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. 2021 Oct 16;21:1105. doi: 10.1186/s12913-021-07106-8

Impact of COVID-19 and mitigation plans on essential health services: institutional experience of a hospital in Ethiopia

Firaol Dandena 1,, Berhanetsehay Teklewold 1, Dagmawi Anteneh 2
PMCID: PMC8519745  PMID: 34654411

Abstract

Background

Health systems around the world are being challenged by an on-going COVID-19 pandemic. The COVID-19 pandemic and associated response can have a significant downstream effect on access to routine health care services, and indirectly cause morbidity and mortality from causes other than the disease itself, especially in resource-poor countries such as Ethiopia. This study aimed to explore the impact of the pandemic on these services and measures taken to combat the effect.

Methods

The study was conducted at St. Paul’s hospital millennium medical college (SPHMMC) from December 15, 2020 to January 15, 2021 using a comparative cross-sectional study design. We collected data on the number of clients getting different essential health care services from May to October 2019 (Pre COVID) and the same period in 2020 (during a COVID-19 pandemic) from the patient registry book. The analysis was done with SPSS version 24 software.

Result

Overall, the essential services of SPHMMC were affected by the COVID-19 pandemic. The most affected service is inpatient admission, which showed a 73.3% (2044 to 682) reduction from the pre-COVID period and the least affected is maternal service, which only decreased by 13% (3671 to 3177). During the 6 months after the COVID-19 pandemic, there was a progressive increment in the number of clients getting essential health services.

Conclusion and recommendation

The establishment of a triple setup for fighting against COVID-19, which encompasses non-COVID services, an isolation center and a COVID-19 treatment center, played a vital role in preserving essential health services.

Keywords: Essential health services, Triple setup, COVID-19, SPHMMC, Ethiopia

Introduction

The outbreak of pneumonia of an unknown ethology was reported in December 2019 in Wuhan, Hubei Province, China [1]. Following this, a novel coronavirus, coronavirus disease 2019 (COVID-19), was identified as the causative virus for the pandemic in China and other parts of the world by the World Health Organization (WHO) [2].

As of March 25, 2021, more than 235 countries/territories are affected with more than 120,383,289 cases and 2, 666, 916 deaths were recorded worldwide. In Africa, 57 countries/territories were affected by more than 4,124,997 COVID-19 cases and more than 109,586 deaths were reported across the continent. On March 13, 2020 a COVID-19 positive case was first reported in Ethiopia. As of March 25, 2021, a total of 187,365 confirmed COVID-19 cases and 2657 deaths were recorded in the country [3].

The supply and demand for health care services have been shown to affect access to these services in the past. Patients may be hesitant to seek treatment because they believe health facilities are infected, or they have doubts about the competence of health care providers to implement adequate infection prevention and control procedures. When health systems are overburdened by outbreaks, people may be unable to get the care they need, resulting in an increase in the number of deaths from COVID-19-related and non-COVID-19 causes [46].

Many countries are struggling to strike a balance between COVID 19-related initiatives and the necessity to continue providing other critical health services. Many routine and optional services have been halted, and new techniques are being developed in response to the changing pandemic situation [7].

A country’s ability to maintain the supply of basic health care is determined by a number of factors. These are baseline health system capacity, illness burden, and COVID-19 transmission locally [8].

The Ethiopian essential health service package includes reproductive, maternal, neonatal, child, and adolescent health services; major communicable diseases; non-communicable diseases; surgical care; and emergency and critical care [9].

The Ebola outbreak in 2014–2015 resulted in an 18% drop in average health-care utilization. The decline was even greater for maternity and children’s health services, such as facility-based deliveries, which fell by 28%. The number of deaths from measles, malaria, HIV/AIDS, and tuberculosis has increased. Which was attributable to health system failures to provide those services [1012].

