Introduction The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide. Maintaining essential health services, including maternal and child health (MCH), while addressing the pandemic is an enormous task. This study aimed to assess the impact of the COVID-19 pandemic on the utilisation of MCH services in Malaysian public primary care.
Methods A retrospective analysis was conducted using national administrative data from 1124 public primary care clinics. Eight indicators were selected to measure service utilisation covering antenatal, postnatal, women’s health, child health, and immunisation services. Interrupted time-series analysis was used to evaluate changes in levels and trends of indicators during four different periods: pre-pandemic (January 2019–February 2020), during pandemic and first lockdown (March–May 2020), after the first lockdown was lifted (June–December 2020) and after the second lockdown was implemented (January–June 2021).
Results Most indicators showed no significant trend in monthly utilisation prior to the pandemic. The onset of the pandemic and first lockdown implementation were associated with significant decreasing trends in child health (−19.23%), women’s health (−10.12%), antenatal care (−8.10%), contraception (−6.50%), postnatal care (−4.85%) and postnatal care 1-week (−3.52%) indicators. These indicators showed varying degrees of recovery after the first lockdown was lifted. The implementation of the second lockdown caused transient reduction ranging from −11.29% to −25.92% in women’s health, contraception, child and two postnatal indicators, but no sustained reducing trend was seen afterwards. Two immunisation indicators appeared unaffected throughout the study period.
Conclusion The COVID-19 pandemic significantly impacted MCH services utilisation in Malaysia. While most MCH services were negatively affected by the lockdown implementation with varying degrees of recovery, infant immunisation showed resilience throughout. This highlights the need for a targeted preparedness plan to ensure the resilience of MCH services in future crises.
- child health
- maternal health
Data availability statement
No data are available.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Many countries across the globe reported disruption in essential health services utilisation, including maternal and child health services, during the COVID-19 pandemic period.
Similar disruptions in essential health utilisation were also seen in previous disease outbreaks.
Minimal data has been published on the impact of COVID-19 responses on maternal and child health (MCH) services in Malaysia.
WHAT THIS STUDY ADDS
Antenatal, postnatal, women’s health and general child health services were negatively affected by the COVID-19 pandemic and the implementation of lockdowns.
Infant immunisation services showed no notable increase or decrease throughout the study period.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Continuous monitoring of the affected services recovery and necessary intervention is crucial to ensure the country’s reinstatement of essential health services.
Early identification of susceptible services will allow targeted policy intervention in future disease outbreaks.
Identification of resilient services will facilitate inter-service learning of best practices to improve MCH services as a whole.
Primary care services in Malaysia, encompassing the full spectrum of care from womb to tomb, serve as the cornerstone of healthcare services for the majority of the population. The services are provided by both public and private sectors, where the public primary care clinics are mainly governed by the Ministry of Health (MOH). In contrast, private primary care clinics are privately owned practices subjected to government regulations.1 Within the realm of primary care, maternal and child health (MCH) services have experienced substantial growth since its inception in the 1950s, which was pivotal in the impressive decline of the country’s maternal mortality ratio over the decades.2 The MCH services in MOH primary care clinics, which cover about 95% of the country’s MCH services,3 are provided by health clinics (HC), standalone maternal and child health clinics (MCHC), and rural or community clinics which are attached to a specific main health or MCHC. The MCH services cover antenatal care, intrapartum care in a few facilities, postnatal care, women’s health (cancer screening, contraception) and child health (growth and development monitoring, nutritional assessment, immunisation and curative care). These services are also provided beyond the clinics in the form of home visits and outreach community activities4 and do not include school-based immunisation activities. In terms of utilisation of public-private primary care services, even though the number of private practices outweighs public clinics,5 6 higher patient visits were recorded in public clinics,7 where MCH services attendance in MOH primary care clinics accounted for more than 95% of the national attendance.3
COVID-19 has caused more than 5 million cumulative cases of infection and more than 36 000 deaths in Malaysia.8 The first national lockdown was declared on 18 March 2020, which overlapped with the global declaration of COVID-19 as a pandemic, as part of mitigation measures to curb the spread of the disease. Malaysia implemented several other series of lockdowns throughout the 3 years of the pandemic with varying degrees of restrictions. Health services delivery was adjusted to respond to the new challenges posed by the pandemic, and at the same time, maintain access to healthcare services. Across the globe, finding a balance between the two has tremendously tested the resiliency of our health systems, particularly the primary care system as the first contact to healthcare.9
