Chiring Tamang holds the family’s new baby while his wife Priya looks on. She delivered the girl at home in their village in Nepal’s Sindhupalchowk district in February 2021. Credit: Marty Logan / IPS

By Marty Logan
Kathmandu, Nepal, Jul 21 2021 (IPS)

One year after Nepal’s Ministry of Health (MoH) appealed to international organisations in the country to urgently supply a drug used to stop excessive bleeding after childbirth, a UN agency has delivered $1 million worth of contraceptives to prevent another shortage.

The 1.6 million cycles of oral contraceptive pills and 776,000 units of injectable contraceptives and syringes will prevent roughly 75 000 unintended pregnancies, 22 000 unsafe abortions and 80 maternal deaths, according to the UN Population Fund (UNFPA).

As it was last year at this time, Nepal is at the tail end of a lockdown designed to break a runaway number of Covid-19 cases. Between April and May 2021, daily cases went from 150 to more than 8,000—fuelled by outbreaks in neighbouring India. Intensive care unit beds were unavailable in most hospitals in the capital Kathmandu and some cities on the southern border with India, and patients attached to oxygen tanks were forced into hospital parking lots. Crematoriums had to be expanded to accommodate the dead.

More than 9 500 people have died, and 667 000 had been infected as of 18 July, according to official figures, which are widely considered to underestimate the true impact.

“This support is very timely as Nepal was on the verge of facing a shortage of the injectable contraceptives and oral pills,” said Dr Tara Nath Pokhrel, Director of the Family Welfare Division (FWD) of the MoH. “These supplies will greatly help the federal, provincial and local governments to address the increasing family planning needs during the COVID-19 pandemic,” he added in a UNFPA press release.

Last year’s urgent need was misoprostol, a drug used for medical abortion and to stop excessive bleeding of new mothers, also known as postpartum haemorrhage (PPH). The condition is the leading cause of death among women who give birth at home, a number that skyrocketed after the first case of Covid-19 was detected in January 2020. Deliveries in health facilities fell by more than 50% during the 2020 lockdown, according to The Lancet journal.

The shortage affected only the three-pill package of misoprostol used to prevent PPH, not medical abortion kits. It was December before UNFPA could deliver nearly 500 000 doses to the government, a one-year supply.

Maintaining a steady supply of misoprostol has been a challenge for the Government of Nepal since it took over the programme from a project sponsored by the US government in 2010. Initially, it was able to turn to international partners to source the drug outside of the country, but it soon absorbed the purchasing into its procurement system.

However, in 2014 the government’s corruption agency charged eight ministry of health employees with importing poor quality misoprostol into the country at inflated prices.

Eventually, they were acquitted, along with private-sector suppliers, but the high-profile case put a ‘chill’ on further buying by government officials, a former employee of the project told IPS. “If the person needed to justify (misoprostol procurement) maybe they were thinking, ‘this created lots of tension in the past, so let’s not go for procurement’.

Shortages resulted. Then in 2015, earthquakes rocked Nepal, killing nearly 9,000 people. That disaster was followed by a months-long blockade of road routes from India after Nepal’s politicians approved a controversial new Constitution. Supply chains became twisted and unreliable.

In 2017, following Nepal’s first elections under a federal governance system, some health responsibilities were transferred from central authorities to provincial or local officials, including the purchase and distribution of misoprostol. But local governments appeared unprepared.

“In general, local governments did not have sufficient time and resources to strengthen their procurement capacity on lifesaving maternal and neonatal health commodities,” a spokesperson for UNFPA noted in a statement. “It also depended on how much priority each local government had given to the health sector in general.”

Before Covid-19 hit, the misoprostol programme was in place in 56 of Nepal’s 77 districts, but in January 2020, a survey of 12 of the 56 districts found that none had the drug, says Surya Bhatta, executive director of One Heart Worldwide, an international NGO working in Nepal.

“I think misoprostol is one of the most discussed matters in our office,” he adds. “We talk about this a lot with local leaders, pregnant mothers, female community health volunteers during their monthly meetings, and with service providers in the health facilities. Even for the managers, in larger government forums, there is a lot of discussion happening, but the implementation side has a lot of holes to fill.”

During the 2020 lockdown, misoprostol shortages and PPH deaths of women who gave birth at home generated many headlines. This year there have been no reports of misoprostol shortages, Dr Punya Poudel of the FWD told IPS. However, maternal deaths remained above average for the second year running. From mid-March 2020 to mid-June 2021, there were 258 maternal deaths, compared to 51 in the same period pre-Covid, according to preliminary statistics.

Nepal’s maternal mortality rate of 239 per 100,000 births is equivalent to roughly 1,200 deaths annually.

In the agency’s press release, UNFPA Representative to Nepal Lubna Baqi urged the government and partners to make reproductive health a priority.

“Nepal has continued to struggle with shortages in supplies due to competing priorities and demands, but it is time for the government and development partners to turn their attention to preventing unwanted pregnancies and unsafe abortions by investing in family planning and comprehensive sexuality education.”

Follow @IPSNewsUNBureau
  

Professor Robyn Norton, co-founder and Principal Director of the George Institute for Global Health. Credit: George Institute/IPS

By Neena Bhandari
SYDNEY, Apr 11 2017 (IPS)

Science and medicine were not subjects of dinnertime conversations in the Norton household in Christchurch, New Zealand, but Professor Robyn Norton grew up observing her parents’ commitment to equity and social justice in improving people’s lives. It left an indelible impression on her young mind.

