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Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health care workers in Nepal.
Semi-structured interviews were conducted among 32 health care workers who were involved in clinical care of COVID-19 patients and four policymakers who were responsible for COVID-19 control and management at central and provincial level. All interviews were conducted through telephone or internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches.
Both health care workers and policymakers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Additionally, health care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue working in the forefront.
Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health care workers for the current and future pandemics.
Chapter 6 focuses on the afterlives of Maoist propaganda outside China following the death of Mao Zedong in 1976, which soon led the end of Cultural Revolution policies. The relatively peaceful post-Mao transition in China contrasts with Maoism outside China. The outbreak of the millenarian “Shining Path” revolution in Peru, led by former philosophy professor Abimael Reinoso Guzmán, better known as Chairman Gonzalo, claimed an estimated 69,000 lives and uprooted those of 600,000 more. In the context of global Maoist ideas of continuous revolution and political militancy, Guzmán’s path to becoming a left-wing revolutionary makes sense, especially his time spent in China and his horror at poverty, systemic racism, and government corruption witnessed in urban Peru. The Sino-Soviet split provided a lasting impetus for Guzmán’s embrace of Maoist revolutionary violence, along with the supply of weapons and training for Latin American leftists. The chapter concludes with a discussion of the development of the Shining Path under the tutelage of Guzmán from an intellectual movement of urban professors and rural students to Maoist military insurrection, indiscriminate state brutality and scorched-earth policies, before turning to the movement’s more moderate legacy in Nepal, where it continues to the present day.
This chapter examines the peace process undertaken by the Government of Nepal and the Community Party of Nepal-Maoist (CPN-M). Nepal’s Comprehensive Peace Agreement (CPA), negotiated in the presence of United Nations officials and signed in 2006, does not include an amnesty provision but a commitment to accountability for human rights violations and an agreement to end impunity for such crimes. Yet, as this chapter demonstrates, agreement to include anti-impunity measures in the CPA was driven, not by a commitment to end impunity for human rights violations, but by a desire to avoid criticism from the international actors present during the negotiations. This lack of intention to comply with the human rights terms of the CPA was evident in the negotiating process and has been born out in the post-conflict period, with several successive governments attempting to legislate in favour of introducing amnesty laws. At the same time, a lack of capacity within those local institutions committed to ending impunity for human rights violations, exacerbated by the withdrawal of UN support for their processes, has hampered efforts to combat these impunity measures.
In the past two decades, peace negotiators around the world have increasingly accepted that granting amnesties for human rights violations is no longer an acceptable bargaining tool or incentive, even when the signing of a peace agreement is at stake. While many states that previously saw sweeping amnesties as integral to their peace processes now avoid amnesties for human rights violations, this anti-amnesty turn has been conspicuously absent in Asia. In Negotiating Peace: Amnesties, Justice and Human Rights Renée Jeffery examines why peace negotiators in Asia have resisted global anti-impunity measures more fervently and successfully than their counterparts around the world. Drawing on a new global dataset of 146 peace agreements (1980–2015) and with in-depth analysis of four key cases - Timor-Leste, Aceh Indonesia, Nepal and the Philippines - Jeffery uncovers the legal, political, economic and cultural reasons for the persistent popularity of amnesties in Asian peace processes.
This study assesses the prevalence of childhood undernutrition from 2001 to 2016 and estimate projections of undernutrition for 2016–2030 in Nepal.
The study used data from four rounds of a cross-sectional survey of Nepal Demographic and Health Survey (NDHS) conducted in 2001, 2006, 2011 and 2016. Descriptive analyses were conducted to calculate prevalence, binary logistic regression was used to test the significance of trends over time and autoregressive integrated moving average model was used to forecast the prevalence of childhood undernutrition.
The children and household member datasets from four NDHS were merged to assess the trends of childhood undernutrition in Nepal.
A total of 16 613 children (8399 male and 8214 female) under 5 years of age were selected for anthropometric measurements using a stratified cluster random sampling method.