During a crisis, a resilient health system has the ability to adequately respond to the crisis and maintain other essential health services at the same time.10 11 Following the Alma Ata Declaration, the term essential healthcare was coined to cover individual, family and community healthcare.12 Like any other country globally, Malaysia put onerous effort into maintaining essential health services while handling the COVID-19 pandemic. This was in line with the WHO recommendation at the start of the COVID-19 pandemic, highlighting the importance of maintaining essential health services despite the increasing burden that COVID-19 put on a country’s health systems.13 Monitoring essential health services utilisation during a crisis as one of the facets of healthcare accessibility is crucial, and WHO suggested a list of indicators to be observed in assessing the maintenance of essential health services.13 Many of these services are provided in a primary care setting, including outpatient and MCH services. Despite abundant efforts to maintain essential health services throughout the pandemic, many countries experienced significant declines in essential health utilisation, including MCH services,14–20 similar to the collateral damages seen during previous disease outbreaks.21
This study aimed to assess the impact of the COVID-19 pandemic on the utilisation of essential health services related to MCH services in Malaysia by comparing key indicators between four different periods: before the pandemic, during the pandemic and implementation of the first lockdown, after the first lockdown was lifted, and after the implementation of second lockdown. This analysis will provide input in determining the resilience of the country’s healthcare system during the COVID-19 crisis within the scope of MCH services and direct focuses or resource allocation for future improvement.
This retrospective study analysed national administrative data on the utilisation of public primary care facilities throughout the country with 1124 public primary care clinics categorised as HC or MCHC were included. The number of facilities included in this study differs from the official number of 1142 HC and MCHC in 20215 as it only covered facilities that reported data for the outcome variables identified.
The indicators to measure MCH services utilisation were adapted from the extensive list of WHO sample indicators for monitoring the maintenance of essential health services during the COVID-19 pandemic.13 Eight MCH indicators were selected by an expert panel, stakeholders and research team members based on relevance to local context and data feasibility, where these eight indicators collectively cover the majority of MCH services utilisation in Malaysia’s primary care. The complete list of indicators included in the study is shown in table 1.
The data for antenatal care clinic attendance (ANC), postnatal care clinic attendance (PNC), women’s health and child health indicators were derived from national administrative data available from the Family Health Development Division, MOH that was manually submitted monthly by each state health department. Data for indicators PNC 1 week, contraception, diphtheria, tetanus and pertussis (DTaP) and measles, mumps and rubella (MMR) were obtained from all state health departments as these data were not routinely reported on a monthly basis at the national level. The data were obtained as monthly aggregates at the facility level for 30 months from January 2019 until June 2021 and does not include individual patient data or variables. These databases were used by the MOH for official statistics and reporting for various national and state-level performance indicator measurements.
Data were entered into Microsoft Excel and exported to STATA V.17 (Stata Corp, College Station, TX, USA) for further analysis. Data were cleaned prior to analysis based on the latest facility registry which is anchored on a unique facility ID. Data that appeared missing, illogical or inconsistent was verified with the data owner for manual checking of raw data and respective correction at the state or national database if required. The temporal data of MCH services utilisation throughout the 30 months was divided into four unique periods: (i) pre-pandemic period (January 2019–February 2020); (ii) pandemic period when the first lockdown was implemented (March–May 2020); (iii) pandemic period after the first lockdown was lifted (June 2020–December 2020) and (iv) pandemic period when the second lockdown was implemented (January–June 2021).
Descriptive statistics were used to summarise the trend across the four periods, expressed as mean and SD. We used interrupted time-series (ITS) analysis for further analysis, where this analysis has been found valuable in evaluating the impact of population-level health interventions with a clearly defined time point.22 The ITS analysis using the ordinary least square (OLS) regression method with Newey-West SEs was conducted using the STATA user-written programme, itsa.23 The programme estimates the effects of lockdowns following the COVID-19 pandemic on MCH utilisation in Malaysia and can handle possible autocorrelation and heteroskedasticity in the dataset concurrently. The estimate coefficients were presented as percentage change by exponentiating the coefficients from the regression of log-transformed outcome variables. Cumby-Huizinga general test for autocorrelation was also performed using a post-estimation programme, actest,24 to assess any residual autocorrelation in the error distribution. Given that residual autocorrelation existed, regression using the generalised least square method (Prais regression model) was used instead of OLS (Newey model).