Studies done in 22 hospitals in France (a country that has been struck early and with a high intensity by the COVID-19 wave) showed a 26% decline in all emergency department visits, including a decrease of 34% in strokes, 32% in transitory ischemic attacks, 64% in unstable angina, 42% in appendicitis and 36% in seizures [13, 14].

According to Global finance faculty prediction in Ethiopia there will be 238,000 women without access to facility-based deliveries, 15% percent increase child mortality and 8% increase in maternal mortality over the next year, due to the compromise in all essential services [15].

A study done in Switzerland showed a 43% decrease in elective visceral surgical procedures was observed after Covid-19 (295 vs. 165, p < 0.01), while emergency operations (all specialties) decreased by 39% (1476 vs. 897, p < 0.01). Fifty-two and 38 major oncological surgeries were performed, respectively, representing a 27% decrease (p < 0.316). Outpatient consultations dropped by 59%, from 728 to 296 (p < 0.01) [16].

Methods

Study setting and design

This comparative cross-sectional study was conducted on December 15, 2020 to January 15, 2021 at St. Paul’s Hospital Millennium Medical College (SPHMMC), the second largest hospital in Ethiopia located in Addis Ababa. Established in 1969, the hospital provides different medical care services to an estimated 1,000,000 people every year [17].

Data collection and procedure

We collected data on the number of clients attending different essential health care services from patient registry books in different service areas of the hospital from May 1st to October 31, 2019 and from May 1st to October 31, 2020. Aggregate data that was collected during the emergence of the COVID-19 pandemic was compared with the number of visits in the same six months of the previous year (pre-COVID). Data collectors also asked interview questions and observed service areas of the hospital.

Data analysis

Data was coded, entered and cleaned using the SPSS version 24 software package by the principal investigator. Simple descriptive statistics such as frequency distribution were done as appropriate and the results were presented in tables and graphs.

Results

Taking an average of six months from (COVID) season to (pre-COVID) season, this study analyzed the impact of the COVID-19 pandemic on six essential services provided at SPHMMC. Outpatient visits fell by 57% from pre-covid to post-covid (37,739 to 16,121) (P 0.0126) (Table 3). From 13,888 to 6489 (53.27%), 6431 to 3000 (53.35%), 2112 to 1006 (52.37%), and 1460 to 647 (55.68%), respectively, the average number of patients visiting medical, surgical, pediatrics, and psychiatry average outpatient visits decreased by more than half compared to the same period the previous year.

Table 3.

Chi -square test between per- COVID-19 and COVID-19 group

Essential healthcare type per- COVID-19 season(average) COVID-19 season (average) P value
Out patient 0.0126 *
 Internal Medicine 13,888 6489
 Surgery 6431 3000
 Gynaecology 3620 1105
 Dermatology 1268 289
 Dental & Maxillofacial 1351 324
 Ophthalmology 4603 1569
 Psychiatry 1460 647
 Ear Nose & Throat (ENT) 1651 555
 Renal Transplant 328 275
 Palliative care 5 3
 Oncology 1022 879
 Pediatrics 2112 1006
Emergency 0.0420 *
 Pediatrics Emergency 554 164
 Adult Emergency 1526 485
 Gynaecology Emergency 1144 1028
 AaBET Emergency 966 527
Other services 0.0657
 Family planning 440 223
 Cervical cancer screening 16 6
 Voluntary Counselling & Testing 67 14
 Post Exposure Prophylaxis 10 3
 Dialysis 144 68
Maternal Service 0.0947
 Spontaneous Vaginal Delivery 505 462
 Instrumental delivery 60 37
 Caesarean section 368 376
 Maternal death 0 0
 Antenatal care 2084 1746
 Postnatal care 636 546
Surgical Service 0.1623
 Emergency surgery 254 193
 Elective surgery 384 168
Inpatient Service 0.0638
 Surgical ward 355 128
 Medical ward 84 49
 Pediatrics ward 68 49
 Maternity ward 497 354
 Gynaecology ward 154 91
 Others 886 504
 Total 2044 682

* Significant association (p-value < 0.05)

During the COVID season, the average number of patients attending emergency departments decreased by 47% (4190 to 2204) (P < 0.0420) (Table 3). Patient visits to pediatric and adult emergency departments decreased by 70% from pre-COVID levels (from 554 to 164) and (1526 to 485) respectively. On average, the number of patients accessing our trauma wing, Addis Ababa Burn, Emergency, and Trauma Hospital (AaBET Hospital), decreased by 45% (966 to 527) per month (Tables 1 & 2).

