Essential Health Services

In 2020, Exemplars in Global Health launched a series of short- and long-term research projects with three main goals:

• To understand the impact of the COVID-19 pandemic in countries and communities around the world
• To inform COVID-response strategies going forward
• To offer lessons that can be applied to future pandemics

This short-term research project aimed to identify and document the policies, approaches, and strategies that four low- and middle-income countries in sub-Saharan Africa—the Democratic Republic of the Congo, Nigeria, Senegal, and Uganda—have adopted to support the maintenance of EHS during the COVID-19 pandemic. The research has been led by partners at the Makerere University School of Public Health in collaboration with the University of Kinshasa, Université Cheikh Anta Diop, and the University of Ibadan and was supported and funded by the Bill & Melinda Gates Foundation Africa Team and by Gates Ventures. Similar research is underway in Latin America and Asia; their findings will be published soon.

What Are Essential Health Services?

There is no single worldwide definition of “essential health services.” Each country’s list of EHS differs based on disease burden and priorities, as well as the cost and feasibility of implementing and delivering the services. In general, EHS are the services health systems prioritize to prevent or treat disease or disability. They include services related to sexual and reproductive health; maternal and newborn health; child health; immunization; nutrition; communicable diseases like tuberculosis, HIV, malaria, and diarrhea; neglected tropical diseases; noncommunicable diseases like diabetes, cardiovascular disease, and cancer; emergency and trauma; and mental health. These are reflected in a common set of indicators that are sometimes used to measure access to and provision of EHS within and between countries.

Although EHS vary from country to country, they can be quantified. For instance, Sustainable Development Goal 3, to ensure healthy lives and promote well-being for all at all ages, is measured in part by coverage of EHS. To measure EHS coverage at the global level, researchers have grouped the services into four broad categories and identified tracer indicators for each one (see table below).

Topics and Indicators to Measure Sustainable Development Goal 3.8.1: Coverage of Essential Health Services

How Are Essential Health Services Measured on a Global Level?

Researchers measure EHS coverage at the global level using a composite of EHS-related indicators that constitute a universal health care effective coverage index. In addition to the indicators that the Sustainable Development Goals use, this expanded list includes maternal and infant mortality rates, treatment for several types of cancer, treatment for circulatory and metabolic diseases, and emergency medical treatment. In 2019, the universal health care effective coverage index tended to be lower in sub-Saharan Africa compared with other parts of the world like the Americas and Europe. (See figure below.)

These estimates show the baseline before the pandemic; they do not measure rapid or immediate changes in universal health care or EHS delivery during the pandemic.

What Have Been the Impacts of COVID-19 on Essential Health Services?

The key to a resilient health system during a crisis is the baseline investment that allows it to exhibit adoptive, absorptive, and transformative capacities to maintain access to care. Without this investment, public health emergencies such as the COVID-19 pandemic force health systems to divert human, financial, and material resources to crisis response. This can severely curtail access to EHS, leading to poor health outcomes in addition to the morbidity and mortality associated with the emergency itself.

For example:

• During the 2013–2016 West African Ebola outbreak, use of health services decreased significantly and malaria morbidity and mortality increased.¹
• During the influenza outbreak in Israel in 2000, there was a significant drop in the number of physician visits as well as visits to emergency departments.²

The COVID-19 pandemic disrupted EHS delivery in many countries, especially between March and May 2020. A World Health Organization survey conducted between January and March 2021 found that 94 percent of the 135 participating countries had a disruption in at least one essential health service, and one-third of all countries had disruptions in more than half of their EHS.³ In part, this is because the pandemic strained health care system resources, requiring many health care providers to shift finances, personal protective equipment, and other commodities and health care staff to care for people sick with COVID-19. Further, people who needed medical care were reluctant or unable to seek care. Evidence suggests that this combination of supply and demand constraints have contributed to substantial reductions in the delivery of EHS during the pandemic.

