Community Medicine Internship Program

Birat Medical College Teaching Hospital

REPORT
(In the partial fulfillment of the requirement of for the completion of
Internship Program at Department of Community Medicine)

Chief Guide
Dr. Surya B. Parajuli Head of Department & Associate Professor Department
of Community Medicine Birat Medical College Teaching Hospital

Trainee

Dr Sadre Alam Intern (Batch of 2017)

Birat Medical College Teaching Hospital, Morang, Nepal (Aug1 –Aug15) 2023

1
 Community Medicine Internship Program
Birat Medical College Teaching Hospital

REPORT
(In the partial fulfillment of the requirement of for the completion of
internship program at Department of Community Medicine)

Guide Dr. Surya B. Parajuli Head of Department & Associate Professor

Department of Community Medicine Birat Medical College Teaching Hospital

Submitted by Dr. Sadre Alam Intern (Batch of 2017)

Birat Medical College Teaching Hospital, Morang, Nepal (Aug1 –Aug15) 2023

CERTIFICATE
2
This is to certify that the report entitled “Community Medicine Internship
Program At Birat Medical College Teaching Hospital” is the result of
original investigative field work carried out by Intern Dr. Sadre Alam,
under the direct supervision and guidance in partial fulfillment of the
requirement for the completion of Internship Program in Department of
Community Medicine from Birat Medical College Teaching Hospital,
Budhiganga-02, Morang, Nepal.

………………………………….

तपाईको
समुदातपाईको
चिचकत्स
य
Kathmandu University क
BIRAT MEDICAL COLLEGE TEACHING HOSPITAL

Department of Community Medicine

udhiganga Rural Municipality 02, Tankisinuwari, Morang, Nepal

Assoc. Prof. Dr. Surya B. Parajuli

Head of Department
Department of Community Medicine
Birat Medical College Teaching Hospital
Budhiganga-02, Morang

CERTIFICATE

3
This report entitled “Community Medicine Internship Program at Birat Medical
College Teaching Hospital” was submitted to the Department of
Community Medicine, Birat Medical College Teaching Hospital. It is the
bonafide work of Intern Dr Sadre Alam, conducted under the direct
supervision and guidance in partial fulfillment of the requirement for the
completion of Internship Program in Department of Community Medicine.

CHIEF GUIDE

………………………………………………….……….
Assoc. Prof. Dr. Surya B. Parajuli
Head of Department

तपाईको
समुदा
तपाईको
चिचकत्स
य
Kathmandu University क
BIRAT MEDICAL COLLEGE TEACHING HOSPITAL

Department of Community Medicine

udhiganga Rural Municipality 02, Tankisinuwari, Morang, Nepal

Department of Community Medicine

Birat Medical College Teaching Hospital, Budhiganga-02, Morang
CO-GUIDES

……………………….…………………. Dr
Ritu Chaudhary
Senior Medical Office
FPAN, Biratnagar

DECLARATION

4
I hereby declare that this report entitled “Community Medicine
Internship Program At Birat Medical College Teaching Hospital” has been
prepared by me under the closed guidance and supervision of Assoc. Prof.
Dr. Surya B. Parajuli as a chief guide, Dr Ritu Choudhary, as co-guide in the
partial fulfillment of the requirement for the completion of Internship
Program in Department of Community Medicine from Birat Medical
College Teaching Hospital, Budhiganga Rural Municipality -02, Morang,
Nepal.

……………………….………………
Intern Dr. Sadre Alam
MBBS
Birat Medical College Teaching Hospital
Budhiganga Rural Mu-02, Morang, Nepal
Batch of 2017

TABLE OF CONTENTS

Title Page no

Acknowledgement 7

5
Abbreviations 8
List of Figures 9
List of Tables 9
Report Summary 10
Program Guidelines 11

1. Family Health Exercise at Budhiganga Rural Municipality

1.1 Introduction 13
1.2 Program Objectives 13
1.3 Program Methodology 15
1.4 Findings and SWOT analysis 16

2. Family Planning Association Nepal (FPAN), Morang

2.1 Introduction 17
2.2 Scope of FPAN 17
2.3 Daily Activities 18
2.4 Program Objectives 18
2.5 Program Methodology 19
2.6 Findings and SWOT analysis 22
2.7 Analysis of FPAN as per WHO’s six building blocks 28