Table 1.

Number of visits to essential healthcare–delivering units in SPHMMC (from May 1to October 31, 2019)

Essential healthcare type May 2019 June 2019 July 2019 August 2019 September 2019 October 2019 Monthly average
Outpatient services
 Internal Medicine 12,413 15,627 13,913 15,775 12,008 13,596 13,888
 Surgery 5605 6650 5780 6805 7925 5821 6431
 Gynaecology 3400 3765 3199 3412 3156 2808 3620
 Dermatology 1027 1217 1180 1104 1648 1432 1268
 Dental & Maxillofacial 888 930 1890 1756 1596 1049 1351
 Ophthalmology 7102 3651 3110 4438 4606 4713 4603
 Psychiatry 1450 1289 1181 1510 1696 1637 1460
 Ear Nose & Throat (ENT) 1330 1596 1867 1814 1706 1598 1651
 Renal Transplant 242 216 240 223 853 195 328
 Palliative care 6 5 6 5 4 4 5
 Oncology 1182 1071 915 1007 1038 920 1022
 Pediatrics 1749 2059 2235 2055 2188 2389 2112
Emergency services
 Pediatrics Emergency 503 610 499 579 549 554 554
 Adult Emergency 1330 1255 1217 1348 2815 1193 1526
 Gynaecology Emergency 929 1346 997 979 1462 1156 1144
 AaBET Emergency 948 1018 954 997 1223 658 966
Other services
 Family planning 276 541 426 416 551 435 440
 Cervical cancer screening 14 14 22 12 17 16 16
 Voluntary Counselling & Testing 49 69 79 82 69 47 67
 Post Exposure Prophylaxis 5 15 10 10 15 4 10
 Dialysis 95 95 93 92 413 81 144
Maternal Service
 Spontaneous Vaginal Delivery 495 530 502 474 532 499 505
 Instrumental delivery 41 70 65 54 73 59 60
 Caesarean section 303 370 384 368 394 393 368
 Maternal death 1 1 0 0 0 0
 Antenatal care 739 1124 2531 2592 2868 2652 2084
 Postnatal care 503 516 552 668 880 702 636
Surgical Service
 Emergency surgery 138 329 248 253 273 286 254
 Elective surgery 243 446 399 393 405 423 384
Inpatient Service
 Surgical ward 330 370 366 336 378 349 355
 Medical ward 83 91 89 92 94 55 84
 Pediatrics ward 55 82 73 67 68 65 68
 Maternity ward 452 464 523 515 571 456 497
 Gynaecology ward 108 141 161 131 175 209 154
*Others 662 891 889 833 1183 862 886
Total inpatient admission 1690 2039 2101 1974 2469 1996 2044

*Others: Dental & Maxillofacial, Ophthalmology, Psychiatry, ENT, ICU and Renal Transplant

Table 2.

