Ensuring access to sexual and reproductive health services amid lockdown

"One of the most profound impact of COVID-19 has been on the lives of women and girls. The lockdown and quarantine measures imposed to curb the spread of virus have put millions of women around the world out of reach of birth control options and other sexual and reproductive health (SRH) services"

The COVID-19 public health emergency has already become a crisis of global proportions as countries imposed national emergency, restrictions on travel, including stop-movement orders. This pandemic has placed unprecedented pressures on our health and social systems. Frontline service providers and systems, such as health, policing and social welfare, are overwhelmed by a plethora of activities related to preparedness and response of the COVID-19 pandemic. The major efforts of the entire health system and workforce are directed towards containing the spread of the disease and often the resources are diverted from the routine health services. In doing so, there is a risk that essential health services which communities expect from the health system, would be compromised. The health seeking of many essential services has been deferred because of lockdown and physical distancing requirements coupled by fear of COVID-19 exposure on venturing out of the house. Nepal has been under lockdown since March 24 and stays to continue till date. With no clear plan about going back to the normal life, the end to the lockdown is still not clear. This are public concerns whether this lockdown would be extended indefinitely.

One of the most profound impact of COVID-19 has been on the lives of women and girls. The lockdown and quarantine measures imposed to curb the spread of virus have put millions of women around the world out of reach of birth control options and other sexual and reproductive health (SRH) services. Confined to the home with their partners, they are much at risk to face unwanted or unplanned pregnancies. Because of COVID-19 related travel bans and closure of many clinics and health facilities, women are less able to access critical SRH services such as maternal health care, contraceptives and family planning, abortion, screening and treatment of STIs & other reproductive morbidities including other routine services. For women using long acting reversible contraceptives such as implants and intra-uterine devices, there might be a need for replacement, re-insertion or switching to another method due to side effects, complications or completion of duration. Even for those using short-term methods such as oral contraceptive pills and condoms, going out to procure a contraceptive is relatively difficult. In both cases, as the services are unavailable, more women are likely to experience unplanned pregnancies. Some women may opt for an abortion and many of these could turn out to be unsafe as the crisis could push women to take abortion drugs without supervision or seek help from people who lack training. Women also face greater exposure and vulnerability to gender-based violence and other harmful practices as they have been obliged to spend long hours at home with abusers, and with limited options for seeking help and support. This is especially problematic for women and girls from hard-to-reach areas including marginalized groups and those with disability. 

Even in places where health services are available, many women refrain from visiting health facilities as they fear being beaten by security forces and accused of defying the lockdown. Although government has long ago declared that the people seeking essential services would be allowed to commute freely, there is no public transportation available. On the other hand, due to shyness and fear of stigmatization women often might not be in a state to openly disclose the reasons to the security forces who impede their movement on the way to health centers. Nonetheless, many women prefer to seek family planning, abortion or other reproductive health services clandestinely from the health centers which are typically away from their residence. Meanwhile, outreach services, the key to reaching rural women and those furthest behind, have largely been suspended to avoid crowds and to prevent the risk of virus transmission from one community to another. The COVID-19 pandemic has also led to disruptions in supply chains across sectors, including with contraceptives and essential medical supplies. The impact of such disruptions are being manifested through stock-outs at health facility levels and community based distribution points followed by increased times for delivery of contraceptives.

Why should it matter?

A recent estimate from a Guttmacher institute revealed that even a 10% decline in contraceptive use in low and middle income countries due to reduced access would result in an additional 49 million women with an unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year. The institute has also predicted that even a modest decline of 10% coverage of pregnancy related and newborn health care would have disastrous implication for the lives of women and their newborns. An additional 1.7 million women who give birth and 2.6 million newborns would experience major health complications but would not receive the care they need resulting in an additional 28,000 maternal deaths and 168,000 newborn deaths. Similarly, the estimates say that if 10% of safe abortions become unsafe because women cannot access safe abortion services amid lockdowns and clinic closures, there would be an increase of three million unsafe abortions and one thousand more maternal deaths in the low and middle income countries. On the other hand, the United Nations Population Fund estimates that 23 million women in 114 low and middle income countries may not be able to access modern contraceptives and 600,000 unintended pregnancies are expected to occur if the lockdown carries on for three months with medium disruptions to health services. In the same period, 31 million additional cases of gender-based violence can be expected to occur. It is therefore clear that the consequences could be severely catastrophic for women and their families if critical sexual and reproductive health services are reduced or suspended during the pandemic. The access to reproductive health services is almost always time sensitive and potentially life-saving and shouldn’t be deferred or placed on hold given any circumstances including a COVID-19 lockdown.