3. Leadership 30

4. Research 31

6
5. Bibliography 32

ACKNOWLEDGEMENTS

Birat Medical College Teaching Hospital, a leading medical college and a health
services provider in Eastern Nepal has been constantly delivering health care
facilities to all the people throughout the Nation. Besides its health care
services, it has been producing qualified doctors every year. As a part of
internship programme, we intern doctors are posted through Department of
Community Medicine to Budhiganga Health Post, FPAN Morang branch and
Family Health Exercise house. There, we get the opportunities to learn about
the health system, health system delivery, the leading problems in the
community, the cause behind the problems and possible solutions. Beside this,
we get to know the standard of living in the community through FHE. We as a
student of community medicine learned what we can do, how we can apply our
knowledge for the better public and environmental health. I, Dr. Sadre alam, as
an intern got this great opportunity to gain knowledge of ground root level
health problems, different health delivery systems, and services and also got
the opportunities to improve some clinical skills.

7
I would like to offer my sincere appreciation to senior MO Dr. Ritu Chaudhary,
branch manager Mr. Shankar Prasad Dahal, Sr. ANM Pancha Maya Magar, staff
nurse Moneeca Chaudhary and all other staffs for providing us knowledge of
SRH, and helping us to strengthen our clinical skills. I would also like to extend
my appreciation to BMCTH, Assoc. Prof. and HOD of Community Medicine Birat
Medical College Teaching Hospital Dr. Surya B.Parajuli, and all faculty members
of Community Medicine for consistently helping me during my MCH Training. I
would also like to thank my friend Dr. Shahnawaz alam and FHE house members
for their cooperation.

Finally, I hope this report will provide some information on the health system of
Nepal, health problems and environmental status at ground root level.

Intern Dr. Sadre Alam Batch of 2017 August 1 2023 -August 15 2024
Birat Medical College Teaching Hospital

Abbreviations

ANC : Antenatal Checkup

ANM : Auxiliary Nurse Midwifery
AUB : Abnormal Uterine Bleeding
CMIS : Content Management Interoperability System
EPI : Extended Programme of Immunization
FHE : Family Health Exercise
FPAN : Family Planning Association Nepal
FP : Family Planning
IPPF : International Planned Parenthood Federation
IUCD : IntraUterine Copper Device
MA : Medical Abortion
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MO : Medical Officer
MVA : Manual Vacuum Aspiration
OPD : Outpatient Department
OT : Operation Theatre
PMSEU : Poor, Marginalized, Socially excluded,and Underserved
POG : Period of Gestation
PV/PS : Per Vaginal/ Per Speculum
SRH : Sexual and Reproductive Health
STI : Sexually Transmitted Infections
SWOT : Strength Weakness Opportunities Threat
USG : Ultrasonography
VIA : Visual Inspection of Cervix with Acetic Acid
WHO : World Health Organization
LSCS : Lower Segment Cesarean Section

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 LIST OF FIGURES

Figure 1: Head of house of my allocated family ……………………………………….…………..13

Figure 2: Interaction and interview with family members……………………………………..14
Figure 3: Family Planning Association Nepal, Morang, Biratnagar………………………….16
Figure 4: Different methods of Family Planning……………………………………………………..18
Figure 5: Mother’s Plus protein supplementation for pregnant ladies……….............
Figure 6: Immunization schedule of Nepal…………………………………………………………….
Figure 7: In first, Staff filling the growth parameters of child and second
the growth chart…………………………………………………………………………………… Figure
8: Services provided by FPAN, Morang………………………………………………………
Figure 9: MVA set for manual vacuum aspiration………………………………………………
Figure 10: Immunizing staff giving vaccination to baby and
Vials of vaccines………………………………………………………………………………….
Figure 11: David-Morley Growth chart………………………………………………………………….
Figure 12: OPD service and Physical examination room………………………………………..
Figure 13: Laboratory FPAN, Biratnagar………………………………………………………………..
Figure 14: UPT and Blood Grouping………………………………………………………………………
Figure 15: USG room…………………………………………………………………………………………….
Figure 16: Norplant insertion and removal……………………………………………………………
Figure 17: Instruments set for VIA and per speculum examination……………………….
Figure 18: Post operative ward…………………………………………………………………………….. Figure
19:Wardrobe with drugs…………………………………………………………………………….

