
technician
specialist
Central Hospital (Pvt.) Based Reference Laboratories Academic Organization based Private Hospital based (100 Private Hospital based (50- Private Hospital based (<50 Independent labs based at private clinics/polyclinics Total number of Private laboratories 5.2 Geographical distribution of the laboratories:
Nepal is divided into five development regions; the Eastern Development Region (EDR), the Central Development Region (CDR), the Western Development Region (WDR), the Mid-Western Development Region (MWDR), the Far-Western Development Region(FWDR). Each region is further subdivided into zones and districts. The capital city Kathmandu is located in the Central Region. This study covered laboratories located in all five development regions, ten zones (Mechi, Koshi, Janakpur, Bagmati, Gandaki, Narayani,Lumbini, Bheri, Seti, Mahakali) and seventeen districts (Jhapa, Morang, Dhankuta, Kathmandu, Bhaktapur, Lalitpur, Makawanpur, Chitwan, Parsa, Dhanusa, Mahottari, Kaski, Rupandahi, Surkhet, Banke, Kailali, Kanchanpur). Region wise analysis showed that of the 203 laboratories, 120 were located in the Central Development Region (CDR), 19 in the eastern development region (EDR), 28 in the Western Development Region (WDR), 21 in the Mid-Western Development Region (MWDR) and 15 in Far Western Development region (FWDR). The categories of different laboratories in these regions are listed in tables 3 and 4. Page 15 of 62
Table 3: Region-wise distribution of Government facility based labs
No. of labs in Government sector
Table 4: Region-wise distribution of Private facility based labs
No. of labs in Private sector
(50 - <100 beds) 5.3 Management and Organization
All government laboratories under MOHP are registered Government organizations. Of the 55 Govt. laboratories, all reported that they are inspected/monitored by higher level authorities such as NPHL, authorities from health ministry, district health office, regional directorate. Among the private laboratories, the ones based at Private Nursing Homes and Academic Institutions were registered when the hospital/institution got approval. These organizations underwent inspection by health ministry, Nepal Medical Council for the approval before they got functional. For the majority of the private clinic based/independent laboratories, the registration or licensing process was not in place. Most of these categories of laboratories (>90%) only had Pan- number (registration at company registrar) and were operational without any inspection from technical team. There is regular Page 16 of 62
monitoring and supervision of Government laboratories, where as most private labs reported that there is no periodic monitoring in these labs. All government laboratories are supported by Government budget (regular budget) while some labs also have development budget (Bikas samiti). However, the percentage of support from the regular budget and/or cost recovery was not clear cut. Some Government laboratories such as NPHL, NTC also receive support (technical/financial) from external sources. NPHL receives financial and technical assistance from WHO/Nepal, Global fund while NTC receives support from WHO, Global fund, SNL Gauting (Germany), Norwegian Health Foundation. Among Private labs, CHB labs (TUTH and Patan Hospital) and some missionary private hospital based labs (AMDA, Rotarian International, Tilganga Eye Center) also receive external support such as from Japanese International Cooperation Association (JICA), Rotary International, USAID/Fred Hollows Foundation etc. Other private laboratories (private hospital based and independent private labs) operate on 100% cost recovery basis. Official working hours for Government labs are 6-7 hours on the working days (6 days a week). In addition to the normal office hour service, the hospital based laboratories give 24 hours service in the form of on-call/ emergency service. Independent private labs operate throughout the week offering 11-23 hours service. Government labs (RHB, ZHB, DHB, PHCB) reported that they procure equipment and lab supplies both centrally (though NPHL or other higher level authorities) and locally. The NPHL has the responsibility to supply public health laboratories at PHC and District level with major equipment and in-house prepared laboratory reagents. Supplies are ordered through tenders and distributed on needs basis. There is annual procurement system in such labs though some smaller items/consumables are also purchased whenever needed. In DPHO based labs the reagent procurement is every 3-6 months. In most private labs, equipments and reagents are procured only when needed, thus different kits/reagents may be used for a particular test in a year. 5.4. Basic infrastructure, facilities and human Resources
Government laboratories including NPHL, CHB, RHB, ZHP and DHB facilities reported inadequate working (laboratory) space. NPHL spanned in around 10 ropanies of land with three buildings. CHB, RHB, SRHB and ZHB labs were part of the large hospital structure and occupying 2- 9 rooms for laboratory work. Almost all DHB, DPHO based and PHC based Government laboratories were functioning in one room. Of the 55 Government Page 17 of 62
Laboratories, only 23 (42%) had separate room for sample collection. The building condition of most Government laboratories needed refurbishment and level of cleanliness were not satisfactory. Facilities such as access to continuous water supply, power supply, and telephone service were available in almost all Government laboratories (>90%), while computer and internet access were present at only 20(36%) and 15(27%) of the centers Of the 148 private labs assessed, 27 (18%) labs including 15 AOB, 2 Private reference labs and 10 PHB labs were functioning at a comparatively larger space (around 1000square feet or more) occupying 2-15 rooms or a separate building, and possess separate room for sample collection. The building condition of majority of the AOB labs was good. In contrast to this, around 20% of private hospital based labs did not have adequate space and poor building condition. Among independent private laboratories, 41(65%) did not have adequate space with respect to their work load, operating in a single room and did not have separate space for sample collection. Power back up either using generator or inverter were reported by majority (>95%) of the labs. In most of these labs, the back up system did not cover uninterrupted power supply to all laboratory equipments, but were used only to complete the tests already run. All Government laboratories reported shortage of staff, while in contrast to this most (68%) private laboratories reported that the existing number of staff were sufficient for their work. Human resources at different categories of Government Laboratories are shown in table 5. In 19 (35%) Government laboratories (PHC and DPHO based), there were only one staff to look after laboratory which seemed inadequate. Hence, alternatives in situations when the recruited staff is unable to come to work should be sought. Among private laboratories, the academic organization based labs had the highest number of staff with subject experts (academic staff) also supervising in different fields of laboratory medicine. Among private hospitals, pathologists were available in 30 centers and medical technologists in 52 centers. Five PHB labs (outside Kathmandu valley in WDR, MWDR and FWDR) had only Lab assistant level of technical staff. Among private clinic/polyclinic based labs, pathologists and medical technologists were present in only 4(6%) and 23(37%) centers respectively. Around 40% of the private independent labs had only Lab assistant level of technical staff. Human resources at different categories of Private Laboratories are shown in table 6. Page 18 of 62
Table 5: Number and categories of Staff at different levels of Government labs
Number of staff at
Other Govt
Level lab
Pathologist
subject experts
Medical Technologist
Lab Technician
Lab Assistant
Other Supportive
Table 6: Number and categories of Staff at different levels of Private labs
Number of staff at
Pvt. Hosp.
Pvt. clinic/ polyclinic
Pvt.CHB lab
Pvt. Ref Lab
Based ( 66)
based (63)
Pathologist
subject experts
Medical Technologist
Lab Technician
Lab Assistant
Supportive staff
5.5 Laboratory Equipments
Equipments of various models and levels of sophistication such as from basic electric microscope (available in all the labs assessed) to PCR thermal cycler and gene sequencer were observed among the labs analyzed depending upon the categories and volume of tests offered. Almost all the labs contain one or more equipments in non- functional or not in use status. There exists an equipment checklist that is being used by NPHL for its routine monitoring and supervision activities which has listed the minimum Page 19 of 62
equipment requirements for various categories of Government laboratories. Minimum equipment requirement for independent private labs based on tests offered does not exist. When this was used as a reference for comparison, more than 90% of the labs did not meet the minimum equipment requirement criteria, especially absence of safety hood/ a closed containment hood which is required for working with BSL level 2 and above organisms for culture, AFB smear preparation etc and needle destroyer. Absence of basic laboratory equipments like hot air oven, autoclave and refrigerators were noted in 33(16%), 47(23%) and 13(6%) labs respectively, belonging to PHC/DPHO based or private independent lab 5.6 Specimen collection and Handling
Almost all laboratories providing routine diagnostic services have test requisition form and in majority (65%) of the labs, 100% samples are collected in the lab complex. Only around 50% of the labs reported that they obtain patient information such as clinical data, specimen source, date of collection and the type of test requested. All laboratories receive specimen that are labeled with patient's identifiers and after arrival in the laboratory, they are given lab numbers. All laboratories keep a record of specimens received for diagnostic testing and manual entry of collected information and handwritten test results on the format designed by the laboratory is practiced by most(86%) laboratories. Almost 50 % of the laboratories reported that they refer slides, clinical specimen to other centers such as NPHL, NTC, other private reference labs for QC, more confirmatory tests and other specialized tests that are not available in their laboratory setting. 5.7 Services offered by the laboratories
Government facilities
National Public Health Laboratory NPHL has the following specialized units:
Histo/Cyto- pathology, Haematology, Biochemistry, Parasitology, Bacteriology, Histology, Immunology, Virology, Coagulation, Registration & OPD Collection which provide routine diagnostic service. In addition, NPHL is also involved as a reference center/lab and has separate units for • Supervision, Monitoring and Supply of Reagents and Equipment to of Public Health • Training/Refresher Training for Medical Laboratory personnel • Quality Assurance Program Page 20 of 62
• Laboratory based surveillance of antimicrobial resistance • Reference laboratory for Japanese encephalitis, measles, rubella other Immunization preventable diseases (IPD) • National Influenza Center (NIC) • Maintenance (Biomed engineer) Section National Tuberculosis Center
The services provided by NTC include • in-service training and infrastructure support for basic microscopy, TB culture and • Basic routine testing Central hospital-based laboratories provide basic clinical laboratory services, including:
Hematology, Biochemistry (basic and comprehensive metabolic panels), thyroid screening, coagulation and serology (both rapid and ELISA based tests), bacteriology culture and susceptibility tests. Histo/Cyto-pathology services were provided only by the centers that have pathologists. Regional and Zonal hospital based laboratories offered similar services as those of CHB
laboratories (exception: bacteriological culture and specialized tests were not available at all centers of this category). District hospital-based laboratories, perform mainly the microscopy of samples, routine
clinical chemistry, hematology, serology (rapid tests) investigations are done. No culture of samples for isolation of pathogens is done. PHC based laboratories perform mainly the microscopy, serology based rapid tests such
as HIV, Blood grouping, pregnancy, test for malarial parasite (kit based). DPHO based laboratories perform mainly the microscopy of samples and test for malarial
parasite (kit based). Private facilities
Academic Organizations At AOB laboratories assessed, all branches of laboratory
medicines including biochemistry, bacteriology, parasitology, immunology, hematology and histo/Cyto- pathology are in existence. Laboratory tests performed by these laboratories are similar to those offered by central level laboratories. Private reference laboratories Two private reference laboratories; Walter Reed Afrims
Research Unit Nepal (WARUN) and National Reference Laboratory(NRL) were assessed during the study. WARUN was involved mainly in the research and surveillance and not in routine testing service. The centre is very well-equipped and is a Nepal station of US Page 21 of 62
Armed Force Research Unit. WARUN also coordinates with NPHL in various investigations including influenza, JE diagnostics/surveillance and other molecular diagnostic tests. NRL offers routine tests service in biochemistry, bacteriology, parasitology, immunology, hematology. Private Hospital based/Independent laboratories Laboratories in these categories are
also providing routine diagnostic services in Hematology, Biochemistry, Immunology, Parasitology. The range of available tests however varied depending upon the categories of staff working. For example, Histo/Cyto-pathology services were offered in 35 centers where pathologists were available, bacteriology culture in 52 PHB labs and 20 independent private clinics and where technician and or medical technologists were present. In independent labs headed by lab assistants, only basic tests such AFB and Gram's stain microscopy, biochemistry (sugar, urea), haematology (TC/DC, ESR, Hb), serology based tests (rapid tests) etc were performed. 5.8 Quality assurance in laboratories