Overall results show a decline in prevalence of stunting from 57·2 % to 35·8 % (P < 0·001), underweight from 42·7 % to 27 % (P < 0·001) and wasting from 11·2 % to 9·7 % (P < 0·05) from 2001 to 2016. However, different population subgroups have a higher prevalence of undernutrition than national average. Further, the analyses show that the prevalence of stunting will decline to 14·3 % and wasting to 8·4 % by 2030.
A remarkable decrease in the prevalence of stunting and underweight has been observed over the last 15 years. Nepal is likely to achieve the nutritional targets for stunting but not for wasting by 2030. Given large subpopulation variations, further improvement in undernutrition require more specific, targeted and localised programmes.
In the aftermath of the devastating 2015 earthquakes in Nepal, three non-governmental organizations collaborated to develop a program responding to the immediate mental health and psychosocial support (MHPSS) needs in three severely affected districts: Dhading, Gorkha, and Sindhuli. The program was implemented between April 2015 and February 2017 and aimed to (i) strengthen health worker capacity to provide integrated MHPSS services; and (ii) increase access to mental health services. This paper describes the program's implementation and the results of a pragmatic evaluation of the program's overall reach, effectiveness, and lessons learned.
The mixed-methods evaluation used routine program data, quantitative data from pre- and post-tests conducted with trainees and service users, and qualitative data from stakeholder interviews and focus group discussions.
A total of 1041 health workers received MHPSS training and supervision. Participants demonstrated significant improvements in skills, knowledge, and self-rated perceived competency. Trainees went on to provide MHPSS services to 3422 people. The most commonly identified presenting problems were epilepsy (29%) and depression (26%). A total of 67% of service users reported being ‘completely satisfied’ with the services received and 83% of those experiencing severe functional impairments on enrollment demonstrated improvement after receiving services.
Despite operational challenges, the program successfully engaged both laypeople and health workers to provide MHPSS in the aftermath of the crisis. Lessons learned can inform the planning and implementation of future training and integration programs to provide large-scale MHPSS efforts in humanitarian settings.
Although training in psychotherapy is an integral part of psychiatry training, standards in psychotherapy training have wide variation across and within countries. Post-graduate psychiatry training has been conducted in Nepal for over two decades, but little is known about its psychotherapy training provisions. An online survey was conducted with early career psychiatrists in Nepal. The findings show that the majority recognised psychotherapy training as important and were eager to pursue further training. However, two-thirds had no access to psychotherapy training opportunities. These results highlight the need to improve access to training in different psychotherapy modalities in Nepal.
This paper describes the current state of mental health services in Nepal and reflects on the significant changes over the past decade. The main challenges to overcome are proper implementation of community-based services, the high suicide rate, stigma of mental illness, financial constraints, lack of mental health legislation and proper utilisation of human resources.
Maize production is central to rural livelihoods in the hills of Nepal. Access to affordable improved maize seed has long been a barrier to productivity gains and livelihood improvement. This study evaluates the direct and indirect (spillover) impacts of a community-based seed production program in Nepal using a quasi-experimental method for selected outcome indicators. Our results show that community-based seed production provides a significant positive direct impact on maize income and female leadership opportunities. The impacts were particularly favorable for disadvantaged households (HHs) from lower castes and HHs that owned less land. There is also strong evidence of spillover impacts on improved seed adoption, yield, and household maize self-sufficiency. Community-based seed production thereby could help Nepal attain cereal self-sufficiency and nutritional security as envisioned in the national agricultural development strategy and seed vision.
The snow leopard Panthera uncia is the flagship species of the high mountains of the Himalayas. There is potentially continuous habitat for the snow leopard along the northern border of Nepal, but there is a gap in information about the snow leopard in Gaurishankar Conservation Area. Previous spatial analysis has suggested that the Lamabagar area in this Conservation Area could serve as a transboundary corridor for snow leopards, and that the area may connect local populations, creating a metapopulation. However, there has been no visual confirmation of the species in Lamabagar. We set 11 infrared camera traps for 7 months in Lapchi Village of Gaurishankar Conservation Area, where blue sheep Pseudois nayaur, musk deer Moschus leucogaster and Himalayan tahr Hemitragus jemlahicus, all snow leopard prey species, had been observed. In November 2018 at 4,100 m, 5 km south-west of Lapchi Village, one camera recorded three images of a snow leopard, the first photographic evidence of the species in the Conservation Area. Sixteen other species of mammals were also recorded. Camera-trap records and sightings indicated a high abundance of Himalayan tahr, blue sheep and musk deer. Lapchi Village may be a potentially important corridor for snow leopard movement between the east and west of Nepal and northwards to Quomolongma National Park in China. However, plans for development in the region present increasing threats to this corridor. We recommend development of a transboundary conservation strategy for snow leopard conservation in this region, with participation of Nepal, China and international agencies.