10
 LIST OF TABLES

1. Day wise activities of FPAN, Biratnagar……………………………………….18

REPORT SUMMARY

As a part of our internship program we were posted under community medicine

as an intern doctor. In the 15 days posting we visited the Family Planning
Association of Nepal (FPAN), Biratnagar, where we observed, learned and
assisted in the activities of the center. We developed counseling skills to select
family planning methods by the clients, observation of immunization process,
observe and access safe abortion and client counseling and lastly performing a
SWOT analysis on FPAN. Also skills like insertion of levonorgestrel implant,
insertion of uterine elevators and administration of immunization vaccines was
attained during the posting. We also visited our allocated house under Family
Health Exercise (FHE), where interaction with the head of household and other
members of the family was done. An assessment of changes that were seen in
regards to lifestyle, hygiene, waste management practices, sanitation, and
health from the start of FHE to present day was made and also a SWOT analysis
was done.

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Program Guideline Department of Community Medicine Internship
Program for MBBS

Background
Community Medicine is an important domain of the MBBS curriculum of Kathmandu
University where students have to spend 3.5 years. Intern doctors training under
Community medicine helps them to learn different life skills of holistic health.
Population-level health intervention is an emerging field. We need to align our future
doctors with this growing need.

Program and Objectives

1. Family Health Exercise Posting
A. Perform a SWOT analysis of assigned family in the Budhiganga community in
terms of natural history and diseases
B. Organize the health education and advocacy program on a prevalent health
issue of the assigned community
C. Help your assigned family member to visit our teaching hospital for screening
and necessary treatment
D. advocate for the concerned community for the importance of social health
insurance

2. Family Planning & Maternal & Child Health Center Posting (FPAN, Biratnagar)
A. Develop counseling skills to select family planning methods by clients
B. Observe and access procedure of different family planning methods
C. Observe and access different antenatal care services
D. Observe and access the safe abortion service and client counseling
E. Observe the immunization process
F. Monitor the growth chart of the children
G. Perform a SWOT analysis of FPAN

3. Academic Activities
A. Seminar and Presentations

4. Health Leadership and Management A. Learn the different health leadership skills
B. Learn different health management skills

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 C. Learn different health communication skills

5. Research
A. Learn different skills of proposal writing and report writing

1. Family Health Exercise Posting

1.1 Introduction
Family Health Exercise has been practiced as a part of community Medicine field
visit from second year of MBBS at BMCTH. A house of the local community is
designated to each student where the student has to observe, investigate,
interview, evaluate, analyze and search for the health and environmental
problem and present their findings to the department. Students share their
knowledge on any aspect of health and environment as they can to the
household.
This provides opportunities to the student to know the problem prevalent in the
community, develop communication skills and help in academic aspects as well.
I was designated a house at Budhiganga Rural Municipality, 02. The head of
the house shyamlal majhi is living with his wife laxmi majhi and their 1 son
Aryan majhi . I have been seeing this family since 10 June 2018

1.2 Program Objectives

Specific objective 1: Perform a SWOT analysis of assigned family in the
Budhiganga community in terms of natural history and diseases
Specific objective 2: Organize the health education and advocacy
program on a prevalent health issue of the assigned community
Specific objective 3: Help your assigned family member to visit our
teaching hospital for screening and necessary treatment

13
 Specific objective 4: Advocate for the concerned community for the
importance of social health insurance

1.3 Program Methodology

Methodology 1
● Studied Park’s Textbook of preventive and Social Medicine
regarding various aspects of housing ( Ventilation, lighting,
overcrowding, waste management, setback, water sources, etc)
● Interviewed with households about their current status in various
aspects of health

● Inspected and evaluated the past and present aspect of house and
it’s both external and internal environment

Methodology 2
● Interviewed with family members about the existing health
problems
● Studied the etiology, risk factors, pathophysiology from Harrison’s
Principle of Internal Medicine and Prevention strategies from
Park’s Textbook of Preventive and Social Medicine
● Advocated family members about modifiable risk factors and
preventive measures, screening modalities and benefit of early
diagnosis and treatment

Methodology 3
● Provided my mobile number for needful
● Informed about various general discounts provided by hospital in
various laboratory tests and treatment modalities