Number of visits to essential healthcare–delivering units in SPHMMC (from May 1to October 31, 2020)

Essential healthcare type May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 Monthly average
Outpatient services
 Internal Medicine 3297 6172 6497 7010 8141 7820 6489
 Surgery 2551 2255 2254 3235 3725 3976 3000
 Gynaecology 769 866 890 1128 1502 1477 1105
 Dermatology 0 58 186 326 475 686 289
 Dental & Maxillofacial 252 169 184 242 388 711 324
 Ophthalmology 232 494 928 1696 2495 3572 1569
 Psychiatry 602 598 615 697 594 777 647
 Ear Nose & Throat (ENT) 0 234 510 629 879 1078 555
 Renal Transplant 170 270 267 259 333 350 275
 Palliative care 1 0 2 3 4 4 3
 Oncology 538 804 832 1016 1075 987 879
 Pediatrics 473 418 917 690 2168 1373 1006
Emergency services
 Pediatrics Emergency 173 116 172 187 254 205 164
 Adult Emergency 426 400 554 571 701 694 485
 Gynaecology Emergency 1063 1002 879 1004 1135 1064 1028
 AaBET Emergency 629 538 260 372 595 431 527
Other services
 Family planning 220 178 298 230 286 265 223
 Cervical cancer screening 1 0 17 16 6
 Voluntary Counselling & Testing 0 0 6 77 4 0 14
 Post Exposure Prophylaxis 0 1 15 0 3
 Dialysis 206 194 211 200 68
Maternal Service
 Spontaneous Vaginal Delivery 443 537 442 291 529 528 462
 Instrumental delivery 45 38 33 33 47 25z 37
 Caesarean section 372 347 356 356 426 399 376
 Maternal death 0 0 0 1 1 0
 Antenatal care 1860 2235 1605 1352 1119 1307 1746
 Postnatal care 384 520 558 509 880 427 546
Surgical Service
 Emergency surgery 203 148 209 192 270 245 193
 Elective surgery 142 133 181 190 206 344 168
Inpatient Service
 Surgical ward 130 145 230 261 128
 Medical ward 76 72 81 66 49
 Pediatrics ward 74 75 73 70 49
 Maternity ward 491 503 607 524 354
 Gynaecology ward 114 127 162 142 91
*Others 211 166 828 524 648 650 504
Total inpatient admission 211 166 1713 1446 1801 1713 682

*Others: Dental & Maxillofacial, Ophthalmology, Psychiatry, ENT, ICU and Renal Transplant

Family planning services decreased by 47% (440 to 233) whereas dialysis services decreased by 53% (144 to 68) during the COVID season as compared to a similar six-month period prior to the emergence of the COVID-19 pandemic.

When compared to other essential health services, maternal services were the least affected, with only a 13% decrease (3671 to 3167). The average number of mothers attending antenatal visits decreased by 15% (2084 to 1746), while postnatal visits decreased by 16%. In terms of facility birth services, spontaneous vaginal deliveries fell by 9% (505 to 462) and instrumental deliveries fell by one-third (60 to 37), whereas the number of caesarean sections performed increased somewhat during the COVID-19 pandemic (Tables 1 & 2).

The average number of emergency surgeries done during the COVID-19 pandemic showed a 24% reduction (254 to 193), whereas the average number of elective surgeries decreased by 56.3% (384 to 168) as compared to a similar six-month period in the pre-COVID year. The most affected service by the COVID-19 pandemic is inpatient admissions, which showed a 73% (2044 to 682) reduction from a similar six month period prior to the COVID-19 emergence and a prominent effect on surgical admissions, decreasing by 64% (355 to 128) (Tables 1 & 2).

Regarding the number of patients visiting SPHMMC during the consecutive six months after the emergence of COVID-19 in Ethiopia, there is an overall increment. The number of patients visiting outpatient departments increased by 61% (8885 to 22,811), whereas visits to different emergency departments increased by 5% (2291 to 2394) over a period of six months. The number of surgeries (both elective & emergency) has increased by 41% (345 to 589), whereas inpatient admissions by 88% (211 to 1713). Unlike the overall increment, maternal services decreased by 13% (3104 to 2686) (Figs. 1 & 2).

Fig. 1.

Fig. 1

The number of client who has visited outpatient and emergency department of SPHMMC in 2019(pre-COVID 19 season) and 2020(COVID 19 season)

Fig. 2.

