Use of healthcare services during the COVID-19 pandemic in urban Ethiopia: evidence from retrospective health facility survey data

BMJ Open, Volume 12, No. 2, Year 2022

Interpretation

Objectives In recent years, Ethiopia has made enormous strides in enhancing access to healthcare, especially, maternal and child healthcare. With the onset and spread of COVID-19, the attention of the healthcare system has pivoted to handling the disease, potentially at the cost of other healthcare needs. This paper explores whether this shift has come at the cost of non-Covid related healthcare, especially the use of maternal and child health (MCH) services. Setting Data covering a 24-month period are drawn from 59 health centres and 29 public hospitals located in urban Ethiopia. Primary and secondary outcomes measures The primary outcome measures are the use of MCH services including family planning, antenatal and postnatal care, abortion care, delivery and immunisation. The secondary outcome measures are the use of health services by adults including antiretroviral therapy (ART), tuberculosis (TB) and leprosy and dental services Results There is a sharp reduction in the use of both inpatient (20%-27%, p<0.001) and outpatient (27%-34%, p<0.001) care, particularly in Addis Ababa, which has been most acutely affected by the virus. This decline does not come at the cost of MCH services. The use of several MCH components (skilled birth attendant deliveries, immunisation, postnatal care) remains unaffected throughout the period while others (family planning services, antenatal care) experience a decline (8%-17%) in the immediate aftermath but recover soon after. Conclusion Concerns about the crowding out of MCH services due to the focus on COVID-19 are unfounded. Proactive measures taken by the government and healthcare facilities to ring-fence the use of essential healthcare services have mitigated service disruptions. The results underline the resilience and agility displayed by one of the world's most resource-constrained healthcare systems. Further research on the approaches used to mitigate disruptions is needed. This study is based on a retrospective cross sectional health facility survey, conducted through phone and internet, which covered four regional states (Tigray, Amhara, Oromia and SNNP) and Addis Ababa city administration. Together, these regions account for 89.5% of the country’s population31 and 85.6% of the COVID-19 cases in the country as per 16 August 2020—the date that data collection commenced.32 Ethiopia confirmed its first COVID-19 case on 13 March 2020 and data collection took place between August and December 2020. At the time of commencing data collection, the bulk of the facilities had collected and validated data up to the end of June 2020 and so for the postcovid period we focused on the 4-month period from March to June 2020. To enable immediate before-after comparisons we gathered information for the 4-month period just prior to COVID-19, that is, November 2019 to February 2020. To avoid seasonal effects, we also gathered data on healthcare use in the 4-month period between March and June 2019. In addition to these 12 months, to enhance longer-term comparisons and avoid criticisms that the time periods have been purposively chosen to augment differences, we collected information for a period of 24 months—that is, July 2018 to June 2020. The plan was to cover 60 health centres and 30 public hospitals while the survey actually covered 59 health centres and 29 hospitals. The regional distribution of the sample was guided by the regional distribution of COVID-19 cases in the country at the end of June 2020 (see figure 1 and table 1). Based on these considerations, the bulk of the sampled facilities were in Addis Ababa which accounted for 73% of COVID-19 cases in June 2020, followed by Oromia (5.6%). There are 91 health centres in Addis Ababa and 44 were randomly chosen for the survey. The city has 12 public hospitals of which 11 were included in the survey (see table 1). Indeed, not only are a majority of the sampled facilities located in Addis Ababa (table 1) but over 60% provide care for COVID-19 infected patients (see online supplemental table A1). Monthly COVID-19 cases in Ethiopia, March to June 2020. SNNP, Southern Nations, Nationalities, and People’s region Share of COVID cases and sample distribution Source: COVID figures are from the National Public Health Emergency Operation Center COVID-19 Situation Reports no. 68, 98, 129, 158. The total number of confirmed cases in the country at the end of June 2020 was 5846. SNNP, Southern Nations, Nationalities, and People’s region. bmjopen-2021-056745supp001.pdf After ensuring that a health facility was willing to participate in the survey, a survey