Nepal | September 22, 2020

Pandemic and State: How is state accountable?

Abhishek Jha
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COVID-19 Global Lens

The COVID-19 pandemic presents the world with a huge challenge: everyone and every area is affected, and the response has to be both quick and consorted. This pandemic may be primarily a health crisis for some states, but COVID-19 is also an education crisis, an employment and economic crisis, a crisis of hunger and poverty, a crisis of governance and political stability like in Nepal.

According to World Bank estimates, a large share of the new poor will be concentrated in countries that are already struggling with high poverty rates. For developing countries with much larger populations at risk, fewer resources, and less capacity, the pressure to develop innovative approaches, test them quickly, and deliver them at scale is especially great. The state-level response towards the pandemic needs to be evaluated through the lens of state accountability. The government has to clear things, which are under its control and which are out of its control, at the outset for better mapping of resources and actions.

WHO’s role as one of the leading health-related research and action-oriented institution, with its independency in given time and reliability because of its scientific research and projections, came into limelight with not all the praises but also criticism. Leadership at WHO failed to announce the necessary measures to be taken in every stage, as the spread continued to soar up globally since it originated in Wuhan of China in December 2019. To accuse WHO for misleading the public and assisting in any sort of information cover-up is also a matter to be seen from the perspective of its own limitation of resources and access on ground-zero, both of which are under the strict control of governments. But for now, it can be observed conclusively that even WHO failed to contemplate the outbreak situation and think of a better preparedness and response plan.

Preparedness and response in Nepal

In Nepal, lockdown was apparently declared only after identification of a positive case. Action lockdown comes with hard implications. For the better and coordinated management of quarantine centres, in May, the Government of Nepal (GoN) issued Quarantine Operations and Management Standard for COVID-19. It was necessary to provide unconditional food assistance to people infected with the virus and in isolation, and collaterally affected people in quarantine.

There has been scarcity of food and lack of essential WASH services (drinking water supply, sanitation and handwashing) in many quarantine centres. The government has seriously failed to properly manage quarantine centres across the country. The government has also failed to check people who use the open and porous border points to cross into Nepal from India. Government failed to collect real-time data related to poverty. Impact of which was seen while distributing relief materials. Random distribution of relief materials reached a limited number of population. Also, the food-related materials were found to be of sub-standard, as local authorities got involved in fund misappropriation.

It was the responsibility of the government to manage infrastructure, ensure quality food and medical care for the people staying in quarantine centres. Media reports suggested that quarantine centres were over-crowded and these centres lacked basic facilities such as clean water, nutritious food, and toilets. People have complained that they do not have health professionals and ambulances available in all quarantine centres. The government also failed to put in place a reliable testing system.

A consolidated information management system was necessary for the assessment of effectiveness of quarantine and isolation centres across the country during the lockdown period. Strategies to mitigate quarantine related challenges and to increase community surveillance have fallen short as the government spheres lack complete data on people who have returned from India, which has now become the third-largest COVID-19 infected country after the United States of America and Brazil.

People staying in quarantine were not happy with the management and complained of necessary infrastructure at management centres. Quarantines and isolation centres proved to be the source of Covid-19 infection in some places. Medical and safety arrangements were found inadequate, and awareness and healthcare interventions were found sub-optimally implemented in quarantine centres.

A number of issues needed timely addressing, such as to ensure that there is necessary infrastructure at quarantine centres with adequate number of health professionals and ambulances. The government had to make sure that both male and female workers and volunteers are deployed at quarantine centres. The government is also responsible for discouraging disinfodemic in order to discourage community from treating those returning from India or other foreign countries as potential COVID-19 carriers.

It is believed that the actual number of excess death is much higher in numbers. As the government has ended lockdown measures and is planning to resume long-haul public transportation and civil aviation, risk of virus spread at community level is still there. Modality of quarantine measures has also been changed as GoN recently issued Home Quarantine Standard, 2020 (Issued on July 17). The responsibility to allow and keep vigilance on home quarantines is given to local governments. Those people travelling to and from the infected areas are to be home quarantined for 14 days. GoN is accountable to answer why lockdown was enforced in the first place, why it was lifted, what progress was made during the lockdown period, and what is the next plan on movement restriction.

Security agencies were deployed to strictly implement the lockdown but security forces were reported to be using excessive force against the public. In Nepal, response of the security agencies in respect to human rights protection and promotion during the pandemic has undermined people’s right to life, liberty and security. Human rights monitoring report shows that during the lockdown, people were beaten or tortured by the police.

The government has not ramped up testing for COVID-19, neither has it done enough to improve isolation and quarantine centres. The prolonged lockdown made the life of poor and vulnerable people — especially daily wage earners — miserable. Provincial and local governments have not been able to reach out to them with adequate relief packages. The government has not come up with any solid plans for generating employment in the country, or any alternatives for those who lost their jobs, or for the people that are returning from the foreign country after losing their jobs.

A cross-sectional study was conducted among COVID Clinics shows 95.8 percent of them had the provision of handwashing (soap water/ alcohol-based hand rub). The provision of infrared thermometer was available at 92.6 percent of the hospital entrances. Designated Emergency for non-COVID patients was available in all the hospitals. 93.5 percent of the hospital had Operation Theatres (OT) with a total of 273 OT rooms and 170 OT ventilators. None of the COVID Clinics had dedicated laboratory services (routine blood tests, special blood tests, culture and tropical disease profile test).

However, all of them shared laboratory facilities with their respective hospital services.

System can better help 

The federal structure of Nepal, which remains in a fragile condition, is damaging healthcare for people in the name of a centralised response. Amidst the pandemic, it is crucial that there be creative and transparent dialogue regarding how Nepal’s cooperative federal structure can remain flexible to respond to the pandemic without compromising the federal province and local comity.

In this time, any small or unique effort of any level government gets media coverage and spreads widely through social media networks. Sub-national governments are on the frontline for supporting the health care and economic livelihood of the people. Sub-national units need to work with the federal government to maximise coordinated response in administering federal programmes related to health insurance and employment programmes, without limiting their proactive measures to combat the crisis through legislative action, executive order, partnering with the private sector, and otherwise.

Most of the quarantine centres constructed so far did not meet the minimal conditions prescribed in the COVID-19 related preparedness and response plan and quarantine operation standard. Poor quarantine facilities have undermined the basic purpose of lockdown and social distancing. Thus, a synchronised effort with federal and local governments is necessary to keep surveillance, establish benchmarks, and monitor performance outcomes, dissemination of information about health messages and to provide better health care. COVID-19 outbreak has shown how quarantine measures have significantly affected economy, livelihood activities, employment opportunities, increased poverty rate and caused food insecurity.

Coordinated and well-communicated effort is a must to address culturally and linguistically appropriate guidance on social distancing, handwashing, self-isolation and quarantine, safe home care of infected people, and support to governments’ ability to contain the spread and take care of public health. Accurate health information needs to be disseminated to community leaders in order to facilitate social practices amidst the pandemic. Province government should also support

i) case finding and contact tracing, leveraging the in-country digital networks

ii) Support development, integration, and/or strengthening of health information and emergency management systems.

To address the second-order impact of the pandemic, the province government will need to develop and implement business continuity plans and counteract market entities effort to exploit the situation with price gouging and black marketing.

Abhishek Jha is an advocate and coordinator at Terai Human Rights Defenders Alliance

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