'Health system needs to be restructured'

Over the years, the country has seen a surge in dengue and scrub typhus cases. Recently, a patient suspected of contracting novel coronavirus was admitted to a hospital. Whenever these cases surface, people start panicking because they do not fully trust the country’s health system. This is not good news for a country which has just rolled out a massive tourism campaign, Visit Nepal 2020, to attract at least two million foreign tourists. Sabitri Dhakal of The Himalayan Times talked to Dr Bibek Kumar Lal, director of the Epidemiology and Disease Control Division, a wing of the Department of Health Services, about government preparations to prevent the spread of infectious diseases in the country. Excerpts:

What is the situation of epidemiological surveillance in Nepal? What are the challenges and the course of action?

We have obtained mixed results so far. Achievements have been made in the last few years in controlling several communicable and tropical diseases such as malaria and lymphatic filariasis. The big challenge for us is emergence of new diseases and re-emergence of diseases that were eliminated in the past. The division looks into 20 kinds of neglected tropical diseases with a team of 25 people. These diseases include dengue, kala-azar, lymphatic filariasis, chikungunya, malaria and scrub typhus. Prevention of non-communicable diseases is another area we work on. We are conducting researches on the spread of such diseases. We have noticed that some vector borne diseases, which were limited to an area, are now spreading to other places because of change in weather conditions. So, climate change and lack of skilled human resources are hurdles for us. This has prevented us from fulfilling international commitments to eliminate some of the diseases within the deadline given to us. This calls for strengthening the surveillance system to detect more diseases and creating rapid response teams to deal with multidimensional hazards. For this, we need to communicate properly with the provincial and local governments and establish an autonomous body with proper systems and human resources to control spread of diseases.

Are you trying to say Nepal isn’t fully prepared to fight or deal with epidemiology outbreaks?

The measures we have taken to control the spread of diseases are not satisfactory. Our latest approach is to improve the capacity of provinces so that they can act as the first line responders and support the local level. Staffers of district hospitals have been trained to respond to the spread of any infectious or unknown disease. We have also trained doctors who teach community medicine at medical colleges on epidemic preparedness, pandemic health preparedness response and investigation of samples collected from the field. Preliminary trainings have been given on clinical capacity building, and epidemiological investigation and enhancement as well. But we need to strengthen the surveillance system in the country for early detection, treatment and prevention of the disease. This might take some time because we can’t make direct interventions at the local level and it is not possible to build the capacity of 753 local bodies overnight. It is unfortunate that some of the posts created in the past, such as focal person of rapid response teams, vector control officers at the district level and district tuberculosis officers have been removed since the country made a transition to the federal system of government. It took years to enhance capacity of those officials and create a system to continuously monitor and report the situation. All those efforts have been in vain. Today, we do not have a strong chain of command to control disease outbreaks and oversee epidemic preparedness and response. We also do not have dengue specialists, epidemiologists and entomologists with us. So, we need to overhaul the health system, train manpower, and create a strong team of specialists.

Does this imply that the shift to federal system of government has weakened the country’s health system?

The health system has been badly hit since we embraced federalism as it has eroded gains made in the past, making the country more vulnerable to disease outbreaks. Today, we may not be able to handle emergency situations and respond to disease outbreaks as effectively as in the past because there is no clear line of communication and a clear chain of command. Restructuring of the health sector so far has been no more than a bureaucratic exercise. It has not properly understood the sensitivity of the health sector and system. The practice of transferring health workers haphazardly without considering their expertise has also backfired. We want the Ministry of Health and Population to address these issues.

Procurement and distribution of medicines at the local level have always been problematic. How are you dealing with this situation?

Medicines are procured by the management division of the Department of Health Services. However, we need to send drugs to treat malaria, lymphatic filariasis, leprosy, rabies and other diseases. But there is no coordination between the federal, provincial and local governments in distribution of medicines. We do not get information on inventories and use of medicines and

vaccines. Without these data, we cannot make forecasts and formulate plans. So, we must build an online reporting system so that all three governments can give updates on inventory and use in real time. We have asked the federal government to develop a national framework in this regard.