Quality assurance in health laboratories incorporates all the factors that may influence the generation of reliable results. This assessment found that laboratory practices are still lagging behind in terms of the critical components of a quality management system (QMS), which is essential to the improvement of overall laboratory diagnostic services and provides a basis for quality assured testing. Quality assurance comprises two key components; Internal quality control (IQC) that includes procedures taken during day-to- day activities to control all possible variables that can influence the outcome of laboratory results. This is a continuous process that should be operated concurrently with analysis. External quality assessment scheme (EQAS) is the other component which is necessary to ensure comparability of results. This component is carried out by an external agency. QMS must be implemented at all levels of the laboratory. To implement an effective QMS, it should be guided by a National laboratory policy that defines the needs and importance of accurate laboratory results. The laboratories assessed do not have a documented quality policy and 90% of the labs do not have any designated personnel for quality management purpose. Moreover, although 60% of laboratories reported that they use some means of internal QC, only less than 20% of the labs reported that they use internal controls with every run, monitored functioning of electrical/mechanical equipments and practiced documentation of the internal QC measures taken at the laboratory. The quality control and quality assurance activities are comparatively well established at only few centers (10%) Page 22 of 62
including NPHL and NTC among Government sector. At NPHL, internal QC measures such as use of internal controls, standards, temperature monitoring of storage devices are in practice and a maintenance section with biomedical engineers is also in place. Various units of NPHL participates in EQAS conducted by different international organizations for biochemistry panels, virology (HIV), influenza PCR, IPD (Japanese encephalitis, measles, rubella). Moreover, NPHL also acts as a National center for conducting National external quality assurance system (NEQAS) and sends testing panels to other labs thrice a year. All the RHB, CHB, SRHB, ZHB and DHB Government laboratories stated that they have been participating in NEQAS. However, most private laboratories (23%) reported that they are not participating in NEQAS or any other EQAS activities. Such laboratories reported that they were unaware about the existence of NEQAS for health laboratories in Nepal which is free of cost. Under such situations, i.e, in the absence of regular internal QC measures and EQA, the test accuracy from such laboratories become questionable. NPHL also sends EQAS panels for CD4 count to zonal and district level laboratories equipped with flow cytometer, panels for bacteriological identification and susceptibility testing to the laboratories participating in antimicrobial resistance surveillance in Nepal. The DPHO based labs refer their slides to NTC as part of external quality check. Nine laboratories reported participation in EQAS conducted by international organizations. Among these labs, Bhaktapur Cancer Hospital, Manipal Teaching Hospital, Birendra Army Hospital, BP Koirala Institute of Health sciences, College of Medical sciences and Universal medical College are participating in EQAS in biochemistry conducted by CMC, Vellore. NTC participates in EQAS conducted by SNL Gaunting, Germany and SAARC Tuberculosis Center (for sputum AFB). Similarly, B&B Hospital lab participates in BioRad EQAS while Rotary Diagnostic Center participates in hematology EQAS of All India Institute of Medical Sciences (AIIMS), Delhi. Quality of service is also affected by availability of trained staff. Most of the Government laboratory staffs (70%) have received training in quality assurance and most of such trainings were provided by NPHL and NTC. The training workshops on Quality Assurance conducted by NPHL are for laboratory assistants and laboratory technician level. Private organizations do not have program on providing quality assurance training to their staff. Only in some (25%) cases when the private laboratory staff is also affiliated with the Government lab, then such staff received QA training through Government organized Page 23 of 62
Other quality assurance related practices such as use of SOP was in place at 51 % of the laboratories. With WHO support, NPHL made an effort to prepare SOP that covers the routine diagnostic test procedures. Of the 102 labs using SOPs, 50 % labs use SOP prepared by NPHL, whereas others used SOPs prepared by international agency or locally developed SOP at the laboratory. All the labs reported that they keep inventory of reagents and materials, > 50% of the reagents were labeled in majority (75%) of the labs. Almost all the labs have developed forms to report their lab results, however the format varied among labs. Manual recording system for tests carried out, results and other laboratory activities were observed in most facilities. These documentation practices varied among individual institutions. Most facilities were using a simple register that summarized information and test results. All the labs maintained confidentiality of the test reports and consultation with referring physician as per the need during laboratory investigation was reported by 65% of 5.9 Laboratory safety and Waste Management
Health and safety
Health and bio-safety procedures include general safety instructions, chemical, fire and electrical safety, medical waste disposal and first-aid instructions. Program on health and safety were in place at 82(40%) of the centers. These included programs such as vaccination of staff, health insurance, allowance of laboratory hazard, medical leave, hazard training. Only 20% of the centers had their staff trained or instructed in laboratory bio-safety and bio-security. Written instructions or charts about post exposure practices were observed only at 15 (7%) of the laboratories. Almost 50% of the laboratories reported that a system of segregation of wastes is in place and only 41% labs used separate container for sharps. Eighty six percent of the labs assessed reported that they do not dispose infectious wastes (such as patient samples, culture plates/ broth) directly into municipal wastes and use some means of treatment. Autoclaving, treatment with chemical disinfectant, incineration or burning and burial after treatment were practiced by 23%, 75%, 22% and 25% of the labs respectively. Needle destroyer was available at 59 centers (29%) and 52(25%) centers reported that used needles were simply discarded in a box and taken by municipality, while others practiced burning or burial of the needles. Around 14% of the laboratories did not treat waste before disposal (either municipality takes waste or throw into toilet/sewage etc.). On enquiring laboratories that dispose infectious waste through municipality, it was reported that a system of collection of hospital waste through Page 24 of 62
municipality exists in some places but how these were eventually treated through municipality was unknown. Such system was observed in laboratories in Makawanpur and some private hospitals in Kathmandu. Personnel protective equipments like gloves and aprons were available for the staff in almost all the labs. A table showing comparison between Governement and Private facility based labs is shown in table 7. 5.10 Status of collection centers providing laboratory diagnostic service
Three collection centers; SRL (Super Religare services), Thyrocare and Lal Path Labs, were visited during the study. These centers were involved in collection of patient samples through their collection centers located in different cities in Nepal and referral of collected samples to laboratories located in India for diagnostic services. Qualitative information was gathered from these centers regarding their physical infrastructure, human resources and equipments, consent received for shipping of clinical specimen out of country, practices adopted for transport of clinical specimen. SRL has 15 collection centers, 5 in Kathmandu valley and one each in 10 major cities of Nepal (Biratnagar, Dharan, Janakpur, Nepalgunj, Dhangadi, Kohalpur, Butwal, Bhairawa, Bharatpur and Pokhara). Two technical staffs (laboratory technician/laboratory assistant) are recruited at each of these centers. Basic laboratory tests in biochemistry, microbiology, immunology, endocrinology are conducted at the SRL laboratory in Kathmandu, while specialized tests (examples: molecular diagnosis and tests requiring sophisticated equipments/technology use of flow cytometery, HPLC, tissue culture, immunohistochemistry) are referred to Ranbaxy, India. The SRL laboratory in Kathmandu has basic laboratory equipments used in biochemistry, microbiology, immunology, endocrinology and storage equipment (-20freezer) for storage of clinical samples awaiting referral to India. The centre has a pan registration, but does not have any legal consent from the Government/ health authorities for international transport of clinical samples. No information was available on packaging of clinical samples and guidelines followed for their transport. Birgunj. The center collects patient samples (blood) for thyroid function test and refers to India for laboratory investigation. The collection center in Kathmandu is operating in a single room and does not have adequate equipment and storage facility, could not provide document on legal consent obtained from the Government/ health authorities for Page 25 of 62
Table 7: Comparison between Private and Government Laboratories
Government Laboratories
Private Laboratories
Regional/ Zonal
District/ DPHO/ PHC
Polyclinic based/
Variables
Hospital based
based labs
Independent labs
hospital based labs
General Organization & management
Majority have adequate Mostly satisfactory Variable among labs Adequacy of Laboratory space 100%(Ref & AOB labs) 65% satisfactory 80% Pvt Hospital based Separate room for sample Satisfactory building condition Satisfactory level of Basic facilities electric / water Available (>90%) Available (>90%) Available (>90%) Available (>75%) supply, telephone, computer Human Resource
Staff number NOT *Staff number NOT
Sufficient number of staff Number adequate in 68% sufficient (100%) sufficient (100%) Availability of pathologists 45% Pvt Hospitals Availability of technologists All AOB, & Pvt Ref labs & 78% Pvt Hospitals Availability of Subject Experts hematologists/cytologist etc.) Equipments
Adequacy of equipment as per Inadequate (>90%) Inadequate (>90%) Inadequate >90% Inadequate >90% System of Regular monitoring and calibration of equipments Quality System
Staff trained on QA in Lab In <25% (when the staff is affiliated to Gov. org.) Participation in EQAS DHB labs participate Only 23% participating Practice of IQC measures Waste Disposal system
Satisfactory waste disposal
*In 35% of Gov labs (PHC/DPHO based), there is only one staff to look after laboratory.
** About 40% of the Pvt. Independent labs have only Lab assistant level of technical staff
*** Subject experts are either hired under contract through different programmatic support or the regular Govt. staff
working as lab technician/medical lab technologist have acquired the specialized degree and thus included in this category
Page 26 of 62
international transport of clinical samples, and no information was available on how samples are packaged and transported to India for laboratory investigation. Lal Path has collection centers in Kathmandu and other major cities of Nepal and refers samples to Lal path laboratory in India for diagnostic service. No information was available on whether the center obtained legal consent from the Government/ health authorities for international transport of clinical samples and how packaging and transport of clinical samples were carried for referral to India. Page 27 of 62
6. Discussion
Laboratory testing plays a vital role in the effective implementation of prevention, care, and treatment programs with regard to disease screening, clinical diagnosis, staging of disease, therapeutic monitoring and surveillance. Because of this pivotal role, the overall goal of laboratory program should be to ensure laboratory capacity that can provide quality, rapid, accurate, affordable, and reliable diagnostic tests. In Nepal in Government sector, laboratories have been established at all levels of healthcare from National and Central level to PHC level and the target is to establish laboratory infrastructure up to health post level in the future. This must have consumed considerable time and resources to do this. In the private sector also, laboratories based at hospitals, clinic/polyclinic have increased rapidly in the last decade. Despite considerable increase in health laboratory services, under-resourced laboratory infrastructure, shortage of trained staff and lack of guiding policy for health laboratories, lack of legislations for licensing procedures, there are considerable challenges to reliable laboratory services in Nepal. Moreover, laboratory component is usually overlooked and lag behind compared to other areas of the health program which limits its ability to provide useful insights and contributions. Several issues need to be addressed to ensure that laboratory results are reliable such as the laboratory infrastructure and quality management in the laboratory. Many laboratories assessed in this study have infrastructural challenges. Most laboratories, especially the government labs located in remote areas and independent private clinic/polyclinic based labs showed minimal physical infrastructure, with even the physical building, space being inadequate for the needs of the laboratory. Moreover, laboratories, when they exist, are often in a disagreeable state in terms of general cleanliness, ventilation and light requirements. Lack of basic facilities such as clean running water and a stable power supply pose additional challenges that must be fulfilled for adequate laboratory services. Efforts should be made to upgrade the laboratory infrastructure and basic facilities in most situations. External supports have been made to improve laboratory infrastructure and technical efficiency in Nepal. These efforts include the United Nations–supported Global Fund to Fight AIDS, Malaria, and Tuberculosis (GFATM); World bank; the World Health Organization (WHO). If well managed through a national strategic laboratory plan and with coordination at the level of the funding bodies, these supports can significantly strengthen laboratory capacity in a sustainable way. Strengthening human resource capacity also has an important role in sustainable laboratory capacity. The lack of adequate number of qualified laboratory personnel Page 28 of 62