The first lockdown implemented in March 2020 was defined as the first intervention, the lifting of the first lockdown in June 2020 was defined as the second intervention, and the second lockdown implemented in January 2021 was defined as the third intervention. The March–June 2020 period covered the official Movement Control Order 1.0 and Conditional Movement Control Order 1.0.25 During these two conditions, the movement restrictions in Malaysia were at the strictest nationally compared with subsequent local movement control orders during other periods. January 2021 indicated the implementation of Movement Control Order 2.0 (MCO 2.0), which involved 6 out of 14 states in the country. Although the MCO 2.0 was not nationally implemented, the average mobility trend of the population was generally reduced at the national level26; hence, it is considered as one of the interruption points in our analysis.
The regression model assumes the following formula:
Yt is the aggregated outcome variable measured at each equally spaced time point t.
β0 represents the estimated outcome variable at the beginning of the pre-pandemic period.
β1 is the slope (trend) of the outcome variable over the pre-pandemic period.
Tt represents the time since the start of the study.
β2 represents the level of change in the outcome variable immediately after the implementation of the first lockdown in March 2020, which is represented by Xt.
Xt is the indicator variable representing the first intervention.
β3 represents the difference in slopes of the outcome variable between the pre-pandemic and first lockdown period.
XtTt is an interaction term (first intervention).
β4 represents the level of change in the outcome variable immediately after the lifting of the first lockdown in June 2020, which is represented by St.
β5 represents the difference in slopes of the outcome variable between the pandemic period during the first lockdown period and after lifting of the first lockdown period.
St is the indicator variable representing the second intervention.
StTt is an interaction term (second intervention).
Β6 represents the level of change in the outcome variable immediately after the implementation of the second lockdown in January 2021, which is represented by Zt.
β7 represents the difference in slopes of the outcome variable between the pandemic period after lifting of the first lockdown and the second lockdown period.
Zt is the indicator variable representing the third intervention.
ZtTt is an interaction term (third intervention).
ϵt represents the error term.
This approach allows for an estimation of changes in levels and trends for each outcome variable following multiple interventions, expressed in percentage change and 95% CI. The visual presentation of the different parameters is shown in figure 1.
Patient and public involvement
No patients were involved in this study. We used secondary aggregated routine health information data available from the MOH, Malaysia.
Table 2 gives an overview of the monthly averages for all eight MCH indicators during the four different periods studied. The monthly averages for ANC, PNC, women’s health, contraception and child health indicators were highest during the pre-pandemic period, whereas the averages for PNC 1 week, DTaP and MMR indicators were highest after the first lockdown was lifted. All indicators had the lowest monthly average during the first or second lockdown. The number of postnatal 1 week mothers with at least two visits showed a higher average than postnatal care visits to the clinic during all three periods.
More detailed insights on the changes in each indicator across the four different periods from the ITS analyses are in table 3, figure 2 and online supplemental table 1. During the pre-pandemic period, all except PNC and contraception indicators showed no significant changes in their monthly utilisation. The contraception indicator showed an increasing trend of 0.66% (0.19% to 1.13%) per month, which equals an additional 588 women receiving oral or injectable contraception monthly (online supplemental table 1). The PNC indicator showed a decreasing trend of −1.43% (−1.98% to −0.88%) per month.
Immediately after the first lockdown implemented in March 2020, a significant decrease was seen in the child health indicator (−16.91%, CI −30.72% to −0.35%), whereas the PNC indicator showed a significant increase (6.50%, CI 3.15% to 9.96%). No significant changes were seen in other indicators. During the subsequent months of the first lockdown, from March until May 2020, all indicators except DTaP and MMR showed a decreasing trend. The reduction in child health attendance was the greatest, decreasing by 19.23% monthly (CI −29.63% to −7.30%), followed by women’s health (−10.12%, CI −13.83% to −6.25%), ANC (−8.10%, CI −8.30% to −7.91%), contraception (−6.50%, CI −9.24% to −3.69%), PNC (−4.85%, CI −5.04% to −4.66%) and PNC 1 week (−3.52%, CI −3.55% to −3.48%). The DTaP and MMR indicators did not experience any significant changes throughout the first lockdown period.
