Using thematic network analysis  the findings from this qualitative research were categorized into four interlinked global themes. The results in this section are presented under the four global themes: i) Community and stakeholders’ perceptions towards COVID-19; ii) Impact of lockdown on health services delivery; iii) Community perceptions and experiences of health services during COVID-19; and, iv) COVID-19: testing, isolation and quarantine services.
Community and stakeholders’ perceptions towards COVID-19
Most participants in this study expressed their fear and worry about the outbreak of COVID-19 due to an increasing number of cases and deaths related to COVID-19 globally and in Nepal. In villages sharing a porous border with India, community members seem to be scared of cases and the mortality in neighboring villages across the border and were concerned about how the mobile trade across the border could bring diseases to their villages. Nonetheless, over the period, the fear seems to decrease, particularly due to the low mortality rate.
People were very afraid at the beginning as the cases were increasing rapidly. At present people's fear has been declining since the death rate is low but this doesn’t mean that we are safe in the coming days. (Participant-19, 40 years, male, Sarlahi district)
While few participants seem to be complacent due to low perceptions of mortality so far, other respondents, especially those who were at the urban hotspots seem to be worried because of the increasing infection, and associated morbidity and mortality among their acquaintances, relatives, family members, and leaders.
Birjung city is a major entry point to Nepal from India. We are in the red zone for COVID-19. Till date, about 21 people have lost their lives in our community due to COVID-19. People are struggling to get health services. COVID-19 cases are both in hospitals and in the community. People are also staying in isolation. Many people are tested positive with COVID-19. Even community leaders and political leaders are infected here in Birjung. Local leaders including the Mayor of all municipalities in our district are infected with COVID-19. The situation is very fearful. (Participant 24, 47 years Male, Parsa district)
The increasing spread of COVID-19 infection among community members was reflected by most of the respondents to be due to lack of accurate information about the disease, stigma attached to it which may have prompted them to conceal the disease. Concealment inevitably led to a lack of early health-seeking and thus transmission among the family members and neighbors. Fear of discrimination and ostracization from the community were some of the major issues among community members.
You know it (COVID-19) is contagious and at the beginning, people were not aware of how to protect from this disease. One of my relative was infected with COVID-19, he was very afraid. He thought that if he reveals the disease he will be put into the hospital and may die without the support from his family. Later all 8 members from his family were infected, one of them being 8 months pregnant. You know why this happened; people have no adequate understanding of this disease. In the beginning, the only slogan we heard was - wash your hands and stay at home - but they did not know why? Slowly people have started to understand the meaning. Still, not all people know what this pandemic is about and what to follow to stop the transmission. People do not understand until he/she gets the disease. Ignorance is a major reason for the transmission of this disease. People have a stigma towards this disease. People have a discriminatory attitude and talk negatively about those suffering from COVID, even after they have recovered. In an apartment, if some family is infected with COVID, they were pressured to get out of the colony. People have created such feelings that if someone is infected with COVID, they are treated as criminals and this is putting mental pressure on such people. (Participant 25, 45 Female, Parsa district)
In terms of abiding by public health measures, there were clear differences between the socio-demographic characteristics of the participants. For instance, community members from urban cities, with higher education and from high socio-economic status seem to be well informed and thus followed the public health measures such as social distancing, wearing facemasks, and maintaining hygiene.
People who are educated and handle technology, especially social media, they are getting updated information about COVID-19 every minute. They know what is happing around the world. Initially, after lockdown, people took precautionary measures but now when I go to the market, I see poor people are not following any preventive measures. I saw people who came to the hospital from rural areas were not wearing masks and not maintaining social distance while those from the urban settlement were wearing masks and were conscious about maintaining social distancing. This may be because rural people do not have access to masks, or this might be due to a lack of awareness and information about COVID. (Participant 27, 40 years female, Parsa district)
Impact of COVID-19 and lockdown on health services delivery
Most of the participants in this research agreed that the lockdown measures had a visible impact on all aspects of health services delivery. Although their perceptions about the level of disruptions varied, most reported that immunization, maternity services, and supply of medicine were the worst affected areas of health care delivery.
