In this study, we explored the challenges in providing health care services in Nepal during the COVID pandemic. Challenges to provide COVID-19 health care services included insufficient implementation or preparedness; indifferent and ineffective administration; low accountability of health care workers and staff; and risk of infection and stigma. Challenges to provide routine outpatients and emergency services include maintaining safety measures in hospitals; managing patients for registration, screening and triage; and fear of infection during patient-physician interaction. These are characteristic of non-resilient health systems which have a poor foundations of strong local and national leadership, of a committed health workforce, and of sufficient infrastructure (19, 20). Clearly, this makes it challenging to withstand a health crisis such as COVID-19, particularly in low income countries (21). There is a need for clear leadership and governance, promoting public trust and investment for the timely and co-ordinated response to COVID-19 as exemplified by many countries including Vietnam, South Korea and Singapore (22–24).
Being a new rapidly evolving contagious disease, health systems worldwide are facing challenges to manage infrastructure, dedicated human resources and adequate supplies to treat COVID-19 patients (25, 26). These challenges are more substantial in settings where there is a weak health system characterised by inadequate infrastructure, and availability of equipment and HCWs (27). Nepal’s health system is already constrained by the lack of HCWs, infrastructure, amenities and equipment, and poor management even before COVID-19 with compromised quality of care (28), which has further deteriorated during this pandemic. Nepal moved to federalism since 2015 with significant devolution of power and resources from central government to provincial and local authorities (municipalities) including health system reformation. This has shifted the primary responsibility for health service provision to provincial governments and municipalities but has met a number of implementation challenges including unclear roles and responsibilities among the three tiers of governance in decision making, and in human and financial resources management (29, 30). This has resulted in poor co-ordination among the three tiers of governance affecting effective response to this pandemic. Overall, health system resiliency is greatly affected by the socio-political environment, for example ‘governance’ and ‘values, beliefs and preferences of the actors within a health system’ are fundamental functions affecting the core dimensions of health systems’ ability to adapt and respond to shocks (31).
Rapid purchase of materials and equipment for COVID-19 preparedness was affected by the lengthy administrative procurement process. The procurement process in Nepal involves stepwise processes and vested interests with reported corruption, mismanagement, purchase of poor quality materials and late arrivals of materials (32). This had an immense impact on preparedness of COVID hospitals and management activities in Nepal resulting in the late availability of COVID facilities and isolation wards. The COVID hospitals in this study had to run without the prerequisite as in the guidelines and set criteria, and this has resulted in inadequate provision of COVID-19 related health care services. Such weakness and inability of health systems to cope with the Ebola epidemic was observed in Guinea, Liberia and Sierra Leone in 2014 (33). Lower resiliency of public health systems in the COVID-19 response have been observed in other low-and-middle-income Asian countries (14, 34).
The efficient use of available human and material resources were challenging due to indifferent and weak hospital administration. On one hand, hospital administration was weak in implementing duty rosters, and on the other hand, there was low accountability on the part of HCWs and health staff to perform their assigned duties in this pandemic. This is very different from the findings that health-care providers volunteered and tried their best to provide care for COVID-19 patients in Hubei province, China (35). The COVID patients in the COVID hospitals and isolation wards complained about the poor management of logistics including food, bathroom, and internet to the HCWs while these logistics were supposed to be managed by health staff and/or hospital administration. This has affected the work efficiency of HCWs and showed poor accountability on the part of health staff.
During pandemics, the accountability of HCWs and health staff can be lowered due to fear of infection and infecting others, prevailing stigma and weak supervision. Effective team work, communication and supervision are lacking in the management of hospitals in Nepal (36). Hospital administration had to hire inexperienced HCWs or use resident doctors in the frontline, who had no experience of infectious diseases management. Yet the service of these frontline health workers was vital for these hospitals. Overall, the low accountability and weak supervision is partly due to prevailing socio-political environment and work culture in the country including in public health care facilities in Nepal (37).
The hospitals in this study are the main health service providers with a wide coverage in Eastern Nepal, mainly for low- and middle-income populations. During COVID-19 pandemic when the lockdown was lifted intermittently, there were considerable health care seekers visiting these hospitals. Maintaining basic infection-prevention measures to minimise risk of COVID-19 infection and spread were the main challenges during provision of outpatients and emergency services in this study. Regular supply of quality and adequate PPE to HCWs involved in non-COVID care is also challenging for the hospital administration. Having allocated specific spaces and wards to COVID-19 care, the hospitals were constrained in maintaining adequate service locations for regular health care services; thus, emergency services and outpatient clinics became congested. Infrastructural and infection control deficits at the lower health facilities were also reported in India in terms of limited physical space and queuing capacity, lack of separate entry and exit gates and inadequate ventilation (38).
The low level of health literacy among the majority of patients and time constraints of being checked and returning to homes in the same day further aggravated the safety measures of social distance while queuing for registration, check-up and laboratory diagnosis. Online registration, prior appointment and online counselling are a few ways suggested to lessen this problem (17), but challenging to implement in these hospitals because of poor accessibility of technology and awareness among patients.
Risk of infection and exhaustion is a unique challenge during this pandemic while providing health care services everywhere because of workplace risk to exposure of the virus (27). The infection prevention and control in outpatient settings of public hospitals of low-income countries during this pandemic were reported to be inadequate because of low compliance in hand hygiene, glove use, disinfection of reusable equipments, and in waste management procedures (39, 40). The adoption to work in this new infectious environment and wearing PPE for the first time is demanding for HCWs. Moreover, the fear and anxiety increases as the whole health system is constrained in the COVID-19 response and co-ordination including supply of PPE. It might be the one reason of low accountability of HCWs to work in COVID wards and hospitals.
The epidemiology of COVID-19 is evolving and as yet is not predictive in outcome. A significant number of asymptomatic carriers are known only by PCR. Since patients with and without COVID-19 initially access health care in the same way, there is a huge challenge to establish an effective patient flow: screening, triage, and targeted referral in hospitals 17. The screening and effective referral becomes more challenging for emergency patients, who need critical care, in the absence of immediate diagnosis of COVID-19, which can occur due to delayed PCR results. Further, practical co-ordinations among other units and departments are not effective. Similar management challenges of suspected and confirmed patients with COVID-19 has been faced by hospitals in France (41).
There are some strengths and limitations of this study. Some interviews were taken virtually where rapport building was difficult. The views of nurses and health staff, especially in COVID-19 health care services are important but not represented in this study. The non-COVID health care services were focussed on outpatient and emergency services while there are also peculiar challenges in inpatient and operative health care services. This study documented only challenges as perceived by health care providers. Resilient factors despite these challenges in providing health care services during COVID-19 pandemic and experiences of health service users are also important and need to be investigated.