Fig. 2

The number of client admitted to inpatient wards and number of deliveries at SPHMMC in 2019(pre-COVID 19 season) and 2020(COVID 19 season)

Discussion

Overall, the essential services of SPHMMC were affected by the COVID-19 pandemic. In maternity and emergency services, a higher number of clients were provided than predicted by the Ethiopian Federal Ministry of Health. This could be due to the lack of limits on maternity and emergency care, as opposed to other non-emergent services that were stopped completely or partially in the early stages of the pandemic to reduce COVID-19 transmission. The institution took various actions using different social media platforms, mainstream media such as television channels, and distributing information via a free call center, the hospital continues to raise awareness of COVID-19 symptoms, prevention measures, and what to do if customers have symptoms or worries.

The hospital has devised a three-pronged strategy for combating COVID-19, including non-COVID services, an isolation facility for suspect patients, and a COVID-19 treatment center with its own personnel and restricted space for confirming patients. Different teams (sample team, ambulance team, Personal Protective Equipment (PPE) quantification team, infection prevention and control (IPC) team, safety & quality team specialized to COVID-19 isolation and treatment center) were organized in addition to the triple arrangement. This makes early testing and notification of suspect patient results easier and more convenient, as well as contact tracing, patient transfer, rational use and supply of PPE, and the availability of standard and transmission-based precaution facilities, all of which help to ensure that proper IPC measures were taken and maintained, as well as that the services delivered are of the expected quality. In addition to the aforementioned procedures, a task force unit made up of hospital executives and key individuals in charge of various service areas and units that directly or indirectly affect COVID-19 service was formed. This task force is in charge of overcoming obstacles, making crucial choices, and developing strategies.

When comparing the findings of this study to those of other similar studies, studies conducted in 22 French hospitals revealed a 26% reduction in all emergency department visits [9, 13]. In comparison to the pre-COVID era, this study found a 47% decrease in the percentage of patients attending all emergency departments of the hospital. COVID 19 occurrences had a significant relationship with a decrease in the number of patients visiting the emergency department (P > 0.0420) (Table 3).

The attendance for the three-month period from March to May 2020 (COVID period) in Ireland’s pediatric emergency department was 21,545. From 39,772 in the same period in 2018/2019, there was a 46% reduction [18]. This study in the pediatric emergency department yielded a substantially higher result. During the COVID period, attendance plummeted by 70% from 554 to 164 patients in average.

Our findings show that maternal services declined by 13% (3671 to 3177), which is similar to the Population Foundation of India’s projection of a 10% drop in coverage of pregnancy-related services [19]. However, when contrasted to the findings from the Ebola outbreak in 2014 and 2015, where facility-based deliveries plummeted by 28%, this study shows better maternal service attendance [10].

Maternal death was anticipated to rise by 8% in 2020 after the outbreak of this pandemic [14] by global finance professors, however our research found no increase in maternal mortality when compared to the same period previous to the outbreak.

In a study conducted in Switzerland, urgent operations were shown to have decreased by 39% (all specialties, 1476 vs. 897, p < 0.01) [15]. Our research yielded a more positive result. During the COVID-19 pandemic, there was a 24% decline in the number of emergency surgeries performed. It is evident that having a separate isolation surgical room and performing emergency procedures regardless of the patient’s COVID-19 result while maintaining the appropriate IPC precautions will result in this.

Regarding elective visceral surgeries, the study in Switzerland showed a 43% reduction after the emergence of COVID-19 (295 vs 165, p < 0.01) [15]. The higher result was found in this study, which showed a 56.3% (384 to 168) reduction in elective surgeries during the COVID-19 pandemic. This could be attributed to the fact that elective surgeries are performed after the RT-PCR test for COVID-19 is negative and the result arrives within 72 h of the surgery. The result usually takes 48–96 h. Outpatient surgical consultations dropped by 59%, from 728 to 296 (p < 0.01) in the Switzerland study [15]. Similar results were observed in this study. The number of patients visiting surgical OPD decreased by 53.35% (6431 to 3000 as a comparison between before and after the emergence of COVID-19.

