Disease surveillanceThough Nepal has made great strides in the health sector, it is yet to take significant steps in disease surveillance and research
Every year, many Nepalis, especially those residing in villages not easily accessed by road or air, die of diarrhoea, influenza, malaria or viral hepatitis. This happens despite the numerous workshops and conferences that are held in remote areas to discuss these diseases. Meetings identify the problems and make recommendations, and the participants go back to their daily routine. The very next year, the cycle resumes, and the solution is as far away as ever. This is the dilemma of the healthcare sector in the country: the knowledge is there, but not enough to intervene in controlling disease transmission, and subsequently, carry out treatment.
Need for research
Infectious diseases can be prevented. Drugs (medication) can be used to prevent pathogenic infection or cure diseases. Vectors that carry infecting agents (for example, mosquitoes in malaria) can be controlled. Vaccines are available to prevent transmission of diseases. In some cases, simple sanitation and hygiene practices (washing the hands with soap) are adequate to prevent the spread of disease. However, in order to identify the best approach to prevent and control diseases, adequate surveillance supported by clinical/epidemiological research is very important.
Research and surveillance together can provide our health sector a holistic picture showing where intervention will work and where it might be a waste of time, energy and money. For example, the government might feel that vaccination is not needed in areas of extremely low prevalence due to the economic implications of the cost of vaccines and vaccination programmes. A glaring example of this was observed in a study carried out by the World Health Organisation (WHO) in collaboration with the Centre for Disease Control and Prevention and the Centre for Molecular Dynamics Nepal (CMDN). It was found that the overall prevalence of hepatitis B virus (HBV) infection was very low among children around the country, thus the birth dose of the immunisation recommended worldwide may not be so important for Nepal. HBV tends to be transmitted from infected mother to child. As a result of this study, it was recommended to the government that certain groups and communities (for example, in the mountainous regions) might benefit from the HBV vaccination programme as chances of HBV infection have been found to be high by a few other studies.
Death and sickness due to vaccine-preventable cholera goes largely under-reported in Nepal, therefore, it receives low priority in the country’s health systems radar. Regular surveillance of cholera is largely missing in Nepal due to inadequate human resources and infrastructure. As a result, it is not possible to understand the true impact of this disease in Nepal. Similarly, lack of adequate surveillance of viral respiratory tract infections is a cause for concern. We have been largely unable to distinguish between different types of respiratory viruses (influenza, SARS and corona) due to lack of regular surveillance efforts. Therefore, we have very limited information about even common influenza infections, and we are nowhere close to introducing the seasonal influenza vaccine in the country. Due to lack of coordination between various government and nongovernment agencies, vulnerable sections of the Nepali population (the very young, very old and immuno-compromised) who could have been protected by the available vaccine, might die of seasonal influenza in the next flu season.
Similarly, hepatitis C virus (HCV) infection can be passed from infected to uninfected individuals through the blood and can cause severe liver disease, possibly leading to death if not treated. Interestingly, recent advances in pharmaceutical science have led to widespread use of medication that has a cure rate of up to 90 percent. In Nepal, the intravenous drug using population appears to be the most affected. Unfortunately, there is no surveillance of HCV infection in the general or high-risk populations in the country.
A recent study by the GIZ in collaboration with the CMDN has provided
new insights into the type of viruses infecting the Nepali population which have led to further studies aimed at developing efficient treatment regimens. However, without a proper and continuous surveillance system, it is hard to implement any guidelines as both the nature of the virus and the efficacy of the medication change over time.
Alignment with PPP model
Nepal can improve its disease surveillance. However, both the government and nongovernment sectors working in the area of health services need to contribute. Unfortunately, there appears to be a general perception that the government health sector should be solely in charge of delegating and implementing the task. Although the government has brought out the public private partnership (PPP) model for efficient service delivery in the country, its seems to have misconceptions about its benefits to the country. This model is important for a country like Nepal where human resources and fund limitations in the government sector make efficient service delivery a huge challenge.
The WHO, as per its historical mandate, continues to push mainly for strengthening government departments, thereby alienating private organisations and NGOs that have been contributing immensely in the research, surveillance and treatment sector. The quality of services is very important for efficient surveillance, and this is not guaranteed in light of the constant changes in the ministries. This results in less efficient service delivery to the people. Thus nongovernmental actors need to be constantly in the loop as support systems when such events do happen. WHO needs to ensure continued partnerships outside government mechanisms too.
In contrast, external donor partners have shown the way in promoting the PPP model for health service delivery in Nepal. The role of the GIZ and USAID in supporting both the government and private/NGO health sectors is highly commendable. Yet, challenges remain, and increased support will result in not only strengthening the general health service delivery but also the efforts being made by the government. The PPP model is a tried and tested model worldwide for a win-win situation.
Nepal has made major inroads towards achieving some of the Millennium Development Goals in the health sector thanks to effective partnerships between government departments, NGOs, private sector organisations and donor communities. Yet, in the area of infectious disease surveillance and research, Nepal’s health sector remains weak. Interestingly, there will be no lack of expert human resources, know-how and facilities if the government and nongovernment sectors join hands. The challenge, therefore, is to identify ways whereby collaboration between these two sectors is achieved. So far, this has been the stumbling block to efficient service delivery. This is one of the major reasons why surveillance and research remains a challenge in public health. A visionary approach focusing on a revised paradigm of deviating from the traditional approach to surveillance and research at the government level is the need of the hour.
Dixit is the director of research at the Centre for Molecular Dynamics Nepal (CMDN)