Immediately following the lifting of the first lockdown in June 2020, all indicators except DTaP and MMR showed significant increases in their levels. These increases were sustained until just prior to the second lockdown implementation across three indicators: child health (2.64%, CI 1.55% to 3.74%), women’s health (1.25%, CI 0.48% to 2.02%) and PNC 1 week (0.68%, CI 0.48% to 0.88%). The rest of the indicators showed no significant increasing or decreasing trend after lifting of the first lockdown, prior to the second lockdown implementation.
As the second lockdown was implemented in January 2021, the PNC, PNC 1 week, women’s health, contraception and child health indicators showed decreases in their levels, ranging from 11.29% to 25.92% reductions. The ANC, DTaP and MMR indicators showed no significant changes in January 2021. In the subsequent months after the second lockdown implementation, no indicators showed a reducing trend after the initial drops in January 2021. Instead, PNC 1 week and MMR indicators showed a significant increasing trend: 3.83% (1.52% to 6.19%) and 2.42% (0.14% to 4.75%), respectively, while others showed no significant change.
Previous publications by the WHO provided an overview of the self-reported changes in various aspects of healthcare services in countries across the world during the COVID-19 pandemic,27 28 and this study provides quantifiable evidence of the changes occurring in Malaysia. This study demonstrated that some indicators in the MCH services were adversely affected by the pandemic and the lockdowns that came with it. In contrast, some other indicators were resilient and not affected. The ANC, PNC, PNC 1 week, women’s health, contraception and child health indicators were susceptible to the implementation of the first lockdown by showing significant declines in level or trends of utilisation but recovered well towards pre-pandemic level after the first lockdown was lifted. The varying degrees of recovery of these indicators could be due to different post-lockdown emphases where services with more profound declines during the lockdown were given more attention for catch-up services. Subsequently, these indicators were briefly affected by the implementation of the second lockdown; however, the reduction during the following months was not sustained, and no significant reducing trend was observed afterwards. The DTaP and MMR immunisations were astonishingly resilient and unaffected by the implementation of lockdowns during the pandemic, where no significant reduction was observed throughout the study period.
The precipitous reduction in the utilisation of antenatal, postnatal and family planning services immediately following the lockdown measures was commonly seen across the world.17 18 27 29–40 Many studies identified fear of contracting the disease, lack of access to transportation, increased transportation cost and cost to purchase PPEs as the most described barriers to MCH services utilisation during this period,19 41–43 besides limited service availability during the crisis. Although the decreasing trend of Malaysia’s population birth rate throughout the study duration44 may partly explain the reduction in pregnancy-related services utilisation, a more acute interruption has caused abrupt changes in the utilisation level. Malaysia’s national lockdown had imposed the closure of schools and non-essential shops and restrictions on non-essential travel beyond a 10 km radius with a limited number of people allowed to travel in a vehicle.45 The general difficulty to travel created by the lockdown measures and fear of contracting COVID-19 reduced the demand for healthcare utilisation in these early months27 even though attending health appointments was considered as essential travel.
On the supply side, public healthcare facilities in Malaysia imposed various measures to decongest the healthcare facilities in curbing the local transmission of COVID-19 cases. These included compulsory fully appointment-based visits as opposed to the hybrid of appointment and walk-in system, rescheduling patients’ appointments to limit the number of crowds at a particular time in the facility, causing longer appointment intervals, and reducing appointment frequency, especially in the well-child clinic. More supply of medication or oral contraceptive pills were also given to patients, hence reducing visit frequency.25 A prioritisation may also have been given to a more acute service over presumed less essential monitoring services such as child growth and nutrition that constituted a large proportion of child health services, which may have caused the more profound declines in child health services. Some resource diversions, such as the deployment of manpower from primary to hospital care or COVID-19 crisis centres, also occurred during the pandemic period.25 The triaging of different health services in identifying prioritised services was one of the most common responses seen in most countries in managing service disruption due to COVID-19,27 and other studies had also identified services involving young children as the most affected as compared with other services.19 46 47 In a dual healthcare system like Malaysia, it is arguable that patients from the public sector were redirected to the private sector to compensate for the overstretched public sector facilities.25 However, the utilisation of private primary care clinics in Malaysia during the pandemic was also markedly reduced, as reported in media and other preliminary studies,48 49 indicating that utilisation was reduced nationally.