What can be done?

It is not logical to protect the people from COVID-19 and yet expose them to other fatalities against which government and other partners have made substantial investments over several years. So, the answer is clear and obvious; despite the lockdown and travel bans, it is imperative that the critical sexual and reproductive health services should be continued and made accessible to everyone without having to face barriers of any kind. However, the most indispensable question is How? The COVID-19 pandemic has been a severe stress-test for all of us. The existing health system is overstretched and preoccupied with preparedness and response activities such that its capacity to deliver the essential health services has been severely undermined. Despite these challenges, the health system should not depart itself from exploring innovative models and approaches of care. Given that the stringent lockdown and travel restriction measures are currently in place, asking women to visit health centers for the services they need might not be both practical and ethical, for many reasons. It is therefore imperative for a health system to adopt alternative models of outreach services in order to cater women at places near to their doorstep.

One approach is to revitalize and reposition the role of visiting service providers who are often found very effective in increasing the uptake of contraceptives especially the long acting methods by rural and marginalized women. Visiting service providers in the form of LARC ANMs, MS ladies or roving ANMs travel to rural health facilities and communities on regular intervals to cater the contraceptives and maternal health care needs of the women and girls. Although these cadre of service providers are currently available in more than fifty districts, mostly remote and hard-to-reach, activities of the majority have been suspended greatly ever since the lockdown. It is a stark reality that these cadres are barely utilized during this period of crisis although the entire health sector is struggling with health workforce shortages. Where feasible, health system must thus consider exploring the opportunity for mobilization of visiting providers by repositioning their role from a family planning service provider to the role as a provider of comprehensive sexual and reproductive health services. In addition, taking into account the local availability of human resources and current pressures on the health system, the local governments and health system authorities may also decide to mobilize other public health care providers (both nurses and paramedics) at peripheral levels to offer SRH and other critical health services in the outreach.

These visiting providers could plan a fixed service day for each village/ward area and organize comprehensive family planning, sexual and reproductive health outreach sessions. Such kind of sessions could be planned on dates and time decided locally based on demands from the community. The beneficiaries may be called in a small group of 3-4 per session to ensure adherence to physical distancing. The existing community networks such as female community health volunteers, local health workers and social mobilizers/volunteers might be utilized to identify and communicate about outreach services to women and girls with need for services, and this could possibly be done through the telephone or local contacts. Furthermore, in circumstance with special needs such as high-risk pregnant, post-partum mother, women with disability, and other women with special needs, the outreach services through home visits can be provisioned and optimized. Such home visits and outreach services should preferably be linked to temporarily established helpline/hotline services such that needs for additional support and referrals can be responded immediately.

Besides, offering family planning services to postpartum women through infant immunization contacts has been considered one of promising high-impact practices in family planning. Given the need for a health system to work efficiently by minimizing the frequency of people contacts, the opportunities could be explored to cater both, the infant for immunization and the mother for family planning and/or SRH services during their solo visit on immunization session.

Ensuring the uninterrupted supply of contraceptives and birth control pills and other essential commodities is another critical aspect to safeguard people’s access to sexual and reproductive health services. In rural communities, where reaching health facilities or private pharmacies could be a problem due to travel restrictions, different alternatives could be considered for increasing people’s access to contraceptives. One approach is to explore whether it would be feasible to make the short-term contraceptives such as condom and pills available at local grocery stores. Amid lockdown, the grocery shops remain open each day, even if it is for certain hours in a day and are often accessible to everyone. Local governments may appoint a local youth volunteer as runner to fetch contraceptive supplies from district/municipal store or health facilities up to these distribution points. Movements of such volunteers should be facilitated locally in coordination with local authorities and police administration.

