While countries across the globe are battling and facing enormous challenges to deal with COVID 19, Nepal is also making preparations and taking concrete steps to deal with the crisis. However, there is a need to further intensify those efforts, enhance coordination and collaboration, and make necessary supply of logistics, increase number of testing, among key priorities to deal with this pandemic. Here are some recommendations for further discussion and the way forward to deal with COVID-19 Crisis in Nepal.

Declaration of Emergency

It is ideal to have regular Security Council Meeting and declare a State of Emergency (Public Health Emergency). WHO declared COVID-19 a pandemic, and therefore, it’s a threat to not only national but global health security. Hence, an emergency declaration for three months would be ideal.

Reason: Imminent threat of a large scale to public health and security, there is a need for preventive measures, preparation and response accordingly.

French President Marcon and Indian PM Modi has called it war, like 3rd World War. German Chancellor Angela Merkel, has said, this is the biggest threat for Germany after World War 2.

Many countries have already declared national emergency or health emergency/ human bio-security emergency. Some of those countries are USA, Thailand, New Zealand, Philippines, Siera leone, Australia, Estonia, Spain, France, some provinces of Germany and Canada.

War like Preparation, Planning, Operation and Implementation is the need of the hour. We need efficiency and time is a very important factor in the outcome of the crisis.

24 Hour Emergency Control Room (just like a war room). Health Emergency Operations Centre (HEOC) at the Ministry of Health and Population (MoHP) is the main centre designated. Although Public Heath Act has been used for the lockdown, it touches so many aspects of life from economy to security. Hence, emergency might be a better option for the government to deal with this crisis.

Strategy: A very clear cut Strategic Plan is the need of the hour.

Strategic Plan need to be endorsed by the Cabinet meeting of Ministers. The roles and responsibilities of federal government, province and local government needs to be clearly defined. Also the role of security agencies and various government offices need to be clearly identified.

Financial Package: An economic plan and package need to be endorsed immediately without any further delay by the government. A relief package and stimulus to the economy and business should be unveiled by the government to take people, business sector, all in confidence in cooperating with government with the lockdown and other measures put by the government to deal with this crisis.

The relief package that government has come forward during last cabinet meeting seems too little and too late. It doesn't look very appealing to the mass and that convincing either. Minister of Finance need to come up with some plan soon to calm down affected people and businesses. People need to know how this crisis going to affect national economy, certainly there are uncertainties for a good forecast at the moment depending upon how the crisis will develop in Nepal and around the world. However, we know, remittance and tourism industry are mostly affected. So, people need to be updated regularly on this part of the crisis as well.

The financial package doesn't address the needs of seasonal migrant workers and other migrant workers who returned home because of this crisis or who have lost their jobs abroad and come back because of COVID 19 crisis. As, migrant workers have significant contribution in national economy and they are ignored in this financial relief package.

Lock down: This has been the main strategy to suppress the cases, community transmission and buy time to make necessary arrangements, preparation and identify, diagnose cases, isolate and quarantine. This comes at a huge economic cost to the country as well as it will cost directly to the people and business. This is the key reason why government should come up with a good stimulus plan and relief package. People are cooperating the government by accepting the lock down and staying home. However, the incentive for doing that for the daily wage earners is very less. People shouldn't go hungry in the name of lock down and necessary provisions should be made at the local level.

While many governments across the world have put even more strict rules regarding physical isolation and lock down, they have also come up with good incentive and financial package. This is where people and business expect creativity and use of expertise as well as leadership from the finance minister. Also, the provisions for the shopping of daily needs should be made more flexible in terms of timing. If the shops are open only at certain time, it is going to be over crowded. It has been seen recently in Kalimati vegetable market.

Supermarkets and big malls, when they are open, would it be possible for people to queue up outside maintaining minimum distance required and food and daily needs delivered if possible right outside in the open space or by avoiding crowds inside.