The objective of the paper is to analyse changes in food commodity prices and estimate the potential effects of food price change on nutrition security in Nepal in the context of COVID-19 contagion control measures. It presents a comparative intra-country observational study design looking at events before and during the pandemic (after implementation of contagion control measures). The study design includes three districts, enabling comparison between diverse agro-ecological zones and geographical contexts. The methodology consists of primary data collection, modelling and quantitative analysis. The analysis is based on actual school meal food baskets which represent culturally and nutritionally optimised food baskets, developed by the local community and notional typical household food baskets. End May/early June 2020 is the ‘Post-COVID-19’ reference point, the same time period in 2019 i.e. June 2019 is the ‘Pre-COVID-19’ reference point. The study finds a substantial increase in food commodity prices across food groups and districts with marked inter-district variation. For school meal basket, all micronutrients show large average declines ranging from 9⋅5 % for zinc to 11 % for vitamin-A. For household food baskets on average, vitamin-A reduced 37 % followed by iron at 19 %, reduction in zinc is low due to the high zinc content in whole grain cereals. COVID-19 control measures are likely to have contributed to substantial price inflation over the reference period with potentially damaging effects on nutrition security in Nepal with serious implications for vulnerable populations.
The catastrophic declines of three species of ‘Critically Endangered’ Gyps vultures in South Asia were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Despite a ban on its veterinary use in 2006 (India, Nepal, Pakistan) and 2010 (Bangladesh), residues of diclofenac have continued to be found in cattle carcasses and in dead wild vultures. Another NSAID, meloxicam, has been shown to be safe to vultures. From 2012 to 2018, we undertook covert surveys of pharmacies in India, Nepal and Bangladesh to investigate the availability and prevalence of NSAIDs for the treatment of livestock. The purpose of the study was to establish whether diclofenac continued to be sold for veterinary use, whether the availability of meloxicam had increased and to determine which other veterinary NSAIDs were available. The availability of diclofenac declined in all three countries, virtually disappearing from pharmacies in Nepal and Bangladesh, highlighting the advances made in these two countries to reduce this threat to vultures. In India, diclofenac still accounted for 10–46% of all NSAIDs offered for sale for livestock treatment in 2017, suggesting weak enforcement of existing regulations and a continued high risk to vultures. Availability of meloxicam increased in all countries and was the most common veterinary NSAID in Nepal (89.9% in 2017). Although the most widely available NSAID in India in 2017, meloxicam accounted for only 32% of products offered for sale. In Bangladesh, meloxicam was less commonly available than the vulture-toxic NSAID ketoprofen (28% and 66%, respectively, in 2018), despite the partial government ban on ketoprofen in 2016. Eleven different NSAIDs were recorded, several of which are known or suspected to be toxic to vultures. Conservation priorities should include awareness raising, stricter implementation of current bans, bans on other vulture-toxic veterinary NSAIDs, especially aceclofenac and nimesulide, and safety-testing of other NSAIDs on Gyps vultures to identify safe and toxic drugs.
The prevalence of dementia is rising in low-resource countries, where specialist memory services are almost non-existent. The COVID-19 pandemic has created opportunities for innovative remote healthcare. Research shows a lack of dementia literacy and help-seeking behaviour for memory-related problems among older adults in South Asian countries. This paper proposes a remote memory service model and virtual dementia training in South Asian countries, called Memory First Aid (MFA). MFA offers help to a person experiencing memory difficulties until appropriate professional help is received. The MFA course is a 12-h webinar-based package consisting of four weekly modules. It covers dementia awareness and clinical features. The aim is to develop a non-medical workforce able to screen and assess older people with suspected dementia.
The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal.
To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP.
A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers.
The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors.
Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.
