Introduction
Public health emergencies like the COVID-19 pandemic cause direct morbidity and mortality. They also disrupt essential health services (EHS) in ways that can undermine the strength of existing health systems, hinder their performance, and block progress toward health goals. For instance, fears of contracting COVID-19 and transportation difficulties due to mobility restrictions have caused people to avoid health care facilities, delaying the delivery of routine EHS. Health workers have been reassigned to help manage care for COVID-19 patients, disrupting their ability to perform routine health care and health information system management. Shortages of essential medicines have also caused delays in treatment or prevention.
This project focused on the maintenance of EHS in four countries in sub-Saharan Africa: the Democratic Republic of the Congo (DRC), Nigeria, Senegal, and Uganda. 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. 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. However, these challenges have been observed worldwide, as health care systems everywhere struggle to meet the acute service needs of the COVID-19 pandemic.
This project had three main goals:
- To identify the strategies adopted to maintain EHS during the COVID-19 pandemic
- To provide qualitative insight into the efficacy of those strategies
- To guide future resource allocation, balancing direct emergency response with the maintenance of EHS
How Well Were Essential Health Services Provided Pre-Pandemic?
Our assessment of the four countries’ pre-pandemic health systems showed that they were not providing universal access to EHS even before the COVID-19 pandemic further stretched their ability to do so (Table Below ). In each country, health system indicators such as the number of physicians per capita and the total health expenditure per capita were below the World Health Organization’s (WHO’s) recommendations. Indicators such as life expectancy at birth and coverage of the third dose of the diphtheria, tetanus, pertussis (DTP) vaccine were also poor.
Pre-pandemic indicators for health care performance
Universal health care effective coverage scores
What Has Been the Pandemic Experience in Case Countries?
On February 27, 2020, Nigeria was one of the first countries in Africa to report its first case of COVID-19. Just days later, on March 2, Senegal reported its first case in a traveler arriving from France. Uganda and the DRC identified their first cases later in March.
Like many other African countries, these four experienced a relatively mild first wave of the pandemic (through July 2020). A second wave of cases and deaths followed between November 2020 and February 2021, except in the DRC where the reported burden remained low. Until June 2021, Senegal had the most cases and deaths per capita among the countries profiled; that month, Uganda began suffering a massive wave of infections and deaths.
Compared with other parts of the world, COVID-19 has not been as severe in the WHO Africa Region. Although it is home to about 14 percent of the world’s population, the region has accounted for only about 2 percent of reported cases and deaths. (It is worthy to note that reporting gaps exist in cases and deaths across the world, and they are particularly acute in sub-Saharan Africa due to limited existing infectious disease and mortality surveillance systems.)
Test positivity, or the proportion of COVID-19 tests that are positive, can be used as a marker to indicate how widespread infection is and whether sufficient testing is being done. WHO suggests that a positivity rate of less than 5 percent is one indicator that a country has the spread of COVID-19 under control. At certain points in time, especially during the second wave between November 2020 and February 2021, all four countries’ test-positivity rates were greater than 10 percent, much higher than the WHO benchmark of 5 percent,1 suggesting a substantial undetected burden of COVID-19.
In Europe and North America, most adults who were willing and able to receive a COVID-19 vaccine have already done so. Now the world is focusing its attention on disparities in vaccine access. Only about 2.7 percent of people in Africa had received at least one dose of the COVID-19 vaccine as of July 1, 2021, compared with more than 40.0 percent in North America and Europe.
Summary of reported cases and deaths due to COVID-19 through July 1, 2021
| Location | Reported Cases |
Reported Deaths |
Population (in millions) | Cases per millions | Deaths per millions |
|---|---|---|---|---|---|
|
World* |
182,600,000 | 3,960,000 | 7,737.5 |
23,400 | 507.7 |
|
Africa* |
5,550,000 | 143,700 |
1,099.6 | 4,140 | 107.2 |
|
DRC |
41,400 | 933 | 87.7 | 470 | 10.6 |
|
Nigeria |
167,700 | 2,121 | 214.8 | 780 | 9.9 |
|
Senegal |
43,300 |
1,168 | 15.1 | 2,860 | 77.1 |
|
Uganda |
81,000 | 1,061 | 41.1 | 1,970 | 25.8 |
*Counts have been rounded |
Time series of cases, deaths, and vaccinations through today.
