COVID-19 Active Response and Expenditure Support Program (RRP NEP 54184)

SECTOR ASSESSMENT (SUMMARY): HEALTH AND SOCIAL PROTECTION

A. Sector Performance, Problems, and Opportunities

1. Sector performance. has made significant improvements on its health status, with maternal mortality ratio (MMR) declining from 539 per 100,000 live births in 1996 to 239 in 2016, and in recent 2017 estimates to 186 per 100,000 live births.1 Nepal reduced under five-year-old mortality rate by 67% and infant mortality rate (IMR) by 66% between 1996 and 2016.2 However, inequities exist between rural and urban areas on important parameters such as IMR which is higher in rural areas with 55 per 1,000 live births, compared to urban areas with 38 per 1,000 live births. Likewise, the under-5-year-old mortality rate in rural areas is 64, and that in urban areas is 45 per 1,000 live births.3 The neonatal mortality rate was 50 per 1,000 live births in 1996 and was reduced to 21 in 2016 (58% reduction).4 Life expectancy for males is 69 years, and for females, it is 72 years.5

2. With the decline of communicable diseases, noncommunicable diseases (NCDs) such as diabetes, cancer and cardiovascular diseases and others are on the rise, particularly in urban areas. NCDs account for more than 44% of deaths, 80% of outpatient contacts and 39% of -adjusted life year (DALY)’s lost.6 People with pre-existing NCDs also appear to be more vulnerable to becoming severely ill with the coronavirus.7 Hence, currently, Nepal is trapped in the "double burden" of diseases.

3. Total annual health expenditure (THE) in Nepal is NRs151 billion. This is 6.7% of the country's GDP. 40% of THE is from the public sector, which is almost 1.8% of the GDP. One- third to one-half of THE is estimated to be the out-of-pocket (OOP) expenditure. External agencies and partners contribute more than 11% of THE.8 In accordance with NHP’s policy commitment and to reduce OOP expenditure, the government initiated basic health services package and minimum service standards for each health facility to achieve Universal Health Coverage (UHC) with a legal and institutional framework.9 The National Health Insurance Act was approved in 2016, and the implementation has been assigned to the Health Insurance Board.10 As of 31 August 2019, 1.6 million beneficiaries have been enrolled, accounting for 14% of the country's population.11

4. Health sector challenges. Providing access to quality health services for UHC, as enunciated in the Constitution and the NHP, requires rapid expansion of access to and improving the quality of health care services. It remains a major challenge both in rural areas because of difficult geographical milieu and in urban areas because of unplanned urbanization and influx of migrants. The expansion of urban health services, owing to rapid urbanization is a burning challenge. Shifting burden of diseases and natural disaster-induced health problems further exacerbates the situation. The devastating in 2015 resulted in 1,200

1 Nepal Demographic and Health Survey 2016. https://www.dhsprogram.com/pubs/pdf/FR336/FR336.pdf; and https://data.worldbank.org/indicator/SH.STA.MMRT?locations=NP 2 Ministry of Health and Population. 2019. National Joint Annual Review Report 2019. Nepal; https://data.unicef.org/country/npl/ 3 K.P. Pathak, T. Gaire. 2020. Nepal: Country Report on Children's Environmental Health. Rev Environ Health. 26; 35(1). pp.53–56. 4 Ministry of Health and Population. 2019. National Joint Annual Review Report 2019. Nepal. 5 WHO. https://www.who.int/countries/npl/en/. Nepal. 6 D. Daniels et al., 2013. Nepal Health Sector Programme II Mid-term Review. . 7 https://www.who.int/who-documents-detail/covid-19-and-ncds 8 National Health Accounts Nepal, 2018. 9 N.K. Raut. 2015. Path to Universal Health Coverage in Nepal: Is it Achievable? National Graduate Institute for Policy Studies. Pp. 1–17. 10 Health Insurance Board of Nepal available at https://hib.gov.np/en 11 Presentation by Health Insurance Board.