COVID-19 and its associated disease control measures have greatly altered everyday life. The burden of these challenges has fallen disproportionately on women. Drawing on qualitative inquiry in agrarian north India and Nepal, this research note analyzes how South Asian COVID-19 lockdowns have affected women's labor responsibilities in sometimes surprising ways. We find increased responsibilities for caregiving within the household, substantial stress in responding to food insecurity, and growing expectations to fulfill public roles in disease response measures. However, we also find that the return of male migrants and youth has, in some cases, reduced women's farming responsibilities and created opportunities for household togetherness at a time of great uncertainty. We conclude that more research is needed to examine the nuanced aspects of COVID-19's gendered labor impacts to create comprehensive policy responses to address the multiple and sometimes conflicting effects the lockdown has had on agrarian women's informal labor and well-being.
To model the potential impact and equity impact of fortifying rice on nutritional adequacy of different subpopulations in Nepal.
Using 24-h dietary recall data and a household consumption survey, we estimated: rice intakes; probability of adequacy (PA) of eight micronutrients commonly fortified in rice (vitamin A, niacin (B3), pyridoxine (B6), cobalamin (B12), thiamin (B1), folate (B9), Fe and Zn) plus riboflavin (B2), vitamin C and Ca and mean probability of adequacy (MPA) of these micronutrients. We modelled: no fortification; fortification of purchased rice, averaged across all households and in rice-buying households only. We compared adequacy increases between population subgroups.
(i) Dhanusha and Mahottari districts of Nepal (24-h recall) and (ii) all agro-ecological zones of Nepal (consumption data).
(i) Pregnant women (n 128), mothers-in-law and male household heads; (ii) households (n 4360).
Unfortified diets were especially inadequate in vitamins B12, A, B9, Zn and Fe. Fortification of purchased rice in rice-purchasing households increased PA > 0·9 for thiamin, niacin, B6, folate and Zn, but B12 and Fe remained inadequate even after fortification (PA range 0·3–0·9). Pregnant women’s increases exceeded men’s for thiamin, niacin, B6, folate and MPA; men had larger gains in vitamin A, B12 and Zn. Adequacy improved more in the hills (coefficient 0·08 (95 % CI 0·05, 0·10)) and mountains (coefficient 0·07 (95 % CI 0·01, 0·14)) but less in rural areas (coefficient −0·05 (95 % CI −0·09, −0·01)).
Consumption of purchased fortified rice improves adequacy and gender equity of nutrient intake, especially in non-rice-growing areas.
This cross-sectional study investigated the factors associated with hypertension among Nepalese adults aged 18 years or above using data from the Nepal Demographic and Health Survey 2016. Prevalence ratios (PRs) and odds ratios (ORs) were obtained using log-binomial regression and logistic regression, respectively. Initially, unadjusted PRs and ORs were obtained. The variables that yielded a significance level below 0.2 in unadjusted analyses were included in the multivariable analysis. The overall prevalence of hypertension among the 13,393 participants (58% male and 61.2% urban) was 21.1% (n = 2827). In the adjusted analysis, those aged 30–49 years (adjusted PR [APR]: 3.1, 95% Confidence Interval (CI): 2.6, 3.7; adjusted OR [AOR]: 3.6, 95% CI: 2.9, 4.5), 50–69 years (APR: 5.3, 95% CI: 4.4, 6.6; AOR: 8.2, 95% CI: 6.4, 10.4) and ≥70 years (APR: 7.3, 95% CI: 5.8, 9.2; AOR: 13.6, 95% CI: 10.1, 18.3) were more likely to be hypertensive than younger participants aged 18–29 years. Males (APR: 1.3, 95% CI: 1.2, 1.4; AOR: 1.5, 95% CI: 1.3, 1.7), overweight/obese participants (APR: 1.8, 95% CI: 1.7, 2.0; AOR: 2.4, 95% CI: 2.2, 2.8) and those in the richest wealth quintile (APR: 1.3, 95% CI: 1.1, 1.5; AOR: 1.5, 95% CI: 1.1, 1.9) had higher prevalences and odds of hypertension than their female, normal weight/underweight and poorest wealth quintile counterparts, respectively. Those residing in Province 4 (APR: 1.2, 95% CI: 1.0, 1.5; AOR: 1.4, 95% CI: 1.1, 1.8) and Province 5 (APR: 1.2, 95% CI: 1.0, 1.4; AOR: 1.3, 95% CI: 1.1, 1.7) were more likely to be hypertensive than those residing in Province 1. The point estimate was inflated more in magnitude by ORs than by PRs, but the direction of association remained the same. Public health programmes in Nepal aimed at preventing hypertension should raise awareness among the elderly, males, individuals in the richest wealth quintile and the residents of Provinces 4 and 5.
