Continuity of Essential Health Services (CES) study - Exploring effect of COVID-19 on demand for maternal, newborn and child health services in selected districts in Malawi by William Stones
| dc.contributor.author | Stones, William | |
| dc.date.accessioned | 2021-12-20T16:48:04Z | |
| dc.date.available | 2021-12-20T16:48:04Z | |
| dc.date.issued | 4-06-21 | |
| dc.description.abstract | Type of Study This is a Qualitative study in selected geographical areas including key informant interviews (KIIs), focus group discussions (FDGs) and in-depth interviews with specific target groups (e.g. women living with HIV/AIDS). The scope will include data collection, data quality monitoring, transcription/translation, data analysis and reports on study results. BACKGROUND RATIONALE Malawi registered its first Covid-19 cases in March 2020. A Presidential Taskforce on Covid -19 was immediately set up and Covid-19 prevention measures were put in place and these included: Closing down of schools, social distancing, wearing of masks, self- quarantine for all who tested COVID positive and all in-coming travelers, public gatherings were initially limited to 100 people and this was suspended due to injunctions. While government public health and social measures have likely forestalled some COVID-19 spread, they also have deleterious indirect social, economic and health impacts. While attention is understandably focused on the direct impact of the COVID-19 pandemic, it is essential to see the health crisis from a broader perspective. In Malawi, health systems are already fragile and people often live in extremely precarious conditions. The coronavirus pandemic risks further reducing vulnerable people’s already limited access to healthcare, as resources – both human and financial – get diverted from regular healthcare to the COVID-19 response. OBJECTIVES The overall study objective is: • To investigate the effect of COVID-19 pandemic on people’s willingness and ability to access essential MNCH services, their experiences of care and the perspectives of staff on MNCH services’ readiness to provide essential care during the pandemic. Specific study objectives are to: 1. Comprehend how COVID-19 has affected pregnant and breastfeeding women’s access to maternal and newborn health services. 2. Comprehend how COVID-19 has affected access to child health services for the under-fives. 3. Comprehend any specific challenges faced by vulnerable groups during COVID-19 with regard to access to MNCH services. METHODS The methodology will include focus group discussions (FGDs) and key informant interviews (KIIs), followed by in-depth interviews (IDIs) to capture respondents of vulnerable groups. The data will be collected from Mchinji and Blantyre Districts (indicative locations to be confirmed following consultation) and the study population will include adult pregnant/breastfeeding women, parents/caretakers of children under five years of age, adolescents (15 to 19 years of age, 7 companions/partners of pregnant/breastfeeding women and pregnant/breastfeeding adolescents, community-based health workers, health workers and facility based managers. DATA MANAGEMENT AND ANALYSIS All audio and handwritten data collected from the FGDs and interviews will be stored securely. Electronic notes, transcripts and translations will be stored electronically and protected by a password. Only members of the research team will have access to these documents. As soon as the audio-recordings have been transcribed and verified, they will be destroyed by erasing the voice recordings. Framework analysis will be used for cross-sectional analysis of data from FGDs, IDIs and KIIs. The focus will be on understanding the demand and supply-side barriers to seeking routine and emergency health care services, the extent to which the pandemic has impacted people’s willingness and ability to access MNCH services and how service readiness and provision has changed as a result of COVID- 19 and its effects. A combination of deductive and inductive themes will be included. POSSIBLE CONSTRAINTS COVID-19 situation might require adaptation of study methods using more or only virtual methods for interviews and FDGs; virtual FDGs might be not ideal given that moderators should be physically present to be able to catch the dynamics in the groups and to be able to guide and facilitate appropriately. However, the research teams will only do virtual FDGs in case there is no alternative. RESULTS PRESENTATION Key findings will be presented during a webinar with a UN, participating districts and MoH audience. All data collected, analytical memos and framework analysis files will be de-identified and shared with UNICEF alongside draft reports. The report will also be shared with COMREC. IMPLICATIONS OF THIS STUDY We anticipate that findings from this study will highlight the impact of Covid-19 on people’s willingness and ability to access essential MNCH services, their experiences of care and the perspectives of staff on MNCH services’ readiness to provide essential care during the pandemic. 1. Background In Malawi, since March 2020 when the first COVID-19 cases were reported, a Presidential Taskforce on Covid -19 was set up with a mixed membership of Public Health Experts, technocrats and members of the Cabinet. Covid-19 prevention measures were put in place and these included: Closing down of schools, social distancing, wearing of masks, self- quarantine for all who tested COVID positive and all in-coming travelers, public gatherings were initially limited to 100 people and this was suspended due to injunctions. In addition, number of passengers in public vehicles were also limited to 2 people per seat only. Between September and December, 2020, the number of COVID-19 cases reduced which may have fuelled non-adherence to COVID prevention measures. Since January, 2021, Malawi has been hit hard by the second wave of COVID-19 which has caused a sharp rise in the numbers of cases and increase in COVID-19 related deaths. The country has been declared a State of Disaster. The Vice President of Malawi has since led the team to develop new guidelines on COVID response and management. Further restrictions have been