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health facilities being affected. Reconstruction and maintenance of these health facilities are still ongoing.

5. Nepal federal reform brought health services closer to the communities through a decentralized health system. There is at least one health post in every former village development committee, one primary health care center in every electoral constituency, a -level hospital in every district and secondary level hospitals in zonal and regional level.12 However, this move from unitary to a three-tiered federal system of governance has created both opportunities and challenges. Decision making on public health services has now been devolved to subnational governments, which has facilitated decisions that are more representative of local public health needs. One of the challenges is to ensure uninterrupted medical supplies and services. This requires institutional capacity development of local governments, including adequate human resources and their capacity building, as the health function, previously done through district health offices, are now delivered through local governments. Also, the delineation of authorities and responsibilities among the three government tiers in the sector is another challenge. Procurement and contract management capacity of local governments and mechanisms for quality assurance of essential medical supplies also need to be strengthened. While telemedicine could provide significant support in the diagnosis and management of patients in remote areas, its expansion, and utilization remains a challenge in the absence of adequate technological and financial support.

6. Coinciding with COVID-19 pandemic, Nepal health system also have to cope with the ongoing influenza season, which can result in significant outbreaks. Furthermore, the impending humanitarian impact due to season and related flooding could further strain the system. The Preparedness and Response Plan (NPRP) for Nepal highlight that pre-existing societal structures, social norms, discriminatory practices and gender roles could contribute to heightened risks due to the pandemic for vulnerable groups. These vulnerable groups include children, persons with , mixed migrants, refugees, sexual and gender minorities, people living with HIV/AIDS, adolescent girls, single women, pregnant women and lactating , senior citizens, women from religious and ethnic minorities and indigenous women.13

B. Government Policies and Plans

7. Health Policy and Sector Strategy. Health has been recognized as the fundamental human right in the (2015). The National Health Policy of 2019 (NHP) commits to availability of free basic health services and access to specialized and emergency services for all citizens.14 NHP emphasizes on integrated preparedness and response measures to combat communicable diseases, epidemics, and disasters with a focus on capacity development as per the International Health Regulations, 2005. It also calls upon collaboration and partnerships among governmental, non-governmental and private sectors along with private, internal and external investments in health education, services and researches. Nepal Health Sector Strategy (2015–2021, NHSS) positions health at the center of the country's overall socio-economic development and corresponds with essential elements of the NHP 2019. NHSS also provides a roadmap for universal coverage of basic health services; encourage meaningful contribution from the private sector; and make health service delivery more transparent and accountable to the public. NHSS has four strategic

12 After the federal restructuring, former village development committees were reorganized under rural and municipalities. There are currently 753 rural municipalities and municipalities. Health posts and primary health care centers are now under rural municipalities and municipalities. 13 Naja F, Hamadeh R. Nutrition amid the COVID-19 pandemic: a multi-level framework for action. European Journal of Clinical Nutrition. 2020:1-5; Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry. 2020. 14 , Ministry of Health and Population. National Health Policy, Nepal (2019). Kathmandu.

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principles: (i) equitable access to health services, (ii) quality health services, (iii) health systems reform, and (iv) multi-sectoral approach.

8. Emergency response has been facilitated by the Infectious Disease Act 1964 and The Constitution of Nepal 2015 which provides the legal authority to the federal government to act and respond to pandemics. Other provisions in the Constitution gives power to the President to declare a in the event of an epidemic (Article 273), and mobilization of the Nepal Army for disaster management works [Article 267(4)]. The Public Health Services Act 2018 and Disaster Risk Reduction and Management Act 2017 provide a legal framework to impose public health emergency and manage disasters, including epidemic outbreak.15 The Act also prescribes a coordinated approach by all three levels of government, with the federal government leading the pandemic response activities. The Operations Act, 2017 provides the legal basis for defining the responsibilities and authorities of local government pertaining to public health surveillance, planning and implementation of epidemic control, disease control and prevention, and running emergency services and management at the local level.