What Interventions Were Implemented to Slow Transmission of COVID-19?
To contain the spread of COVID-19, all four countries implemented population-based public health measures. These included health system interventions as well as nonpharmaceutical interventions, such as restrictions in travel, movement lockdowns, and mask-use mandates.
Timeline of early COVID-19 response
What Was the Impact of Social and Physical Distancing Interventions?
Social and physical distancing interventions had unintended effects on the health system as a whole. In fact, their negative effects on health outcomes may exceed the morbidity and mortality associated with COVID-19.
The effect of the response to COVID-19 generally decreased EHS delivery but varied across countries and across disease programs. Across low- and middle-income countries, millions of children missed doses of essential vaccines, maternal and child health visits were disrupted, fewer people sought care for chronic diseases, and many people delayed medical treatment because of disruptions in EHS and because they were afraid of getting sick with COVID-19. In the study countries, there was a 30 percent reduction in the number of people initiated on antiretroviral treatment in Uganda, a 13 percent reduction in the number of children fully vaccinated in Nigeria, and a reduction in the number of diabetes visits per facility in the DRC. Especially at the beginning of the COVID-19 pandemic, government-imposed social distancing and lockdown mandates and voluntary behavior change dramatically reduced how much people traveled outside their homes. This may have been a barrier to seeking EHS among people who needed them and a barrier to healthcare workers getting to hospitals or clinics to provide EHS delivery.
Relative change in population-level mobility
How Well Have the Countries Maintained Essential Health Services during the COVID-19 Pandemic?
To assess how well the four countries maintained EHS during the COVID-19 pandemic, we compared monthly data for three indicators of EHS delivery before and during 2020: doses of DTP vaccine, number of in-facility deliveries (births at health care facilities), and number of maternal deaths. Immunizations and maternal health care are among the services prioritized in many countries during public health emergencies; consequently, immunizations and in-facility deliveries provide insight into the availability and delivery of EHS, and maternal deaths could be more indicative of quality of care.
The COVID-19 pandemic disrupted routine childhood immunizations in many countries around the world, leaving between 3.5 and 8.5 million more children unvaccinated against DTP in 2020 compared with 2019.2, 3 The disruptions in DTP vaccine delivery were not uniform between the study countries. Doses in Nigeria and Uganda were much lower in the early months of the pandemic but recovered to pre-2020 levels later in the year. In contrast, Senegal was not able to recover to pre-2020 levels of vaccine delivery and the DRC had no observed disruptions in vaccine delivery at the national level.
Interruptions in doses of DTP delivered.
Comprehensive maternal and newborn care policies have been a critical component of EHS packages in many settings. Like childhood vaccinations, in-facility deliveries may represent how well health care systems are able to provide EHS. In-facility deliveries were increasing across all four study countries before the pandemic. During the pandemic, the number of in-facility deliveries in Nigeria and Senegal was much lower than expected based on the pre-pandemic trend; in-facility deliveries were less affected by the pandemic in the DRC and Uganda.
Maternal mortality also depends on the quality of available EHS. Maternal deaths spiked in the months immediately after the start of the pandemic in Uganda and Senegal. This may reflect that women delayed seeking care at the start of labor, skipped antenatal care visits, chose to deliver at home because of a gap in services, faced difficulty traveling during government-imposed lockdowns, or feared contracting COVID-19.
Performance across essential health indicators
Trends in households missing needed healthcare during the pandemic
Across all countries, the main reasons for delaying or missing EHS care were fear of contracting COVID-19 and inability to pay for care. Financial barriers were likely higher during the pandemic as lockdowns prevented people from selling goods and services. These barriers were greatest during the first six months of the pandemic.5
What Actions Did Countries Take to Maintain Essential Health Services during the Pandemic?