made to public gatherings now at 50 people only, the wearing of masks has become mandatory in all public places including markets, shops etc. Restrictions have also been made to trading hours in bars and markets. Since the second wave of COVID-19, more people have tested and hospitalized leading to an overburdened health care system. Government has embarked on efforts to increase the number of health care staff, increase treatment centres and lobby for resources (equipment and supplies) especially oxygen cylinders and accessories and COVID-19 testing kits which are in limited supply. While government public health and social measures have likely forestalled some COVID-19 spread, they also have deleterious indirect social, economic and health impacts. Given relatively limited health care capacity, particularly for critical care, a “bend the curve” paradigm may be less salient in the region and governments need to balance the threat of COVID-19-specific mortality with the potential secondary impacts of mitigation measures, which may also result in excess mortality. The West Africa Ebola epidemic (2014-16) is instructive as it demonstrated that indirect mortality can exceed the direct mortality of the health emergency. Scenario-based modelling of excess maternal and child mortality due to reduced coverage of essential health and nutrition services suggests that the indirect impact of COVID-19 mitigation measures could result in an increase of 9·8% to 44·7% in under-5 child deaths per month, and an 8·3% to 38·6% increase in maternal deaths per month, across 118 countries1. COVID-19 projections estimate that 15 million additional unintended pregnancies could occur over one year if COVID-related service disruptions affected 10% of women in need of sexual and reproductive health (SRH) services in low- and middle-income countries2. Anecdotal evidence from Kenya, Malawi and Mozambique indicates an increase in adolescent pregnancies since the closure of schools due to COVID-19. Within schools, Malawian adolescents have some access to reproductive health information and counselling, presence of mother-groups to support girls in need of services, peer to peer support. The impact of COVID-19 on the availability and quality of MNCH services and social-economic disruption on access to these services requires investigation. The Pulse survey by WHO in 105 responding countries on continuity of essential health services during the COVID-19 pandemic showed disruptions of essential health services reported by nearly all countries, and more so in lower- 1 Timothy Roberton, DrPH. Emily D Carter, PhD. Victoria B Chou, PhD. Angela R Stegmuller, BS. Bianca D Jackson, MSPH. Yvonne Tam, MHS. et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Articles; Volume 8, ISSUE 7, E901-E908, July 01, 2020 2 Riley T, Sully E, Ahmed Z, Biddlecom A. Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health In Low- and Middle-Income Countries. Int Perspect Sex Reprod Health. 2020;46:73–6 income than higher-income countries. The majority of service disruptions were partial defined as a change of 5–50% in service provision or use. All services were affected, including essential services for communicable diseases, non-communicable diseases, mental health, reproductive, maternal, newborn, child and adolescent health, and nutrition services. Emergency services were the least disrupted, although 16 countries reported disruptions across all emergency services. The most severely affected service delivery platforms were mobile services, often suspended by government, and campaigns, for example as used for malaria prevention or immunization. The causes of the disruptions were a mix of demand and supply factors. On the demand side, 76% of countries reported reductions in outpatient care attendance. Other factors, such as lockdowns hindering access and financial difficulties during lockdown were also mentioned. On the supply side, the most commonly reported factor was cancellation of elective services (66%). Other factors mentioned included staff redeployment to provide COVID-19 relief, unavailability of services owing to closures of health facilities or health services, and supply-chain difficulties. 2. RATIONALE While attention is understandably focused on the direct impact of the COVID-19 pandemic, it is essential to see the health crisis from a broader perspective. In Malawi, health systems are already fragile and people often live in extremely precarious conditions. The coronavirus pandemic risks further reducing vulnerable people’s already limited access to healthcare, as resources – both human and financial – get diverted from regular healthcare to the COVID-19 response. During 2020, Malawi experienced that health services were downsized or closed to limit the risk of transmission. Shortage of staff was accelerated as frontline healthcare workers fell sick or died in places where there were already too few to provide essential services. Keeping essential health services available and accessible is vital to prevent losing even more lives, whether from malaria, measles, malnutrition or complicated pregnancies. This study study on Continuity of Essential Health Services (CES) aims at contributing to fill the knowledge gap on the demand and supply-side factors exploring barriers to seeking routine and emergency MNCH services. The immediate target groups include pregnant women, women of reproductive age with newborns and children under five years of age including breast-feeding women and adolescent women. In addition, health personnel, both clinical and management, as well as relevant community members will be included in the study. There is a need to understand the extent to which the pandemic has impacted people’s willingness and ability to access (i.e. availability, accessibility, affordability and acceptability) essential MNCH services and experiences of care during the pandemic. Furthermore, this study will also explore the supply side of health service delivery including the perception of health programme managers and health staff on resiliency of the health system and their view on why people are or are not coming in for care and the impact that the pandemic has on quality and the continuation of routine services delivery. The study will have a specific focus on vulnerable populations groups of women of reproductive age, including those living with HIV/AIDS and adolescents, as well as children under five. 3. Objectives of the study The overall study objective is: To investigate the effect of COVID-19 pandemic on people’s willingness and ability to access essential MNCH services, their experiences of care and the perspectives of staff on MNCH services’ readiness to provide essential care during the pandemic. Specific study objectives are to: 1. Comprehend how COVID-19 has affected pregnant and breastfeeding women’s access to maternal and newborn health services.2. Comprehend how COVID-19 has affected access to child health services for the under-fives. 