9. In April 2020, under the framework of the National Relief Program, the government released the Health Sector Emergency Response Plan: COVID-19 Pandemic.16 The plan was further revised in May 2020. The plan’s objective is to prepare and strengthen the response of the health system to minimize the pandemic’s health impact. It presents four scenarios based on COVID-19 positive case load including (i) a maximum number of positive cases under 2000 (ii) a maximum number of positive cases between 2000 and 5000 (iii) a maximum number of positive cases between 5000 and 10000 and lastly (iv) a maximum number of positive cases greater than 10,000.17 Each of these levels further segregates cases into three levels of severity assuming that 80% of cases would need general treatment at the hospital with isolation ward and beds, 15% would need hospitalization with oxygen support and only 5% would need intensive care unit (ICU) services. The plan prescribes strategic approaches and key interventions for (i) health systems (ii) public health and social measures (iii) curative care interventions, and (iv) strengthened management for COVID-19 response.18

C. Response to the COVID-19 Pandemic

10. Leadership and institutional support. The government has taken swift action in setting up a committee called the “High-Level Coordination Committee on Covid-19 Transmission, Containment and Control” under the leadership of the Prime Minister and /Defense Minister to address multi-sectoral coordination with representation from several line ministries.19 A Steering Committee led by the MOHP Secretary has been setup for guiding overall health sector response, with the Health Emergency Operation Center (HEOC) as its secretariat. An information management unit with a dedicated team and adequate resources is established within the HEOC to monitor and report on the key indicators.20 A technical coordination committee chaired by the Director-

15 Government of Nepal. 2018. Disaster Risk Reduction and Management Act, 2017. Kathmandu. 16 Government of Nepal, Ministry of Health and Population. 2020. Health Sector Emergency Response Plan: COVID-19 Pandemic. Kathmandu. 17 The plan would be periodically revised based on positive case load in collaboration with WHO and other partners 18 The government’s is closely monitoring the case load and adjusting its response outlined within the plan. 19 https://english.onlinekhabar.com/govt-to-adopt-much-needed-prevention-against-coronavirus.html 20 The key indicators include (i) percentage of budget allocated to support COVID-19 response plan, (ii) number of positive cases and daily/weekly trend, (iii) per capita cases by province/district, (iv) percentage of cases cured among outcome group patient, (v) case fatality rate of confirmed cases by age groups and sex, (vi) number of new confirmed cases in health care workers, (vii) number of referred cases, (viii) number of positive cases identified during contact tracing, (ix) number of isolation beds available by province/district, (x) number of ICU beds to provide services to the COVID-19 cases, (xi) number of people quarantined, (xii) number of suspected cases isolated, (xiii) proportion of positive cases among suspected cases, and (xiv) percentage of laboratories scoring 100% on EQAP.

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General of the Department of Health Services provides technical recommendations to the Steering Committee. The Humanitarian Country Team (HCT) led by the United Nations has been working closely with the government to combat the pandemic. Several other development partners are also providing immediate support or preparing interventions to respond to the pandemic.21

11. Prevention. Nepal announced the suspension of visa-upon-arrival for nationals from any country from midnight on 14 March 2020. All land ports of entry into Nepal remain were also closed from 14 March 2020. Suspected cases and contacts already in the country are quarantined in designated institutions for 14 days. The high-risk groups include those with international travel history (ground and air) and also those for whom the home-based quarantine might not be appropriate. Institutional quarantine facilities are being arranged by mobilizing available infrastructures such as schools, campuses, hostels, hotels and other accommodating facilities across the country, particularly focusing on and bordering . On 24 March 2020, a nation-wide lockdown came into effect, which has been extended until 5 May 2020, with international flights suspended until 15 May 2020.

