The health sector is no doubt the hardest hit by the coronavirus crisis. It has shaken weak foundations of health systems across the world and exposed the weaknesses of even the best hospitals to weather the storm.
As Bill and Melinda Gates Foundation puts it, the threats are clear but health structures across the world must take actions that matter a great in the next few months. According to the 2020 Goalkeepers report, “progress is possible but not inevitable”. Consequently, the foundation has made a case for actions to be taken in the following key areas of health indicators.
Maternal mortality
Indirectly, COVID will cause more women than men to suffer and die, largely because the pandemic has disrupted health care before, during, and immediately after childbirth.
Preventable, treatable complications such as severe bleeding, infection, and high blood pressure cause the vast majority of maternal deaths. Many health care workers, who used to manage these emergencies, including experienced nurse-midwives, are being diverted to COVID wards.
Meanwhile, pregnant women and new mothers must weigh the benefits of visiting a clinic—where they may not have received high-quality care in the past, against the risk of exposure to COVID. Some are deciding to deliver at home or skip new born care visits as a result.
Expert maternal care is the definition of an essential service. Unlike some other services, it can’t be safely postponed and caught up later. A pregnant woman is pregnant now and delivers her baby when she delivers. It is imperative that health systems have all the resources they need to ensure that she can do so safely and with dignity.
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Under-5 mortality
Current data suggests that children are less likely to have severe disease from coronavirus infection than older adults. However, as coverage for routine immunizations decreases and case management for pneumonia and diarrhoea have been interrupted due to the pandemic, children are increasingly vulnerable.
Models predict that acute malnutrition will increase dramatically, which will make it harder for children to fight off infectious diseases.
These consequences of the pandemic emphasize the need to figure out how to prevent secondary and tertiary crises. Yet even now, lifesaving innovation continues. Vaccines exist to protect against many causes of pneumonia, the leading infectious killer of young children. But they can be expensive—they account for about half the budget of Gavi, the Vaccine Alliance. Several months ago, however, the World Health Organization prequalified a new pneumonia vaccine that costs only $6 for a three-dose regimen instead of $9. And thanks to increased investment due to COVID-19, more health care facilities are providing access to oxygen to treat respiratory conditions; this will help save the lives of many children infected with pneumonia.
Neonatal mortality
Neonatal mortality has been declining, but more slowly than mortality among older children. Part of the reason for this pattern is that in general, newborns die when health systems falter.
This is precisely what is happening now. Many facilities are even more short-staffed and under-equipped than usual. The pandemic is likely to push some pregnant women to deliver their babies at home. In either case, women and their babies may not have access to lifesaving care. Saving new-borns require providing pregnant women with high-quality, dignified prenatal care by a skilled facility provider—and when facility-based birth is impossible, ensuring that in-home deliveries are attended by a skilled birth attendant with a safe birth kit to prevent infections and manage emergencies.
The Foundation recommends the need to understand more about the impact of COVID-19 itself on pregnant women and new-borns. Specifically, pregnant and breastfeeding women and children should be included in vaccine clinical trials so that we know whether vaccines are safe and effective for them.
HIV
Current evidence shows that people living with HIV are at increased risk of death due to COVID-19. But the indirect effects of the pandemic are also worrying.
Disruptions to health services could mean people don’t get antiretroviral therapy (ART), which would result in more deaths and more infections (because viral loads are higher in untreated patients, they are more likely to transmit to others). So far, this worst-case scenario has not happened, although some countries are struggling to maintain services.
One innovation that seems to be helping is multi-month dispensing—a simple approach that helps people fit treatment into their lives and keeps them out of overburdened clinics.
Even after COVID is under control, this will be a more effective, efficient way to dispense ART.
Tuberculosis
Before COVID-19, there were already 3 million “missing cases” of TB: people with active TB who didn’t know it and were passing the disease to others while going untreated themselves. Now, that number will grow even larger as people either cannot go to health facilities for diagnosis or choose not to go to avoid the possibility of exposure to COVID-19.
For similar reasons, people who know they have TB may not go in for treatment. Our fear is that this expanded pool of undiagnosed infections will lead to a long-term increase in the number of TB cases around the world. As they come out of COVID, countries are going to have to make case-finding and funding for TB a major priority.