The country has just launched Visit Nepal 2020 campaign. What measures have been taken to control transmission of infectious diseases?

Greater cross-border movement of people and goods certainly poses a threat. Diseases such as influenza, ebola, dengue, scrub typhus and Zika virus enter the country from foreign lands and affect both Nepalis and foreigners. Since dengue cases have gone up in tourist destinations such as Chitwan and Pokhara, we need to improve sanitation and make necessary arrangements to provide proper treatment. So, on the one hand, we need to ensure that foreigners do not carry diseases to Nepal, while on the other, take preventive measures to make sure diseases that have entered Nepal do not spread rapidly.

Do health desks at Tribhuvan International Airport and land border points have proper equipment to screen the health condition of visitors?

We need to keep skilled human resources at those desks round-the-clock. But we do not have adequate number of trained human resources. We also lag behind in technology and we do not have adequate budget. These deficiencies have affected us. To prevent spread of diseases we need to screen everyone properly and isolate patients suffering from a disease on time. For that, we need equipment such as thermal scanners to detect fever and infrared detectors. A full-fledged facility should be in place at airports to screen patients, isolate those with diseases and transfer them to hospitals. At present, foreigners use eight land border points to enter the country. They are at Kakadbhitta, Biratnagar, Birgunj, Bhairahawa, Nepalgunj, Dhangadi, Pashupati Nagar and Rasuwa, but the health desks in Nepalgunj and Bhairahawa are not operational. We want the government to introduce a hassle-free process ensuring timely release of the budget to operate health desks at land border points.

At present, we are keeping records of people returning from Africa who are suspected of having contracted yellow fever. We have also started keeping records of travellers with respiratory illness symptoms following the outbreak of coronavirus in China.

What preparations has the government made to contain the spread of coronavirus infection in the country?

We are working closely with the National Public Health Laboratory and Sukraraj Tropical and Infectious Disease Hospital. We do not have laboratories to diagnose the disease. So we have to send the samples collected from people suspected of having contracted the disease abroad. But the World Health Organisation has given us a provisional guideline based on which we isolate those who are suspected of having contracted the disease. We definitely need to remain alert, but we need not panic because it has not been established that the virus can spread from one human to another. This is a new disease and there is no specific guideline to prevent its spread. It will be best if preventive measures taken to contain influenza are followed to prevent infection.

National Centre for Disease Control in New Delhi has already asked Nepal about the screening procedure and other measures deployed at Tribhuvan International Airport following the outbreak of coronavirus in Wuhan, China. Could you please explain those procedures?

We are in routine communication with countries that follow international health regulations. International health regulations represent an agreement between 196 countries, including all World Health Organisation member states, to work together for global health security. We are in touch with other countries where patients suffering from such illnesses have been detected. We have already responded to requests made by foreign countries.

What measures are being taken to combat spread of dengue, scrub typhus and similar other diseases in the country, as cases of those diseases have gone up lately?

We have taken the support of international experts to train clinicians in all seven provinces. We have also prepared guidelines for management of those diseases. We will soon have new pumps to spray insecticides to contain malaria and other diseases, and training will be given on their use. We have held preliminary discussions to prepare contingency plans for hospitals as those facilities will see a surge in patients if there is an outbreak of such diseases. We want the Ministry of Health to deploy full-fledged teams comprising clinicians and entomologists at federal, provincial and local levels. Also, authority should be given to provinces to hire the required number for human resources if there is an outbreak. We should begin this process now because it will take a few years to train these people and make them ready to handle emergency situations.

Lastly, what are the biggest problems facing the health sector and how can they be resolved?

We are expected to rapidly respond to any outbreak and emergency situation, but since the context has changed we are no longer in the driving seat. Regarding hurdles, the biggest facing the health sector is lack of qualified human resources. We also do not have adequate financial and technical resources. We want the health system to be restructured so that there is better communication between federal, provincial and local governments. Also, the public health sector should not suffer because of lack of budget and there should be clear mechanisms to respond to outbreaks and mitigate risks of outbreak.