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

ABSTRACT

IntroductionThe 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. MethodsMixed-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 students t test. Qualitative data were analysed using thematic analysis. ResultsFrom 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. ConclusionThe 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?O_LIDuring the Ebola epidemic, Sierra Leone experienced drastic reductions in health service utilisation, that are thought to have led to high mortality. C_LIO_LIReductions 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. C_LI What are the new findings?O_LIHealthcare utilisation in Sierra Leone decreased modestly during the first wave of the COVID-19 pandemic. C_LIO_LIDecreases in hospital admissions were less than those seen during Ebola and less than decreases seen globally. C_LIO_LIThe 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. C_LI What do the new findings imply?O_LIThe minimal reduction in service utilisation suggest that lessons have been learnt in protecting essential health services during outbreaks. C_LIO_LISimilar patterns of decreases in healthcare utilisation from COVID-19 to Ebola, should inform future preparedness and outbreak response planning. C_LIO_LIThe resilience of services covered by the free healthcare initiative supports the argument for Universal Health Coverage in Sierra Leone. C_LI