Security Council Meeting

Security Council meeting on Regular basis for proper coordination between security forces and other institutions. Off course if Emergency is declared then it might be necessary. However if government chooses to use the current format/ committee then it may not be necessary. However, if 3 months national emergency is declared then this might be necessary.

Budget allocation: More funds need to be allocated as per necessary by the government. Currently Karnali province have allocated more funds than the Federal Government as I read the news. So, is the amount allocated meets the need? How are the three tiers of government coordinating efforts and avoiding duplication of resources and addressing the gaps in this situation?

There have been news of policeman and traffics doing duty by just having noodles and biscuits or like that. The shops are closed. The provision of good food and water is mandatory for any police, traffic police or security force deployed.

The budget should not be an issue to fight this disease and to deal with this pandemic. As this is a big priority, the adequate budget and resources need to be allocated accordingly.

Emergency Purchase

Emergency purchase under emergency or security heading including airlifting if required because like in War, time is the key factor so are the basic resources. What can be done should be done immediately.

ICU Set up and Mobile Hospitals:  Purchase of ICU equipment, ventilators, AMBU bags, may be mobile hospitals if needed. Fully equipped mobile hospitals in the containers with ICU facilities, isolation blocks can be purchased (Clinic in a Can, Hospitainer).

Oxygen supply and production will be crucial. It would be important for the government to purchase as many oxygen concentrators as possible which could be helpful when the cases start to rise. It would be wise to purchase all these equipments without any delay, infact, should have been purchased much earlier. Now, with the crisis, even getting those equipment in the market is already so difficult.

Test Kits: Varities of them are being produced including (IgM or antigen, IgG for antibodies). Need to contact China, India, Germany, UK, South Korea, etc. for any potential help. It would be great if we could purchase from different places, a variety of them in good numbers. WHO has stressed the key strategy and only strategy is: Testing, Testing and Testing. So, this is the most important step in containing COVID 19 pandemic.

The government has just bought some PCR machines and test kits. Hope this will help alleviate the constraints with testing COVID 19 to some extent. However, government should keep looking at the possible use of existing GeneXpert machines by purchasing and supplying cartridges immediately could be another possible option.

IR Guns and Thermal Scans: Infrared Thermometer Guns (IR guns) are needed in adequate numbers for all mobile teams across the country. Thermal Scans may be of use while resuming services or getting back to normal once crisis comes under control for super markets, airports, etc. 

Isolation Wards and Quarantine

Make best use of Isolation beds at hospitals and quarantine rooms. They are hardly being used in large number at the moment. If TV, Wifi, good food, good temperature control, then people will be happy to stay more easily. Government should make good provision of all this including security. Provision of good sanitation facility is important. Security of isolation rooms need to be given to Security force most preferably army. Discussions about making hotels/ resorts into quarantine houses are also being put forwarded. People need at least a good place where they can conveniently spend 2 week time. The people arriving from India or abroad need to be put mandatorily in quarantine for 2 weeks. 

The guideline related to quarantine has been approved and issued by MOHP today itself so that is already addressed. The guidelines should be followed by everyone concerned. There need to be security forces deployed to secure the quarantine area and to make sure people don't escape.

Use of Technology: Purchase Drones, Robots, etc. and use GPS/mobile tracking of the infected patients. This will certainly help. China, Israel, South Korea, as using it successfully. Careful use for target persons only for this crisis with approval from Cabinet could be useful.

Safety of Health and Security Personals: Safety of Health workers, Security Personals and Drivers (Ambulance). Personal Protective Equipment (PPE), N95 masks, surgical masks for affected or people with respiratory problems. The government should try its best to provide these materials in adequate quantity as we need to protect the frontline workers in the first place. This is also important to have high morale of our frontline health workers and security personals deployed.

Provision of local production now and for future use mainly surgical masks and PPE: (Mahabir Pun can give some idea, he is doing some, Army can produce in large scale, and logistics of these materials is a very big issue and may be Nepal Army can help solve it to some extent. This is a lesson for future also, local production capacity is necessary to deal with any future public health emergencies. Binod Chaudhary has pledged PPE and N95 masks from Chaudhary Foundation so that might be helpful.