instrument was sent by email to health facility ICT (Information and Communication Technology) workers responsible for facility HMIS. To ensure data quality, discussions to clarify concerns took place with ICT workers throughout the data collection and data cleaning process. From the HMIS, information was culled on monthly inpatient and outpatient visits for 24 months (July 2018 till June 2020). In addition to the total visits, data were collected on specific outpatient services including the gamut of maternal and childcare health services (family planning services (FPS), ANC, abortions, delivery, PNC, immunisation, integrated management of neonatal and childhood illnesses (IMNCI), prevention of mother-to-child HIV transmission care (PMTCT). The survey also included modules to ascertain the level of preparedness and provision of COVID-19-related services, provision of supplies such as personal protective equipment (PPE), measures taken to mitigate the spread of COVID-19 and challenges faced by facilities due to the virus, especially related to absenteeism of healthcare professionals and support staff. Information on facility-level preparations to deal with COVID-19 was provided by facility directors while information on absenteeism was provided by facility human resources officers. Graphs, descriptive statistics and paired non-parametric (Wilcoxon signed-rank) tests of significance which do not assume that the differences between paired samples is normally distributed are used to compare levels of inpatient and outpatient healthcare service utilisation (number of patients per month) before and after the onset and spread of the virus. The analysis of outpatient visits includes data from health centres and public hospitals while inpatient care utilisation is restricted to data from public hospitals as health centres mainly provide outpatient services. In addition to the total visits for healthcare, we also compare the number of visits for different types of mother and child health services such as family planning, ANC, abortion, delivery, PNC, immunisation, IMNCI, PMTCT. we assess absenteeism of hospital staff by comparing the number of staff members that should be in the hospital and the number of staff members that were present on the day of the survey. we test for temporal changes in 14 types of healthcare use and absenteeism. To avoid pitfalls associated with multiple-hypothesis testing, we interpret results, tables 2–5, keeping in mind the Bonferroni correction—that is, we use a p value of 0.003 (0.05/15) to draw inferences rather than the conventional 5% level of significance. Inpatient and outpatient healthcare use A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. SNNP, Southern Nations, Nationalities, and People’s region. Mother and child healthcare use—prebirth and delivery average monthly visits A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. SNNP, Southern Nations, Nationalities, and People’s region. Mother and child healthcare use—postbirth average monthly visits A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. SNNP, Southern Nations, Nationalities, and People’s region. Utilisationof various health services by adults average monthly visits A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. ART, antiretroviral therapy; SNNP, Southern Nations, Nationalities, and People’s region; TB, tuberculosis. Although we have 2 years of utilisation data, the focus is on the 4-month period, March to June 2020 as compared with healthcare use in the 4-month period March to June 2019. Comparing service use volumes for similar months, as opposed to before and after March 2020, helps to account for seasonal variations in patient flows.33 However, to account for the possibility that year-on-year comparisons may underestimate the extent of the decline, if there is an increase in healthcare utilisation over time, we also compare healthcare use between the 4-month period, March to June 2020 with the 4-month period, November 2019 to February 2020, which precedes the first COVID-19 case in Ethiopia. Additionally, graphs are used to demonstrate year-on-year changes in healthcare use, that is, comparing healthcare use, per month, over the period July 2019–June 2020 to the period July 2018–June 2019. The research questions were developed based on conversations with and concerns about declines in non-Covid healthcare use and health worker absenteeism expressed by healthcare providers in the country’s largest hospital located in Addis Ababa. Suggestions on appropriate comparison periods and the type of healthcare services to be investigated were provided by managers of healthcare facilities. The results have been discussed with and corroborated by healthcare workers at two large hospitals in Addis Ababa.