To maintain access to essential health care, health systems in the countries we studied adopted strategies such as task shifting, designation of specific health facilities for non-COVID-19 EHS, and service delivery adaptations. Despite these interventions, countries could not always respond to the surge in demand for health care services that COVID-19 caused. For example, the DRC had to divert large portions of its health budget to pandemic response; the DRC, Nigeria, and Uganda experienced commodity stockouts.
| Democratic Republic of the Congo |
Nigeria |
Senegal |
Uganda |
|---|---|---|---|
|
Virtual platforms to monitor program implementation |
Follow-up services through messaging apps and peer support networks |
Video observation to monitor treatment adherence |
Use of social media platforms to communicate availability / continuity of health services |
|
Provision of internet and tablets to strengthen data reporting |
Provision of smartphones to monitor treatment adherence |
Use of text messages and digital solutions for patient follow-up |
Electronic Logistics Management System (eLIMS) to process orders for COVID-19 commodities |
|
Provision of internet modems & tablets to strengthen data reporting |
Ministry of Health developed COVID-19 awareness website for information on services continuity and campaign to increase access to sexual & reproductive health |
| Democratic Republic of the Congo |
Nigeria |
Senegal |
Uganda |
|---|---|---|---|
|
Leveraged clinical health workers in training non-medical staff in infection prevention and simple healthcare tasks
|
The roles of community health workers (CHWs) were expanded substantially |
Engaged with the local communities to relieve the stress on the health care system |
Increased the role of non-medical staff and community health workers (CHWs) |
|
Community Health Workers (CHWs) provided free essential health services like diagnostic screening, treatment of minor conditions, and nutritional services |
CHWs provided antenatal & postnatal care, treatment for malaria & diarrhea |
Creation of community COVID-19 vigilance & awareness committee |
Non-medical staff (like security guards and janitors) taught how to conduct temperature screening |
| CHWs disseminated information on service availability and conducted patient follow-up | CHWs disseminated information on service availability | Community members recruited as additional health workers to minimize service delivery impact | Antenatal & postnatal care, treatment for malaria & diarrhea transferred to CHWs |
| CHWs trained to continue routine immunizations | Community actors, religious leaders, youth associations promoted use of reproductive, maternal, and child health services | CHWs trained to identify and refer patients, and generate demand for services |
| Democratic Republic of the Congo |
Nigeria |
Senegal |
Uganda |
|---|---|---|---|
|
Reduced the number of mothers per ANC session |
Multi-month drug dispensing to reduce visits to health centers |
Functional mapping of health facilities to ensure availability and use of reproductive, maternal, and child health services |
Special clinics for maternal and child health services |
|
Multi-month drug dispensing (e.g., HIV drugs) to reduce visits to health centers
|
Deployment of geocoded mobile health vans |
Implemented hotlines to contact health district to avoid home births and delays in use of care |
Multi-month drug dispensing to reduce visits to health centers |
| Introduction of self-initiation of care (e.g., training clients on self-injection) | Telemedicine to fill service delivery gap caused by patient fear of contracting COVID-19 | Introduction of self-initiation of care (e.g., training clients on self-injection) | Designation of regional facilities for COVID-19 treatment Introduction of Young Child Clinics, special clinics for maternal and child health, HIV services, and daily static immunization services |
| Use of mobile surgery and PHC clinics in remote areas in Eastern provinces where most displaced person live | Adapted patient follow-up strategies (e.g., telephone reminders, public screamers & relays) |
What Did Countries Learn from These Challenges during the First 18 Months of the COVID-19 Pandemic?
