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

Building on the strengths of country governments, institutions, and local communities while recognizing the importance of the local leadership and ownership have been of central importance to USAID programming. The USAID-funded Data for Impact (D4I) Associate Award of MEASURE Evaluation IV, is one initiative that is a testament to the local capacity strengthening approach that appreciates the existing capacities of local actors and strengths of local systems. Introducing our new blog series that highlights local research produced with support from the D4I project, ‘Going Local: Strengthening Local Capacity in General Local Data to Solve Local FP/RH Development Challenges.’

D4I supports countries that generate strong evidence for program and policy decision making by strengthening individual and organizational capacity to conduct high-quality research. One approach to this objective is to administer a small research grants program and collaborate with local researchers to:

  1. Build and strengthen research capacity among local country organizations and agencies;
  2. Address research gaps in family planning (FP) to inform policy and programmatic decision-making; and
  3. Increase use of research findings by providing an opportunity for the data to be disseminated to and used by local stakeholders and decision makers.

Oftentimes, when articles are published about research they focus on the findings and the potential implications. However, if another country or program aims to implement a similar study, it is also equally important to document how they conducted the research, what was learned and what are the recommendations for others interested in doing similar research in their own context.

With this goal in mind, Knowledge SUCCESS has partnered with the D4I award program for a 4-part blog series featuring the tacit lessons and experiences of family planning and reproductive health (FP/RH) research conducted in four countries:

  • Afghanistan: Analysis of 2018 Afghanistan Household Survey: Understanding Regional Variations in FP Use
  • Bangladesh: Assessing the Readiness of Health Facilities for FP Services in Low-resource Settings: Insights from Nationally Representative Service Provision Assessment Surveys in 10 Countries
  • Nepal: Appraisal of FP Commodities Management during the COVID-19 Crisis in Gandaki Province, Nepal
  • Nigeria: Identifying Innovative Approaches to Increase Domestic Resource Mobilization and Financing Contributions for FP

In each post, Knowledge SUCCESS interviews a member of the research team of each country to highlight how the research addressed gaps in FP knowledge, how the research will contribute to improving FP programming in the country, lessons learned, and their recommendations for others interested in conducting similar research.

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.

A group of three people sits inside an office. The man on the left is dressed in a blue checkered dress shirt and blue pants, and sits on a black leather couch. He is holding a pen and papers on his lap, and is looking up at the camera. The man in the center is wearing a green dress shirt and sits by the door (to the left of the photo) on a metal chair. He is holding a piece of paper in his hands and is looking down at the paper. There is an empty chair next top him, to the right of the photo. The woman on the right is wearing a pink sweatshirt and sits behind a dark wooden desk and is using a laptop. Another laptop sits on the desk with two water bottles, a cell phone, and papers. Photo credit: Nepal D4I Research Team
Credit: Nepal D4I Research Team

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.

Pranab Rajbhandari

Country Manager, Breakthrough ACTION Nepal, and and Regional Knowledge Management Advisor with Knowledge SUCCESS, Johns Hopkins Center for Communications Programs

Pranab Rajbhandari is the Country Manager/Sr. Social Behavior Change (SBC) Advisor for Breakthrough ACTION project in Nepal. He is also the Regional Knowledge Management Advisor-Asia for Knowledge SUCCESS. He is a Social Behavior Change (SBC) practitioner with more than two decades of public health work experience. He has grounded field experience starting as a program officer and has in the past decade led projects and country teams. He has also consulted independently nationally and internationally for USAID, UN, GIZ projects. He holds a Master’s in Public Health (MPH) from Mahidol University, Bangkok, a Master’s (MA) in Sociology from Michigan State University, Michigan and is an Ohio Wesleyan University alumnus.

Santosh Khadka

Public Health Professional, Lecturer, Central Institute of Science and Technology (CiST) College

Mr. Khadka is a Public Health Professional with more than six years of experience in various projects and organizations. He has a Bachelor and Master’s degree in Public Health and has contributed to several publications related to public health issues. He has keen interest and motivation in research, proven capacity to promote nutrition, health, hygiene and sanitation to women and children in Nepal, and has also worked in academia for more than 3 years, gaining expertise in research and teaching. He also has skills in monitoring and evaluation as a program officer and as a consultant in various international donor-funded projects. He is passionate about improving the health and wellbeing of communities and is a dedicated professional who brings a wealth of knowledge and experience to every project he undertakes.