Interviewed by Isha Datta, FP2020

This interview has been edited and condensed for clarity

FP2020:  Thank you so much for speaking with me, Dr. Bhatta. First, let me ask you: the pandemic has had profound and destabilizing effects around the world. Talk to me about how COVID-19 has affected Nepal? How has the government responded and what has been the impact on daily life?

Dr. Bhatta: The COVID-19 pandemic has had a big impact on the economy as well as the health sector. The government instituted a country-wide lockdown from March 12^th to. This has led to very restricted mobility in the general population. The livelihoods of people across the country have been impacted—and poor populations are the most vulnerable.

Our organization, ADRA, supports the government in providing family planning and women’s health services more generally. There was a decrease in service utilization across facilities due to restricted mobility within communities, lack of adequate PPE and health worker concerns for procedures in service delivery, in the initial days. This impacted services including childbirth and ante-natal care, general check-ups, family planning services, and nutrition assessments, which was later sorted through various operational guidelines, better coordination between health/non health actors (for travel to/from health centers) and increased investment in making PPE available. Hence, essential services have gradually resumed.

FP2020:  What has your organization done to adjust your work during the COVID-19 pandemic and the situation in Nepal?

Dr: Bhatta: [At an organizational level] ADRA has developed a business continuity plan and contingency plan, and we are working to minimize the risk of transmission in the workplace. There’s limited travel from our Kathmandu office to the periphery. However, last week, I traveled to a health facility to deliver ventilators and PPE with support from ADRA Management to acquire travel approval from Ministry of Health and Population. Our organization is working on both sides - on humanitarian support and regular services.

After the lockdown, we started following up with our nurses on the ground. We knew some women were due to have their implants replaced, so we started counseling them on using short-term methods under the lockdown period. We’re using mobile technology for counseling some women, responding to questions according to the WHO’s Family Planning counseling guidance and the Medical Eligibility Criteria wheel. However, where we’re working in birthing centers and hospitals, we’re physically doing counseling while trying to minimize the risk of [COVID-19] transmission—for example, by using PPE.

For women who are coming to facilities to give birth, we are offering short-term methods — because when mothers deliver and leave, it’s very hard to reach them again. We’re tracking home deliveries through female community health volunteers (FCHV). We can identify postpartum mothers because we have their estimated delivery date. If they deliver in the home, we reach out through an FCHV to get a status check and to make sure they’re counseled on family planning. But this can still present a challenge: the FCHVs have a fear of [COVID-19] transmission—so we try to reach these postpartum women, but it is very hard. The government has restricted mobile outreach/camp services, so we are hoping to reach people at satellite clinics near health facilities.

Because of a lack of transportation and difficulties with logistics management of reproductive health commodities, we, along with other organizations have supported the Government to map out where family planning supplies are available—so now we know where commodities are out of stock. We have sufficient commodities at the central-level warehouse. But at the periphery level there were some stock-outs, because women who were using long-term methods have been switched to short-term methods—and we didn’t have an immediate replacement for short term methods. This has been recently sorted and peripheral health facilities also have adequate stock now.

We also started a survey (informal data collection in ADRA working area) to see which health facilities have services available, and to understand what the bottlenecks are in providing essential health services.

FP2020: Are there any specific roadblocks you’ve encountered from a policy perspective? That is to say, do you think advocates could push for a policy that would allow you to serve your clients more effectively in this time?

Dr. Bhatta: In the first 15 days following the lockdown, no one was clear on what was happening. Then stakeholders started their advocacy to the government and the Ministry of Health. Last week, the government declared that we need to resume essential health services—so now immunization and family planning services are resuming. Although the government had prioritized short-term family planning methods under essential FP service, initially, now the Interim guideline also mentions Long Term Reversible Contraception as well.

ADRA is part of [Nepal’s] Reproductive Health (RH) Cluster, along with the government, UNFPA, and other stakeholders. Together we developed the RH Interim Guideline, which was recently endorsed by the Ministry of Health and Population. I’m hoping that with this document, which includes pre-natal and ante-natal care, long-term family planning methods, and other essential service delivery components, things will be easier for all of us. The government has endorsed an overall plan and guidelines for COVID-19—but it’s more related to how to manage COVID hospitals and isolation wards.

We have started a discussion at the stakeholder level (those organizations working in RH Cluster) and are planning to modify our service approaches, especially for FCHVs to deliver short-term family planning methods (which was disrupted in the initial days of lockdown, due to mobility restriction) to women at home. We’re also trying to get adequate PPE, sanitizer and other support to our community health volunteers and visiting service providers. But this is not yet fully materialized.

FP2020:  What are the specific challenges that you’ve encountered while providing family planning and/or postpartum family planning during the pandemic?

Dr. Bhatta: The population restrictions are managed by the police, armed forces, and others. The coordination from one Ministry to the other is a challenge. For example, the Ministry of Health may say: “We want to open and provide all essential health services,” but the Home Ministry still needs to understand why the public is traveling to the health facilities. When we started the lockdown, we told the public: “If you don’t have an emergency situation, don’t visit the health facility.” And that’s had a big impact because now people are not fully understanding that the health facilities have become well-secured. They hesitate to visit health facilities. That’s why we’re seeing an increase of home-based deliveries in Nepal.

FP2020: What are you hearing from the women you serve? How has this pandemic affected their lives and their ability to access family planning or postpartum family planning services?

Dr. Bhatta: They have a lot of fear—they don’t visit health facilities because they know a lot of people are coming and going. There’s a lot of fear and anxiety about catching the virus at the facility level. [Women] want to know where they can safely receive family planning services. There is some confusion about service availability. [This leads to] poor service utilization, which is also a problem. Healthcare workers don’t think clients are coming in, so they don't always open their facilities and that leads to complications and confusion.

We are planning to initiate a radio campaign to let communities know what services that are available in each facility. We started this in one or two districts, sharing what are the services available, what are the short-term and long-term methods we have, that we are offering these at your nearest health facility. This is also a need I’m hearing from women’s groups: information around critical service availability, as well as how to minimize the risk of infection. Adolescent groups have also been showing great leadership at the community level—especially on issues such as menstrual hygiene. We’re using these groups to advocate at the local level.

FP2020: What have you learned as a faith-based organization in service delivery during the pandemic? Anything that you think is particularly valuable?

Dr. Bhatta: When we started providing family planning services in Nepal, the big challenge was the cultural context. It’s very diverse. We involved religious leaders using the model that was used in Indonesia, for example. We’ve trained them to be community-based “goodwill Ambassadors” [for family planning]. In this situation, where we’re seeing a lot of stigma, we’re hoping to engage them in mass communication. Messages from religious leaders are very effective in mitigating stigma within their communities. In pandemic conditions, it’s helpful if religious leaders are involved from the beginning.