3-pronged strategy to save Nepal from Covid-19

Photo: AMIT MACHAMASI

The deadly COVID-19 surge that has engulfed neighbouring India appears to be spilling over into Nepal. Daily deaths have been exploding. The experience from India shows that fragile health systems can get overwhelmed quickly leading to needless suffering: citizens’ pleas for oxygen, lack of ICU beds and medicines. 

Tackling this threat requires Nepal to adopt a three-pronged approach immediately: 

  1. Promote consistent mask-wearing to contain the spread of disease, especially in rural areas where the healthcare infrastructure is even more deficient.
  2. Prepare a healthcare response in the event of localised surges
  3. Prepare for quick last-mile vaccination delivery, in anticipation of vaccine arrival. 

There are rigorous evidence-based strategies to implement such a response, as Nepal’s other South Asian neighbours are doing.  

On mask-wearing, researchers at Yale University and Stanford University, together with the non-profits Innovations for Poverty Action and GreenVoice ran a large-scale (350,000 adults) randomised controlled trial to identify a precise combination of strategies that are successful in changing mask-wearing norms. Randomised controlled trials are the same techniques used to test vaccine efficacy. When the strategies were jointly implemented, they tripled mask-wearing in rural Bangladesh, and this effect was persistent over 10 weeks of observation, including after the intervention activities ended. 

These four strategies form the NORM model: 

No-Cost masks distributed at scale

Offering Information on mask-wearing

Reinforcement in public places by intercepting non-mask wearers

Modelling and endorsement by trusted leaders  

The researchers tested a dozen other strategies like verbal commitments, text message reminders, social signaling, involving the village police in reinforcement, and even village-level monetary rewards, but none of these were successful in increasing mask-wearing rates any further. The basic NORM model without these unnecessary add-ons is an extremely cost-effective way to reduce transmission risk and save lives. 

Why do these strategies work?  Door-to-door distribution with messaging makes it public knowledge that everyone in the community was given a mask, and neighbors are aware of the public health threat of not wearing one. Public, in-person reinforcement creates some social shame from being confronted by a stranger and creates incentives for people to carry the mask to avoid the awkward confrontation. The endorsement from community leaders makes the program personal and credible. 

The Stanford engineers on the research team produced high-quality reusable, washable masks that can be procured very quickly and cheaply in South Asia. The research team also provides detailed implementation protocols for all project activities, to make each step easily and quickly implementable for governments.    

The results of this study  were so compelling that state governments and groups in India, Pakistan and Bangladesh have quickly moved to implement the NORM model, and it has drawn headlines such as ‘India draws lessons from Bangladesh’s mask study, in a leading newspaper in India. 

In India, SEWA (Self-Employed Women’s Association) is distributing 3-5 million masks and has implemented the model for 1 million people in Gujarat. The Mayor of Dhaka North quickly mobilised a consortium of partners within 48 hours to implement in crowded shopping malls and at transit hubs before the Eid travel rush.  

The commissioner of Lahore and the health minister of Khyber-Pakhtunkhwa Province in Pakistan have mobilised staff and resources to implement after Ramadan. BRAC, the world’s largest non-governmental organisation, is poised to reach 77 million people in Bangladesh with the NORM masking interventions, along with associated healthcare responses and vaccine preparation strategies. 

This model of community-level mask distribution, promotion, and reinforcement can serve as the anchor to cost-effectively deliver the other necessary components of an effective COVID response strategy: empowering community health workers to provide more accurate treatment options to those who fall ill, and undertaking the activities required to overcome vaccine hesitancy and facilitate vaccine registration.  

In both India and Bangladesh, SEWA and BRAC are taking advantage of the economies of scale in mask delivery to also set up Covid care centres to take pressure off hospitals. Distinguishing effective from inaccurate treatment strategies requires medical expertise and clinical experience. We have partnered with the Swasth Alliance convened by a professor at Harvard Medical School to create training manuals on effective Covid treatment plans for community health workers. We have also collected large-sample data to systematically understand the nature of vaccine hesitancy in Nepal, and other low and middle-income countries, to inform the design of vaccine campaigns.   

Quick implementation of the NORM model in Nepal is feasible with decisive leadership and political will, as other South Asian neighbours are doing. Our international research team stands ready to provide any necessary technical support to adapt the model, share all implementation protocols, and monitor results to aid further tinkering and any necessary course-correction, as we have done for our other partners in India, Pakistan, and Bangladesh. 

The team is not looking for any monetary or research rewards. The evidence is convincing that this is a cost-effective way to stem Covid transmission and save lives, and we would therefore like to facilitate implementation by the Nepali government or other local non-government actors.    

Mushfiq Mobarak is Professor of Economics, Yale University, and Neela Saldanha has a PhD in marketing from the Wharton School of the University of Pennsylvania and an MBA from the Indian Institute of Management, Calcutta.

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