Impacts of the COVID-19 Pandemic on Family Planning Services in Gandaki Province, Nepal

The Government of Nepal (GON) prioritizes family planning (FP) and has made it a prominent theme in Nepal’s strategies and plans. However, the global COVID-19 pandemic led to nationwide lockdowns for several months in 2020 leading to interrupted public health services, including FP services.

A team of four faculty – Isha Karmacharya (lead), Santosh Khadka (co-lead), Laxmi Adhikari, and Maheswor Kafle – from the Central Institute of Science and Technology (CiST) College wanted to study the impact the COVID-19 pandemic had on FP commodities procurement, supply chain, and stock management in Gandaki province to determine if there were any variations and effect on FP service delivery. One of the team members from Knowledge SUCCESS, Pranab Rajbhandari, talked with the study’s Co-Principal Investigator, Mr. Santosh Khadka, to learn about their experiences and learning of designing and implementing this study.

Pranab: Why did you choose to appraise FP commodity supply during a crisis? How did you come up with the research objectives?

Santosh: We heard about increased births and difficult service access issues due to COVID-19 lockdowns which informed our research focus. We decided that the main objective would be to study the impact of the COVID-19 crisis on FP services. During COVID-19, all resources were diverted to tackle COVID-19 challenges. We were interested to see how the crisis might have affected FP commodity supplies and services, and the impact of the crisis on a national priority program such as FP due to the diversion of resources. What kind of challenges came up? How did the different levels of government (local, central) handle the crisis along with providing regular services? We were especially interested in the procurement, service delivery, stock, and supply variations. We were interested to find out if new strategies and interventions were put in place, and used.

Pranab: Why did you focus on only one of the seven provinces in Nepal?

Santosh: The study location was selected based on multiple criteria: geographic diversity and how to be inclusive–the province has mountain, hill, and terai (lowland plains) districts within it. We also considered contraceptive prevalence rate (CPR) and other FP indicators, as well as accessibility for the research team from Kathmandu. Gandaki province, from among the seven provinces in Nepal, had the worst FP indicators. It had a lower CPR compared to other provinces.

Pranab: Who did your team consult with in this study process?

Santosh: We had two main sources of support: a local advisory group and the D4I team. The local advisory group was made up of former USAID staff and those with USAID-related experience (Hare Ram Bhattarai – CiST College Advisor, Dr. Karuna Laxmi Shakya, Naveen Shrestha – CiST College Principal). The local advisory group guided the study team extensively throughout the study process. They provided technical support and in-depth feedback, helped review tools, and training preparation. They were a very integral part of the process and consulted extensively. We proceeded only after getting the advisory group’s guidance as we proceeded with key parts of the study.

Bridgit Adamou, Family Planning Technical Advisor at D4I, was there from the start to finish. She provided extensive support and guidance to us. She was our focal person, and we reported to her. She also consulted with her team and higher-ups for any support we needed. She was always available to clear any confusion we had and was very supportive throughout. She was the main person providing technical support to us.

Pranab: How did you technically prepare to assess the commodity supply?

Santosh: We first conducted a literature review which helped us to draft research questions and tools to collect information. We designed both quantitative and qualitative tools. The advisory group reviewed research questions and tools and helped revise them. After this review and revision, Bridgit then further reviewed and helped refine these documents.

We also visited the selected study sites (i.e., three districts representing the mountain, hill, and terai ecological zones) for preliminary studies and to get local authorization for the study. Ethical approval was also received for the study prior to data collection.

Pranab: How did you collect data?

Santosh: The data collectors, made up of CiST college recent graduates and students, were trained at the college venue. The two-day orientation included practice sessions and project orientation. We utilized breaks between academic semesters for data collection so that we, full-time CiST college faculty with teaching responsibilities, could provide oversight and technical support directly to the data collectors at the field level. This was crucial for data quality assurance and proper time management.

We were interested in comparing the FP situation before and after the COVID-19 lockdowns. We set our study period markers as the three months before the long lockdown and three months after lockdown. Comparative studies help look at the impact, and in our case the challenges and changes in FP services due to COVID-19’s impact. We compared time periods and studied all levels from the grassroots, provincial, and federal levels.

We collected secondary data and conducted key informant interviews (KII) at the federal, provincial, district, and municipality levels. We faced difficulties gathering secondary data related to stocks and supplies as online reporting using the electronic Logistics Management Information System (eLMIS) had not been put into practice in the study locations. This required travel directly to the sources/stores to collect information by looking at old files. USAID project supported staff seconded in government offices helped us extensively to get access to secondary data.

