Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. METHODS AND FINDINGS: Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population. CONCLUSIONS: Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries.

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

A tool for assessing management capacity at the decentralized level in a fragile state.

Fragile states need assessment of decentralized management capabilities, not just of the central level, to design capacity-building efforts focused on improving management. Improving the management capacity of health departments at the provincial or district level is just as critical as strengthening the central ministry in fragile states if a health system that effectively addresses the real health needs of the population is to be formed. This paper describes a management capacity assessment tool developed for use in fragile states. It uses a framework that describes six critical management areas: oversight and coordination; human resources; resource management; health financing; community involvement; and health information management. These core areas of health system management are assessed with regard to capacity in three core management functions: the capacity to plan, to implement, and to monitor and evaluate. The tool was applied to assess the management capacity of six counties in Liberia. The results helped differentiate the level of capacity of the different counties and clarify the actions required to strengthen the health system in the periphery. The assessment also allowed the prioritizing of county health offices with regard to the level of capacity building required to improve management. The tool also identified successes that can inform the design of future health programs in other county health offices. The tool can be applied to other challenging country situations to assess management capacity, which will help focus technical assistance to the health sector in fragile states.

Cooperation, integration, and long-term commitment: what Solomon Islanders and development workers say about health sector aid.

INTRODUCTION: The Solomon Islands is experiencing instability and insecurity and also a concomitant increase in aid. This article aims to address the need for theoretical coordination frameworks to be further informed by the actual experiences, requirements, and views of the recipients of aid. METHODS: Qualitative research techniques were used to better understand governmental and nongovernmental leaders' views of health sector aid in the Solomon Islands. Data were collected using previously published literature, government and nongovernmental documents, and in-person interviews. RESULTS: Two key themes emerged from the interviews: the need for coordination and integration of aid and the need for this integration to occur over the long-term. These themes are presented using quotations from key informants. CONCLUSION: Themes and quotations arising from the analyses may assist in understanding theoretical frameworks for coordination, particularly in postconflict states. Future needs regarding mechanisms of collaboration in the Solomons are also discussed.