accounts for another major constraint in reliable lab testing. National reference laboratory, central hospital based laboratories and bigger private nursing homes that are situated in the capital city tend to have more qualified staff than at zonal/district-level laboratories situated in remote areas. The lack of trained laboratory experts at peripheral laboratories adds challenges to the decentralization and expansion of health-care services to rural areas where 2/3 country's population resides. To address quality service, efforts have been made towards in-service/refresher training and the organization of test-specific workshops to meet immediate needs in the country. National centers such as NPHL, NTC have been organizing such trainings and external partners like WHO, Global fund have provided support to run lab related training programs. To expand the range of tests offered and address the need for specialization in different fields of laboratory medicine as demanded by time, recruitment of subject experts such as microbiologists, immunologists, hematologists cytologists, biochemists should be reconsidered both at Government and private facilities. Retention of well-trained laboratory staff is also essential for total quality management programs. Strategies such as providing opportunity in career advancement through university degree and other training can be effective in retention of the staff. Along with standardized training/education programs, it is important to develop a guideline for individual certification that establishes criteria for issues such as necessary qualifications for personnel performing different levels of tests. Guidelines are needed to establish the minimum tests that are to be performed at each level of laboratories. This requires developing minimum requirements for each category of lab performing different levels of Adequate and timely supply of quality reagents/kits and supplies also affect the quality of services. In a resource-limited country like Nepal, consistent supply and provision of laboratory commodities to meet the demand created by the expansion of laboratory services has been a challenge. The timely availability of essential equipment, supplies, and reagents is important to ensure the overall quality of laboratory testing. Various purchased and donated equipment of different models, ages, and conditions were observed throughout different laboratories. Moreover, some facilities have acquired new equipment, which has not been implemented for various reasons; other facilities own equipment which has been displaced for years, yet remains located within the laboratory space. In most laboratories one or more equipments are in non-functional status. Staff members and/or maintenance staff need to be trained on routine preventive maintenance, calibration, and QC of equipment. Standardization of laboratory commodities can be Page 29 of 62
introduced and will be useful to coordinate the maintenance of equipment, bulk purchases, training on common instrumentation, and contract service mechanisms. The lack of proper waste management systems is another crucial problem encountered in many health facilities, where laboratory waste is often disposed of inappropriately, exposing patients, health workers, and the community at large to possibly dangerous infectious waste. Current infrastructure in most facilities also does not allow the development of adequate bio-safety procedures in the laboratory and the health facility in general. In Nepal, national guidelines on health and bio-safety are not available. With the increased thread of HIV, Hepatitis and the prevalence of many infectious diseases in Nepal, urgent action is required in this regard. Medical waste management programs need to be initiated, not only at laboratories, but at all medical facilities. Written guidelines and training on the subject are needed to advocate lab workers on laboratory safety practices and waste disposal. Most of the laboratories were using paper-based manual entry system for documentation of laboratory tests, results and activities. This process creates many opportunities for error and resultant losses. In addition, accurate compilation of data for laboratory organization such as assessment and for annual review purposes is difficult. The recording system also varied among individual labs. Hence a standardized, paper-based system is needed at different levels of the laboratory. Moreover, with time, the implementation of laboratory information and management system (LIMS) technology can be a better alternative for laboratory data management. In the absence of a LIMS, a computerized system for the management of data, with entry performed directly from source documents can be practiced. Regardless of what approach is used, a well-defined standardized system is needed to ensure proper laboratory processing, reporting and record Laboratory networking and coordination is another important mechanism for optimum use of available resources. In this regard, development of a national laboratory strategic plan that specifies the role of laboratories (Government sector) at each level in a tiered system can be useful for task division, decentralization, optimum utilization of resources and surveillance purposes. Networking between laboratories can be initiated for referral of samples, training, technical support, supervision, and laboratory supplies and data sharing. Hence a national laboratory plan that integrates the testing required at each level for the prevention and treatment of diseases of major public-health importance in context to Nepal can be updated. For example, the NPHL and the central hospital based Page 30 of 62
laboratories constitute the first level of laboratory services, the regional/sub-regional make up the second level of laboratories services, zonal hospital based labs constitute the third level of laboratories, the district and private hospitals make up the next level of laboratories and so on upto the PHC and health post level laboratories. At each level, there should be a defined package of requirements, needs, and capabilities, accompanied by specific SOPs and testing abilities. Moreover, laboratory networking may be improved through modern technologies like using LIMS system to link different levels of laboratories which will improve data sharing across tiered laboratory networks. Such networking among laboratories will also enhance the capability to provide epidemic alert and response by recording and analyzing laboratory data and facilitating frequent exchanges of information and surveillance data with other laboratories within the network. Quality assurance at all stages of laboratory testing process, from the pre-analytic phase, which involves competency of personnel, test selection, test requisition, correct labeling, transport of specimens, the analytic phase, which includes specimen processing and storage, reagent preparation, quality control measures, test performance, proficiency testing, to the post-analytic phase, which includes reviewing results, reporting test results and interpretation, and record keeping is essential for generation of reliable laboratory result. A functional quality system integrated into laboratory services is fundamental to achieving reliable laboratory results. Due to resource constraints and lack of proper guidelines, there is compromise in the implementation of QA measures in all these three phases. This remains a major limitation in most of the laboratories assessed and this gap must be bridged to achieve a sustainable laboratory-capacity. Despite various efforts from NPHL such as organization of quality assurance training, development of SOP for tests offered in different fields in laboratory sciences, technical support and supervisory visits, the quality systems continue to be at primordial stages in most laboratories. Though some laboratories reported that they are making efforts to implement QA practices in their labs, their achievements were not regular and well documented. Use of SOP is necessary to perform tests in uniform manners throughout the centers. It is advisable to distribute updated SOPs to all the centers. Quality assurance part was even more pathetic at private clinic/ polyclinic based labs. As majority of the labs belong to this category and most of such labs do not have any system of regular internal quality control measures, the accuracy of results generated by such labs become questionable. Hence, emphasis should be put on Internal Quality Control Procedures and EQAS participation (include private labs) for generation of reliable reports. In addition, laboratories should be advocated to consider Page 31 of 62
EQAS results for undertaking necessary actions to improve the quality of their service. Also NPHL's capacity should be strengthened to develop a well-characterized panel for use in proficiency testing to monitor the quality and performance of other laboratories. On overall, a well functioning supervising and controlling mechanism is important for the quality management in laboratory services. Strategies and Policies are needed to deal with issues such as certification, licensing and periodic renewal of laboratories and should form the backbone of sustainable quality management systems. One of the key challenges for quality laboratory services is to ensure that the recommendations and the minimum standard are fulfilled by all levels of laboratories so that individuals and communities will benefit from improved laboratory services. This calls for establishment of appropriate regulatory and legal support structures that gives rights to the relevant stakeholders and a firm commitment by Government to effectively implement strategies for strengthening health laboratory services. This includes developing a national laboratory policy and strategic plan; defining managerial and regulatory mechanisms; and establishing the required support services within the context of each country. Hence establishing a national laboratory policy and laboratory strategic plan provides the framework for the coordinated development and delivery of quality and accessible laboratory services. The national laboratory policy for Nepal is in the process development and the finalized version should address all such issues including laboratory licensing procedures, authorized regulatory body in laboratory system etc. Moreover, assessment of three collection centers providing diagnostic services in Nepal showed lack of defined minimal requirements to be met by collection centers involved in international transport of clinical/biological materials. This shows the need of development of guidelines and regulations to address transport of clinical materials. The laboratory policy should identify/define Government national accreditation/regulating authorized body giving formal recognition to and control over laboratories should be identified. As a national reference laboratory, NPHL's capacity can be strengthened to evaluate laboratories with regard to their compliance with relevant national/international standards and assessing their competence to perform the tasks defined in their scope of duties. For Nepal, it may be difficult to meet the standards set by the international community such as the International Standards Organization (ISO) and internal accreditation systems in the immediate future. Hence, considering the existing infrastructure and resources in the country, the ultimate approach should be to establish national standards which may not be as rigid as international standards but can be used as a means to strengthen the quality system and set Page 32 of 62
achievable targets for laboratories. Moreover, laboratory inspection at the beginning to grant approval to start the laboratory may not be sufficient. A periodic assessment, monitoring system should be developed for continuity or renewal of the already approved laboratories, both in Government and Private sector. Also to maintain the quality service, system should be put in place for continued on-site monitoring for the competency of the laboratory such as use of SOPs, handing of samples, interpretation of results based on protocols, internal quality control measures adopted and record keeping. Page 33 of 62
The results of the study showed that the condition of the most of the laboratories needs significant strengthening especially in basic infrastructure and laboratory quality management issues. The concerned authorities should consider licensing of the health laboratories which are growing in numbers and to gain a control over inadvertently functioning laboratories that do not meet the basic criteria to improve the existing condition of laboratory services in Nepal. Some key challenges faced in the health laboratory system are listed below: • Lack of national policy on laboratory services • No set norms in health laboratory establishments • Low priority to laboratory services in hospital set-up • Inadequate laboratory infrastructure and basic facilities at many laboratories • Limited laboratory space in many laboratories • Shortage of qualified laboratory staff • IQC not being followed routinely and lack of private lab participation in NEQAS • Inadequate equipments and unsatisfactory maintenance of equipment • Inconsistent supply of electricity and water in labs • Inadequate laboratory waste disposal practices • Lack of standardized documentation system to record laboratory activities • Lack of regulating authority to control over inadvertently functioning laboratories Page 34 of 62
7. Recommendations
Challenges that limit the proper functioning of quality laboratory services must be addressed to strengthen laboratory capacity. These include: 1. Role of NPHL as a supervisory and regulatory body should be strengthened. 2. Definition for the different levels of laboratories should be reviewed and TOR for each level should be developed for their clear roles and responsibilities. 3. Standardize the organizational system and work processes 4. Define essential test-procedure and essential equipment list for all levels 5. Implementation of an effective tiered laboratory network and effective coordination among laboratories for optimum use of resources 6. Strengthen the lab quality management system. 7. Expand the External Quality Assessment program and making mandatory participation in NEQAS for all lab 8. Increase emphasis on Internal Quality Control Procedures. 9. Establish a laboratory equipment maintenance system 10. Consideration to renovate and upgrade the existing facilities at the labs to improve the working environment, efficiencies and capacity to better serve the needs of the country 11. A periodic review of the SOP should be conducted to assess the status of existing SOPs and efforts should be made to maintain uniformity in the testing procedures and test- 12. The Staff category and number should be reviewed depending on the work load and expansion of service. Also efforts to timely recruit/ retain qualified staff and fellowship programmes for staff development should be in place. 13. Standardized documentation and data management system should be developed for bringing uniformity in all laboratories. 14. The issue of international transport of clinical specimen for diagnostic purpose should Page 35 of 62
ANNEX I The assessment tool
Assessing the Health Laboratory SECTION A: General information about the Laboratory Name of the facility Name of officer in-charge Type of Laboratory