We conducted seventeen KIIs: 1 at the Federal level, 1 at the provincial level, and 15 at the districts. The study team started their KIIs with the Family Welfare Division, Department of Health Services at the federal level, proceeded to the provincial level and then to the district and local levels. We included relevant focal persons at the federal and provincial level, district FP supervisors, storekeepers, municipality health coordinators, and ward-level female community health volunteers (FCHV).

Pranab: Why did you decide to use both quantitative and qualitative techniques?

Santosh: All of us had quantitative research skills. We wanted to do a mixed method study to learn and experience qualitative techniques. The use of qualitative research methods and processes (such as KIIs) was a major learning for us. The qualitative approach helped us triangulate findings and made the results stronger by verifying information found in one source with information found in other sources across the health system. We cross verified the secondary data across the levels for data validation (i.e., data provided by the federal level was cross-checked with the provincial level; provincial-level data with district; the district-level data with the municipalities, and then FCHVs at the local levels). The in-depth experiences and explanations shared during the qualitative research helped with the validation of the results.

Pranab: How did you clean, analyze, and review findings? What skills were required?

Santosh: Only frequency and percentages could be calculated due to the dearth of information. It would have been better if we had been able to use more complex statistical methods. If we had designed socio-demographic information collection into the tools used, it might have helped us to do these analyses. There were time constraints too. More complex analysis might have been possible with better tool design. This was a major learning for us.

Pranab: What were your major learnings during this D4I small grants study process?

Santosh: We had numerous learnings from the whole process which strengthened our study team’s capacity.

Process learning: We were new to the USAID grant management process and learned a lot about the procedures. I learn a lot about leading a study. I have gained skills in organizing meetings, managing meetings, meeting deadlines, and preparing reports.

Time management: We had to balance our teaching responsibilities and the study. We could not fully focus on the project. The training preparation for the data collectors took time and the field data collection had to be postponed. Additionally, the Advisory Group members’ travel and busy schedules led to delays. Even though we had made a detailed plan for the year-long project, it still required a three month no-cost extension. As of publication of this post, the final dissemination is not yet complete. We now see the value of adding part-time faculty during similar studies so more time can be devoted to research. Having experienced this process, we are also more confident about completing studies on time in the future.

Managing and planning for external factors: We faced delays due to external factors such as the government employees who were the study’s information sources being busy managing the COVID-19 pandemic. Missing online secondary information required on-site visits for data collection and also added to the delays. Fear about the infectious nature of COVID-19 led to our teams’ anxiety about locals’ possible reaction to the study team visits for data collection. We were anxious about personal risks related to the pandemic. We managed these fears by following recommended precautions– masking, maintaining distance, and getting vaccinated as they became available.

Writing skills: We went through a lengthy process to get our proposal accepted during the grant preparation process. It went through ten plus rounds of grant submission and refinements. It took a lot of effort, but the process refined our plans and approaches. Similarly, each step of the study implementation process involved drafts, extensive reviews, and refinements before final approval.

Technical Analysis Skills: We learned about planning, implementing, and analyzing results using qualitative research methods. We became familiar with the NVivo qualitative analysis software. We are now confident in our skills to conduct mixed method studies or qualitative studies. Anticipating analysis challenges and pre-planning for these during the tool design phase was another learning.

Pranab: What were your major findings? How do you hope these research findings will be used?

Santosh: Our main learning was that the service seekers modify their behavior during emergencies. They relied more on short-term FP methods which were more readily available locally. Those using long-term methods shifted to short-term methods. The service seekers and the providers both tried to reduce close human interaction due to the highly infectious nature of COVID-19 transmission. The ongoing lockdowns made travel difficult to get to the health facilities to access long-term FP services.

We have prepared a policy brief. We are waiting for the time availability of the government officials to plan a dissemination event for wider learning and sharing. We will prepare the document for publication in a peer-reviewed journal once the dissemination event is over. We hope this small research of ours will make a difference.

Pranab: Anything else you would like to share with us?

Santosh: These grants should be available for individuals or non-institutions too. Students would especially benefit from small grants like these to strengthen their research capacity.

To explore more resources related to this interview series, don’t miss Data for Impact (D4I)’s FP insight collection, with further reading and materials shared by their staff in Afghanistan, Bangladesh, Nepal, Nigeria, and the U.S.