12. Testing. As of 30 April, Polymerase Chain Reaction (PCR) testing is being carried out at 16 locations, including one in each of the seven provinces.22 The National Public Health Laboratory (NPHL), in Kathmandu, is the primary testing laboratory for COVID-19. On 6 April, the Ministry of Home Affairs launched an official site 'COVID-19 Integrated Information and Quarantine Monitoring System' to deliver and disseminate actual information and data related to COVID-19 and its impact across the country.23

13. Case investigation, contact tracing and surveillance. Teams have been formed and mobilized at a local level including a public health professional, lab technician and health worker for case investigation and contact tracing. Female volunteers are also engaged when necessary. In terms of deployment, there are at least five teams in the metropolitan city, three in sub-metropolitan, two in each and one in rural municipalities totaling to 1,075 teams. Epidemiology and Disease Control Division (EDCD) of the Department of Health Services is responsible for surveillance and the Early Warning and Reporting System (EWARS). It currently covers all 77 districts of Nepal with 118 sites for sentinel surveillance. The system gathers and compares data of severe acute respiratory illness/infection (), which indicates the number of severe cases of influenza-like illness (ILI) for a timely response. Communicable disease epidemiological experts are being designated at EDCD to perform rigorous epidemiological analysis of surveillance data and present key findings and recommendations to the incident command system for decision making. National and sub- national capacity on epidemiological analysis is also being strengthened. Simultaneously, call- center and text-based reporting systems are being established to enable effective event-based surveillance.

14. Risk communication. Government has been making efforts to engage communities through risk communication. In the absence of specific medicine or vaccine to treat or prevent COVID-19, non-pharmaceutical measures viz social distancing, cough and hand hygiene, and

21 Development Coordination (accessible from the list of linked documents in Appendix 2 of the report and recommendation of the President). 22 Other testing facilities around the country include the Bir Hospital, Sukraraj Tropical and Infectious Disease Hospital and Patan Academy of Health Sciences in Kathmandu. COVID-19 testing outside Kathmandu is being carried at the B.P. Koirala Institute of Health Science, (Province-1); Koshi Hospital, (Province- 1); Provincial Hospital, Janakpurdham (Province-2); Vector-Borne Disease Research and Training Center, (); Kathmandu University Teaching Hospital, (Bagmati Province); Bharatpur COVID-19 Diagnostic Laboratory, Chitwan (Bagmati Province); Academy of Health Science, Pokhara (); Provincial Laboratory, Bhairahawa (Province-5); Rapti Academy of Health Sciences, Dang (Province-5); Surkhet Provincial Hospital, Surkhet (); Bheri Hospital, (Province-5); and Seti Provincial Hospital, Dhangadi (Sudurpaschim Province). 23 https://covid19.ndrrma.gov.np/

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efficient management of comorbidities especially amongst elderly are important for preventing morbidity and mortality as well as cutting short the transmission of the virus. The Humanitarian Country Team (HCT) in conjunction with the Red Cross Movement and national and international nongovernment organizations (60 organizations) have commenced preparedness interventions including dissemination of communications materials to raise community-level awareness across the country. Various communication platforms, including a partnership with private telecommunications service providers, have been used to raise awareness on COVID-19. The MOHP has established dedicated hotlines and a -based information platform to share information.

15. Scaling up hospital-based service delivery for effective response. The Sukraraj Infectious and Tropical Disease Hospital (STIDH) in Teku, Kathmandu has been designated as the primary hospital along with Patan Hospital and the Armed Police Forces Hospital. Recently, all the central hospitals, provincial hospitals, medical colleges, academic institutions and hub-hospitals have been designated to provide treatment care for COVID-19 cases. Currently, there are 111 hospitals with COVID Clinics, and 28 COVID designated hospitals. There are 194 hospitals with ICU facilities with a total of 26,930 hospital beds, 1,595 ICU beds and 840 ventilators.24 MOHP has also instructed all private hospitals with a capacity of 50 or more beds to prepare isolation chambers and to treat suspected COVID-19 patients. However, gaps remain. With rapidly increasing cases in neighboring countries and challenges of porous borders, Nepal's service delivery needs to be further strengthened, given the increasing vulnerability. The COVID-19 virus spreads fast with a reproductive number – the number of secondary infections generated from one infected individual – between 2 and 2.5, which is higher than for influenza. Additionally, for COVID-19, data suggest that 80% of infections are mild or asymptomatic, 15% are severe infection, requiring oxygen and 5% are critical infections, requiring ventilation. These fractions of severe and critical infection need hospitalization, and thus increased hospital bed capacity is crucial for effective response.25 Additionally, infection prevention and control including the provision of personal protective equipment needs strengthening.