National Level Laboratory Regional hospital based Laboratory Sub-regional hospital based Laboratory Zonal hospital based Laboratory District hospital based Laboratory Central hospital based Laboratory Laboratory based at district public health office /regional directorate Private Hospital Laboratory Independent private laboratory Academic/Teaching hospital Laboratory Others: (Please specify) Name of the respondent Page 1 of 62
SECTION B: ORGANIZATION AND MANAGEMENT General management
Affiliation of the Laboratory (More than one may be applicable):

[1]Government
[2]Private/commercial organizations
[3]Academic organizations
[4] NGOs or religious organizations
Is the laboratory registered/ licensed?
If yes:
Where:
Pan No./ Registration No.:
Date of registration:

Is the laboratory inspected by higher level authorities?
If yes,
Name the authority
:
Is there any National/International organization supporting the laboratory?
If yes, [1] Technical (please specify names): _ [2] Financial (please specify names): _ Is there a specific budget for the operation of the laboratory?
If yes, what is the total budget for the reporting year? Please provide the information on the funding for operations of the laboratory in the current budget
year.
[1] Percentage of funding from the government:
[2] Percentage of funding from the non-governmental organization: [3] Percentage of funding from fees and/ or cost recovery: [4] Percentage of funding from the external donors: Normal hours/days of service of the laboratory
(1)Number of days per week <5
(2)Hours per day <6 If no 24-hour service,
is emergency lab service available? Yes
No
is 24 hrs emergency on call service available? Yes
No
Page 2 of 62
Does the laboratory perform tests for:
Yes No
(1) Microscopy (AFB, MP)
(2) Parasitology (3)Virological analysis (4)Serological analysis (5)Bacteriology culture (7)Biochemistry analysis (8)Hematology analysis (10) Histo/Cyto pathology (11) Molecular diagnostics (12)Other (please specify) Does the laboratory has Standard Operating Procedures (SOPs) or local written instructions for
performing each test? (Please tick as appropriate)