It is also critically important to make the best use of existing digital and tele-health platforms to ensure the provision of reproductive health information, counseling and services. Digital platforms worldwide have become a more popular, safer and effective means to reach client with comprehensive and reliable information and services during this lockdown period. A number of toll free helpline facilities are currently available for sexual and reproductive health services in Nepal. For instance, a Meri Saathi free helpline has been offering information, counseling and referrals on sexual and reproductive health issues through the dedicated counselors. Also, there are other hotline services and mobile health platforms operated by few other NGOs including the Ministry of Health and Population. In addition, a 24-hour hotline service operated by National Women Commission offers support to survivors of Gender Based Violence. Such hotline service can respond promptly during emergencies and offer referral services for women to receive health services, legal aid, psychosocial support, child support and safe shelter. Clients requiring any type of information and support services should therefore be encouraged to utilize these tele-platforms to obtain comprehensive information, identify a need to visit a health facility/hospital and to determine whether referral services are needed. A number of mass-media could be used to inform the public about its availability, to build public trust that these services are confidential and reliable and to promote the use of such services. 

Having considered all these approaches, the government and health system must also be thoughtful on few other basic issues. Firstly, as the public transports have been closed, health care providers may face difficulties in their commute to outreach sessions, particularly those who rely on public transports for their movements. Where feasible, the inter-mediate means of transportation such as bicycle, scooter or other local means could be provisionally made available to theses providers to enable their movements to distant or hard-to-reach areas. Secondly, the protection of visiting service providers is crucially important. Thus, before deployment for outreach services it is imperative that these nurses and health care providers are well-informed and orientated on the standard protocols for infection prevention and control and are aware of the advisories for infection prevention, personal protection and physical distancing norms. Provision for the adequate and appropriate personal protective equipment would be equally necessary. Lastly, the key to successful pandemic response and continuity of essential health services largely depend on how robustly the governments and health system apply their efforts and resources and how effectively the coordination has been sustained with other private and non-government sectors at local level.

For universal access to sexual and reproductive health services to become a reality, there is an urgent need for concerted efforts, quick and decisive action. It is the responsibility of everyone including the public health sector, governments at all three tiers, for-profit as well as not-for-profit sectors to devise necessary measures to ensure that reproductive health services remain readily accessible to everyone and ensure the functioning of community systems to protect the rights and dignity of all women and girls. While COVID-19 pandemic is inevitable, the devastating impacts of lockdown on SRH services can be significantly mitigated if the community level efforts are well-integrated.

This article was published at Online Khabar on 06 May 2020: Please follow the link below
https://english.onlinekhabar.com/ensuring-access-to-sexual-and-reproductive-health-services-amid-lockdown.html

दुई हजार तेह्र सालमा

न त बाँझो खेतबारीमा धानमकै फल्छ भोलि
न त सस्तो ईन्धनले नै मोटर गाडी चल्छ भोलि
अनि नयाँ के होला त दुई हजार तेह्र सालमा
न त बिना लोडसेडिङ रातभर बत्ति बल्छ भोलि

बगाउनै छ पसिना त जनताले हर सालमा
जति शरिर गल्छ आज उत्तिनै गल्छ भोलि
के छ त खै आशा राख्ने दुई हजार तेह्र सालमा?
न यो भ्रटाचारी देशको समस्या नै टल्छ भोलि 

अवस्था यस्तै रहे देशमा अशान्तिको, 

हत्या हिँसा काटमारले मुलुक अझै जल्छ भोलि
परिवर्तन के होला र दुई हजार तेह्र सालमा?
राष्ट्रिय मुद्दा बेरोजगारको न त कुनै हल छ भोलि

छुँदैछ चन्द्रमा नै मुल्यबृद्धि महँगीले,
यस्तै रहे गरिवीले जीउ ज्यान ढल्छ भोलि
के खुशीमा मनाउनु खै दुई हजार तेह्र साल यो
न त कुनै नव अवसर न खुशीको पल छ भोलि..

, 

Handwashing- A Key to Public Health

The issue of handwashing is not a modern story of recent decades. However, in the lack of appropriate concern and significant promotion it was on shade for centuries. With the rise of health and health related organizations, professionals and media technologies, hand washing has at least gained a global concern at recent. Public health experts recommend handwashing with soap as a key action in protecting the public health because it’s a mainstay in infection and disease control. Handwashing is linked to achievement of 2015 millennium development goal 4 of reducing under-five child mortality. Because handwashing can prevent the transmission of a variety of pathogens, it is considered to be more effective than any single vaccine.

