Indirect impacts of Covid-19 on other essential health services

This briefing note was co-created in collaboration with Action for Global Health’s members.

1. Key trends on the ground

Even before Covid-19, more than half the world’s population still did not have access to all essential health services. The Covid-19 pandemic is exacerbating existing inequalities and weaknesses in countries’ health systems and these are impacting their ability to deliver the full spectrum of health services. Action for Global Health and our partner networks have already collated more than 30 case studies that document the projected and actual impact of Covid-19 across child health services, immunisation, nutrition services, prevention, treatment and diagnostics for communicable diseases and non-communicable diseases, sexual and reproductive health (SRH) services, harm reduction, inappropriate use of antibiotics leading to increasing rates of drug-resistant infections, mental health services, rehabilitation services, palliative care, WASH, and health research and development.

A few examples of projected impacts:

• A joint statement from UNICEF, Gavi and WHO has warned that up to 80 million children under the age of 1 are at risk of missing out on routine immunisations for diseases such as measles, polio and yellow fever as mass immunisation campaigns are disrupted.
• Lancet analysis projects that the prevalence of wasting (acute malnutrition) in children is estimated to increase by 10-50% in low and middle-income countries.
• The Guttmacher Institute estimates the impact of a 10% decrease in SRH service provision over 12 months could lead to 49 million more women with unmet need for modern contraception, 15 million more unintended pregnancies, 168,000 more new-born deaths, 29,000 more maternal deaths and 3 million more unsafe abortions.

Examples of actual impacts being measured:

• Programme deliverables for neglected tropical disease programmes have been significantly affected, delaying the treatment of around 45 million individuals against schistosomiasis and soil-transmitted helminths (UK Coalition Against NTDs briefing).
• King’s Global Health Partnerships have been collecting patient referral data across 17 hospitals in Sierra Leone, showing some entire hospital closures and a nationwide drop from 80% to 20% in average bed occupancy since January.
• A recent WHO survey of 155 countries found 120 countries are reporting disruptions to non-communicable disease services including rehabilitation, hypertension, diabetes, asthma, palliative care, dental care, cancer treatment and cardiovascular emergencies.

There are a number of key challenges leading to these indirect impacts. Some of these are identified below:

• Movement restrictions and border closures are leading to negatively impacted supply chains, procurement mechanisms and logistics efforts, causing shipping delays and stock-outs of essential health goods and equipment. Many drug stocks are also expiring in storage as drug administration campaigns have been shut down.
• Increased programme costs are not being met– for example: prices for transport and shipping are skyrocketing, which in turn increases the cost of basic health commodities. Additionally, physical distancing is likely to make some cost-effective health interventions more expensive, as they can no longer be delivered in mass settings and instead require door-to-door delivery.
• Movement restrictions are impacting on maintenance of infrastructure, meaning that whole communities are living with no access to clean water supply, sanitation and handwashing facilities. This is leading to low compliance on hygiene behaviour change and an increased risk of water-borne diseases and outbreaks.
• Movement restrictions and absence of appropriate protocols for essential health providers mean that there is a lack of access to home-based care, which is of significant concern for people who are care-dependent, including older people and people with disabilities.
• Isolation and lockdown are impacting significantly on mental and physical wellbeing.
• Increased and additional barriers to accessing to health and preventative services are exacerbating the challenges faced by the poorest and most marginalised (eg. human rights violations and discrimination against marginalised communities, ageism, financial barriers from user fees).
• Civil society and communities are mostly being excluded from local and national Covid-19 response co-ordination and this is resulting in a lack of social accountability.
• Key health personnel, R&D, healthcare funding and health systems infrastructure are being redeployed to COVID-19 response efforts and away from other basic healthcare services. For example, GeneXpert diagnostic machines – the most widely used equipment for rapid TB testing – have also been approved to diagnose COVID-19, meaning that machines in high TB burden countries are being repurposed.
• Poor hospital preparedness – such as lack of funding for PPE, inadequate WASH infrastructure, insufficient oxygen supply and essential medicines – mean that key staff do not feel safe and are not coming to work. This leads to shortages of health, care, sanitation and waste workers to maintain essential health and preventative services.
• Lack of public confidence in health systems (hospitals felt to be unsafe) and unclear and/or inaccessible public health information and communication is stopping patients from seeking treatment. In the long run, fear of public gatherings can reduce uptake of public health interventions delivered in mass settings.