• COVID-19-related decreases in routine childhood immunizations like diphtheria, tetanus, pertussis and measles left between 3 and 8 million additional children unprotected from those diseases in 2020. Shortfalls in immunization coverage may persist for years, even with catch-up campaigns.^4, 5
• Outpatient visits decreased overall, potentially affecting tens of millions of people in sub-Saharan Africa who delayed seeking treatment (most commonly diagnostics and prescriptions).⁷ People with chronic illnesses like HIV infection, diabetes, or hypertension may have been particularly impacted.
• Up to 40 percent of people in Africa lived with someone who needed medical care but skipped or delayed it in the first year of the pandemic. Delayed care seeking could lead to people being sicker than they would have been had they sought treatment earlier and to more advanced illnesses that are more challenging and expensive to treat. For example, failures in public health surveillance for detection of early-stage cancer could lead to poorer prognoses. Similarly, the discontinuation of blood pressure screening could result in higher risk of ischemic heart disease.
• About one in five people reported that they missed medical care because of disruptions in health facility services, and one in four reported missing medical care because they were worried about catching COVID-19.⁶ Delays in elective care may cause significant demand for care as health systems return to normal, which systems do not have the resources to meet.

How Were Impacts of the Pandemic on Essential Health Services Measured?

Our assessment of the performance and maintenance of EHS delivery in the four countries involved quantitative and qualitative analysis of secondary data, including:

• Review of scientific peer-reviewed and gray literature
• Selection of health service maintenance indicators
• Analysis of health services delivery data
• Analysis of the processes of health services maintenance, including policies and strategies implemented
• Analysis, synthesis, and documentation of challenges and lessons learned to identify best practices

In addition, we collected primary data through key informant interviews at the national, subnational, and community levels to gain insight into barriers and interventions across health system components, like governance, service delivery, and personnel.

Continuation of health service delivery during the COVID-19 pandemic is a measure of resilience and a demonstration of the absorptive, adoptive, and transformative capacities of a health system. Absorptive capacity refers to a health system’s ability to maintain the quantity and quality of health services equitably during a health crisis; it can be evaluated by assessing the baseline capacities of the countries across health system components. Adaptive capacity refers to a health system’s ability to maintain service delivery with fewer or different resources.Transformative capacity refers to a health system’s ability to adjust its functions and structure when responding to a crisis. These capacities can be assessed by documenting countries’ innovations and interventions to continue health services during the pandemic.

We adapted our analytical framework from the adaptive epidemic response framework,⁸ dividing the process of maintaining health services during the COVID-19 pandemic into four stages.

• First Stage: Outbreak Analysis. This examines the introduction and progression of the COVID-19 pandemic in the country under study. This includes examination of the cumulative confirmed cases per million people as well as information about the virus strain circulating in that country.
• Second Stage: Context Analysis. This examines the components of the health system, as described in the health systems dynamics framework,⁹ which indicates that baseline investments in a system determine the extent to which that system is able to maintain services when faced with shocks.
• Third Stage: Intervention and Process Analysis. Intervention analysis documents the interventions to ensure continuity of health services (such as provision of personal protective equipment to health workers) and the public health and social interventions implemented in response to COVID-19 at national, subnational, and community levels.
• Fourth Stage: Performance Analysis. This is an assessment of the extent to which interventions achieve their intended objective—maintaining the delivery of critical health services. We obtained quantitative information on performance from key informants at various levels of the health system.

Health Systems Building Blocks Used to Assess Challenges and Interventions to Maintain Essential Health Services

We used these building blocks of health systems to assess the challenges and interventions associated with maintaining essential health services

Key Takeaways

During public health emergencies, governments and health systems should devote resources and attention to maintaining and extending EHS so that they can continue to improve (or at least not regress) on key indicators of population health. In times of public health emergencies, such as COVID-19, governments and health systems should act to promote the delivery and maintenance of EHS.

OUR PARTNERS

This research was conducted by the Makerere University School of Public Health, in partnership with the University of Kinshasa in the Democratic Republic of the Congo, Université Cheikh Anta Diop in Dakar, Senegal, and the University of Ibadan in Nigeria. The four countries in this study were selected for the variability in their COVID-19 response and outcomes, their experience in managing past epidemics of global concern, the strong existing partnerships between in-country research institutions and the countries’ ministries of health to facilitate access to data and enable the translation of findings to action, and the representation of Francophone and Anglophone countries to enhance Africa-based research collaboration.