Malaria
Malaria is unforgiving: As long as it exists, it will kill the most vulnerable and take advantage of emergencies. That’s why the Gates Foundation’s malaria strategy is geared toward eradicating the disease. Even under ordinary circumstances, both the malaria parasite and the mosquitoes that transmit it develop resistance to the drugs and insecticides used to fight them.
“We invest in modelling and surveillance technologies designed to help countries tailor strategies for deploying malaria tools so that they drive down ongoing, high-level transmission as much as possible. Modelling, in fact, helped many countries decide to continue bed net campaigns despite COVID-19, ensuring that, so far, the backsliding in 2020 has been less severe than it might have been,” the foundation stated. These same tools are also critical for epidemic preparedness and response—and it is essential that the global community keep investing in them.
Neglected Tropical Diseases (NTDs)
Ordinarily, a single curve that tracks a group of 15 neglected tropical diseases is a useful shortcut. During COVID-19, however, that shortcut doesn’t work as well. Each disease is very different, with different treatment and prevention tools and programs and the pandemic’s impact on each one differs, too.
Some NTDs are treated using annual “mass drug administration” campaigns (MDAs), which many countries are postponing for fear that health care workers could spread COVID-19. For some NTDs, this delay may not pose a serious problem, because catching up later is relatively easy. However, for more contagious NTDs (like trachoma, schistosomiasis, and visceral leishmaniasis), delayed MDAs are likely to cause surges in infection.
Progress on this subset of NTDs was too slow in some settings before the pandemic, and modelling suggests that biannual or quarterly campaigns (trachoma) or detecting cases to better target campaigns (visceral leishmaniasis) is necessary in any case.
Family planning
Before COVID-19, there was good news about this indicator. In West Africa, for instance, where progress had been slow, the number of women using contraceptives more than doubled between 2011 and 2020.
But health care systems are now struggling to provide family planning services. For example, postpartum family planning—helping women space their next pregnancy after they have a baby—is vitally important but doesn’t always happen at health facilities, let alone when women deliver at home. And because family planning can enable a healthier, more prosperous future for mothers and their babies, these gaps in care could have lasting adverse effects.
One solution is to shift toward a model of self-care that equips women and families with the expertise, tools, and confidence to plan without having to rely on the health care system. This can include specific interventions like self-injectable contraceptives or platforms like telemedicine, but it is broader than that. Self-care is deeply rooted in women’s needs and can promote access to family planning and other essential health services.
Universal health coverage
The Universal Health Coverage (UHC) Effective Coverage Index produced by IHME includes 23 indicators that, together, are a shortcut for thinking about whether people in a country have access to essential health services.
This year, COVID is pushing these numbers down. Supply chains are cut off; personal protective equipment (PPE) is scarce; and resources are being shifted to acute COVID care. Demand is down, too, as people avoid (or can’t get to) health facilities.
Because the UHC index is a composite across different services provided through health systems, no single action can reverse this decline, the Foundation says. Yet the ultimate pathway to UHC is primary health care (PHC). PHC is the backbone of a comprehensive health care system: It is accessible and affordable, and it can address more than 80 per cent of a person’s health needs over the course of their lifetime. Steering more spending into PHC (and relatively less into secondary and tertiary care)—and spending that money more efficiently—will lead to better patient outcomes. Ultimately, it will also lead to the goal of UHC.
Vaccines
In the 1970s, vaccinations reached only about 5 per cent of the world’s children; by 2019, they reached over 80 per cent and prevented more than 2 million deaths. That progress is now at risk. Because of COVID-19, vaccination rates are going back to 1990s levels. In some cases, these vaccinations are simply delayed, and kids can “catch up” later without much consequence. However, some infections, such as measles, spread easily, and even short-term disruptions can lead to immediate increases in illness and death.
Highly affected countries are innovating to regain this ground quickly. For example, combining health campaigns (for vaccines, deworming pills, bed nets, etc.) so that communities receive these services all at the same time instead of one by one would increase coverage while minimizing exposure during the pandemic. Innovations like this can help health systems reach the estimated 14 million children who didn’t receive even the most basic vaccines in 2019 and the millions more at risk of being left behind in 2020 because of COVID-19.
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