The present study aims to assess associations between parental depression and parental and child nutritional status and diets in Nepal.
A cross-sectional survey conducted from June to September 2017.
This monitoring survey was conducted in sixteen of forty-two Suaahara intervention districts spanning mountains, hills and plains in Nepal. Multi-stage cluster sampling was used to sample communities in this survey.
Women and men with a child 6–59 months of age were randomly selected (n 3158 mothers and children; n 826 fathers).
Overall, 36 % of mothers, 37 % of fathers and 55 % of children met minimum dietary diversity, indicating that they consumed foods from at least four of seven food groups (children) and at least five of ten food groups (adults) in the 24 h prior to the interview. The percentage of children stunted, wasted and underweight was 28, 11 and 23, respectively. Only 5 % of mothers and 3 % of fathers screened positive for moderate or severe depression (Patient Health Questionnaire-9 score ≥ 10). In adjusted models, we found maternal depression was positively associated with maternal underweight (OR = 1·48, 95 % CI 1·01, 2·17). Maternal and paternal depression, however, were not associated with other indicators of anthropometric status or dietary diversity.
Maternal and paternal depression, measured by the Patient Health Questionnaire-9, were not associated with dietary diversity or anthropometric status of fathers or children in Nepal, whereas depressed mothers were at increased risk of being underweight. Additional studies are needed to further assess relationships between mental health and nutritional outcomes.
There is no specific law in Nepal that directly criminalizes sex work. However, many sex workers have experienced arbitrary detention by law-enforcement authorities. The Human Trafficking and Transportation (Control) Act, 2007 (HTTCA) criminalizes pimps and clients, but not sex workers directly. However, the Act was overinclusive and often criminalized women engaged in voluntary sex work. The new Criminal (Code) Act 2017 criminalizes advertising and providing facilities for sex work in the section concerning crimes against the public good. These laws are used to prosecute sex workers. Two identity-based associations (IBAs) emphasize the importance of decriminalization, but do not support the legalization of sex work. A licensing system, if introduced under legalization, may exclude the most vulnerable sex workers, including housewives, migrants, and sexual minorities, who are secretly engaged in the business. I conclude that ongoing advocacy of IBAs should seek to provide safe working environments for sex workers in Nepal.
Cross-national studies have found, unexpectedly, that mental disorder prevalence is higher in high-income relative to low-income countries, but few rigorous studies have been conducted in very low-income countries. This study assessed mental disorders in Nepal, employing unique methodological features designed to maximize disorder detection and reporting.
In 2016–2018, 10714 respondents aged 15–59 were interviewed as part of an ongoing panel study, with a response rate of 93%. The World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI 3.0) measured lifetime and 12-month prevalence of selected anxiety, mood, alcohol use, and impulse control disorders. Lifetime recall was enhanced using a life history calendar.
Lifetime prevalence ranged from 0.3% (95% CI 0.2–0.4) for bipolar disorder to 15.1% (95% CI 14.4–15.7) for major depressive disorder. The 12-month prevalences were low, ranging from 0.2% for panic disorder (95% CI 0.1–0.3) and bipolar disorder (95% CI 0.1–0.2) to 2.7% for depression (95% CI 2.4–3.0). Lifetime disorders were higher among those with less education and in the low-caste ethnic group. Gender differences were pronounced.
Although cultural effects on reporting cannot be ruled out, these low 12-month prevalences are consistent with reduced prevalence of mental disorders in other low-income countries. Identification of sociocultural factors that mediate the lower prevalence of mental disorders in low-income, non-Westernized settings may have implications for understanding disorder etiology and for clinical or policy interventions aimed at facilitating resilience.