Abstract
Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. 
By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies. Data and health services analyzed We modeled the pandemic’s impact using an interrupted time series design. We used administrative and Routine Health Information System data on the number of health services provided each month for the period of January 2019 to December 2020. These datasets covered varying health sectors or sub-national regions and represent the services provided by a total of 94,655 health facilities in ten countries. The interruption was defined as the declaration of a pandemic by the World Health Organization on 11 March 2020, resulting in 15 months of baseline and 9 months of follow-up during the COVID-19 pandemic. Trends in services until June 2021 are also available for a subset of indicators and countries. The primary parameters of interest were
(1) the change in the level of health services after the declaration of the pandemic and
(2) the remaining difference in level at the end of 2020 (to assess whether services had resumed to pre-pandemic levels). We express results in relative terms as the percent change from the average in the pre-COVID-19 period. Finally, to estimate the burden of missed healthcare across the ten countries, we provide estimates of the cumulative number of visits missed for three groups of services: maternal and neonatal care, chronic disease care and childhood vaccination. For each service, we predicted what service delivery would have been in each post-pandemic month had the pre-pandemic trend continued and subtracted that from the observed value after adjusting for seasonality. Using regression models, we assessed whether services had returned to pre-pandemic predicted levels by the end of 2020. Although the COVID-19 pandemic continued beyond 2020 globally, health systems should have adjusted to the continuing circumstances and adapted service delivery. We found that, by the last quarter of 2020, most services had improved compared to the early months of the pandemic, but not all had returned to pre-pandemic levels.
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