AI Digest

Study Justification:

– The study aims to investigate whether the focus on COVID-19 has led to a decline in non-COVID healthcare services, particularly maternal and child health (MCH) services, in urban Ethiopia.
– The study is important because Ethiopia has made significant progress in improving access to healthcare, especially MCH services, and it is crucial to understand the impact of the pandemic on these services.
– The findings of the study can inform policymakers and healthcare providers about the need to prioritize and protect essential healthcare services during the pandemic.

Highlights:

– The study found a sharp reduction in both inpatient and outpatient care utilization during the COVID-19 pandemic, particularly in Addis Ababa, the most affected city.
– However, the decline in healthcare utilization did not come at the cost of MCH services. Some MCH components, such as skilled birth attendant deliveries, immunization, and postnatal care, remained unaffected throughout the period.
– Other MCH services, such as family planning and antenatal care, experienced a decline in the immediate aftermath of the pandemic but recovered soon after.
– The study highlights the resilience and agility of Ethiopia’s healthcare system in mitigating service disruptions and addressing the potential crowding out of MCH services due to the focus on COVID-19.

Recommendations:

– The study recommends further research on the approaches used to mitigate disruptions in healthcare services during the pandemic.
– Policymakers should continue to prioritize and protect essential healthcare services, especially MCH services, to ensure that they are not neglected during the pandemic.
– Healthcare facilities should implement proactive measures to ring-fence the use of essential healthcare services and ensure their availability to the population.
– Efforts should be made to address the decline in certain MCH services, such as family planning and antenatal care, to ensure that women’s healthcare needs are met.

Key Role Players:

– Government health departments and ministries responsible for healthcare policy and planning.
– Healthcare facility directors and managers.
– Healthcare providers, including doctors, nurses, and midwives.
– Health information management system (HMIS) workers responsible for data collection and analysis.
– Public health experts and researchers.

Cost Items for Planning Recommendations:

– Personal protective equipment (PPE) for healthcare providers.
– Supplies and equipment for MCH services, including family planning, antenatal care, and immunization.
– Training and capacity building for healthcare providers to address the specific needs of MCH services during the pandemic.
– Communication and public awareness campaigns to promote the importance of accessing essential healthcare services.
– Data collection and analysis for monitoring healthcare utilization and service delivery.
– Implementation of measures to mitigate the spread of COVID-19 in healthcare facilities, such as infection control protocols and facility modifications.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a retrospective health facility survey conducted over a 24-month period in urban Ethiopia. The study includes data from 59 health centers and 29 public hospitals. The primary outcome measures are the use of maternal and child health services, while the secondary outcome measures are the use of health services by adults. The study finds a sharp reduction in both inpatient and outpatient care during the COVID-19 pandemic, particularly in Addis Ababa. However, the use of maternal and child health services remains largely unaffected. The study concludes that concerns about the crowding out of these services due to the focus on COVID-19 are unfounded. The evidence is based on a large sample size and covers a significant period of time. To improve the strength of the evidence, future studies could consider including data from a wider geographic area and conducting a prospective study to assess the long-term impact of the pandemic on healthcare utilization.