If Yes, SOP used in the laboratory is developed by Yes
[1]Developed by international agencies [2]Developed by NPHL [3]Developed locally by the laboratory [4]Others: Human Resource
How many staff work in the lab in following categories and how many of them have received lab related
training (Please specify numbers)

Category of Staff
Total number Highest
National
training International training
Education
[2] Microbiologist [5]Med. Technologist [6]Lab technicians [7]Lab assistant Page 3 of 62
[8] Other technical staff* [9] Supporting staff *Please specify:
Does the laboratory have adequate staff for its operations? Yes Are ALL tests reviewed before results dispatched? If Yes, who reviews the results of tests (or test runs)
Yes
(1) Pathologist (2) Microbiologist (5) Med technologists (6) Lab technicians (7) Lab assistant (8) Others (Please specify) Equipment & Supplies
14
Please provide information on the availability of the equipment in the laboratory based on the list at the
end of the section.

Does the laboratory have adequate equipment for its work?
16
How are equipments procured?
Please tick as appropriate

[1]Purchased locally by the laboratory [2]Purchased centrally or through upper level agencies [3]Donated by international development agencies/donor countries [4]Other (please specify) 17
How key supplies1 in the laboratory were purchased?
Please tick (
) whenever applicable.

[1] Purchased locally at the laboratory? [2] Purchased centrally or through upper 1 Key supplies include laboratory glasswares, test kits, reagents etc. Page 4 of 62
Frequency of consumables procurement:
Every 3-6 months Whenever needed Building facilities and utility services
Laboratory infrastructure a free-standing building or part of larger structure Condition of the laboratory building good medium poor State of cleanliness of the laboratory good medium poor
How many rooms with bench space are there in the laboratory? _
Does the laboratory have separate room for sample collection? Yes What is the total area (space) of the laboratory?.sq ft. Is the laboratory space adequate for its work? Does the laboratory have/access to:
[1] Adequate ventilation [2] Adequate light [3]Continuous water supply [4]Continuous Power supply [5]Computer [6] Telephone [7] Internet Is there a back-up power source in case of power failure (e.g. emergency generator)?
Yes No
If Yes, what systems are protected?
Yes

(2)Ventilation/AC (3)Computers
(4)Others
Please specify:
Page 5 of 62
Equipments in the Laboratory
1. For general Laboratory

(If the laboratory has different divisions, skip No.1 and go to No. 2) Ref: Minimum Instruments required for facilities with no. of beds
Available
Tissue Processor Semi-auto analyzer Elisa Reader/washer Chemical balance Flame photometer Blood cell counter WBC counter chamber Computer with printer Safety hood with hepa filter Electronic balance Distillation plant Needle destroyer Page 6 of 62
For laboratory with different units
Equipments
Weighing balance Bio safety cabinet : Class…. Microbiology unit
Spectrophotometer Electric Microscope Weighing balance Bio safety cabinet : Class…. Spectrophotometer Biochemistry analyzer Hormone analyzer Hematology unit
Freezer –20°C Electric Microscope Freezer –70°C Bunsen burner/loop sterilizer Hematology auto-analyzer Fluorescent microscope Cell counter (Auto/Semi Auto) Automated systems( API/Bactec) Hematocrit Centrifuge Hemoglobinometer Immunology unit
Spectrophotometer Histo/Cytology unit
Electric Microscope Electrophoresis Reader Tissue processor Serological rotator Virology unit
Biochemistry/Endocrinology unit
Spectrophotometer Page 7 of 62
Serological rotator Inverted Microscope Specialized / Molecular Biology Unit
Spectrophotometer Serological rotator Inverted Microscope Bio safety cabinet : Class…. Refrigerated centrifuge (tube) Refrigerated centrifuge (eppendorf) Magnetic stirrer Electronic balance Gel electrophoresis PCR thermalcycler Genetic analyzer PCR Mater mix cabinet PCR gel doc/ View system Real time PCR- Computerized View Liquid nitrogen container Shaker incubator Virus culture system Page 7 of 62
SECTION C: Specimen collection and handling Proportion of samples collected in the lab complex
<25% around 25% around 50% 100%

Does the laboratory use standardized request forms to order laboratory tests?
Do request forms contain ALL of the following patient information:
clinical info/data specimen source date and time of collection type of test requested Do request forms provide details or a link which enable the lab to contact the patient? Are specimens that are received are labeled with the patient's name and unique identifiers? Does the laboratory provide a unique accession /lab number for all specimens? Does your laboratory receive samples for bacteriological culture? If yes, How are following samples for cultural investigation handled?
(1) CSF processed immediately preserved at 4oC preserved at 35 oC left at room temp (2) Urine processed immediately preserved at 4oC preserved at 35 oC left at room temp
(3) Stool
processed immediately preserved at 4oC preserved at 35 oC left at room temp
Does the laboratory keep a record of all specimens received for diagnostic testing?
If yes, how are the records maintained?
Manual
Electronic
Does you laboratory refer isolates/slides/organisms/specimens to NPHL or any other reference laboratory? Yes If yes, reason for referral:
Does the laboratory keep a record of isolates/specimen sent to reference lab? Does the laboratory receive feed-back on referred isolates/specimen? SECTION D: Test Information (Please include only if tests that are performed by the laboratory, do not include the tests referred elsewhere)
Stool R/E Yes No
If yes, Average no./month: In-charge:
Urine R/E Yes No
If yes, Average no./month: In-charge:
Microscopy for AFB
If yes, Average no./month: In-charge:
Microscopy for malarial parasite
If yes, Average no./month: In-charge:
Please fill up the information on the tests performed by the laboratory
Haematology Yes No
If yes, Average no./month: In-charge:
Does your laboratory carry out following tests?
Yes/NO Number Yes/NO Number Platelets Reticulocytes Bone marrow Aldehyde Test Fluid cell count Histo/Cytology Yes No
If yes,
6.1 Histology:
Biopsy Surgical specimen Average no./month: In-charge:
6.2 Cytology :
Average no./month: In-charge:
Biochemistry Yes
If yes, Average no./month: In-charge:
Does your laboratory carry out following tests?
Yes/NO Number Yes/NO Number Alkn Phosph. T. Protein Creatinine Albumin Uric Acid A/G ratio Cholestrol Triglyceride Alpha amylase Calcium Phosphorus Potassium Bilirubin T/D Gamma GT Acid Phosphate Globulin Serological/Virology analysis Yes No
If yes, Average no./month: In-charge:
Does your laboratory carry out following tests?
Yes/NO Number Yes/NO Number Blood grouping Rheumatoid factor C-reactive protein Anti-streptolysin 'O' titre Ferritine (iron binding capacity) Brucella Antigen Serum protein electrophoresis TORCH: Toxoplasma Ab
AntiD antibody titre Rubella Ab Urine for pregnancy CMV Ab Tumour Markers
HSV Ab Alpha Fetoprotein (AFP) Japanese encephalitis Carcinoembryonic antigen Leptospira Ag/Ab Prostrate specific antigen HIV I, II Beta-HCG Anti HCV Measles Auto Antibody Test
Rubella Anti nuclear antibody Anti DNA antibody Seasonal & Pandemic Influ. Antibody test for thyroglobulin Drug level: Phenytoin
Antibody for Cysticercosis Carbamazepine Echinococcus Cyclosporine CO level Hormones: Prolactin
Cyclosporine C2 level Testosteron Valproic Acid TSH, T3 T4 Mycology: Yes
Fungal Microscopy
Fungal culture
If yes, Average no./month: In-charge:
Bacteriology Yes No
If yes, Average no./month: In-charge:
Does your laboratory carry out following tests?
Yes/ NO Number Yes/ NO Number Gram stain Urine C/S Skin scraping for AFB Blood C/S CSF/body fluid C/S Eye swab C/S Throat swab C/S Ear Swab C/S Sputum C/S Urethral/vaginal specimen C/S Stool C/S
Do you use any internationally recognized standards for definitions of resistance/susceptibility (e.g.,
CLSI, Stokes, DIN, SGRA)

