Executive summary

This report was commissioned by the Ministry of Health and Population (MoHP) to provide an overview of the epidemiology of COVID-19 and the health sector response to the COVID-19 pandemic which posed an unprecedented challenge to the health system in Nepal, as in many other countries worldwide. This report is expected to be a useful resource for improving pandemic responses in both the short- and long-run, and contribute to better preparedness and planning for
future epidemics.

As of 31 December 2021, epidemiological trend data show two large case waves in Nepal, the first wave from 23 January 2020-14 March 2021 and the second wave from 15 March 2021 onwards. Similarly on that date, the cumulative number of RT PCR/Antigen positive cases had reached 922, 942 with the recovery rate of 98% and Fatality Rate of 1.26%. The highest numbers of RT-PCR positive cases were reported on 22 October 2020 (5,713 cases) during the first wave and 11 May 2021 (9,317 cases) during the second wave. Nepal had its highest test positivity rates on 26 October 2020 during the first wave (34.8%) and 10 May 2021 during the second wave (51.8%). There have been important variations in the distribution of disease across populations and geographies in Nepal. In particular, Bagmati Province has seen the largest number of cases, with a majority of cases concentrated in the three districts of the Kathmandu valley.

The Health Emergency Operation Center (HEOC) under the Health Emergency and Disaster Management Unit (HEDMU) of the MoHP steered the response during the early pandemic phase, and remained as a core body for the COVID-19 response within the MoHP. The Incident Command System accelerated the evidence-informed decision-making process within the MoHP and helped to improve the overall effectiveness of the COVID-19 response. As a technology intervention a software was developed by the Information Management Unit (IMU) under the MoHP secretary. The IMU had six sub-groups: data/information collection team, data quality assurance team, data analysis team, IT management team, report preparation team, and COVID 19 vaccine related support team (after vaccination start) aiming to capture and provide the right data to the right persons on the right time through a one-door policy as per a Secretary-level decision. Daily data analysis was continuously done and shared to higher authorities by members of Information, Statistics and Monitoring under the ICS for decision making in the planning process.

The MoHP was able to align the support from partners in priority areas identified in the early phase of the pandemic which were regularly updated, reviewed, and shared in cluster meetings. There were some challenges in engaging the private sector in testing and service delivery during the early phase of the response. However, in later stages, the role of the private sector remained crucial in expanding the health system capacity for testing and delivery of COVID-19 and non-COVID-19 services.

The MoHP, in collaboration with other partners, rolled out a series of communication activities to spread awareness of COVID-19 and help increase adherence to preventive measures. These included radio and television placements, SMS messaging, and use of web-based tools. More than 500 radio stations and 22 television channels throughout the country disseminated COVID-19 related information in multiple languages.

Delivery of laboratory testing was a success story for the response in Nepal, given resource constraints. At the beginning of the pandemic, the National Public Health Laboratory (NPHL) was the only COVID-19 RT-PCR capable laboratory, but over the course of pandemic the capacity was rapidly expanded in all seven provinces with a total 101 laboratories performing COVID-19 RT-PCR testing as of December 2021. Although antibody-based rapid testing was introduced as case numbers rose,
exceeding the RT-PCR testing capacity particularly during the first wave, the MoHP shifted its focus on expansion of RT-PCR testing capacity due to the limited sensitivity of antibody-based testing. In the second wave, the introduction of antigen-based rapid testing helped to expand the testing capacity throughout the country. These efforts in expansion of testing capacity were supported by a series of guidance documents to help ensure adherence to proper laboratory and testing procedures. As the testing capacity rapidly expanded during the pandemic, there is an opportunity to ensure the sustainability of laboratory capacity by diversifying the activities of these laboratories to include testing for other common pathogens which could be useful for future outbreak response.

The MoHP placed high emphasis on contact tracing and community isolation systems in Nepal over the course of the pandemic. However, the performance was constrained by some operational challenges such as the lack of human resources at local level.
Remarkable improvements in the clinical management of COVID-19 patients were made over the course of the first and second waves as familiarity with the disease improved, evidence on effectiveness of therapeutics became clearer, and pathways for care became more established. Particular improvements were noted in triage and referral especially in the second wave, and the availability and use of ambulance services. There is now an important opportunity to take stock of best practices from clinical teams working across the country, documenting the best practices, and disseminating them widely ahead of potential future waves.
Shortages of oxygen became more pronounced during the second wave and prevented hospitals from operating to their full capacity. The recent period with receding numbers of cases could be used as an opportunity for the country to prepare and bolster the supply of essential equipment and commodities including oxygen supply so as to be better positioned for future waves (if any).

