Driver | Additional explanation |
Disruptions to medical supply chains | Global and local medical supply chains stopped or slowed activity as production, transport routes and border controls have been disrupted, resulting in shortages, delays and stockouts of essential health resources, including contraceptives,38 antimalarials,39 antiretrovirals40 and vaccines,41 with import-reliant countries being particularly vulnerable. |
Transportation challenges | HCWs, informal carers and those requiring care may be unable to travel to deliver or receive it if transport systems are disrupted. A ban on motorcycle taxis in Uganda, for instance, relied on especially by poor and rural people, made it difficult for them to reach facilities.42 Several pregnant women died after attempting to walk to reach care.43 |
Facility closures | Both public and private health facilities have been intentionally closed, often due to lack of resources to continue operating safely (clean water, disinfectant, personal protective equipment and COVID-19 outbreaks among staff). In Karachi, Pakistan, 18% of child immunisation facilities closed during lockdown.44 |
Resource diversion | Closures or service reductions may also occur due to resources, including staff and facilities, being diverted/repurposed for COVID-19 response. A survey found that 20% of labs normally supporting TB and HIV diagnostics across 106 countries experienced severe disruption as they pivoted to focus on COVID-19.45 In Kenya, Iraq and Honduras, facilities and hospitals where pregnant women have traditionally given birth, if not shut down, were converted.46 |
Funding shortfalls | Governments and organisations reliant on aid to operate health services struggled as donors failed to provide funds, particularly at the grassroots.47 In Yemen, resource diversions and cuts to acute malnutrition services resulted in nearly 30 000 fewer children a month receiving life-saving care.48 Only 17% of 160 countries allocated additional funds to sustain non-communicable disease services.49 |
Adaptations to health service delivery | Service delivery has been modified to minimise COVID-19 infection risk, including via adoption of phone-based or digital platforms.50 In LMICs, access to mobile phones or other communications technology, credit, coverage, data, internet and skills—while increasing—remain limited among patients and HCWs.51 The need for strict infection prevention control for services requiring in-person care (eg, immunisations, medical testing and surgery) raises service delivery costs. |
Failures of health communication | If people are unaware of whether and how services have changed, they may be unable to access needed care. In India, confusion about whether TB clinics were open (alongside transport restrictions) left patients with TB dangerously low on medicine. It took the government a month into lockdown to clarify that TB services should continue uninterrupted.52 |
Suspension of specific health services | Governments are encouraged to identify and sustain ‘essential’ services and suspend ‘non-essential’ ones, especially during acute COVID-19 outbreaks.53 However, even if services are declared essential, not everyone with power over access to them may agree. Women seeking sexual and reproductive services in Zimbabwe and Ghana have reported being stopped by security officials.54 |
HCW, healthcare worker; LMICs, low-income and middle-income countries; TB, tuberculosis.