Coagulation Yes No
If yes, Average no./month: In-charge:
Does your laboratory carry out following tests?
Yes/NO Number Factor VIII Protein electrophoresis Factor IX Hb Electrophoresis Micro-albumin SECTION E: Quality Assurance and Reporting A. Quality Assurance
Does the laboratory have a quality policy? Does the laboratory use any system for internal quality control? Has the laboratory appointed a person responsible for quality management? Are internal controls included in each test run? Yes
If Yes, is the performance of these internal controls recorded and monitored over time?
Yes
Does the laboratory participate in national external quality assurance scheme (NEQAS) program? Yes If Yes,
3.1 How many times do you receive EQA sample from NPHL/year?
3.2 Which is the latest NEQAS lot No. you received?
3.2 Do you send EQA test results to NPHL? Yes
3.3 If No, please state the reason:- _
3.4 Do you get feedback from NPHL regularly? Yes Does the laboratory participate in other (National/International) external quality assurance schemes? If Yes, what programs?
Does the laboratory document EQA results in the laboratory? Yes
Does the laboratory take EQAS results into consideration and make necessary actions for quality management ? Does the laboratory staff get training on quality assurance? Yes No If yes:
Training is conducted by the institution
Participate in the QA Training organized by NPHL Participate in trainings conducted by other organizations*
*Please specify:
Is the functioning of ALL electrical or mechanical equipment routinely monitored and recorded (e.g. microscope calibration, checking temperatures of refrigerators or incubators, calibration of pipettes or handling devices, autoclave function, etc.)? Yes Are calibration, maintenance and service records kept? Does the laboratory keep inventory of reagents and materials? Proportion of reagents labelled appropriately? None < 50% >50% Recording and Reporting test results

Does the laboratory use standardized forms to report lab results? Does the laboratory maintain confidentiality of the test results? Do the patients have access to the test reports? Are records kept of the number and type of tests performed and results? If yes,
Does the laboratory use standardized format to document lab results?
Yes
Does the laboratory consult referring physician for correlation of laboratory results? Does the laboratory have a list of diseases that are supposed to be reported to NPHL/ other reference labs? SECTION F: Laboratory safety and Waste disposal Does the laboratory staff receive training/instruction in 1
Yes No Bio-safety Bio-security Bio-ethics Are there written instructions/chart about post exposure practices available in the lab? 2
Laboratory safety program for staff: Yes (1) Vaccination
(2) Insurance/ allowance
System for segregation of waste Yes Use of sharp container Yes
What methods are used for hazardous waste disposal? (tick all applicable)
Solid Liquid
Yes No Yes
(1) No treatment If yes: Time Temp