Handwashing with soap is the single most cost-effective intervention to prevention and control of diarrhoeal related morbidities and mortalities. Yet, tragically, more than 5,000 children every day or 1.7 million every year around the world die from diarrhoeal causes before the age of five. According to the report by UNICEF, 2008, diarrhoea is the second most cause of death in children accounting for 18% of all under five deaths. In Nepal alone, each year 10,500 children under five years of age continue to die of diarrhoeal diseases. Studies reveal that effective practices of handwashing at critical times including before meals or food handling and after the use of toilet, can reduce such diarrhoeal incidence among under-five children by almost 50%. Further, handwashing with soap can reduce the incidence rates of Acute Respiratory Tract Infections (ARIs) by around 23%. Pneumonia, a major form of ARI is another leading cause of childhood mortality claiming the lives of an estimated 1.8 million children each year. Diarrhoea and pneumonia, together account for almost 3.5 million childhood deaths annually in developing countries. It is estimated that wide practice of handwashing with soaps and intensively monitored trials at monitored household and school levels could prevent one million of these deaths. The simple act of washing hands with soap can cut diarrhea risk by almost half, and respiratory tract infection by a third. 

Apart from diarrhoea and pneumonia, handwashing can also be a significant measure in controlling pandemic outbreaks of other respiratory infections. Several studies carried out during the 2006 outbreak of severe acute respiratory syndrome (SARS) suggest that washing hands more than 10 times a day can cut the spread of the respiratory viruses by 55 percent. Handwashing is also the foundation in averting many skin infections, worm infestations and eye infections. A study has also shown that handwashing with soap by birth attendants and mothers significantly increased new born survival rates by up to 44%. This makes handwashing a better option for disease prevention than any single vaccine. However this is just a missed opportunity for public health as we are still not in a state to habituate public towards effective handwashing.

Despite of its life saving potential, the rates of handwashing around the globe are still minimal. The observed rates of handwashing with soap at critical moments such as before handling food and after using the toilet range from zero to only 34%. Such lower rates are rarely caused by a lack of soap as almost every household in the world, regardless of economic status, have soap but is used commonly for bathing and laundry. Handwashing with soap at key times, however, is not widely practiced. Though industry has succeeded in getting soap into almost every home, it has not consistently promoted good hygiene or handwashing to accompany their products. In studies around the world, the main reason given why rates of handwashing with soap are so low is that it is simply not a habit. The underlying reasons not only limit to the low awareness level of the public but also to their reluctance and ignorance in using soaps for handwashing despite their better knowledge in this regard. Regardless of nationwide and global efforts in promoting handwashing with soap, it is infrequently practiced and thus behaviour change in this regard is not so straightforward unless the benefits of handwashing are well recognized and internalized by the general public.

Further, efforts at promoting effective hygiene have been piecemeal and ineffective.  Current efforts in the nation to promote good hygiene, including handwashing, have not been sufficient to engender mass behavior change. Many public health programs include improved hygiene among their objectives such as in diarrhoeal disease control program, a school health education program that includes hygiene, a water supply and sanitation program that invests in raising hygiene awareness, and sporadic local-level hygiene education or the advertisement of soap itself that incorporates the message of handwashing. However, all these efforts share the weakness of treating hygiene as a side issue, rather than a central one. Hand washing has only been taken as an ingredient of any other public health programs and in lack of concrete approach towards promotion of handwashing and effective behaviour change programs, the public health is at full gear to suffer.

 At the present context, the nation is demanding for a specific public health measures to drive into action to contribute significantly towards improvement of public health through successful handwashing. It is necessary to build alliances between the public and the private sectors and mobilize the necessary resources and expertise in promoting hygiene and handwashing. High-impact communications outreach is to be employed to promote handwashing to a mass audience. In a noisy world of competing messages aimed at people from all directions, only the most effective, best-designed campaigns will lead to behavior change.

 If the 2015 millennium development targets for reduction in child mortality are to be met, handwashing practices must be improved along with access to safe water and sanitation. This requires Ministries of Health, Education, and Physical Planning in addition to Water and Sanitation Division, Non-Governmental Organizations (NGOs) and community-based groups, to utilize every opportunity to promote handwashing with soap. However, these global efforts to encourage effective handwashing can’t become a success without individual efforts translate into action. Hence, behaviour change efforts targeting every individual, especially children should be the prime focus of all public health programs that incorporate handwashing. Otherwise, the immense global and national approaches with massive expenses to promote handwashing would be in vain without individual compliance to accustom them in handwashing with soap.