When we compared the number of patients receiving essential health services six months after COVID-19 emerged, we found a gradual increase in all services except maternal services, which fell by 13%. (3104 to 2686). This could be owing to an influx of patients from other private and public healthcare institutions, hospitals, and homes during the early stages of the epidemic, as a result of the complete or partial shutdown of most facilities due to fear, stigma, and misinformation.

This study showed a significant association between the occurrence of COVID 19 and the number of clients seen in outpatient (p < 0.0126) and emergency departments (p < 0.0420) (Table 3). This may be due to extended appointments for chronic patients and restrictions on the number of patients seen in outpatient clinics. In the emergency department, it could be the fear of contracting COVID 19 while visiting for other concerns.

Conclusion

The number of clients visiting almost all essential health care services declined during the COVID-19 pandemic. The most affected services were inpatient admissions that showed a 73% (2044 to 682) reduction from the previous year and the list of affected maternal services only decreased by 13% (3671 to 3177). During six months of follow up after the emergence of COVID-19, a progressive increment in the number of patients getting essential services was observed.

Essential healthcare services are as important as COVID-19 prevention and treatment. These services should be provided alongside COVID-19 services. We can improve the number of clients visiting hospitals in times of a pandemic by endorsing a continuous information campaign with available media, implementation and monitoring of IPC measures, and establishing a holistic triple setup for delivering quality medical service in times of a pandemic.

Recommendation

1. At the national level the health care system should be rearrangement the classification of “COVID” and “non-COVID” health facilities in each town in the event of a particularly significant caseload. This helps us to limit the danger of contamination, enhance patient routes, and combine health facilities and skilled caregivers; while on the other hand, it allows us to continue managing non-COVID patients without raising risk.

2. At national level there should be continues awareness creation of COVID-19 symptoms, prevention measures and treatment options. Develop educational materials and disseminate using different social media platforms and mainstream media such as television channels.

3. At hospital level we recommend creating a triple setup to battle COVID-19, which includes non-COVID services, an isolation center for suspect patients, and a COVID-19 treatment center with its own personnel and restricted access.

Limitation

We did not include all essential services and it was conducted in a single hospital.

Acknowledgments

We would like to thank our management team for their willingness to be involved in this study and for their invaluable insights shared at such a challenging time.

Abbreviations

COVID-19

Coronavirus disease

SPHMMC

St. Paul’s Hospital Millennium Medical College

SPSS

Statistical Package for Social Sciences

PPE

Personal Protective Equipment

WHO

World Health Organization

Authors’ contributions

BT conceived of and designed the research, reviewed the literature, prepared the data and contributed to the revision of the final manuscript. FD drafted the manuscript, discussed the results, performed the analysis and contributed to the revision of the final manuscript. DA supported data preparation, conducted data collection and analysis, and contributed to the revision of the final manuscript. All authors read and approved the final manuscript.

Funding

Not applicable. No funding was received for this work.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The current manuscript had ethical approval from Saint Paul’s Hospital Millennium Medical College (SPHMMC) IRB as part of the original research proposal which was entitled “Impact of Covid-19 and Mitigation Plans on Essential Health Services: Institutional Experience of St. Paul’s Hospital Millennium Medical College”. Informed consent was obtained from all study participants before they enrolled in the study. They were told that their participation was voluntary, and they could withdraw at any time or refuse to answer any question if they wanted to. No information concerning the individual was passed to a third party. Therefore, in general, we carried out the current research by fulfilling all the requirements of the institutional (SPHMMC) IRB guidelines and relevant guidelines of BMC.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Firaol Dandena, Email: firadandena123@gmail.com.

Berhanetsehay Teklewold, Email: berhanetsehay.teklewold@sphmmc.edu.et.

Dagmawi Anteneh, Email: dagmawianteneh16@gmail.com.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.


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