The impact of COVID-19 and national pandemic responses on health service utilisation in seven low- and middle-income countries

Figures & data

Table 1. National- and district-level features of countries in the study on health service utilisation during the COVID-19 pandemic, 2020–2021.

Feature	Haiti	Lesotho	Liberia	Malawi	Mexico	Rwanda	Sierra Leone
Overview of participating Partners In Health locations
Local organization name	Zanmi Lasante	Bo-mphato Litsebeletsong Tsa Bophelo	Partners In Health Liberia	Abewenzi Pa Za Umoyo	Compañeros En Salud	Inshuti Mu Buzima	Partners In Health Sierra Leone
Supported districts included in this study	Central plateau and lower Artibonite	Mohale’s Hoek, Thaba Tseka, Mokhotlong, and Qacha’s Nek	Harper, Pleebo, and Karluway 1	Neno	Sierra and Fraylesca Regions, Chiapas	Burera, Kayonza, and Kirehe	Kono
# health facilities reported on	14	7	4	15	12	50	2
Health services data source	Internal PIH database	Internal PIH database	DHIS-2	DHIS-2	OpenMRS EMR (outpatient visits); Excel spreadsheets (facility-based deliveries and family planning)	DHIS-2	Internal PIH database
National COVID-19 situation through December 31, 2021
First COVID case, 2020 [24]	March	May	March	April	March	March	March
Cumulative COVID-19 cases, per million people [25]	2,251	13,734	1,212	3,859	30,622	8,485	874
Cumulative case fatality rate, % [26]	2.95	2.26	4.57	3.12	7.51	1.20	1.73

PIH: Partners In Health; DHIS-2: District Health Information System-2.

Figure 1. Estimated percent deviation in outpatient visits (difference in observed count from expected in black with 95% prediction interval in grey), by month and country, March 2020 – December 2021.

Table 2. Cumulative deviation in health service utilisation from baseline (January 2016 – February 2020) during the study period (March 2020 – December 2021).

Country, indicator	Cumulative observed counts (true value)	Cumulative deviation from expected counts (95% Prediction Interval)	Cumulative percent deviation (95% Prediction Interval)
Haiti
Outpatient visits	1,539,840	−13,198.0 (−107,119.0, 75061.1)	−1.4% (−10.3%, 8.7%)
Deliveries in health facilities	38,216	−4,472.0 (−6,209.7, −3,012.5)	−16.6% (−21.6%, −11.8%)
Family planning services	13,653	436.5 (−1,204.1, 1,795.0)	5.3% (−12.1%, 26.0%)
Lesotho
Outpatient visits	60,837	−25,086.5 (−30,016.9, −21,240.7)	−38.9% (−43.2%, −35.0%)
Deliveries in health facilities	1,509	−126.0 (−257.5, −10.0)	−11.4% (−20.9%, −1.0%)
Family planning services	17,427	−782.0 (−2,145.7, 348.4)	−6.3% (−15.5%, 3.1%)
Liberia
Outpatient visits	131,538	−17,641.5 (−29,557.4, −8,792.4)	−18.6% (−27.7%, −10.2%)
Deliveries in health facilities	3,306	−187.0 (−441.1, 14.0)	−8.7% (−18.3%, 0.7%)
Family planning services	37,754	−6,776.5 (−15,274.3, 303.3)	−21.5% (−38.1%, 1.2%)
Malawi
Outpatient visits	530,054	−95,520.0 (−159,718.9, −46,299.8)	−21.6% (−31.6%, −11.8%)
Deliveries in health facilities	8,912	−86.5 (−458.6, 240.2)	−1.5% (−7.4%, 4.4%)
Family planning services	2,435	245.5 (−99.3, 493.0)	19.2% (−6.1%, 47.8%)
Mexico
Outpatient visits	31,019	−2,544.0 (−5,210.6, 9.4)	−11.2% (−20.5%, 0.0%)
Deliveries in health facilities	1,095	−116.5 (−218.0, −21.0)	−14.7% (−24.3%, −3.0%)
Family planning services	1,151	−140.0 (−442.5, 55.6)	−17.9% (−40.8%, 9.5%)
Rwanda
Outpatient visits	1,973,750	−167,037.5 (−219,404.4, −121,458.3)	−11.8% (−15.0%, −8.9%)
Deliveries in health facilities	45,205	−746.0 (−1,553.6, 28.1)	−2.6% (−5.3%, 0.1%)
Family planning services	2,897,781	−3,191.5 (−46,417.2, 39083.4)	−0.2% (−2.4%, 2.1%)
Sierra Leone
Outpatient visits	117,982	−50,380.0 (−60,915.5, −41,793.1)	−41.5% (−46.2%, −37.1%)
Deliveries in health facilities	4,610	−504.0 (−748.6, −301.8)	−15.7% (−21.6%, −10.0%)
Family planning services	NA	NA	NA

Figure 2. Estimated percent deviation in deliveries in health facilities (difference in observed count from expected in black with 95% prediction interval in grey), by month and country, March 2020 – December 2021.

Figure 3. Estimated percent deviation in family planning services (difference in observed count from expected in black with 95% prediction interval in grey), by month and country, March 2020–December 2021.

*Both facilities in Sierra Leone were excluded for family planning (see Methods)

Table 3. Relationship between the average monthly stringency index (fixed effect) and estimated deviation in health service utilisation, adjusted for country (random effect) and 1-month lagged monthly COVID-19 cases per 1,000 people (fixed effect).

Outcome	Regression type	Indicator	Stringency index beta coefficient (95% CI)	p-value
Estimated proportion deviation	Linear	Outpatient visits	−0.0039 (−0.0051, −0.0016)	0.0002*
		Deliveries in health facilities	−0.0011 (−0.0023, 0.0004)	0.0578
		Family planning services	−0.0005 (−0.0028, 0.0026)	0.9721
Binary indicator for a significant decrease in utilization (below 95% PI)	Logistic	Outpatient visits	0.0472 (0.0137, 0.0807)	0.0057*
		Deliveries in health facilities	−0.0012 (−0.0275, 0.0251)	0.9288
		Family planning services	−0.0272 (−0.0751, 0.0207)	0.2652

*Indicates a p-value below the 0.05 significance-level cutoff.

Hale T, Anania J, de Mello BA, Angrist N, Barnes R, Baby T, et al. Variation in government responses to COVID-19. Vol. 13. Oxford: Blavatnik School of Government Working Paper; 2022. DOI:10.25259/SNI_432_2022.

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Data availability statement

Data from this study may be shared upon reasonable request to the corresponding author and approval from country-teams.