Methodology 4
● Advocated about various health insurance policies like Nepal
Government’s Health Insurance Programme and Social Security
fund
● Discussed about the methods and process of registration of
insurance

14
1.4 Findings

Positive Changes that I noticed in my allocated family:

● The living standard has increased than before
● The environment looked cleaner than before
● Every members of family has positive attitude towards health insurance
policy
● Hospital visits for any health related problem has increased

Major Problems observed

● Improper arrangement of sheds and cattle rearing practice

● Lack of proper concern in few matters of personal hygiene ( walking bare
feet, spitting in nearby open land)

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 SWOT ANALYSIS OF FHE

STRENGTHS
● Maintain proper sanitation inside and outside their house.
● Family member usually attend different programmes that are
organized in community.
● They are using mosquito net( that prevents from mosquito borne
disease)

WEAKNESS

16
 ● Poor drinking habit and have poor method of purification of water.
● Poor lighting and ventilation
● Habit of drinking alcohol and smoking cigarettes

OPPORTUNITIES

● Family member have good family income So, can change the
architecture of the house, preventing from overcrowding.
● Proper ventilation and lightening

THREAT
● High risk of flood
● Habit of drinking alcohol may lead to chronic alcohol misuse
leading to different medical and social consequences.
● Infection prone

2. Family Planning Association Nepal (FPAN), Morang Visit

2.1 Introduction
Family Planning Association of Nepal (FPAN), a non-government organization
(NGO) and a member association of the International Planned Parenthood
Federation (IPPF) is a major partner of the Government of Nepal’s national
family planning program. It is contributing larger number of all family

17
Figure 3 : Family Planning Association Nepal, Morang Branch, Biratnagar

18
planning services in Nepal annually and is Nepal’s first national sexual and
reproductive health service delivery and advocacy organization. FPAN works
across 37 districts to provide critical health services to poor, marginalized,
socially excluded, and underserved (PMSEU) communities, including sex
workers. The branch at Biratnagar Morang working since its establishment in
1983 A.D, dedicated to provide health services such as ANC checkup, Family
planning, Contraception, Safe abortion, Immunization and reproductive health
services to people of eastern Nepal. They are providing various health care
services by trained health care workers on every working day at a cheap cost
primarily focusing on SRH under leadership of senior MO Dr. Ritu Chaudhary.

2.2 Scope of FPAN

FPAN Biratnagar has been providing services on following fields:
a. Advice on sexual and reproductive health
b. Temporary family planning services
c. Permanent family planning ( Minilap) for female
d. Immunization ( Every Monday) and Child health care
e. Safe abortion services ( up to 12 weeks)
f. Laboratory services
g. Emergency family planning services
h. Pregnancy test
i. ANC clinic ( Monday and Friday)
j. Venereology clinic and treatment service
k. Adult reproductive health service
l. General health checkup

2.3 Daily Activities of FPAN, Biratnagar

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FPAN has provision of different services on different days to provide coverage
to all health issues. They provide their various services on day to day basis as
follows:

DAYS ACTIVITIS/ SERVICES

Sunday ANC, Gynae OPD, Contraception, Safe Medical Abortion

Monday ANC, Immunization, Medical Abortion

Tuesday Implant Insertion and Removal

Wednesday VIA, STI clinic, Medical Abortion Services

Thursday ANC

Friday ANC and Implants

Saturday Off Day

Table 1: Day wise activities of FPAN, Biratnagar

2.4 Program Objectives

Specific Objective 1: Develop counseling skills to select family planning
methods by clients
Specific Objective 2: Observe and access procedure of different family
planning methods
Specific Objective 3: Observe and access different antenatal care services
Specific Objective 4: Observe and access the safe abortion service and
client counseling

20
 Specific Objective 5: Observe the immunization process
Specific Objective 6: Monitor the growth chart of the children Specific
Objective 7: Perform a SWOT analysis of FPAN

2.5 Program Methodology

Methodology 1: Studied and learned various family planning techniques
which are appropriate for each couple, advantage of one over the other
and methods that best suits at that particular age group

Methodology 2:
● Visited FPAN, Biratnagar and interacted with Dr. Ritu Chaudhary
(Senior Medical Officer) regarding different hormonal and
nonhormonal methods of family planning.
● Observed the family planning chart which was present over there