People suffered a lot during this lockdown period. No services were available for a few months, even general health services were not available. Child and maternal health services were totally affected at the community health post. Child immunization was halted for months. Later, the local health facility started to provide immunization services, but most parents did not want to go to the health facility for their child’s immunization because of the fear of getting COVID. Older adults who were suffering from non-communicable diseases like diabetes, hypertension, had to go without medicine for several weeks and it was a very terrible situation. We could not even get iron tablets for pregnant women during the lockdown. Local private pharmacies remained closed for 3–4 months, they did not even care for any emergency situation, even if people were dying or suffering from complications of long-term illness. We had to go to the city for medicines which is far from our village. (Participant 11, 45 years Female, Parsa district)
The disruption in health services was echoed by the local health workers who reflected on how the COVID-19 changed their clinical practice and the quality of services to patients. As a result of the disruption in health services, community based female community health volunteers received increased consultation and were burdened to provide services to patients with their limited resources and capacities.
Health services were interrupted for few months…….For the first three months, we did not have PPE, even we did not have gloves and masks, as a result, we [health workers] stopped providing maternal and other general health services, although the health post was open……We just provided medicine through a window by listening to their signs/symptoms. Patients were referred to primary health care centers near to our community and most of the cases were also referred to hospitals at the district headquarter which is 20 kilometers [away] from our village…………… (Participant 10, 24 years Female, Parsa district)
We were told by health workers to inform community people not to visit health facilities as health service providers would not respond to them at the health facility. We took life risks to serve people from our community during this COVID crisis though we are not trained to deal with such health issues. (Participant 1, 47 years Female, Saptari district)
Disruption in health services was echoed across by other stakeholders such as social workers who particularly expressed concerns around poor arrangements in the hospital for COVID-19 patients, the reluctance of doctors to attend patients, lack of ambulance services amidst the rising cases of COVID-19 and deaths. Nonetheless, few community leaders seem to defend how health services were continuously provided.
The lack of coordination and pre-emptive preparation among the three tiers of government was recognized as one of the main reasons why there was a disruption in health services. In addition to the poor coordination and preparedness, the spread of infection among health workers further jeopardized the capacity to respond to COVID-19 cases among the population.
We have three levels of government but there is no adequate coordination amongst them. When COVID cases started to increase, they closed local hospitals and had no plans for COVID-19 hospital, as a result, existing health facilities struggled to meet the needs and therefore it has created serious disruptions in general health services. We had 39 health workers who were tested positive in our government hospital. After that health workers are not admitting any patients. The number of healthcare workers has started to decrease due to COVID-19 infection among health workers and this has directly affected the services in our hospital. (Participant 27, 40 years Female, Parsa district)
Community perceptions and experiences of health services during COVID-19
Community members perceived that the risk of transmission of infection was high at the hospitals and thus expressed concerns visiting health facilities. These concerns led some of these participants reluctant to seek health care in time.
People are very worried and are not willing to go to health facilities even if they have general health problems. They used to contact health personnel through phone calls, but they were not willing to visit any health centers due to fear of getting COVID-19 from health workers. (Participant 1, 47 years Female)
Fear of transmission was pervasive among health workers as well. Participants perceived the reluctance of health care workers in providing health care due to fear of transmission of COVID-19.
Health workers were very afraid to provide services at the local health facility. They did not touch or examine the patient properly and did not give enough time for consultation with the patient. They just used to give medicine by maintaining the distance. (Participant 22, 32 years Female, Sarlahi district)
When participants had to seek health care for severe cases, the other major barriers were the availability of transportation means, particularly during the lockdown. While few were able to connect to the health care workers remotely through mobile phones, much of the health services were severely hindered by a lack of transportation services. Availability of ambulance services was also constrained during this lockdown and few participants shared their narrative on how some of them struggled to get an ambulance service.