Her high school years coincided with the women’s movement reaching its peak. She got drawn into thinking about addressing women’s health issues and moved to Sydney, Australia to enroll in a Master’s in Public Health.Norton feels its time the global health agenda expands from a predominant focus on women’s reproductive organs to include women’s whole bodies — and the NCDs, such as heart disease, stroke, cancer, chronic respiratory disease and diabetes.

“It was a light bulb moment for me. At that time, women’s reproductive rights and the high rates of maternal and infant mortality were paramount in global and women’s health agendas, which in the next 30 years would result in significant improvements in maternal health. Since then the burden of disease has changed. Today, the single highest cause of death for women in every single country is non-communicable diseases [NCDs] and injuries,” says Professor Norton, who is the co-founder and Principal Director of the George Institute for Global Health, a not-for-profit medical research institute that aims to increase the provision of safe, effective and affordable healthcare worldwide.

In 1999, she co-founded the Institute with Professor Stephen MacMahon for three main reasons. First, a recognition that the global burden of disease had changed, particularly in lower and middle-income countries where NCDs and injuries were emerging as a leading cause of death and disability. Secondly, the expertise to manage the emerging epidemic of NCDs and injuries was not available in these countries. Thirdly, most of the global collaborations between the high income and low income countries were still focused on maternal and child health and under nutrition.

“Global health policymakers needed to acknowledge and address these issues. Our expertise in NCDs and injuries, along with working in low and middle income countries, made it the right time to set up the Institute. The Institute of Health Metrics and Evaluation study, which emphasised the growing importance of NCDs and injuries was release around the same time, providing a significant impetus for us to move forward,” says Norton, who is Professor of Global Health at the University of Oxford and Public Health at the University of Sydney.

The Institute founders chose to partner with the University of Sydney as they felt geographically Sydney would be a natural hub for collaborations, particularly in the Asia-Pacific region. Soon the Institute began collaborative partnerships for research in India.

“We realised that if we were to make a difference in the world, we had to be in a country with a huge population. India also fitted our original idea because it was going through a transition with triple burden of disease and changing demographics. It was starting to see under nutrition co-existing with over nutrition; infectious diseases beginning to co-exist with the growing incidence of cardiovascular diseases and strokes,” explains Norton.

The model of an external organisation partnering with colleagues in India to particularly address NCDs and injuries was a relatively new one for India. The Institute’s biggest challenge was to raise the importance of NCDs and the need to address the burden of these diseases, which account for seven of the top 10 killers of women, and 18 million women around the world die from them each year.

Norton feels its time the global health agenda expands from a predominant focus on women’s reproductive organs to include women’s whole bodies — and the NCDs, such as heart disease, stroke, cancer, chronic respiratory disease and diabetes.

This year marks the 10th anniversary of the George Institute in India. “We have laid the foundation in India for growing the institute with a larger critical mass and greater impact. We would like to produce research that impacts on policy and practice that ultimately leads to reduction in NCDs and injuries and greater access to healthcare for a larger proportion of the populace,” she adds.

Evidence shows that there is a lack of gender sensitive research, data and policy, which is impeding gender equity in health. The Institute has joined a global call for a gendered approach to the collection and utilisation of health data.

Says Norton, “As we deepen our understanding of how the human body works, we know that women and men respond differently to disease and to possible interventions. We are also beginning to understand that health systems respond differently to women and men such that both access to care and the quality of care differs. Yet, far too commonly, there is no delineation of gender in health data, and women are underrepresented in many scientific and clinical studies.”

To improve the health of women and girls in developing countries, Norton says, “We have to look at the leading causes of death and disability and then allocate resources into addressing those issues. We now know that seven out of 10 causes of death and disability for women in India are NCDs. It is critical to begin with making women understand the risk factors of NCDs and how best to prevent and manage those.”

She suggests restructuring the health services and utilising existing workforce by retraining them to integrate NCDs. “India has enormous resource in the cadre of Accredited Social Health Activists [ASHA], who have been focusing on improving the health of women during pregnancy. If we can look at ways of upskilling them then it is going to be incredibly important as part of the process of bringing more women into the health sector.”

The Institute has been researching innovative ways to provide greater access to high quality, low cost essential drugs in developing countries.

“The approach we are taking is three-fold. First, looking at ways to make generic drugs more widely available. Secondly, combining drugs, for example four pills into a single pill, to keep costs low and ensure greater adherence. Thirdly, training non-physician healthcare workers and equipping primary healthcare centres to provide quality care, so people have the confidence in their quality of care and realise that they don’t need to travel miles to a tertiary healthcare centre or pay lots of money to see a specialist for everyday illnesses,” she adds.

The other issue close to her heart has been road traffic injuries. She is the Chair Emeritus of the World Bank and the World Health Organisation supported Road Traffic Injuries Research Network, which is aimed at building research capacity and agendas to address the growing burden of road traffic injuries in low and middle income countries.

“It has been a tendency to think about road traffic injuries as an accident or an act of God rather than a health problem. We have to take the same scientific approach to injury as we have used, for example, to address heart disease. Injuries in many respects fall between the world of infectious diseases and NCDs. Ten percent of people die as a result of injuries worldwide and the burden of injuries mostly rests on adolescents and young pre-middle aged people,” says Norton.

She feels India needs to look at the data and causative factors, monitor it and then intervene, to address the causes of road traffic accidents.

“We know that speeding, drink driving, not wearing helmets, seatbelts and child restraints, are some of the key factors associated with road traffic injuries. If we focus on educating the public on those issues, along with introducing and enforcing legislation, it would make a huge difference in India. We need advocacy and leadership by governments, non-governmental organisations and academics, such as ourselves, to take these issues together,” she adds.

*Neena Bhandari is a Sydney-based journalist and president of the Foreign Correspondents’ Association (Australia and South Pacific).