Cross Country Synthesis

Public health emergencies like the COVID-19 pandemic cause direct morbidity and mortality. They also disrupt  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

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.

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, 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

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.

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.

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.,  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.

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.

Evidence from population-based surveys showed other demand-side barriers to EHS during the COVID-19 pandemic. For instance, about 40 percent of people in Africa skipped or delayed needed health care and/or had difficulty accessing medication.

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.

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.

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.

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.

Key Recommendations

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