COVID-19 is arguably perceived as an opportunity to reduce unnecessary healthcare that existed before the pandemic, especially for young children.20 50 51 Malaysia’s under-5 mortality rate in the pandemic year 2020 (6.9) and 2021 (7.4) was notably lower than in the pre-pandemic year 2019 (7.7),52 53 even though child health services utilisation was reported to be greatly reduced during the pandemic period. This, however, does not conclude that the child health services provided in the pre-pandemic era were largely unnecessary, as distinguishing populations who have missed necessary care from those who have avoided unnecessary care requires sensitive and distinct analyses, with crucial adjustment for multiple potentially confounding factors.20
As for pregnancy-related services, Malaysia’s maternal mortality ratio showed an increasing trend: 21.1 in 2019, 24.9 in 2020 and 68.2 (including COVID-19 deaths) in 2021.52 53 Even after removing COVID-19-related cases, maternal deaths were still higher during the pandemic years when there were 128 deaths in 2021 and 117 deaths in 2020 compared with 103 deaths in 2019.52 53 The increasing maternal mortality during the COVID-19 pandemic was also seen across the globe, even in developed and high-income countries.54–57 In Malaysia, this phenomenon cannot be merely explained by the reduced utilisation of pregnancy-related services. Although there were significant reductions in utilisation of these services throughout the study period, high coverage for antenatal care services was maintained during the pandemic, where the estimated national antenatal coverage for new mothers attending clinics was 101.59% in 2021,3 and a national population survey in 2022 reported 98.1% mothers had at least four ANC visits.58 The reduced utilisation of pregnancy-related services also resonates with the reducing crude birth rate throughout the study period: 15.1 (2019), 14.5 (2020) and 13.5 (2021) per 1000 population.44 The increasing maternal mortality despite high coverage of antenatal care highlighted the importance of ensuring high-quality services during every point of care throughout the antenatal, intrapartum and postnatal period as the renowned strategies to reduce maternal mortality.59–61 This echoed The Lancet Global Health Commission and The United Nations Population Fund (UNFPA Malaysia) reports, which highlighted the suboptimal quality of care, instead of inadequate access, as the bigger barrier to improving health outcomes62 63 even in the absence of a pandemic. The presence of COVID-19 aggravated the situation where the quality of care is further jeopardised due to compromised inputs (eg, appropriate manpower, equipment and infrastructure) and processes (eg, appropriate examination, investigations and consultations) that are necessary for a good quality of care.64–67
Our study reported astonishing resilience in the DTaP and MMR indicators throughout the 18-month pandemic, although there was a sizeable decline in general child health services utilisation. This reflected the effectiveness of the MOH policies in maintaining the provision of immunisation at primary care clinics where infant immunisations were considered business-as-usual throughout the pandemic period. Globally, many countries had seen disruptions in routine immunisation coverage and services,14–16 with lower/middle-income countries suffering more than high-income countries,16 although some countries do report resilience,68 69 similar to our study findings. Several factors were identified as facilitators in maintaining routine vaccinations during the pandemic, including parents’ awareness of the importance of routine vaccinations and healthcare access, stakeholder education on routine vaccinations outweighing the risk of COVID-19, and adaptation of health facilities on COVID-19 safety measures that enable a safe environment for patients attending facilities.41 70 Infant immunisations were also more preserved during the COVID-19 pandemic as compared with older toddler immunisation,69 71 indicating that parents or guardians prioritised the vaccination of the infants.15
It is important to note that the national immunisation coverage for DTaP (booster) and MMR in 2020 was slightly reduced as compared with 2019, from 98.39% (2019) to 97.68% (2020) for DTaP and from 97.67% (2019) to 97.42% (2020) for MMR,5 6 although these figures surpass the WHO’s target of 85% immunisation coverage. Since our study only included MOH health clinics, reductions in infant immunisations may occur in other healthcare facilities in the country, such as private health clinics. Private healthcare facilities were more susceptible to a decline in vaccine delivery services during a pandemic as compared with publicly funded healthcare.16 Nevertheless, the majority of infant immunisation delivery in Malaysia occurred in public health facilities,3 which provide the service for free and are available throughout the nation, including mobile services for remote areas. This is consistent with other low/middle-income countries where the public sector accounted for 83%–99% of immunisation delivery in a country.72
The apparent reduction in essential healthcare services in the country calls for continuous monitoring of the long-term impacts of this reduced healthcare utilisation and better preparedness to reduce the compromise of essential health services in future health crises.20 Some of the evident policy responses to address the disruptions in essential healthcare utilisation during the pandemic include reconfiguration of primary healthcare delivery, investment in essential public health functions, and leveraging on digital tools and systems.73 74 Expanding home-based programmes and telemedicine use in primary care delivery will help to ensure continuity of high-quality care for all patients despite increasing pandemic burden.74–76 These strategies should be coupled with clear and straightforward public campaigns using multiple media platforms to urge people to seek medical care when needed and control over-exposure to news to alleviate fears of seeking care in society.77 All in all, these measures resonate with the call to strengthen primary healthcare and a whole-of-government and society approach in ensuring health system resilience.73
The findings from our study call for many future research and exploration. Studies to explore patient outcomes such as pregnancy complications, neonatal outcomes and young children morbidity may help to answer the question of what happened to our patients as the utilisation of primary care services reduced. The varying susceptibility of different MCH services during the pandemic period calls for investigation of barriers and facilitators to service resiliency, which will aid in improving the health system preparedness in the future. Rigorous qualitative explorations of patient factors influencing healthcare services uptake are also important to explain the varying utilisation across the services. Finally, distinguishing and addressing genuine unmet needs from unnecessary care is a complex but beneficial study area to be further explored.