Emergency supply Store with Nepal government as well as Nepal army and Security Forces: N95 masks and PPE need to be stored in large number for future as well once it is contained. So, stores with Emergency supplies of such materials and equipment necessary for Army and for public use in disaster or pandemics.

Local production and supply of Sanitizer: This is feasible and could be done and would be important step forward. A concrete immediate action need to be taken to implement this either by government, private sector or army. In the meantime, interrupted supply of sanitizers for the health workers and security personals.

Make availability of soap and public hand washing facilities: This could be done by local government in each wards, village wherever possible.

Possible Prophylaxis: Use of Hydorxychloroquine Sulphate has been approved by Indian Council of Medical Research for the empiric use as prophylaxis. Please contact Nepal Health Research Council and Nepal Medical Council on this matter for regular update, discussion and potential use if necessary. May be frontline Health workers and Security personals can potentially benefit. So, we need to keep an eye on it and decide what to do. Even US, FDA has authorized limited and emergency use of chloroquine and hydroxychloroquine suplhate which means the supply and stockpile in US government warehouse. So, Nepal also need to carefully consider about potential options in this regards.

Bioterrorism Control Unit

A Nepal Army unit to handle any radioactive and bioterrorism crisis is ideal to be put in place. It seems Nepal Army needs a BSL 3 lab at least for now and future use including PCR machines, a well functional lab, experts and training. That will be useful also for Army Medical College but mainly for security and defense and public health purpose. The country could certainly benefit from the bioterrorism point of view. Even though we don't have Nuclear reactors, I think it would be important that Nepal army be trained in radioactive disaster management.

Nepal army certainly needs to be trained and well equipped to deal with any forms of bioterrorism or disasters that are risk to public health and security. If this were a manmade virus then the response would have been certainly different and from security point of view. Nepal needs to be prepared for any such epidemic, pandemic, bio-terrorism and radioactive leak/ emergency even though we don't have nuclear power.

The national capacity of the public health labs across the provinces and that of army seems necessary to deal with current and any future epidemics/pandemics or crisis.

While the government is trying its best to contain the current pandemic and to minimize loss of lives, the suggestion is to scale up efforts further to make it more coherent and create synergy from federal to province and local government levels.

Having everything into our context, Operation Janarachhya/ Jana Surachhya/ JanaSwasthya Rachhya has been proposed to bring the much needed synergy, rapid response and maximize the efforts and urgency to make best use of the time and window of opportunity. It is also important to instill confidence in the public and also boost morale of healthworkers and security forces.

Operation

Civilian Leadership and overall command by PM DPM.

Nepal Army - Plan, coordinate and execution of tracing/ quarantine etc. (Mainly contact tracing, mobile teams, sample collection, quarantine and isolation rooms and hospital security).

Nepali Police - Policing duties

Armed Police Force - Border control; road and highways control; support the Army

Health Ministry - Supply of medical equipment and items; treatment, mobilisation of health workers, tests, among others.

Role of provinces and local governments need to be clearly identified.

Province: The province will have more role in technical assistance, logistics, overall management of quarantines and isolation wards and ICU as well as ambulances and health care workers. The province can overall monitor, supervise, train, and provide experts in coordination with federal government. The provincial government can also support with mobilization of health workers, financial resources and logistics supply, sample collection and testing, communication of results, treatment of patients.

Local Government: The local government will have more role in enforcing lock down, quarantine, contact tracing and providing support to the needy people as well as necessary data collection and coordination with province. The local government can mobilize local volunteers and Female Community Health Volunteers and elected representatives and also mobilize local resources, to raise awareness, to take necessary measures, sample collection and referral of patients or suspected cases.

