The impact of the COVID-19 pandemic on health service utilisation in Sierra Leone (preprint)

ABSTRACT

Introduction The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on health service utilisation in a sub-Saharan country, Sierra Leone. Methods Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals), and qualitative interviews with healthcare workers and patients. Hospital data were compared across Quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity, paediatric), and hospital type (government or private not for profit). Referrals in 2020 were compared with 2019, to assess whether any changes were the result of seasonality. Comparisons were performed using student’s t test. Qualitative data were analysed using thematic analysis. Results From Q1-Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8%, than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8 % decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), whilst caesarean sections and facility-based deliveries showed significant increases, 12.7 % (p=0.014) and 7.5% (p=0.03) respectively. In Q3 total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared to 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. Conclusion The study demonstrated a decrease in health service utilisation during Covid-19, the decrease is less than in other countries during COVID-19 and less than reported during the Ebola epidemic. What is already known? During the Ebola epidemic, Sierra Leone experienced drastic reductions in health service utilisation, that are thought to have led to high mortality. Reductions in healthcare utilisation have been reported in other countries due to the COVID-19 pandemic, however little is known about the effects of the pandemic on healthcare utilisation in sub Saharan Africa, including Sierra Leone. What are the new findings? Healthcare utilisation in Sierra Leone decreased modestly during the first wave of the COVID-19 pandemic. Decreases in hospital admissions were less than those seen during Ebola and less than decreases seen globally. The largest reductions were seen in adult medical and surgical services, populations covered under the free healthcare act including maternal and child (under 5 years) health were more resilient. What do the new findings imply? The minimal reduction in service utilisation suggest that lessons have been learnt in protecting essential health services during outbreaks. Similar patterns of decreases in healthcare utilisation from COVID-19 to Ebola, should inform future preparedness and outbreak response planning. The resilience of services covered by the free healthcare initiative supports the argument for Universal Health Coverage in Sierra Leone.