3. Comprehend any specific challenges faced by vulnerable groups during COVID-19 with regard to access to MNCH services. Specific research questions: The two main research questions are: (A) What is the influence of demand side factors (intention action/gap drivers, reaching care, and receiving care); (B) what is the influence of supply side factors (providing care). These are further elaborated as below. A. Maternal, newborn and child health: Demand side factors Intention action/gap drivers a. Did the target groups of primary interest (as defined above) during COVID-19 pandemic use essential MNCH services (essential as defined in the national packages of care and provided by skilled personnel) to the same extent (frequency, based on needs/demands) as during non-COVID times? b. What were the main factors / reasons that affected the use of essential MNCH services by the primary target groups during COVID-19 pandemic? What was different to non-COVID times in regard to the topics below? Reaching essential MNCH services a. To what extent and how were the primary target groups able to reach to a health facility / seek essential MNCH services during COVID-19 pandemic compared to non-COVID times? b. What were the main factors/reasons that stopped or made it difficult for the primary target groups to reach essential MNCH care during COVID-19 pandemic compared to non-COVID times? Receiving essential MNCH services when the health facility is reached c. To what extent and why were essential MNCH services not available to the primary target groups when reached? d. What kind of changes were observed or experienced by the primary target groups with regard to the quality of MNCH services provided during COVID-19 pandemic compared to non-COVID times? B. Maternal, newborn and child health: Supply side factors Providing adequate care to the primary target groups according to demand and needs a. To what extent did essential MNCH services become disrupted and/or unavailable during COVD-19? How was the readiness of essential MNCH - to serve the primary target population as needed - affected? b. Which MNCH services were most affected and why? Lessons learned- demand and supply-side The study teams will elaborate based on above raised questions on what were the main lessons learned from the COVID-19 pandemic in regard to demand for, access to and readiness of MNCH services. In addition, the interviews will include a question on what the lessons learned were 11 Health services Health care providers Health care users Community-based health service delivery Referral pathways/linkages between community systems and health systems, and other. 4.3 Target groups of the study The target groups will include specifically: (1) Adult pregnant/breastfeeding women (20 to 49 years) (2) Adolescent pregnant/breastfeeding women (15-19 years) (3) Pregnant/breastfeeding women (15 – 49 years) living with HIV/AIDS (4) Parents/caretakers of children under five years of age including adolescent mothers and fathers (5) Facility based health care workers and health facility managers (6) Community health workers/volunteers and other community-based health agents such as peer mother supporters etc. (7) Sub-national health care managers (district/subcounty, region/county/province) 4. STUDY DESIGN This is a Qualitative study in selected geographical areas including key informant interviews (KIIs), focus group discussions (FDGs) and in-depth interviews with specific target groups (e.g. women living with HIV/AIDS). The scope will include data collection, data quality monitoring, transcription/translation, data analysis and reports on study results. Conceptual Framework The “Governance and Capacity to Manage Resilience of Health Systems” conceptual framework postulates that health systems have three levels of resilience: absorptive capacity, adaptivecapacity and transformative capacity3. This framework is considered relevant as it arose from African experience of the Ebola outbreaks, that presented certain similar challenges to health systems. The absorptive capacity relates to the capacity of a health system to continue to deliver the same level (quantity, quality and equity) of basic healthcare services and protection to populations despite the shock (in this instance the Covid-19 pandemic) using the same level of resources and capacities. Adaptive capacity is the capacity of the health system actors (such as health workers) to deliver the same level of healthcare services with fewer and/ or different resources, which requires making organisational adaptations. Finally, the transformative capacity describes the ability of health system actors to transform the functions and structure of the health system to respond to a changing environment such as adaptations to Covid-19 guidelines and provision of Covid-19 care without compromising other services. | en_US |
| dc.description.sponsorship | UNICEF Eastern and Southern Africa Regional Office | en_US |
| dc.identifier.uri | http://rscarchive.kuhes.ac.mw/handle/20.500.12988/613 | |
| dc.language.iso | en_US | en_US |
| dc.publisher | Kamuzu University of Health Sciences | en_US |
| dc.relation.ispartofseries | Protocol;P.03/21/3282 | |
| dc.title | Continuity of Essential Health Services (CES) study - Exploring effect of COVID-19 on demand for maternal, newborn and child health services in selected districts in Malawi by William Stones | en_US |