The COVID-19 pandemic and disruptions to essential health services in Kenya: a retrospective time-series analysis

by Helen Kiarie, Marleen Temmerman, Mutono Nyamai, Nzisa Liku, Wangari Thuo, Violet Oramisi, Lilly Nyaga,Janette Karimi, Phidelis Wamalwa, Gladwell Gatheca, Valerian Mwenda, Loice Achieng Ombajo, S M Thumbi, on behalf of the Essential Health Services Data Monitoring and Evaluation sub-working group

Summary

Background Public health emergencies can disrupt the provision of and access to essential health-care services, exacerbating health crises. We aimed to assess the effect of the COVID-19 pandemic on essential health-care services in Kenya.

Methods Using county-level data routinely collected from the health information system from health facilities across the country, we used a robust mixed-effect model to examine changes in 17 indicators of essential health services across four periods: the pre-pandemic period (from January, 2018 to February, 2020), two pandemic periods (from March to November 2020, and February to October, 2021), and the period during the COVID-19-associated health-care workers’ strike (from December, 2020 to January, 2021).

Findings In the pre-pandemic period, we observed a positive trend for multiple indicators. The onset of the pandemic was associated with statistically significant decreases in multiple indicators, including outpatient visits (28·7%; 95% CI 16·0–43·5%), cervical cancer screening (49·8%; 20·6–57·9%), number of HIV tests conducted (45·3%; 23·9–63·0%), patients tested for malaria (31·9%; 16·7–46·7%), number of notified tuberculosis cases (26·6%; 14·7–45·1%), hypertension cases (10·4%; 6·0–39·4%), vitamin A supplements (8·7%; 7·9–10·5%), and three doses of the diphtheria, tetanus toxoid, and pertussis vaccine administered (0·9%; 0·5–1·3%). Pneumonia cases reduced by 50·6% (31·3–67·3%), diarrhoea by 39·7% (24·8–62·7%), and children attending welfare clinics by 39·6% (23·5–47·1%). Cases of sexual violence increased by 8·0% (4·3–25·0%). Skilled deliveries, antenatal care, people with HIV infection newly started on antiretroviral therapy, confirmed cases of malaria, and diabetes cases detected were not significantly affected negatively. Although most of the health indicators began to recover during the pandemic, the health-care workers’ strike resulted in nearly all indicators falling to numbers lower than those observed at the onset or during the pre-strike pandemic period.

Interpretation The COVID-19 pandemic and the associated health-care workers’ strike in Kenya have been associated with a substantial disruption of essential health services, with the use of outpatient visits, screening and diagnostic services, and child immunisation adversely affected. Efforts to maintain the provision of these essential health services during a health-care crisis should target the susceptible services to prevent the exacerbation of associated disease burdens during such health crises.

Introduction

Public health emergencies, such as disease outbreaks and epidemics, can have a substantial effect on the use of and access to essential health-care services, exacerbating morbidity and mortality from other diseases.1–3 Data from the 2013 and 2014 Ebola virus epidemic in west Africa showed statistically significant declines in health-care use. Notable declines were observed in settings with a high incidence of Ebola cases, and inpatient care was more affected than outpatient care services.2,4 Studies on the consequences of the Ebola epidemic have reported a decline in the use of primary health-care and maternal and child health services,5,6 an increase in the population of children susceptible to measles and measles outbreaks associated with decreases in the number of vaccinations,7,8 and increased malaria, HIV/AIDS, and tuberculosis deaths that were similar to or greater than the total number of deaths caused by the Ebola virus disease.1,9,10

Responses to the COVID-19 pandemic, such as lockdowns, stay-at-home orders, and restricted movement, as well as fear of contracting the virus in health facilities and the cancellation of elective and preventive visits to health-care facilities, have disrupted the use of different health-care services in multiple settings.11–16 After several epidemics and their effects in the past few years, there is a recognised need for building resilient health systems that are able to protect human life and result in good health outcomes during and after a health crisis.17 An analysis of studies on the effect of the pandemic on maternal, fetal, and neonatal outcomes has found adverse effects on these

Epidemiological Modelling and Analysis, University of Nairobi, Nairobi 30197-00100, Kenya thumbi.mwangi@wsu.edu