Table 1: COVID-19 Status Report in Nepal (As of 30 April 2020) Total Confirmed Cases 57 Total Quarantined 23,336 Total Active Cases 41 Total Number of Quarantine beds 49,334 Total Recovered Cases 16 Total Isolated 80 Total Number of Deaths 0 Total Number of Isolation beds 3,097 Total Swab Tested (PCR) 12,011 Tests/1000 Population .41 Sources: https://www.who.int/nepal/covid19nepal; https://heoc.mohp.gov.np/update-on-novel-corona-virus-covid- 19/; https://covid19.ndrrma.gov.np/; https://www.worldometers.info/coronavirus/; https://ourworldindata.org/about

Table 2: COVID-19 Situation in Nepal by Provinces (As of 30 April 2020) Province Province Province Bagmati Gandaki Karnali Sundurpa- Total 1 2 5 shchim Land Area sqkm 25,905 9,661 22,288 20,300 21,504 27,984 19,539 147,181 Cases 31 12 - 7 2 - 5 57 Active 31 8 - 1 - - 1 41 Recovered - 4 - 6 2 - 4 16 Quarantine beds 5627 4150 17011 4703 3813 7314 6716 49334 Quarantined 2576 1400 12752 551 593 3998 1466 23336 Isolated beds 449 266 534 948 289 457 154 3097 Isolated 38 13 16 10 0 0 3 80 Ambulances 321 336 366 471 227 55 138 1,914 Sources: https://www.who.int/nepal/covid19nepal; https://heoc.mohp.gov.np/update-on-novel-corona-virus-covid- 19/; https://covid19.ndrrma.gov.np/; https://www.worldometers.info/coronavirus/; https://ourworldindata.org/about

24 Government of Nepal, Ministry of Health and Population. 2020. Health Sector Emergency Response Plan: COVID-19 Pandemic. Kathmandu. 25 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200306-sitrep-46-covid- 19.pdf?sfvrsn=96b04adf_4

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Table 3: Summary of Cross-Country Comparison of COVID-19 Related Health Indicators Country No. of Total COVID-19 Total Critical Number of Cases (as tests per 1,000 confirmed care doctors per of 30 April)a people (as of 9 COVID-19 Beds/ 10,000 May)b deathsc 100,000d populatione 33,050 1.10 1,981 2.3 8.57 7 3.21 0 n.a. 4.24 Nepal 57 0.56 0 2.8 7.49 649 1.25 9 2.3 10.04 7,103 0.71 206 0.7 5.81 277 15.60 3 n.a. 45.63 COVID-19 = coronavirus 2019, n.a. = not available. a https://ourworldindata.org/grapher/total-cases-covid- 19?country=IND+BTN+LKA+MDV+BGD+NPL b https://ourworldindata.org/grapher/full-list-cumulative-total-tests-per- thousand?time=2020-02-24..&country=BGD+IND+NPL c https://ourworldindata.org/grapher/total-deaths-covid- 19?country=IND+MDV+LKA+BTN+BGD+NPL d Phua, Jason & Faruq, Mohammad & Kulkarni, et.al. (2020). Critical Care Bed Capacity in Asian Countries and Regions. Critical Care Medicine. 48. 1. 10.1097/CCM.0000000000004222. e https://www.who.int/data/gho/data/indicators/indicator-details/GHO/medical-doctors-(per- 10-000-population)