Because most indicators—including financing for the health sector, health worker to population ratios, investment in infrastructure and commodities like medicines and critical care facilities—were below WHO benchmarks even before the COVID-19 emergency in the countries we studied, their health systems faced a number of challenges in maintaining access to EHS in the context of the pandemic. From their experience in the first 18 months of the COVID-19 pandemic, we can learn how to strengthen the maintenance of EHS in future health emergencies.
We have categorized these challenges and recommendations according to the building blocks of the health system: governance and leadership, human resources, finances, health service delivery, infrastructure and commodities, and health information systems.
Challenges
In general, there was a lack of leadership, policies, and guidelines to inform the implementation of efforts to promote the maintenance of EHS during the pandemic. As a result, countries were not monitoring service delivery indicators or putting corrective actions in place to limit the disruption of health programs. Where guidelines did exist, they were often poorly disseminated to all levels of the health care system.
Recommendations
- Create or strengthen multisectoral working groups (including scientists, government officials, and representatives from the private sector) with clear and transparent communication and collaboration within and across multiple levels of the health care system (from local to national).
- Clearly define what EHS are in a given country or health district. Although these “essential” health services should be based in part on country-specific needs, WHO has suggestions for which services should be considered.
- Implement and quickly disseminate comprehensive guidance on maintaining EHS delivery during public health emergencies. Better still, develop this guidance as part of preparedness efforts before any public health emergency occurs.
- Identify an individual or small committee to be the focal point for coordinating the continuation of EHS during public health emergencies across all levels of the health care system.
- Run media campaigns for health promotion and risk communication to improve access to services.
Challenges
Human resources were challenged over the course of the pandemic. Poor investment in human-resource surge capacity affected the maintenance of EHS delivery, as health workers were repurposed to conduct surveillance, contact tracing, and other COVID-19 response activities. Further, restricting the mobility of service providers to control the spread of the pandemic led to absenteeism and tardiness among health workers. Absenteeism was exacerbated by high rates of COVID-19 infections and fatalities. The consequent fear of infection among health workers reduced worker productivity and was a major barrier to the maintenance of EHS delivery.
Recommendations
- Train and support a robust health care workforce (including provision of sufficient personal protective equipment and training on appropriate use of infection prevention and control procedures).
- Strengthen capacity for virtual trainings to rapidly reach health workers across locations for urgent communication.
- Provide regular, free testing of health workers and psychosocial support for those infected.
- Invest in capacity strengthening to enable sufficient response to public health emergencies without affecting routine service delivery.
- Address fear and demotivation among health workers by providing incentives such as risk allowances or free transportation.
Challenges
The countries’ governments received resources to support their COVID-19 response but committed limited or no funding for activities to promote the maintenance of EHS (activities such as health communications, transportation for health workers and people seeking health care, and the tracking and analysis of routine health data). Even when funding existed, the countries experienced suspensions and delays in the disbursement of funds for EHS.
Recommendations
- Establish a separate resource envelope for financing EHS delivery activities, such as monitoring essential health indicators and promoting the continuity of EHS.
- Establish strong partnerships with the private sector and the international community, and frameworks through which those partners can contribute to specific efforts to maintain the delivery of EHS.
Challenges
Two main factors reduced health care seeking among people in the countries we studied. First, mobility restrictions exacerbated preexisting obstacles in physical access to care for patients. Second, the perception of risk of COVID-19 infection in health care facilities diminished patient trust in the safety of the health care system.
Sometimes, gaps in EHS delivery came from a lack of communication between the health system and the communities. The suspension of existing service delivery models that involved interaction between health workers and communities (such as immunization outreach and mass health campaigns) disrupted the provision of EHS as well as treatment for chronic illnesses.
Recommendations
- Leverage technology to provide EHS while minimizing the risk of COVID-19. For example, expand the use of telemedicine, video-observed treatment, and use of phone calls and messaging apps to communicate with patients and provide peer support. Additionally, establish toll-free telephone lines to provide information about accessing EHS.
- Broadcast messages on the radio and social media to communicate to the public about EHS delivery during the pandemic, including examples of how the government and health care centers are protecting non-COVID-19 patients.