Abstract

This study is based on a retrospective cross sectional health facility survey, conducted through phone and internet, which covered four regional states (Tigray, Amhara, Oromia and SNNP) and Addis Ababa city administration. Together, these regions account for 89.5% of the country’s population31 and 85.6% of the COVID-19 cases in the country as per 16 August 2020—the date that data collection commenced.32 Ethiopia confirmed its first COVID-19 case on 13 March 2020 and data collection took place between August and December 2020. At the time of commencing data collection, the bulk of the facilities had collected and validated data up to the end of June 2020 and so for the postcovid period we focused on the 4-month period from March to June 2020. To enable immediate before-after comparisons we gathered information for the 4-month period just prior to COVID-19, that is, November 2019 to February 2020. To avoid seasonal effects, we also gathered data on healthcare use in the 4-month period between March and June 2019. In addition to these 12 months, to enhance longer-term comparisons and avoid criticisms that the time periods have been purposively chosen to augment differences, we collected information for a period of 24 months—that is, July 2018 to June 2020. The plan was to cover 60 health centres and 30 public hospitals while the survey actually covered 59 health centres and 29 hospitals. The regional distribution of the sample was guided by the regional distribution of COVID-19 cases in the country at the end of June 2020 (see figure 1 and table 1). Based on these considerations, the bulk of the sampled facilities were in Addis Ababa which accounted for 73% of COVID-19 cases in June 2020, followed by Oromia (5.6%). There are 91 health centres in Addis Ababa and 44 were randomly chosen for the survey. The city has 12 public hospitals of which 11 were included in the survey (see table 1). Indeed, not only are a majority of the sampled facilities located in Addis Ababa (table 1) but over 60% provide care for COVID-19 infected patients (see online supplemental table A1). Monthly COVID-19 cases in Ethiopia, March to June 2020. SNNP, Southern Nations, Nationalities, and People’s region Share of COVID cases and sample distribution Source: COVID figures are from the National Public Health Emergency Operation Center COVID-19 Situation Reports no. 68, 98, 129, 158. The total number of confirmed cases in the country at the end of June 2020 was 5846. SNNP, Southern Nations, Nationalities, and People’s region. bmjopen-2021-056745supp001.pdf After ensuring that a health facility was willing to participate in the survey, a survey instrument was sent by email to health facility ICT (Information and Communication Technology) workers responsible for facility HMIS. To ensure data quality, discussions to clarify concerns took place with ICT workers throughout the data collection and data cleaning process. From the HMIS, information was culled on monthly inpatient and outpatient visits for 24 months (July 2018 till June 2020). In addition to the total visits, data were collected on specific outpatient services including the gamut of maternal and childcare health services (family planning services (FPS), ANC, abortions, delivery, PNC, immunisation, integrated management of neonatal and childhood illnesses (IMNCI), prevention of mother-to-child HIV transmission care (PMTCT). The survey also included modules to ascertain the level of preparedness and provision of COVID-19-related services, provision of supplies such as personal protective equipment (PPE), measures taken to mitigate the spread of COVID-19 and challenges faced by facilities due to the virus, especially related to absenteeism of healthcare professionals and support staff. Information on facility-level preparations to deal with COVID-19 was provided by facility directors while information on absenteeism was provided by facility human resources officers. Graphs, descriptive statistics and paired non-parametric (Wilcoxon signed-rank) tests of significance which do not assume that the differences between paired samples is normally distributed are used to compare levels of inpatient and outpatient healthcare service utilisation (number of patients per month) before and after the onset and spread of the virus. The analysis of outpatient visits includes data from health centres and public hospitals while inpatient care utilisation is restricted to data from public hospitals as health centres mainly provide outpatient services. In addition to the total visits for healthcare, we also compare the number of visits for different types of mother and child health services such as family planning, ANC, abortion, delivery, PNC, immunisation, IMNCI, PMTCT. we assess absenteeism of hospital staff by comparing the number of staff members that should be in the hospital and the number of staff members that were present on the day of the survey. we test for temporal changes in 14 types of healthcare use and absenteeism. To avoid pitfalls associated with multiple-hypothesis testing, we interpret results, tables 2–5, keeping in mind the Bonferroni correction—that is, we use a p value of 0.003 (0.05/15) to draw inferences rather than the conventional 5% level of significance. Inpatient and outpatient healthcare use A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. SNNP, Southern Nations, Nationalities, and People’s region. Mother and child healthcare use—prebirth and delivery average monthly visits A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. SNNP, Southern Nations, Nationalities, and People’s region. Mother and child healthcare use—postbirth average monthly visits A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. SNNP, Southern Nations, Nationalities, and People’s region. Utilisationof various health services by adults average monthly visits A Bonferroni-corrected p value of 0.003 (0.05/15) is used to interpret results. ART, antiretroviral therapy; SNNP, Southern Nations, Nationalities, and People’s region; TB, tuberculosis. Although we have 2 years of utilisation data, the focus is on the 4-month period, March to June 2020 as compared with healthcare use in the 4-month period March to June 2019. Comparing service use volumes for similar months, as opposed to before and after March 2020, helps to account for seasonal variations in patient flows.33 However, to account for the possibility that year-on-year comparisons may underestimate the extent of the decline, if there is an increase in healthcare utilisation over time, we also compare healthcare use between the 4-month period, March to June 2020 with the 4-month period, November 2019 to February 2020, which precedes the first COVID-19 case in Ethiopia. Additionally, graphs are used to demonstrate year-on-year changes in healthcare use, that is, comparing healthcare use, per month, over the period July 2019–June 2020 to the period July 2018–June 2019. The research questions were developed based on conversations with and concerns about declines in non-Covid healthcare use and health worker absenteeism expressed by healthcare providers in the country’s largest hospital located in Addis Ababa. Suggestions on appropriate comparison periods and the type of healthcare services to be investigated were provided by managers of healthcare facilities. The results have been discussed with and corroborated by healthcare workers at two large hospitals in Addis Ababa.

Materials

Innovations

Based on the information provided, it is difficult to identify specific innovations for improving access to maternal health. However, some potential recommendations could include:

1. Telemedicine and virtual consultations: Implementing telemedicine platforms and virtual consultations can help pregnant women access healthcare services remotely, reducing the need for in-person visits and increasing convenience.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and support for maternal health, such as pregnancy tracking, nutrition guidance, and appointment reminders, can empower women to take control of their own health.

3. Community health workers: Expanding the role of community health workers can improve access to maternal health services, especially in remote or underserved areas. These workers can provide education, support, and referrals to pregnant women, ensuring they receive the care they need.

4. Transportation solutions: Addressing transportation barriers by providing affordable and accessible transportation options for pregnant women can help them reach healthcare facilities for prenatal care, delivery, and postnatal care.

5. Public-private partnerships: Collaborating with private healthcare providers and organizations can help increase the availability and accessibility of maternal health services, especially in areas with limited public healthcare infrastructure.