Figure 4: Different methods of Family Planning

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Assisted and performed Jadelle Implant insertion (LEVONORGESTREL 75 mg*2)

Methodology 3
● Interviewed and interacted with Dr. Chaudhary regarding various
ANC services provided there
● Read pamphlets and posters about different ANC protocols, various
ANC checkup and Fetal wellbeing assessment
● Observed various nutrients supplementation provided by FPAN to
expectant mothers

Figure 5: Mother’s Plus protein supplementation for pregnant ladies

Methodology 4
● Learned different conditions for which abortion is legalized through
MULUKI AIN OF NEPAL
● Read pamphlets and charts as well as DC Dutta’s Textboook of
Obstetrics about various techniques of Trimester wise abortion
● Learned to prescribe Mifepristone 200 mg and Misoprostol 800
mcg for Medical Termination of Pregnancy
● Observed YouTube video on MVA procedure
● Observed and assisted performing Manual Vacuum Aspiration for
incomplete/missed abortion and after failure of MTP
● Counseling regarding post abortion care and family planning
techniques was explained

22
 Methodology 5
● Read the latest National Immunization Schedule of Nepal

Figure 6: Immunization schedule of Nepal

● Read routes, sites and dosage as well as possible adverse effects of

various vaccine listed in National Immunization Schedule
● Counseling to parents about importance of timely and complete
immunization of their children

Methodology 6
● Observed Road-to-health chart, parameters to access and
techniques to measure each parameter
● Read “Growth and Development of Children” in Ghai Essential of
Paediatrics and learned to interpret different growth patterns
● Learned technique of filling those measured parameter on the
chart

23
Figure 7 : In first, Staff filling the growth parameters of child and second the growth chart

● Interpreted different growth pattern observed

● Parents counseling regarding the causes and complication of
inappropriate growth showing pictures in mobile

Methodology 7
● Observed and inspected various facilities and services provided by
FPAN, Biratnagar
● Interviewed service takers about their satisfaction and
dissatisfaction regarding services
● Also noticed different patient being referred in/ referred out
● Interviewed the Branch Manager of FPAN, Biratnagar regarding
budget allocation and distribution in different areas of services
● Inspected local environment to see for other higher centers if
present/ or not

2.6 Findings
● FPAN, Biratnagar provides cheap and affordable facilities on a daily basis.
Those services cover many service takers from Itahari of Sunsari district,
Entire Morang district and also from the border area of India.

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 Figure 8 : Services provided by FPAN, Morang

● Presence of trained and experienced staff has boosted the service

providing capacity of FPAN, Biratnagar. Staff are limited in quality but
they are highly experienced and dedicated towards their responsibility.

● Safe abortion service provided by FPAN, Biratnagar at its affordable and

feasible cost has decreased the illegal and unsafe abortion in this area.
Medical terminations of Pregnancy with Mifepristone and Misoprostol
for pregnancy up to 6 weeks and MVA for pregnancy up to 12 weeks are
carried out here.

Figure 9 : MVA set for manual vacuum aspiration

25
● Immunization programme for children is held every Monday where
infants and children are vaccinated according to the EPI schedule of
Nepal. Also growth and development of infants and children is assessed
and plotted in David-Morley Chart

Figure 10 : Baby receiving Rota vaccine, Immunizing staff giving vaccination to

baby and Vials of vaccines

26
 Figure 11 : David-Morley Growth chart

● OPD service and physical examination service where usually maternal

health is checked, ANC done, per abdominal, per vaginal and per
speculum examination are done.

Figure 12 : OPD service and Physical examination room

● Laboratory and Diagnostic service for Hemoglobin estimation, Urine and

stool R/M/E, UPT and Blood Sugar estimation helps to rule out anemia,
UTI and diabetes mellitus in patients.

27
 Figure 13 : Laboratory FPAN, Biratnagar

Figure 14 : UPT and Blood Grouping

● Ultrasonography services provide aid to dating scans during ANC.

Figure 15 : USG and USG room

28
 ● A separate room for Implant insertion, removal and VIA is present where
Norplant (Levonorgestrel 75 mg) rods are inserted, removed after 5 years
and Visual inspection of Cervix is done under Acetic Acid.

