David E Phillips, Zulfiqar A Bhutta, Agnes Binagwaho, Ties Boerma, Matthew C Freeman, Lisa R Hirschhorn, Raj Panjabi, On behalf of the Exemplars in Global Health Partnership

Summary box

To minimise these negative indirect effects, countries will need to consider all domains of health systems, including demand, supply, resources and social determinants.

To this end, learning from countries that have improved health outcomes amid other crises could provide helpful strategies.

Some of the strategies used by these positive outlier countries include clear national leadership, data-driven targeting, community-focused health services and a strong emphasis on equity.

Studying positive outlier countries to find lessons applicable for other settings is the focus of the recently launched Exemplars in Global Health programme.

Introduction – Indirect effects of COVID-19 threaten greater maternal and child health losses than direct effects

The effect of COVID-19 on health and health systems around the world has been unprecedented. Now with over 15 million confirmed cases and 618 000 confirmed deaths globally, the toll on human health has been a tragedy. Daily cases continue to increase as well; the 3-day rolling average of new confirmed cases was 246 597 on July 18, up from 223 597 one week prior. And while daily confirmed deaths have levelled off from their peak in April, hospital resource use is at risk of returning to levels that exceed intensive care unit capacity in 92 out of 160 countries with available projections in 2020.

This excess resource use across health systems threatens to impact more patients than just those suffering from coronavirus disease. The strain it places on medical staff, supplies and facility capacity could cause enormous disruptions to primary healthcare in general, limiting the ability to adequately respond to and prevent infectious disease, non-communicable disease and injuries alike.

The policy and funding response to the COVID-19 pandemic, necessary as it is, creates further challenges than health system strain, however. Financial resources have already begun diverting away from routine services and interventions, as financial channels such as the Global Fund allow the reprogramming of funds originally intended for other purposes. Demand to use health services is also being interrupted as physical distancing remains an effective mitigation strategy and understandable concerns about disease transmission create hesitance to seek care. Worse, the broader economic impact of the pandemic, coupled with existing healthcare inequalities and a disproportionate disease burden, is exacerbating socioeconomic disparities and the social determinants of health.

The combination of these four forces—constrained supply, reduced resources, suppressed demand and worsening socioeconomic inequality—creates a likelihood that the indirect effects on health and nutrition will be more harmful than the direct health consequences of the disease. Projections already suggest that COVID-19 could lead to up to a 45% increase in child deaths and a 39% increase in maternal deaths across low and middle-income countries.1 Such a backslide would undermine dramatic gains made since 2000. Under-five mortality has declined by 43% globally, with 4.3 million fewer annual deaths in 2017 than 2000. During the same period, the prevalence of stunted growth in children under age 5 declined from 32% to 22%, or 48.7 million fewer children.

Progress in maternal and child health is at especially high risk during the COVID-19 response. The suspension of national immunisation programmes has been projected to cause 140 child deaths per COVID-19 death averted, putting 80 million infants at risk of contracting vaccine-preventable diseases. Disruptions in distribution campaigns for insecticide-treated bed nets and effective antimalarial treatments have been projected to set malaria mortality back to levels not seen in 20 years under the worst scenario, with most of those affected being children. The socioeconomic consequences of the pandemic could leave mothers and children especially vulnerable to health risks, and pose new challenges for the utilisation and access of healthcare.