This has been done to quite some extent. However, the speed of action taken and implementation of decisions made is still seems to be slow to deal with this situation. For this reason also, to make use of limited time we have before the COVID 19 spreads across the community, speed of doing things is very important. Just like in a war, timing is one of the key factors while dealing with this pandemic. Losing time means losing battle or losing more lives.

Conduct of Operations - Jana Rakshya/ Jana Surakshya/ Jana Swasthya Rakshya

• Issue of Strategic Guidelines by Prime Minister

• Concrete Operations Guidelines by Defence Minister

• Execution plan and execution by Nepal Army for security agencies

• Medical treatment plan and execution by Health Ministry, among others.

Operations Modality

Plan: National Plan, Province Plan, District Plan/ Palika level Plan/ Ward Level Plan need to be very clear. Responsibility need to be allocated clearly to each level. The plan needs to be tested and revised/ updated if necessary. I understand there is certainly a plan, to test it and to implement it rapidly is where we need to focus on.

Operations Control Centre: Communication Channel, Command and Control from the Operations Control Center. HEOC is the designated center at the moment and generally for Health Emergencies. It is up to the government to decide upon the modality depending upon the type of response and scale of emergency.

Data: Data Collection, Mobile teams (Search teams that can be deployed to each wards up to village/ tole level. Data collection and database of people who came from abroad or India within last 2 weeks. They need to be properly screened and tested followed by their contacts.

Collect Data from TIA/Airlines for the passengers in last two weeks who arrived/entered Nepal and do the necessary follow up.

Collect data from land borders if available. The government and army is trying to collect data through app. The data should be collected without any further delay. 7 Days of lockdown has already been spent till date and still data is not available, not significant number of people are tested or in quarantine.

Collect information, data and names and mobile numbers of Female Health Community Volunteers and local Health Workers. We are already losing precious time on this front.

Contact Screening and Testing: Mobilize Ward committee and health workers. Do screening/ fever clinic outside in open space if not tent and symptomatic management/ refer to nearby referral center/ isolation ward in hospital setting. Screening of airport staffs, mainly immigration, health workers and security personals mobilized at health desks in borders and airports should be a priority for screening and testing among those coming from abroad and contacts.

Mobilise health workers to collect samples instead of moving patients or asking patients to come. Do the entire contact screening of the community in the meantime. There may be a need of large number of mobile teams across the country that includes health workers and security personals and if possible FCHV or local health staffs. Certainly ward or municipality can provide support for the mobile team.

Strengthening Referral Mechanism and Courier/ transport of Samples: Screening and testing as per protocol. Sample collection and courier/transport as per the protocol. A very good coordination and communication is needed. 

Provision of transport: Vehicles (jeeps/cars), ambulances and motorbikes, cycles as available and as per context for the security personals and health workers/ mobile team. Standby vehicles.

Pooling of Health Personnel and experts: Proper mobilization and pooling of health workers from PHC, HP, district hospitals, or national academies, mobilize Residents from academies as well. This is a crisis situation. Enroll volunteer health workers, lab personals, nurses, recently retired health workers from civilian and government service etc. Also mobilize health staffs/technical staffs from Nepal Police, Nepal Armed Police Force and Nepal Army as well. Also make sure we best use the medical facilities and hospitals of the Security forces as well.

Time for voluntary recruitment and orientation

Orient, train and mobilise volunteer health workers. (They can receive good honorarium and work for honor in the moment of national crisis.) It should be about honor to serve the people and country and not just paid work for a month or two. People should feel worthy and respect to join the services. Otherwise, the vacancies that are being posted now, there will not be many people motivated to apply to work for a month or two in frontline with such a pay. This is not very encouraging. We need to make best use of any resources available and mobilize private hospitals and medical colleges to the extent possible.