The transportation facilities are hugely affected, as a result, people have problems in reaching health facilities and receiving health services in time. One of my neighbors had a leg fracture and he could not reach the hospital due to a lack of transportation services. One pregnant woman in my village had a problem during this lockdown, their families were very worried, as they could not reach the health facility due to lack of transportation. (Participant 14, 45 years Female, Siraha district)
One other alternative for participants was to seek health care at private hospitals at the expense of higher costs. Participants claimed that people had to seek private health care services as an alternative option, which was more expensive. Inevitably, people from poor and disadvantaged communities were worst affected. Despite these pre-existing barriers, private hospitals were more restrictive in treating patients and often demanded COVID tests (which was done in only a few designated COVID-19 hospitals/laboratories) before they could admit the patients. Although tests are justifiable and are critical before initiating the treatment, tests as a pre-requisite for health care were also perceived as a deterrent by participants.
Private hospitals are very careless as they are not responding to support during this pandemic situation. The community has pressured the health chief of major hospitals in the city, now they have slowly started to respond to patients. Even if people are admitted they have to test for COVID first. People have perceptions that without the COVID-19 test, none of the hospitals will admit patients. So, many people are not going to hospitals even if they need health services. (Participant 24, 47 years Male, Parsa district)
Even if community members were able to get the test done, the quality of care remained very poor, and sometimes, family members had to visit multiple hospitals to admit patients for treatment. As a result, some of these patients lost their lives.
COVID-19: testing, isolation, and quarantine services
Participants in this research claimed that the government has not planned well for the COVID-19 pandemic, which has affected the overall health services delivery for the local population. The establishment of COVID-dedicated hospitals without allocating health services for non-COVID illnesses was particularly seen to be problematic. This led patients to seek somewhere else from their usual health service centers.
At the beginning of the outbreak, our district hospital, which is the only major hospital in this district, was made a dedicated isolation center for COVID-19. This has hampered all the secondary level of health care services for thousands of people who used to visit this facility as a referral center from different health posts within the districts. Now, we need to go to the nearby city general health services. (Participant 37, 36 years female, Bara district)
While COVID-19 designated hospitals already affected the non-COVID health services, COVID related health services were inefficient. For instance, the availability of COVID-19 testing was limited including the high costs and long time for the test results.
People are getting COVID-19 test reports in more than a week. The government has said people can go to a private hospital for a COVID test by paying 5500 (NRS) but how can general people pay this amount. (Participant 28, 61 years Male, Dhanusha district)
Participants reported that the isolation and quarantine services were not adequate to provide effective care for COVID-19 patients, which was additionally complicated by the politicization of the services. Specifically, political affiliation and people with power and privilege exercised the health facilities, leaving the poor and vulnerable without services.
… at the quarantine center, we do not have a good facility. The center is overcrowded, patients are given only two meals per day and there is no separate toilet facility for males and females. People are afraid to stay at the quarantine center and even if they have symptoms, they try to hide it. If someone is close to the local leaders or affiliated with the leader’s party then he/she can have all services keeping them on high priority. For normal people, it is really very difficult to survive there. Sometimes leaders directly say that those who have not voted for them will not get these services. We feel discriminated by our local leaders based on caste and votes. Dalits and other castes (not caste of local leaders) are left behind and nobody cares about that. We are victims of these discrimination practices at quarantine and health facilities here within our own community. (Participant 35, 38 years Female, Rautahat district)
Testing, isolation, and quarantine services were also affected by the lack of coordination between the three tiers of governance with poor accountability and responsibilities by each one of these tiers. Task shifting and blame-game were found prominent among these authorities when discussed the responsibilities; and cited the constraints in the management of COVID-19 testing and management.
Our three tiers of government are totally confused about their roles and responsibilities. Suppose if a person is tested positive with COVID-19, there is no clear understanding of where to seek health services. Sometimes local authorities’ say it is not their responsibility, the again provincial government says it is not their duty and at the end, patients have to lose because of their conflicts of power clash and ambiguity in policies. Whose responsibility is testing and tracing, public health office says it’s not my duty, the local authority says it’s not my duty, the hospital says it’s not my duty so whose duty is this? (Participant 24, 47 years Male, Parsa district)