When the World Health Organization declared COVID-19 a global pandemic a year ago, many countries imposed stringent measures to limit the virus’s spread. Most of these policy approaches focused narrowly on limiting cases and deaths from COVID-19, without sufficient attention to the broader indirect impacts of the pandemic and various response measures across other health needs. While the evidence of disruptions to essential health services was largely anecdotal to begin with, and its health effects mostly modeled, increasingly detailed evidence is beginning to emerge from countries (see our recent blog looking at claims data from the Philippines).
Over the past year we partnered with researchers in Kenya, the Philippines, South Africa and Uganda to document, from a whole-of-health perspective, what we know about the nature, scale, and scope of the disruptions to essential health services in those countries, and the health effects of such disruptions. Today we release working papers from each country team (the papers are available here: Kenya, the Philippines, South Africa, Uganda). At a virtual event tomorrow we’ll discuss the findings from Kenya and Uganda and their implications for policymaking in the ongoing response and recovery efforts. This event is the first in a series in which we will share our project’s findings, previewed below.
A range of data and analytical approaches
The four working papers we release today provide initial insights on the observed near-term disruptions and indirect health impacts of the pandemic and response measures, relying on a range of approaches and data sources in the months following lockdown measures. Supplementing reviews of the published and grey literature, the teams used a mix of qualitative and quantitative methods. For example, in Kenya and the Philippines the researchers used key informant interviews to identify emerging themes, including how the pandemic response affected the health workforce across settings and programs. The teams in Kenya and Uganda looked at data from the health management information systems; they conducted interrupted time series analysis to test for significant differences between the levels and trends of health service indicators before and after the start of the March 2020 lockdown.
Experiences vary across and within countries
Each of the four countries experienced disruptions—consistent with the pulse surveys conducted by WHO and UNICEF—but the disruptions varied in terms of which services, where, who was affected, and most importantly, the degree and duration of the disruptions. For example, Uganda experienced serious disruptions to both general health service utilization (as measured by outpatient department attendance) and specific services such as immunizations, while in Kenya there is minimal evidence of disruptions to the service indicators analyzed. Worryingly, both countries show significant increasing trends in gender-based violence (see figures below).
Figure 1. Interrupted time series analysis, trend in the number of sexual violence cases per outpatient department visits in Kenya from January 2019 to November 2020
Figure 2. Interrupted time series analysis, trend in the number of sexual violence cases in Uganda from October 2019 to June 2020
In the Philippines, key informant interviews reveal the multiple ways in which COVID-19 disrupted the health system by crowding out, in particular, the supply of health workers; in short, long-standing symptoms of inequitable resource allocation were exacerbated. As one rural health physician explained,
“patient access to healthcare was already very poor even before enhanced community quarantine…the indigenous peoples have more difficulty accessing care since their needs have never been met even before COVID-19, so they were already at a bigger disadvantage.”
In much of South Africa, the stringent lockdown implemented by the government was little or no better than measures already in place for controlling transmission of COVID-19 (see also this blog). And yet, evidence of the collateral health damage of these measures is mounting.
Making sense of the evidence amidst various challenges
The work for these papers was conducted between August and November. In normal circumstances, routine lags between when research is carried out and when it is published may not matter—but conducting research during a pandemic, in a continuously evolving epidemiological and policy context, imposes limitations. It will take time to fully unpack and understand the role of various factors at play that affect access and utilization, with corresponding effects on health outcomes in the near and longer term.
Nevertheless, we believe this research provides important insights that can inform how countries approach the use of restrictions in the face of new outbreaks, and also as the COVID-19 situation continues to evolve—with attention to optimal mitigations strategies as countries work toward vaccinating their people. Furthermore, we plan to build on these studies as more and better data become available, and as public health responses continue until the pandemic is brought under control.
Importantly, a major challenge for understanding the extent of the indirect health impact is another type of lag: a lag in the reporting of the health effects caused by the disruptions to essential health services. Fortunately, urgent care appears to have been spared the deep and long-lasting disruptions seen by elective and preventive care. For the latter care, increased morbidity and mortality arising from missed vaccinations and screening at the primary level, and delayed diagnoses of chronic conditions, are likely to be reported in months or even years to come. Similarly, the health consequences of the economic impact of COVID-19 will occur in the future.
We therefore encourage more efforts to model these impacts on disease and death—with ongoing tracking to see what manifests over time—to provide a more complete picture of the pandemic’s health effects. Data emerging from countries that implemented moderate restrictions such as Kenya (curfews and movement restrictions only in hotspots) are only seeing minimal disruptions to many essential health services in the short term, which suggest the possibility that long-term impacts could be alleviated. And even in countries where stronger restrictions were implemented, and services such as vaccinations were seriously disrupted, good data systems can make it possible to track who was missed and target catch-up services to mitigate serious health consequences, as was the case in Pakistan, where electronic immunization records enabled reaching children who missed routine immunizations. Learning from innovations in service delivery or implementation of dedicated policies (e.g., vaccination catch-up campaigns, telemedicine, or changes in medication dispensary practices) that helped countries alleviate the impact of COVID-19 on essential services should be the focus of future research.
We hope the findings from these working papers will contribute to global knowledge about the ongoing and lingering effects of the pandemic, and ways to mitigate these effects. It is not too late for action.
Armed with the kind of evidence in these papers, national governments and global partners must focus their efforts on the most affected, most cost-effective services, and ensure that ongoing response and recovery activities include minimizing the impacts of foregone essential health services.
Key recommendations from this body of research are:
There is a continued need for governments and their global health partners to invest in generating local data and evidence, not just modeled effects, that can build our understanding of what’s happening on the ground. This includes facility-level data but also collecting information at the community level, leveraging opportunities through community health workers and other methods.
Researchers should adopt a whole-of-health perspective, and a mixed methods approach to better understand not just what the effects are to utilization of a range of essential health services, but why and how we might see different patterns emerge.
Countries and donor partners must invest in stronger routine systems to collect, manage, and analyze health data. These health information systems are always critical, but in a time of crisis, can support countries in producing timely estimates of disruptions and indirect health impacts to tailor response measures and recovery efforts accordingly.
We encourage governments and their global health partners to build on this work to further explore the most successful adaptations and needed catchup activities to mitigate harms from disruptions—and what additional resources may be needed to resume progress on achieving various global health goals.