Priorities for action to reduce negative indirect impacts and protect the most vulnerable, and interventions through which DFID is particularly well-placed to add value.

DFID must protect and maintain its investments in other essential health services, in order to prevent severe loss of life (as per the UK Government’s manifesto commitment to ‘ending preventable deaths’). Evidence from the Ebola epidemic in 2014-16 showed the detrimental impact of resources being diverted from routine health services. In all there were about 12,000 Ebola deaths in Upper West Africa in 2014-15, but many additional fatalities resulted from closure of facilities such as maternity clinics and an estimated additional 10,600 lives were lost to HIV, TB and malaria during the epidemic. Shifting funding from these health crises to fight another risks undoing years of progress improving global health outcomes, in which the UK has been a leading donor and global champion. The UK Government should also continue to advocate globally for sexual and reproductive health services to be designated as ‘essential services’ in Covid-19 responses.

Integrated response to Covid-19 and indirect impacts through investing in health systems strengthening

There is an opportunity to integrate the Covid-19 response with broader health systems strengthening and efforts to deliver universal health coverage, with significant, positive implications for all essential health services in the longer-term. In order to respond to Covid-19 and deliver essential health services, we need strong health systems everywhere and for them to be accessible to all. The same issues which are negatively impacting the Covid-19 response – inadequate PPE and supplies, global shortages of health workers due to fear, low pay and incentives, low access to WASH services in health facilities, unclear public health information and communication – are also impacting the ability to maintain other essential health services, at even greater cost. The speed of the response is a critical factor here; the faster that funds are disbursed to frontline health facilities, the faster they are able to manage Covid-19 patients and create safe environments for non-Covid-19 patients. This has a ripple effect on public confidence in the health system and uptake of essential services. For older people and people with underlying health conditions who are more at risk of severe Covid-19 outcomes, ensuring their continued access to these services will also increase the resilience of these groups, thus mitigating the impact of Covid-19.

Our case studies show that Covid-19 is exacerbating the barriers faced by many in accessing essential health services, but this is not reflected in prioritisation at the national level. A critical approach to mitigating this issue is ensuring the meaningful participation of affected communities and local civil society in Covid-19 response mechanisms, thus providing a direct, feedback loop on these barriers. A recent rapid survey of 175 CSOs from 56 countries found that the majority of respondents found little or no opportunity for civil society to contribute to their government’s response, to call for implementation of essential health services. The UK Government has been a strong ally for meaningful engagement of communities and civil society and could play an active role advocating for social accountability at the global, national and local level. Additionally, the UK Government should ensure widespread collection of disaggregated data in terms of access to non-Covid-19 essential health services, which is essential in ensuring the most vulnerable and marginalised populations are not left behind. We also urge the UK Government to take a rights-based approach in their response to Covid-19, using every opportunity to call for partner governments to respect human rights and increasing their advocacy efforts in response to human rights violations carried out under the guise of the Covid-19 pandemic.

Learning from the Ebola pandemic and the implications of travel restrictions mean that there is a particular emphasis on the need for community-based health interventions. In terms of indirect impacts, local interventions are critical to share trusted, accessible public health information and provide essential health and preventative services to the most vulnerable and marginalised groups. But grassroots organisations need support and flexibility from donors just to keep going at this time, as well as to maintain these services (particularly when they are facing increased programme costs), and to deliver them safely, in line with Covid-19 restrictions. Where there has been greater and swifter flexibility in modifying procurement procedures, there has been greater success in responding to Covid-19 and maintaining other health interventions.

Effective coordination at the international level (UN agencies, GHIs) and at the national level is critical to maintain essential health and preventative services. A recent case study from Benin showed that effective coordination between 5 international partners (including the Global Fund and WHO) and in-country partners was essential in ensuring that a bed net distribution campaign could still be implemented ahead of the high-transmission malaria season, meaning that more than 13.5 million people have now been protected. Given the UK Government’s role on the boards of a number of health institutions (WHO, Global Fund, Gavi) and their historic role pushing for reforms, the UK Government is particularly well-placed to be leading the call for better global coordination.