The changes in health service utilisation in Malawi during the COVID-19 pandemic

Abstract

Introduction: The COVID-19 pandemic and the restriction policies implemented by the Government of Malawi may have disrupted routine health service utilisation. We aimed to find evidence for such disruptions and quantify any changes by service type and level of health care.

Methods: We extracted nationwide routine health service usage data for 2015-2021 from the electronic health information management systems in Malawi. Two datasets were prepared: unadjusted and adjusted; for the latter, unreported monthly data entries for a facility were filled in through systematic rules based on reported mean values of that facility or facility type and considering both reporting rates and comparability with published data. Using statistical descriptive methods, we first described the patterns of service utilisation in pre-pandemic years (2015-2019). We then tested for evidence of departures from this routine pattern, i.e., service volume delivered being below recent average by more than two standard deviations was viewed as a substantial reduction, and calculated the cumulative net differences of service volume during the pandemic period (2020-2021), in aggregate and within each specific facility.

Results: Evidence of disruptions were found: from April 2020 to December 2021, services delivered of several types were reduced across primary and secondary levels of care-including inpatient care (-20.03% less total interactions in that period compared to the recent average), immunisation (-17.61%), malnutrition treatment (-34.5%), accidents and emergency services (-16.03%), HIV (human immunodeficiency viruses) tests (-27.34%), antiretroviral therapy (ART) initiations for adults (-33.52%), and ART treatment for paediatrics (-41.32%). Reductions of service volume were greatest in the first wave of the pandemic during April-August 2020, and whereas some service types rebounded quickly (e.g., outpatient visits from -17.7% to +3.23%), many others persisted at lower level through 2021 (e.g., under-five malnutrition treatment from -15.24% to -42.23%). The total reduced service volume between April 2020 and December 2021 was 8 066 956 (-10.23%), equating to 444 units per 1000 persons.

Conclusion: We have found substantial evidence for reductions in health service delivered in Malawi during the COVID-19 pandemic which may have potential health consequences, the effect of which should inform how decisions are taken in the future to maximise the resilience of healthcare system during similar events.

Fig 1. COVID-19 confirmed cases and stringency index in Malawi, 2020–2021.

There have been four waves (> 49 cases per 1 million persons) as indicated in red time labels. The data source is [22].

Fig 2. Three types of missing data for health service records in Malawi DHIS2 system.

*These are approximate numbers, as the numbers of facilities with expected reports vary among different reports (e.g., HMIS report: 683 facilities, Maternity report: 575, EPI report: 694).

Fig 3. Average annual health service utilisation by service type and facility level 2015–2019.

The frequency is calculated as the number of services delivered per 10,000 persons in Malawi, using “Adjusted” dataset. The area of each rectangle is proportional to the frequency of each service type at each facility level. The legend is ordered by the area of the rectangle.

Fig 4. Standard monthly change in 2020–2021, per Test One.

Red, yellow and green areas indicate substantial, small and no evidence of reductions, respectively, during the pandemic months. Service types were divided to three groups accordingly (also see Table 2). Standard change per service type per level is presented in S2 Fig.