Strengths and limitations
This study uses national-level data from all public health clinics in the country, obtained through manual submission to MOH Malaysia’s administrative database. This limits the capacity of the study to provide real-time analysis in the monitoring of MCH services utilisation throughout the pandemic period. There is a slight chance of under-reporting as our data covered 98.4% of the officially published total number of facilities. Those excluded facilities may have provided the services; however, the utilisation was not captured. This study did not include MCH utilisation data from non-MOH health clinics, such as the army or university clinics and private sectors, which contributed to about 5% of MCH primary care utilisation annually.3 We also did not include other potential independent variables in the analyses, such as curfew time, mobility, and COVID-19 incidence or mortality rate that may affect healthcare utilisation. Although we captured the changes in MCH services utilisation associated with the pandemic and lockdowns, other factors might have resulted in the observed changes. Our time-series study also could not account for further interventions after the second lockdown, such as the lifting of the second lockdown (March 2021) and the implementation of the third lockdown (June 2021), due to insufficient data points.78 Despite these limitations, continued monitoring and analysis of essential health services utilisation post-pandemic is crucial to ensure all components of the health systems are recovering on the right track.
Our analyses of the MCH primary care utilisation indicators revealed variations in the trend and magnitude of effects caused by COVID-19. All indicators except the infant immunisation indicators showed varying degrees of susceptibility to the national restriction imposed in response to the pandemic. These findings highlighted the importance of diligent monitoring and immediate mitigation responses to maintain essential health services throughout a health crisis in minimising detrimental collateral damages from other diseases. These damages might be associated with the shift of focus and resources to combat the ongoing public threat, such as COVID-19, compromising the maintenance of essential health services such as MCH. The identification of MCH indicators that are susceptible or resilient is vital for targeting interventions and prioritising resources to minimise the risk of further collateral damages as COVID-19 subsides. It also provides an opportunity to implement the best-practices learning process from the resilient indicators or services.
Data availability statement
No data are available.
Patient consent for publication
This study received ethical approval from the Medical Research and Ethics Committee (MREC) (KKM/NIHSEC/P20-1586) Ministry of Health, Malaysia.
We would like to thank the Family Health Development Division and liaison officers from all states in Malaysia for access to the data for this study, Dr Asnida Anjang Ab. Rahman and Dr Majdah Mohamed for reviewing the draft, and the Director General of Health Malaysia for permission to publish this article.
Handling editor Seye Abimbola
Contributors IRMU was involved in designing the study, data acquisition, analysis and interpretation, and wrote the first draft and revisions of the article. NH and JAH were involved in the acquisition, analysis and interpretation of data and writing of the first draft. SA was involved in conceptualising the research project and provided oversight of the project. NWZ was involved in the initial design of the study and the acquisition of the data. RSupadi and RSooryanarayana were involved in the acquisition of data. NEM was involved in the interpretation of data and conceptualisation of the draft. All authors declare that they participated in the process of revising the drafts and approved the final version of the manuscript. IRMU accepts full responsibility for the finished work and the conduct of the study, had access to the data, and controlled the decision to publish.
Funding This publication was produced as part of a research study titled Impact of COVID-19 pandemic on healthcare accessibility in Malaysia (NMRR-20-989-54777), funded by the Ministry of Health, Malaysia.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.