Public Private Partnership and Civil Society engagement: Civil society support and engagement has been almost non-existent so far. This needs to be changed. Religious leaders, Chamber of Commerce, FNCCI, Hotel Association, Professional Associations, Ex-army, Ex-police, Ex-Indian Army, Ex-Gurkha, association, etc. The medical colleges have both resources including facilities, equipment as well as human resources who could be /should be deployed in this crisis depending upon the scale of emergency it creates. So, declaration of emergency may be important even to take this necessary steps. Off course, PPE should be provided for them however government should not hold back from enforcing strict measures in order to make best use of private medical colleges and health facilities.

Security of Health and Security Personals and drivers or health workers involved: Strong action need to be taken and protection and security to be provided to any health workers, security personals. Any harassment should be punished very strictly. The families of health workers should feel safe. The landlords need to be punished and penalized heavily who ask for evacuation citing infection fears.

Overall Logistics and Supply: Besides, smooth and uninterrupted supply of medical logistics but also regular supply of daily essentials for the public to maintain peace and calm and enable them stay home.

Track 2 diplomacy: Track 2 diplomacy and army to army connections to be mobilized to seek medical equipment, test kits, PCR machines and facilitate government efforts in getting those equipment or purchasing them. If Defense Minister can discuss with Nepal army if they can help on purchasing the necessary test kits and equipment that would be great. Nepal army has good links with other armies and can seek assistance on this matter. It would be nice to approach for some test kits from South Korea, China, UK, Germany, USA, etc.

We also need to explore and request ICRC/ Red Cross, Rotary Clubs, Lion Clubs, Nepal Scouts, NRNs about how to seek their support to acquire as much PPE, N95 masks, IR thermometer guns. Nepal government can also request for INGOs to try to provide possible support including Global Fund Program if they can purchase and supply much necessary test kits, PPE and N95 masks, other very important medical equipment, ventilators, etc.

Crisis Communication: This will be the key to deal with this crisis as fake news, rumors, misuse of social media, etc. can pose serious challenges. The communication between government and public need to be very clear, transparent and on regular basis. Use of Social media by the government is very important in this hour along with the press briefings. Something can be certainly learnt from the press briefings of the Governor of New York by watching at his Press Conferences.

Technical Assistance: Seek technical assistance from China, South Korea, etc. on how to contain the COVID 19 Crisis and lessons learnt. Use of technology, planning, contact screening, etc. So, experts from those countries can help and provide assistance in planning and implementing the plans as well as provide trainings, orientations, etc.

Use of Existing Government and Private Facilities

Enlisting potential labs, mainly BSL2 facility that has necessary infrastructure and Human Resources within government system and private facilities. There are existing labs under Veterinary/ Animal Health division of the concerned line ministry and also VVDRC, Hetaunda under MOHP. Those could be used and it needs to be explored along with other private labs. Existing TB labs and facilities / GeneXpert sites and their potential use need to be discussed.

Potential collaboration 

Collaboration in Kailali: May be if support from Provincial government , upgrading Laxmi Narayan TB Referral Center into a tropical hospital which also deals with MDR TB could be away forward. This could be developed now if investment from government and add ICU set up and staffs so it would be both short term and long term solution. A provincial lab, provincial tropical hospital with ICU and isolation wards, it could be a long term solution. However, it is provincial government that needs to come up with a concrete plan and also need to make necessary investment. 

Collaboration in Madhyabindhu District Hospital: This can also be upgraded into a tropical hospital beyond district hospital. The TB Referral Center is also going to be constructed therensoon. As there is enough land, government hospital building under construction, if Gandaki province takes initiative, this could be another potential place for collaboration and to be developed as a tropical hospital. 

Sahid Smirity Hospital, Chaupatta, Nawalparasi West: It is a community hospital with good infrastructure. If government / province 5 takes concrete steps, it could be developed into a Tropical hospital as it is in an isolated area, accessible, good transport, adequate infrastructure and land. This could be both short term and long term solution for handling such crisis. Federal and Provincial government if they take necessary steps and discuss with community hospital a solution might come out. The hospital is already quite equipped off course no ICU and OT equipment need to be set up. 