(3)Chemical disinfection
If yes, Disinfectant used: Concentration: Time:
(4)Incineration
(5)Burial after treatment (6)Other (briefly describe): How do you do with used needles? Treatment used before cleaning of reusable glass wares Infectious Non-infectious Yes No Yes (1) No treatment (cleaning using detergent only) (2) Autoclaving (3) Treated with disinfectant (4) Others: What protective clothing/equipments are available for laboratory staff? (tick all applicable)
(1)Gloves (2)Lab coat (4)Others (Please specify): List of laboratories assessed, location, Lab-incharge and contact number
National Public Health Laboratory Sukraraj Tropical and Infectious Central hospital Mrs Jyoti Acharya Disease Hospital Surendra Pathology Clinic Independent Pvt. Shikhar medical and diagnostic Independent Pvt. Nardevi Ayurvedic Central Central hospital Independent Pvt. Nepal Janswastya Lab Dependra K Yadav National tuberculosis Center Independent Pvt. Wellness pathology lab Jogendra Rauniar Independent Pvt. Med technologist Mahabouddha Clinic Lab Ganesh P Acharya Independent Pvt. Bir pathology Laboratory Narendra Shrestha B&B Hospital Laboratory Private. Hospital Bhaktapur Cancer Hospital Bode PHC Lab Lalitpur directorate based Central hospital Bhaktapur hospital Gokarna PHC Laboratory Lekhnath Bhattarai Central hospital Paropakar Maternity Hospital Mrs Urmila Vaidya People's General Hospital Private. Hospital Alka Pathology lab Private. Hospital Capital hospital and research Private. Hospital Kathmandu Hospital Pathology Private. Hospital Ibamura hospital Private. Hospital Med technologist Shiva Jyoti Hospital Private Hospital Bhagwan K Sharma Med technologist International Friendship Hospital Private. Hospital Independent Pvt. Dakshin Barahi Polyclinic Independent Pvt. Nishan Health Clinic Shahid Memorial Hospital Private. Hospital 24-hr Nursing Home Private. Hospital Janmaitri Hospital Independent Pvt. Narayan Pathology Lab Narayan L Shrestha Independent Pvt. Anmol Pathology services Dr Bharat Amatya Ishan Paediatric Hospital Private Hospital Kathmandu Model hospital Private. Hospital Tilganga Eye center Private. Hospital helping hands Community Private. Hospital Independent Pvt. Sudama Pathology Lab Hetauda Samudayik Sahakari Private. Hospital Kanjay Chaudhary Regional hospital Hetauda Regional Hospital District Public Helath office lab Independent Pvt. Safal Clinic and Pathology Private. Hospital Independent Pvt. Sangam pathology Independent Pvt. New Sagarmatha path Lab Rabindar K Aryal Bhawani Hospital Pathology Private. Hospital National Medical college Rotary Diag Center Private. Hospital Independent Pvt. Aashirwad Diagnostic Path Narayani sub-regional Hosp Independent Pvt. directorate based College of Medial sciences Independent Pvt. Suryodaya Pathology National City Hospital path lab Private hospital Chitwan Medical College Chitwan Hospiltal Pvt pathology Private. Hospital Rajendra P Joshi Narayani Samudayik Hosp Private. Hospital Independent Pvt. Fewa Pathology Lab Private. Hospital Dr Sabin Ranabhat District hospital Bharatpur Hospital Independent Pvt. Chitwan Pathology lab Bharatpur Samudayik Hospital Private. Hospital BP Memorial cancer hospital Moulakalika Pathology Private. Hospital Independent Pvt. Bhagwati Path Lab Jaya Boudha Hosp Private. Hospital Asha Hospital Path Lab Private. Hospital Makawanpur Sahakari hospital Private. Hospital Nawajeevan Hospital Pathology Private. Hospital Chandimaya Hosp Pathology Private. Hospital Mel Kuna PHC Surkhet Regional hospital Mid Western Regional Hospital Maya Nursing Home Private. Hospital Bharat P Devkota Devi NursingHome Private. Hospital Krishna B Khatri Independent Pvt. Nepalgunj Medical College Bheri Zonal hospital Independent Pvt. City Poly clinic Dodharachandani PHC Independent Pvt. Mahakali Zonal Hospital Seti zonal hospital Yadav Psd Shrestha District hospital Tikapur Hospital Independent Pvt. Bhandari pathology Lab Shankar Bhandari Baishnavi Hospital pathology Private. Hospital Independent Pvt. Star Path Centre Western Hospital pathology Private. Hospital Independent Pvt. Lal Ratna Hosp Path Private. Hospital Chirayu pathology Private. Hospital Independent Pvt. Gurung Pathology General alb Prasant Pathology Private. Hospital Mahesh Raj Joshi Independent Pvt. District hospital Jaleshwar Hospital Hope Bardibas Hospital Private. Hospital Hira Babu Pandey District hospital Bardibas Hospital Hira Babu Pandey Independent Pvt. Pradeep Pathology Sanjay Kumar Shah Independent Pvt. Ambika Polyclinic Jitendra Kr Yadav Janakpur Public Hospital Private. Hospital Janaki Health care & research Private. Hospital Independent Pvt. Gyatri Pathology District hospital Nabal Prasad Shah Independent Pvt. Shree Ram Pathology Independent Pvt. Janaki Pathology Independent Pvt. Om Pathology Center Independent Pvt. Janaki Medical College & Birendra Jha /Dr R Teaching Hospital Independent Pvt. Janakpur Zonal Hospital Independent Pvt. Sita Diagnostic And Research Private. Hospital Private. Hospital Nepalgunj Nursing Home Private Hospital Nepalgunj United Hospital Private. Hospital Nepalgunj Medical College & Teaching Hospital Western Hospital & Research Private. Hospital Charak Hospital & Gandaki Dr Banita Gurung Pokhara Om Hospital Private. Hospital Phewa City Hospital Private Hospital Manipal Teaching hospital Regional hospital Western Regional hospital Capital Hospital pvt ltd Private. Hospital Fishtail Hospital & Research Private. Hospital Padam Nursing home Private. Hospital Nepal diabetic thyroid and Independent Pvt. endocrine centre Metro City Hospital Pokhara Private. Hospital Kist Medical College Lalitpur Norvic international Hospital and Private. Hospital Bhagish C Mishra Bp Smiriti Hospital Private. Hospital Chirayu National Hospital & Private. Hospital North Point Hospital Private. Hospital Rup Shova Nakerni Private. Hospital Dr Sunil Singh & Kantipur Hospital pvt ltd Private. Hospital Central Hospital Kathmandu Medical College, Teaching hospital Birendra Army Hospital Civil Service Hospital Central Hospital Dr Bandana Sigdel Sahid Gangalal Hospital Independent Pvt. Meridian Polyclinic Chintamani Sharma Independent Pvt. Green Medical Centre Independent Pvt. Nishan polyclinic Bishnu Raj Majhi Manmohan Memorial community Dr Basista Prasad Private Hospital Independent Pvt. Basundhara Polyclinic Om Hospital And Research Private. Hospital Bp Koirala Institute Of Health Dr Arbind Sinha/Dr Independent Pvt. Yadav Diagnostic Centre Private. Hospital Dr Sagar Raj Pande Birat Hospital & Research Center Private. Hospital Nobal Medical College & Teaching Hospital Green Cross Hopital & Research Private. Hospital Koshi Zonal Hospital Independent Pvt. Dharan Diagnostic Center Private. Hospital Lifeline Hospital Pathology Private. Hospital Anjani Kumar Jha District Public Health Office Mechi Zonal Hospital Pathology Amda Hospital Pathology Private. Hospital Om Sai Pathivara Hospital Private. Hospital Independent Pvt. Mechi Public Health Laboratory Ram Prashad Shah Independent Pvt. Adhikari Pathology Independent Pvt. Private. Hospital Independent Pvt. Dhakal Pathology Independent Pvt. Sidhartha Pathology Bhairawa Hospital Private. Hospital Chiranjivi Lal Joshi SiddartaNagar City Hospital Private. Hospital Universal College of Medical Teaching Hospital District hospital Walter Reed/ Afrim Research Private reference Healthcare Nursing Home Pvt Ltd Private. Hospital Edmond City Hospital Private. Hospital Meditech Hospital Private. Hospital Amda Hospital, Butwal Private. Hospital Lumbini Zonal Hospital Butwal Pathology Private. Hospital Lumbini Hospital & Technical Private. Hospital Chaudhary Raj Kumar Butwal Hospital Pvt Ltd Private. Hospital Independent Pvt. Sanjibani Pathology Independent Pvt. Kantipur Pathology Independent Pvt. Siddhababa Pathology Independent Pvt. Bishal Pathology Surendra Churasia Independent Pvt. Chirayo Pathology Prasanta Pathology Private. Hospital National Refrence laboratory Central hospital Central hospital Kanti Children hospital ANNEX III
List of Government laboratories in Nepal and their location
1 NPHL, National, CDR, Bagmati CR Bagmati Kathmandu
3 Bir Hospital CHB CDR Bagmati Kathmandu
4 Kanti Hospital CHB CDR Bagmati Kathmandu
5 Maternity Hospital CHB CDR Bagmati Kathmandu
6 Mental Hospital in Patan CHB CDR Bagmati Kathmandu
7 National Tuberculosis Centre CHB CDR Bagmati Kathmandu
8 Teku Hospital DHB CDR Bagmati Kathmandu
9 Mulpani PHC CDR Bagmati Kathmandu
10 Ramghat PHC CDR Bagmati Kathmandu
11 Patan (Mission) DHB CDR Bagmati Lalitpur
12 Bhaktapur DHB CDR Bagmati Bhaktapur
13 Balkot PHC CDR Bagmati Bhaktapur
14 Chalnakel PHC CDR Bagmati Bhaktapur
15 Dadhikot PHC CDR Bagmati Bhaktapur
16 Dhading + DPHO DHB CDR Bagmati Dhading
17 Gajuritar PHC CDR Bagmati Dhading
18 Salyantar PHC CDR Bagmati Dhading
19 Dhulikhel PHC CDR Bagmati Kabhre
20 Khopasi PHC CDR Bagmati Kabhre