Figure 16 : Norplant insertion and removal

29
 Figure 17 : Instruments set for VIA and per speculum examination

● Minilap (permanent family planning ) for women is carried out in OT and

provision for a postoperative observation ward for a few hours-days.
This ward is also used after MVA to observe patients few hours after the
procedure

Figure 18 : Post operative ward

● Distribution of analgesics, iron, folic acid,multivitamin complex,

albendazole, antibiotics, calcium, vitamin D and
protein supplementation to pregnant

Figure 19 :Wardrobe with drugs

SWOT analysis of FPAN, Biratnagar
STRENGTHS

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 ● Easy to reach.
● Cheap and affordable facilities.
● Trained and experienced staff.
● Safe abortion service.
● Immunization.
● Maternal and child health programme.

WEAKNESS
● Insufficient funding,
● Limited diagnostic tools.
● Limited working staff.
● Lack of infrastructures.
● Poor storage of medicine and equipment.

OPPORTUNITIES
● Improvement of the lab.
● Storage facilities of medicines.
● Staff addition.
● Awareness campaign.

THREATS
● Lack of Fund.
● Preference to hospitals.
● Koshi Zonal Hospital nearby.

2.7 FPAN analysis as per WHO’s 6 building blocks.

LEADERSHIP
Organogram of FPAN
Branch Manager: Mr. Shankar Prasad Dahal
Senior Medical Officer: Dr. Ritu Chaudhary
Senior ANM: Pancha Maya Magar
Staff Nurse: ArunaThapa, Moneeca Chaudhary
Office Assistant: Jagat Shrestha

31
 Lab Assistant: Jiten Rajbansi
Cleaner: Punam Mehata

FPAN has limited funding sources. It has an economic setback. This obliged
them to limit the staff and carry out activities in limited resources.
However the organization is hopeful of future solutions. Branch manager
and sr. MO Dr. Ritu Chaudhary has successfully led the organization even
with minimum resources and manpower. They demonstrate a good
example of leadership.

FINANCING
IPPF is the main donor of FPAN and its programme. A large sum of funding
is provided by the Norway and the Sweden governments. However,
because of ongoing political conflicts among different nations and ongoing
inflation, the funding hasn't been enough. The branch has been planning
to solve financial problems by lending its unused area as a rent in the
coming days.

HUMAN RESOURCES
Health Team at FPAN
Dr. Ritu Chaudhary, Senior Medical Officer
Sr. ANM, Pancha Maya Magar
Staff Nurse, ArunaThapa, Moneeca Chaudhary
Office Assistant, Jagat Shrestha
Lab Assistant, JitenRajbansi
Cleaner, Punam Mehta

Dr. Ritu Chaudhary has organized her team and provides the service to all
patients efficiently despite lack of adequate human resources.

HEALTH INFORMATION
FPAN uses Content Management Interoperability System (CMIS) software to
send and collect their records into the database. This database can be
accessed through FPAN headquarter and IPPF as well. The records obtained
are utilized in preparation of annual reports and budget allocation in an
equitable manner.
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MEDICAL PRODUCTS
FPAN is dedicated to provide following services and medical products:
● OPD services
● ANC checkup
● ANC investigations
● Safe Abortion Service
● Manual Vacuum Aspiration (MVA)
● Medical Abortion (MA)
● Visual and Inspection of cervix with Acetic acid (VIA)
● Laboratory services
● USG service
● Immunization
● Condoms and oral contraceptives (free of cost)
● Norplant
● IUCDs
● Referral services

HEALTH SERVICE DELIVERY

Following services are delivered via FPAN:
● ANC
● Maternal and Child Health
● Immunization
● Safe Abortion
● Family Planning and Contraception
● Cervical Cancer Screening

3. Leadership
We also got the opportunity to be a part of the Family Health Exercise program
of first year MBBS students. We performed following during this visit:
● Guided and shared our previous experiences with our junior colleagues

33
● Helped them to conduct various informative dramas, role play, dance and
other activities.

4. Research

34
 Worked on a case report of a case of epiploic appendagitis and went
through multiple research articles regarding it.
● Read WHO guideline for health hygiene in health care.

5. Bibliography
1. Park’s Textbook of preventive and Social Medicine. K. Park. 24th edition.
2. DC Dutta’s Textbook of obstetrics. 9th edition.
3. Harrison’s Principle of Internal Medicine. 21st edition.
4. https://mohp.gov.np/program/national-immunisation-programme/en

35