Demand-side drivers of broader health system and health impacts
| Driver | Additional explanation |
| Fear of infection | Individuals needing care, caregivers and HCWs may reasonably fear contracting COVID-19 at or in transit to health facilities or transmitting it to loved ones. Without adequate resources to protect themselves (personal protective equipment and clean water), HCWs may also refuse to work; in Nigeria, there were reports of HCWs refusing to handle TB testing samples because of fear they may be COVID-19.55 |
| Fear of quarantine or isolation | Qualitative evidence suggests the consequences of being found to have COVID-19 may be perceived to be worse than not receiving care for it or other conditions. Quarantine and isolation may mean separation from security, income and family, including others needing care. In Uganda, some people did not seek medical care from hospitals, fearing being put into quarantine if found to have COVID-19.56 |
| Fear of punishment or violence | Fear of harassment, violence, fines or imprisonment for disobeying restrictive measures may impact health seeking or provision. After the brutal beating of a driver transporting a pregnant woman to hospital after curfew in Kenya, it became difficult for women to find transport.46 Enforcers may also use the pandemic as pretext to harass already vulnerable LGBTQI people or sex workers, making it difficult or dangerous for them to travel to services.57 58 |
| Increased caring responsibilities | Carers—mainly women—may be forced to leave their jobs (if they have not already lost them) to provide care for children and elders in the wake of school, nursery and support service closures. They may also be reluctant or unable to leave them home, or bring them along for fear of exposing them to COVID-19 while attempting to access services for themselves.59 |
| Loss of income | Income losses due to unemployment may make it harder for people to travel to, or to pay for health services for themselves or loved ones. Evidence from the Democratic Republic of Congo suggests recent falls in family planning service use are more attributable to lack of money than fear of contracting COVID-19.60 |
| Stigma | People with stigmatising conditions such as HIV may hesitate to access care through new pathways for fear of having their status revealed. Mistrust of digital platforms or inability to engage with a familiar doctor may discourage care-seeking. HCWs are also vulnerable to stigma, if perceived as a source of infection. Resulting abuse adds to immense psychological stress, intense work pressure and fear of infection.61 62 |
| Difficulty adhering to treatment | Uncomfortable side effects can make it difficult for patients to take drugs for certain conditions (eg, TB and HIV) without support. Lack of food can increase this difficulty as it can exacerbate side effects like vomiting, which also diminishes drug effectiveness. Increased food prices and loss of income has made it difficult for LGBT+ people living with HIV in Uganda to buy food—the fever, headaches and weakness the drugs cause on an empty stomach make it difficult to sustain treatment.57 |
HCW, healthcare worker; LGBT+, lesbian, gay, bisexual and transgender/transsexual; LGBTQI, lesbian, gay, bisexual, transgender, queer and intersex; TB, tuberculosis.