21 Mithinkot PHC DCR Bagmati Kabhre
22 Trisuli DHB CDR Bagmati Nuwakot
23 Deurali PHC DCR Bagmati Nuwakot
24 Kakani PHC CDR Bagmati Nuwakot
25 Kharanitar PHC CDR Bagmati Nuwakot
26 Samudratar PHC CDR Bagmati Nuwakot
27 Betini HP CDR Bagmati Nuwakot
28 Rasuwa + DPHO DHB CDR Bagmati Rasuwa
29 Chautara DHB CDR Bagmati Sindhupalchok
30 Bahrabise PHC CDR Bagmati Sindhupalchok
31 Melamchi PHC CDR Bagmati Sindhupalchok
32 Janakpur ZHB CR Janakpur Dhanusha
33 Mahendranagar PHC CDR Janakpur Dhanusha
34 Sabaila PHC CDR Janakpur Dhanusha
35 Yadukoha PHC CDR Janakpur Dhanusha
36 Gangapipra HP CDR Janakpur Dhanusha
37 Jiri DHB CDR Janakpur Dolakha
38 Charikot PHC CDR Janakpur Dolakha
39 Jhule HP CDR Janakpur Dolakha
40 Namdu HP CDR Janakpur Dolakha
41 Phasku HP CDR Janakpur Dolakha
42 Jaleswor DHB CDR Janakpur Mahottari
43 Goushala PHC CDR Janakpur Mahottari
44 Loharpatti PHC CR Janakpur Mahottari
45 Ramechhap DHB CDR Janakpur Ramechhap
46 Manthali PHC CDR Janakpur Ramechhap
47 Malangawa DHB CDR Janakpur Sarlahi
48 Barathahawa PHC CDR Janakpur Sarlahi
49 Haripur PHC CDR Janakpur Sarlahi
50 Lalbandi PHC CDR Janakpur Sarlahi
51 Sindhulimadi+ DPHO DHB CDR Janakpur Sindhuli
52 Kapilakot PHC CDR Janakpur Sindhuli
53 Kalaiya DHB CDR Narayani Bara
54 Simara PHC CDR Narayani Bara
55 Chyutaha HP CDR Narayani Bara
56 Fetaha HP CDR Narayani Bara
57 Nichyuta HP CDR Narayani Bara
58 Nijgadha HP CDR Narayani Bara
59 Simaraungadha HP CDR Narayani Bara
60 Bharatpur ZHB CDR Narayani Chitwan
61 Baghaudamadi PHC CDR Narayani Chitwan
62 Khairahani PHC CDR Narayani Chitwan
63 Langadhi HP CDR Narayani Chitwan
64 Hetauda + DPHO DHB CDR Narayani Makwanpur
65 Bhimphedi PHC CDR Narayani Makwanpur
66 Manahari PHC CDR Narayani Makwanpur
67 Palung PHC CDR Narayani Makwanpur
68 Birgunj SRHB CDR Narayani Parsa
69 Pokhariya PHC CDR Narayani Parsa
70 Satbariya PHC CDR Narayani Parsa
71 Gaur DHB CDR Narayani Rautahat
72 Chandranigahapur PHC CDR Narayani Rautahat
73 Bhojpur DHB EDR Koshi Bhojpur
74 Dingla PHC EDR Koshi Bhojpur
75 Mulpani PHC EDR Koshi Bhojpur
76 Pyauli PHC EDR Koshi Bhojpur
77 Dhankuta + DPHO DHB EDR Koshi Dhankuta
78 Budhabare PHC EDR Koshi Dhankuta
79 Jeetpur PHC EDR Koshi Dhankuta
80 Dandabasar PHC EDR Koshi Dhankuta
81 Ankhisalla HP EDR Koshi Dhankuta
82 Ligligebaddanda HP EDR Koshi Dhankuta
83 Koshi Biratnagar ZHB EDR Koshi Morang
84 Rangeli DHB EDR Koshi Morang
85 Haraicha PHC EDR Koshi Morang
86 Jhurkia PHC EDR Koshi Morang
87 Letang PHC EDR Koshi Morang
88 Urlabari PHC EDR Koshi Morang
89 Khandhbari DHB EDR Koshi Sankhuwasabha
90 Chainpur PHC EDR Koshi Sankhuwasabha
91 Inaruwa DHB EDR Koshi Sunsari
92 Harinagara PHC EDR Koshi Sunsari
93 Itahari PHC EDR Koshi Sunsari
94 Prakashpur PHC EDR Koshi Sunsari
95 Terhathum + DPHO DHB EDR Koshi Terhathum
96 Basantapur PHC EDR Koshi Terhathum
97 Ilam DHB EDR Mechi Ilam
98 Mangalbare PHC EDR Mechi Ilam
99 Phikkal PHC EDR Mechi Ilam
100 Pasupatinagar PHC EDR Mechi Ilam
101 Mechi ZHB EDR Mechi Jhapa
102 Dhulabari PHC EDR Mechi Jhapa
103 Shivagunj PHC EDR Mechi Jhapa
104 Sanischare PHC EDR Mechi Jhapa
105 Gauriganj PHC EDR Mechi Jhapa
106 Surunga PHC EDR Mechi Jhapa
107 Panchthar + DPHO DHB EDR Mechi Panchthar
108 Rabi PHC EDR Mechi Panchthar
109 Gopetar PHC EDR Mechi Panchthar
110 Taplejung DHB EDR Mechi Taplejung
111 Tellok PHC EDR Mechi Taplejung
112 Dhungesangu Tembe PHC EDR Mechi Taplejung
113 Khotang DHB EDR Sagarmatha Khotang
114 Aiselukarka PHC EDR Sagarmatha Khotang
116 Okhaldhunga DHB EDR Sagarmatha Okhaldhunga
117 Raniban PHC EDR Sagarmatha Okhaldhunga
118 Rumjatar PHC EDR Sagarmatha Okhaldhunga
119 Sagarmatha ZHB EDR Sagarmatha Saptari
120 Bavangama Katti PHC EDR Sagarmatha Saptari
121 Kalyanpur PHC EDR Sagarmatha Saptari
122 Kanchanpur PHC EDR Sagarmatha Saptari
123 Bodebarsain HP EDR Sagarmatha Saptari
124 HanumanNagar HP EDR Sagarmatha Saptari
125 Paroha HP EDR Sagarmatha Saptari
126 Sukhipur HP EDR Sagarmatha Saptari
127 Lahan DHB EDR Sagarmatha Siraha
128 Siraha DHB EDR Sagarmatha Siraha
129 Aurahi PHC EDR Sagarmatha Siraha
130 Mirchaiya PHC EDR Sagarmatha Siraha
131 Golbazar HP EDR Sagarmatha Siraha
132 Salleri + DPHO DHB EDR Sagarmatha Solukhumbu
133 Gorakhani PHC EDR Sagarmatha Solukhumbu
134 Salyan PHC EDR Sagarmatha Solukhumbu
135 Udayapur Gaighat DHB EDR Sagarmatha Udayapur
136 Katari PHC EDR Sagarmatha Udayapur
137 Baitadi DHB FWDR Mahakali Baitadi
138 Patan PHC FWDR Mahakali Baitadi
139 Dadeldhura + DPHO DHB FWDR Mahakali Dadeldhura
140 Jogbuda PHC FWDR Mahakali Dadeldhura
141 Darchula DHB FWDR Mahakali Darchula
142 Gokuleshwor PHC FWDR Mahakali Darchula
143 Mahakali Mahendranagar ZHB FWDR Mahakali Kanchanpur
144 Achham DHB FWDR Seti Achham
145 Kamalbazar PHC FWDR Seti Achham
146 Bajhang DHB FWDR Seti Bajhang
147 Bajura + DPHO DHB FWDR Seti Bajura
148 Doti + DPHO DHB FWDR Seti Doti
149 Kedarakharda PHC FWDR Seti Doti
150 Seti ZHB FWDR Seti Kailali
151 Bhajani PHC FWDR Seti Kailali
152 Choumala PHC FWDR Seti Kailali
153 Malwara PHC FWDR Seti Kailali
154 Tikapur PHC FWDR Seti Kailali
155 Bheri ZHB MWDR Bheri Banke
156 Bankatawa PHC MWDR Bheri Banke
157 Laxmanpur PHC MWDR Bheri Banke
158 Bardiya + DPHO DHB MWDR Bheri Bardiya
159 Rajapur PHC MWDR Bheri Bardiya
160 Dailekh DHB MWDR Bheri Dailekh
161 Lakran PHC MWDR Bheri Dailekh
162 Jajarkot DHB MWDR Bheri Jajarkot
163 Gorkhkot PHC MWDR Bheri Jajarkot
164 Surket + DPHO D MWDR Bheri Surkhet
165 Mehelkuna PHC MWDR Bheri Surkhet
166 Salkot PHC MWDR Bheri Surkhet
167 Dolpa PHC MWDR Karnali Dolpa
168 Humla + DPHO PHC MWDR Karnali Humla
169 Jumla + DPHO DHB MWDR Karnali Jumla
170 Kalikot PHC MWDR Karnali Kalikot
171 Kumalgaun PHC MWDR Karnali Kalikot
172 Mugu DHB MWDR Karnali Mugu
173 Dang DHB MWDR Rapti Dang
174 Lamahi PHC MWDR Rapti Dang
175 Shrigaun PHC MWDR Rapti Dang
176 Tulsipur PHC MWDR Rapti Dang
177 Pyuthan + DPHO DHB MWDR Rapti Pyuthan
178 Bhringri PHC MWDR Rapti Pyuthan
179 Khalanga PHC MWDR Rapti Pyuthan
180 Rolpa + DPHO DHB MWDR Rapti Rolpa
181 Sabi PHC MWDR Rapti Rolpa
182 Rukum Musikot + DPHO DHB MWDR Rapti Rukum
183 Jorzuri PHC MWDR Rapti Rukum
184 Salyan DHB MWDR Rapti Salyan
185 Tharmare PHC MWDR Rapti Salyan
186 Baglung + DPHO DHB MWDR Dhawalagiri Baglung
187 Burtibang PHC WDR Dhawalagiri Baglung
188 Galkot PHC WDR Dhawalagiri Baglung
189 Harichour PHC WDR Dhawalagiri Baglung
190 Jomsom + DPHO DHB WDR Dhawalagiri Mustang
191 Lete HP WDR Dhawalagiri Mustang
192 Tukuche HP WDR Dhawalagiri Mustang
193 Myagdi DHB WDR Dhawalagiri Myagdi
194 Darwang PHC WDR Dhawalagiri Myagdi
195 Parbat + DPHO DHB WDR Dhawalagiri Parbat
196 Lanku Deurali PHC WDR Dhawalagiri Parbat
197 Gorkha + DPHO DHB WDR Gandaki Gorkha
198 Gumda PHC WDR Gandaki Gorkha
199 Jaubari PHC WDR Gandaki Gorkha
200 Makaising PHC WDR Gandaki Gorkha
201 Pokhara Regional Hospital RHB WDR Gandaki Kaski
202 Batulechour PHC WDR Gandaki Kaski
203 Bhedabhari PHC WDR Gandaki Kaski
204 Naudanda PHC WDR Gandaki Kaski
205 Sisuwa PHC WDR Gandaki Kaski
206 Tellkot PHC WDR Gandaki Kaski
207 Chandreswor HP WDR Gandaki Kaski
208 Kunchha HP WDR Gandaki Kaski
209 Yanjakot HP WDR Gandaki Kaski
210 Lamjung + DPHO DHB WDR Gandaki Lamjung
211 Gaunda PHC WDR Gandaki Lamjung
212 Manang DHB WDR Gandaki Manang
213 Syangja DHB WDR Gandaki Syangja
214 Gahraunghangling(Waling) PHC WDR Gandaki Syangja
215 Malunga PHC WDR Gandaki Syangja
216 Panchmul PHC WDR Gandaki Syangja
217 Tulasibhanjang PHC WDR Gandaki Syangja
218 Bandipur DHB WDR Gandaki Tanahu
219 Damauli PHC WDR Gandaki Tanahu
220 Vimad PHC WDR Gandaki Tanahu
221 Arghakhanchi + DPHO DHB WDR Lumbini Arghakhanchi
222 Belkot PHC WDR Lumbini Arghakhanchi
223 Thada PHC WDR Lumbini Arghakhanchi
224 Sandhikhraka HP WDR Lumbini Arghakhanchi
225 Gulmi + DPHO DHB WDR Lumbini Gulmi
226 Durkot PHC WDR Lumbini Gulmi
227 Johang PHC WDR Lumbini Gulmi
228 Sringa PHC WDR Lumbini Gulmi
229 Shivaraj DHB WDR Lumbini Kapilvastu
230 Taulihawa DHB WDR Lumbini Kapilvastu
231 Mahendrakot PHC WDR Lumbini Kapilvastu
232 Nawalparasi PritibiChan.H. DHB WDR Lumbini Nawalparasi
233 Chormara PHC WDR Lumbini Nawalparasi
234 Jaganathpur PHC WDR Lumbini Nawalparasi
235 Dumkauli PHC WDR Lumbini Nawalparasi
236 Palpa DHB WDR Lumbini Palpa
237 Kharseuli PHC WDR Lumbini Palpa
238 Rampur PHC WDR Lumbini Palpa
239 Tahu PHC WDR Lumbini Palpa
240 Butwal Lumbini ZHB WDR Lumbini Rupandehi
241 Bhim Hospital Bhairahawa DHB WDR Lumbini Rupandehi

Source: http://nphl.gov.np/downloads/lab_assessment_report_final_9584.pdf

fatlossaustralia.com.au2

Physiology of Hormones by Dr. Sherrill Sellman Women and hormones equal big business these days. Like animals lured into a snare by a trail of crumbs, women have been cajoled with scientific studies, media advertising, patient handbooks and drug samples to accept Hormone Replacement Therapy as a magic potion. HRT is praised as the cure for hot flashes and all the other symptoms assigned to the menopause pantheon. In