- Adopt health service delivery models that reduce the risk of infection in health care settings, such as home follow-ups for chronically ill patients and multimonth dispensing for chronic-care drugs.
- Introduce or strengthen service delivery models, such as integration of multiple services (e.g. gender-based violence services into antenatal care), young-child clinics, and maternal, newborn, and child health clinics.
- Use community health workers to provide some EHS.
Challenges
An acute need for hospital space and resources to treat COVID-19 patients resulted in a lack of facility space, prevention and control commodities, and other resources for delivering EHS. Further, disruption of global supply chains led to stockouts of infection prevention and control commodities (gloves, handwashing supplies, and personal protective equipment for health workers) as well as family planning commodities, vaccines, and testing reagents and equipment.
Recommendations
- Strengthen patient and health worker safety at the point of care by minimizing the risk of infection via infection prevention and control commodities (such as handwashing facilities) and ensuring the observation of physical distancing requirements.
- Strengthen commodity supply chains and allow emergency ordering to prevent stockouts of essential commodities. Establish and support a domestic emergency stockpile of essential commodities (including medicines and personal protective equipment).
- Designate specific facilities to treat COVID-19 exclusively, and designate other facilities to provide general medical care. Clearly communicate those designations to patients and the public.
- Map essential services and resource requirements to understand baseline supply, medication, and equipment needs. Inventory available resources across public and private health care providers and commodity suppliers. Create a platform for reporting inventory and stockouts.
Challenges
Routine health data (e.g., data collected in health management information systems) suffered from drops in data-reporting rates, which made it difficult to monitor the extent of EHS disruption and to respond accordingly.
Recommendations
- Provide logistical, technical, and financial support for routine health information system data collection to build surveillance and monitoring capacity before and during public health emergencies.
- Monitor EHS to quickly identify program areas so that corrective interventions can be put in place.
Conclusion
Although the health systems we studied were able to maintain EHS delivery to some extent during the COVID-19 crisis, they did so with minimal investment in various components of the health care system and amid poor indicators of baseline health system capacity.
In order for a country’s health care system to display the adoptive, absorptive, and transformative capacities it needs to remain resilient in any crisis, officials must dedicate baseline resources—including funding for the health sector, investment in infrastructure and commodities, and investment in surge capacity across the health care system.
In times of crisis, governments and health systems should:
- Develop clear guidelines to promote the maintenance of EHS and disseminate these to all levels of the health system
- Ensure the safety and well-being of health workers
- Implement innovative health service delivery models and strategies
- Enable effective, evidence-based decision and policy making by promoting the use of reliable, accurate, and connected data-reporting systems across all levels of the health system
- Champion strong government coordination, public-private partnerships, and international cooperation
Country-specific profiles will be available soon
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1
Dowdy D, D’Souza G. COVID-19 testing: understanding the “percent positive.” Johns Hopkins Bloomberg School of Public Health website. Published August 10, 2020. Accessed August 13, 2021. https://www.jhsph.edu/covid-19/articles/covid-19-testing-understanding-the-percent-positive.html
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2
Causey K, Fullman N, Sorensen RJD, et al. Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study. Lancet. 2021;398(10299):522-534. https://doi.org/10.1016/S0140-6736(21)01337-4
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3
COVID-19 pandemic leads to major backsliding on childhood vaccinations, new WHO, UNICEF data shows. World Health Organization website. Published July 15, 2021. Accessed August 10, 2021. https://www.who.int/news/item/15-07-2021-covid-19-pandemic-leads-to-major-backsliding-on-childhood-vaccinations-new-who-unicef-data-shows
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4
Partnership for Evidence-Based Response to COVID-19. Prevent Epidemics website. Accessed August 10, 2021. https://preventepidemics.org/covid19/perc/
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5
Partnership for Evidence-Based Response to COVID-19. Prevent Epidemics website. Accessed August 10, 2021. https://preventepidemics.org/covid19/perc/