Kapilvastu Community Hospital: This hospital can also be developed for any kind of disasters/ RTA and even for epidemics with some support from government. This is ideally located in the high way. They have already quite good infrastructure and land as well. Mainly suitable for Road Traffic Accident, trauma and disaster because of location. However, it can also be used for epidemics or pandemic like this as well. 

Tropical hospitals and provincial labs 

There is a need to establish or upgrade existing hospitals or take over some community hospitals and transform them into tropical hospitals with ICU, enough beds and human resources in each province. The isolation wards need to be foreseen and it should be well equipped. Similarly, the provincial labs that are going to be established should be fully equipped at least BSL 3 and with adequate human resources.At least, MOHP can make best us of existing resources in the country and strengthen public private partnership/ government and community partnership. Prime Minister has suggested making isolation hospitals/ tropical hospitals in each province. We need to catch this opportunity. Certainly above mentioned hospitals could be developed for relevant provinces if provinces decide to do so. For the rest of the provinces, it can also be developed in the coming days with high priority. Other such hospitals can be identified across the country.

Center for Disease Control (CDC): With the implementation of federalism and during restructuring of the state, the concept of CDC came forward and was discussed. However, it didn't come to an agreement and hence the idea didn't materialize. However, with this pandemic it can be seen that such a center need to be in place in order to deal with any epidemics, pandemics, disasters. Epidemiology and Disease Control Division (EDCD) today doesn't have that much human resources, budget or structure to deal with the big epidemics and disasters. Health Emergency Operations Center (HEOC) is mainly a coordinating body and center. Hence, once the crisis subsides and things calm down, the idea of CDC needs to be rigorously discussed and implemented. CDC exists in many countries across the world where there are is federalism. 

International Collaboration: If tropical hospitals are developed, provincial labs established then, certainly, we can seek international collaboration for technical assistance with renowned tropical institutes. Also seek collaborate with Supranational labs. We need to strengthen labs and capacity and that includes capacity of Nepal army in the matter of biosafety lab, technical human resources, etc.

Well, some of the suggestions are more long term, while some are feasible to implement immediately. While we respond to the crisis immediately, we also need to create resilience, capacity and long term solutions. Sometimes, just some fine tuning, advocacy in the right place with the right persons is all that is needed to make things happen. Academic exchange and technical collaboration in the future can be developed to build the local and national capacity and technical know-how.

We can learn lessons from the 2nd World war in which USA highly benefitted and developed itself during into a Super Power. We have to emerge stronger from this crisis, together. We have to try our best to overcome this crisis, strengthen our national unity and come together stronger, united, resilient economy together.

Conclusion

We need a more efficient approach and warlike efforts to deal with this crisis of this scale. Our efforts mainly need to be focused on increased testing, contact screening and isolation. Lockdowns mainly help prevent the spread of disease rapidly and buy time for countries to make necessary preparation. The country need to make the most use of this lockdown period. Also making sure of logistics supply and protecting health workers and security personals who are in the frontline and making them well equipped and trained is necessary.

Globally, there is a shortage of medical equipment, PPE, N95 masks, ventilators, etc. However, if Nepal government uses its all diplomatic contacts/ track 1 and track 2 diplomacy and even seek advantages from the contacts and goodwill of Nepal army to mobilize support/ facilitate for Nepal government in securing necessary PPE, N95 masks, Test kits, PCR machines, Ventilators and other necessary medical equipment from various countries that would be one of the major contribution in dealing with this crisis.

Government also need to come up with a good economic and financial plan in the meantime to deal with this crisis soon. If handled properly and together if we emerge from this crisis without much loss although it’s a very challenging task then we will emerge as a stronger country together and which can also strengthen federalism and also increase the national capacity to deal with any disasters or pandemics and contribute to the overall health security of the country.

Disclaimer: These are my personal opinion and intended for contribution in good faith in the time of crisis. This in no means is related to any organization or office I work for. These are certainly for discussion.