6. Health information systems: Strengthening health information systems can improve data collection and analysis, enabling better monitoring and evaluation of maternal health services. This can help identify gaps and inform evidence-based decision-making for improving access.

7. Maternal health education and awareness campaigns: Implementing targeted education and awareness campaigns can help increase knowledge and understanding of maternal health issues, encouraging women to seek timely and appropriate care.

It is important to note that these recommendations are general and may need to be tailored to the specific context and challenges faced in Ethiopia. Further research and consultation with local stakeholders would be necessary to determine the most effective innovations for improving access to maternal health in the country.

AI Innovations Description

Based on the description provided, the study found that there was a sharp reduction in the use of both inpatient and outpatient care during the COVID-19 pandemic in urban Ethiopia. However, the use of maternal and child health (MCH) services remained relatively unaffected throughout the period. Some MCH components, such as family planning services and antenatal care, experienced a decline in the immediate aftermath of the pandemic but recovered soon after.

Based on these findings, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Telemedicine and Mobile Health (mHealth) Solutions: Develop and implement telemedicine and mHealth solutions to provide remote access to maternal health services. This can include virtual consultations with healthcare providers, remote monitoring of maternal health indicators, and the delivery of essential medications and supplies to pregnant women in their homes. These solutions can help overcome barriers to accessing healthcare facilities during the pandemic, such as transportation challenges and fear of exposure to the virus.

By leveraging technology, pregnant women can receive timely and appropriate care, including antenatal check-ups, counseling, and support, without the need to physically visit healthcare facilities. This innovation can improve access to maternal health services, particularly for women in remote or underserved areas.

It is important to ensure that these telemedicine and mHealth solutions are accessible to all pregnant women, including those who may have limited access to smartphones or internet connectivity. Collaborations with local community organizations and government agencies can help ensure equitable access to these services.

Implementing this recommendation can help mitigate the impact of the COVID-19 pandemic on maternal health and ensure that pregnant women continue to receive the care they need to have a safe and healthy pregnancy.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Telemedicine and Remote Monitoring: Implement telemedicine services to provide remote consultations and monitoring for pregnant women. This can help reduce the need for in-person visits and improve access to healthcare, especially in rural areas.

2. Mobile Health (mHealth) Applications: Develop and promote mobile health applications that provide information, reminders, and support for maternal health. These apps can help educate and empower pregnant women, as well as provide access to healthcare resources.

3. Community Health Workers: Train and deploy community health workers to provide maternal health services and education at the grassroots level. These workers can bridge the gap between healthcare facilities and remote communities, ensuring that pregnant women receive the necessary care and support.

4. Transportation Support: Establish transportation support systems to help pregnant women reach healthcare facilities, especially in areas with limited transportation options. This can include providing subsidies for transportation or organizing community-based transportation services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as the number of pregnant women accessing healthcare services, the reduction in maternal mortality rates, or the increase in antenatal care coverage.

2. Data collection: Gather data on the current state of maternal health access, including the number of healthcare facilities, the availability of services, and the utilization rates. This can be done through surveys, interviews, or existing data sources.

3. Model development: Develop a simulation model that incorporates the recommendations and their potential impact on the identified indicators. This model should consider factors such as population demographics, geographical distribution, and healthcare infrastructure.

4. Parameter estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This may involve conducting surveys or consulting with healthcare professionals.

5. Scenario analysis: Run the simulation model with different scenarios, varying the implementation levels and effectiveness of the recommendations. This can help assess the potential impact under different conditions and identify the most effective strategies.

6. Impact assessment: Analyze the simulation results to assess the impact of the recommendations on improving access to maternal health. This can involve comparing the indicators before and after the implementation of the recommendations, as well as evaluating the cost-effectiveness of the interventions.

7. Sensitivity analysis: Conduct sensitivity analysis to test the robustness of the results and identify the key factors that influence the outcomes. This can help identify potential risks and uncertainties associated with the recommendations.

8. Policy recommendations: Based on the simulation results, provide policy recommendations on the most effective strategies to improve access to maternal health. Consider factors such as scalability, sustainability, and equity in the implementation of these recommendations.

It is important to note that the methodology described above is a general framework and can be adapted based on the specific context and available data.

Author

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1136/bmjopen-2021-056745

Research Areas:

Community Interventions, COVID, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations

Study Countries:

Ethiopia

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative