As health systems in all countries around the world—regardless of income level—are overwhelmed by the rapid spread of COVID-19, low- and middle-income countries (LMICs) are particularly vulnerable. In places where health systems already struggle to meet all of their population's needs, the stress of COVID-19 is likely to undermine routine health services—from ensuring women can safely deliver babies, access family planning services, and immunize their children, to maintaining lifesaving treatments for malaria, HIV, tuberculosis, non-communicable diseases, and childhood pneumonia.
This vulnerability has played out in past outbreaks and other crises, which have disrupted these essential health services and led to preventable loss of life—especially among the most marginalized communities. For example, during the 2014-2016 West African Ebola outbreak, use of routine health services decreased by an estimated 18 percent. Other researchers estimate that service disruptions resulted in as many as 10,000 additional preventable deaths due to malaria, HIV/AIDS, and tuberculosis, and additional deaths due to measles and other health conditions. The good news is that the countries that fought Ebola have many lessons to share about how to protect these essential health services. Unfortunately, COVID-19 is much more widespread than Ebola, meaning the impact of health service disruption could be much greater. As policymakers around the world face this new challenge, we must all look to the lessons of history in order to do better now.
To ensure continuity of health services, we propose policymakers at every level of governance take three urgent actions:
1. COVID-19 task forces should appoint an “Essential Health Services Coordinator” tasked with:
- Ensuring that COVID-19 response strategies, in particular those related to physical distancing, take steps to protect the delivery of routine health services (vaccination, antenatal care, birth, provision of HIV and TB medications, etc.) and do not unintentionally limit access to services, for example by requiring women in labor to seek permission from local authorities to travel to health facilities.
- Examining and using data from routine health management information systems to identify service disruptions, in as close to real time as possible. Whether data are integrated into COVID-19 dashboards or are accessed separately, what is most essential is that managers across the health system have tools to track service utilization, rapidly investigate the causes of any declines, and take appropriate actions. PATH has developed guidance for how to monitor these data, and we will continue to track guidance and innovative actions taken to protect essential health services during COVID-19—such as repurposing existing community facilities like schools for easy and safe access to preventative care services, or determining how to structure financing to maintain service utilization.
- Liaising daily with health directors, technical working groups, and civil society groups—just as most COVID-19 task forces convene daily “stand-up” meetings—to receive rapid feedback and refine strategies based on data and community feedback. This will enable the Coordinator to make rapid decisions to strengthen COVID-19 responses with a view toward protecting other essential health services.
2. Heads of state, health ministers, and leaders of COVID-19 taskforces should include messages on the importance of continuity of essential health services in their routine public updates on the status of COVID-19.
It is key that all citizens are aware and informed that they should continue to seek essential health services. Leaders could also provide examples of actions taken to protect non-COVID patients.
3. Normative and technical agencies, including WHO regional offices, UNICEF, and Africa CDC, should quickly provide contextualized programmatic and operational guidance for low and middle income countries.
While there are many resources and guidelines for policymakers in high-income settings, there is currently an insufficient amount of guidance tailored to low-resource settings. The most urgent needs include:
- Ways to provide all health workers, including community health workers, with personal protective equipment (PPE) to enable them to keep providing services while also protecting themselves and their families.
- Context-specific strategies to protect the most vulnerable segments of society, considering the infeasibility, negative health impacts, and economic consequences of lockdown policies.
- Context-specific guidance on the use of community health workers in COVID-19 response efforts, given the central role they play in LMICs for delivery of critical primary health services.
- Improved guidance and operational support to ensure clear and accurate communication about how populations can access essential services during COVID-19.
As decision-makers in low- and middle-income countries must act fast to respond to the COVID-19 pandemic, it is crucial that they have easy access to the best guidance and learnings—tailored specifically to their contexts—to inform the efficient design of effective policies. Recognizing guidance has been shared by various agencies but is not, to our knowledge, assembled in one place for policymakers, practitioners, and other health stakeholders, PATH has compiled guidance and model language from across many sources into one resource page to equip and inform low- and middle- income country responses to COVID-19.