Essential health services (especially reproductive, maternal, newborn child and adolescent health and routine immunization delivery) in Nepal, for the most part, have shown signs of resilience and weathered the COVID-19 storm reasonably well, with attendance rates showing rapid recoveries even during the lockdown period. However, evidence is lacking on how NCDs (including mental health) and other essential services were impacted by COVID-19 pandemic and if they have recovered to normal levels now that second wave case numbers have declined.

Despite initial challenges, Nepal has been able to roll out vaccines quite efficiently with more than half of the population ≥18 years of age being fully vaccinated as of 31 December 2021. As health workers were vaccinated as the first priority, restoring service delivery became relatively easy in the second phase. However, with high demand and acceptance of COVID-19 vaccines from public, maintaining preventive measures like social distancing in vaccination sites emerged as an issue in some facilities.

Strengthening situational awareness systems that provides better understanding of the disease situation and bolstering modelling/forecasting capabilities within the country based on real time collected IMU data could be priority areas for action.

This could be achieved through capacity development of the researchers in country and close collaboration of the MoHP, NHRC, academia, and other partners. Strengthening and sustaining the Knowledge Café initiatives under Policy, Planning and Monitoring Division of MoHP could help further in evidence-informed decision making in the future.

Lessons and future directions

• There is a need for periodically updating the priority list for research considering the evidence generated within and outside the country. Furthermore, having a system or mechanism in place to track the ongoing and completed research could facilitate evidence-informed decision making and also help in preventing duplication of resources.
• A primary route for uptake of new evidence appears to have been through Knowledge Cafes organised through the PPMD which was particularly helpful in evidence-informed decision making during the first wave of the pandemic. Sustaining the Knowledge Café initiative could improve the evidence informed decision making in future during normal circumstances or during the time of pandemic. NHRC role in sustaining the Knowledge Café initiative could be crucial as one the mandate of NHRC by an Act is promoting use of evidence.
• To strengthen the pandemic response, there is a need for establishing a mechanism to develop and synthesise a pool of research results conducted within Nepal, so that policy makers can have access to locally-contextualised evidence.

Conclusion

The list given below is non-exhaustive, focusing instead on high priority actions from the response domains covered in this report (fuller lists of suggested future directions are given at the end of each chapter in the main report).

• Clearer alignment of institutional structures governing the response should be a top priority for action. This report has documented evidence of overlapping remits between newly established bodies at various levels of the health response and potential duplication. To improve governance effectiveness in the near term, there should be sufficient support and space to the ICS to enable it to continue overseeing the health response. In the longer term, it will be necessary to further strengthen the role and capacity of HEOC, which coordinated pandemic response in multiple ways during the course of the pandemic.
• Strengthening situational awareness systems should be a priority for both the near-term COVID19 response to better inform the actions of the ICS, and longer-term preparedness for future outbreaks. There are several components to this, including (i) improvements to routine surveillance systems to improve data capture; (ii) strengthening epidemic modelling capacity available to the MoHP, NHRC, and academia within country; and (iii) strengthening the mortality surveillance system.
• The health system encountered challenges in ensuring adequate supply of oxygen particularly during the second wave. There is a need to bolster pre-positioned supplies of oxygen as a part of preparation for potential future waves, working with other ministries, development partners and health facilities. Initiatives taken for installation of oxygen plants should be supported and sustained in the future.
• While health workforce shortages cannot reasonably be solved in the short term, there are opportunities to strengthen training for current staff – which has been somewhat ad hoc during the pandemic – and to support lesson learning in terms of best practices for clinical care of COVID-19 based on learning from the first and second waves. There is need for additional attempts in documenting and disseminating the best practices and exchanging skills through practitioners’ exchange programmes.
• While the MoHP was successful in aligning development partners’ support in priority areas identified, the engagement with the private sector in early phase of pandemic was limited. To support preparedness and particularly surge capacity for future epidemic response, consideration should be given as what incentives could encourage greater and earlier private sector involvement in both clinical care and provision of testing.
• In this report, we have identified a number of cross-cutting areas where further research may be helpful to address knowledge gaps. The NHRC could play an important coordinating role in this area. Examples of priority areas include (i) detailed evaluation of RCCE approaches deployed during the pandemic so far to understand what worked in changing behaviours, why, and how interventions could be improved; and (ii) building academic capacity in Nepal (and through partner institutions overseas) to generate timely research outputs through, for example, infectious disease modelling to better inform scenario planning.
• Regular meeting of the Knowledge Café initiative will be crucial for timely communication of research findings for evidence informed decision making for addressing the pandemic such as COVID-19.