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Impact of COVID‐19 on access to healthcare in low‐ and middle‐income countries: Current evidence and future recommendations

August 2020
International Journal of Health Planning and Management 36(2)

DOI:10.1002/hpm.3067

Authors:

Melody Okereke

University of Ilorin

Nelson Ukor

University of Port Harcourt

Yusuff Adebayo Adebisi

University of Glasgow

Isaac Olushola Ogunkola

University of Calabar

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The COVID‐19 pandemic continues to be a major public health threat globally and low‐ and middle‐income countries (LMICs) are not an exception. The impact of the COVID‐19 pandemic is far‐reaching on many areas including but not limited to global health security, economic and healthcare delivery with a potential impact on access to healthcare in LMICs. We evaluate the impact of the COVID‐19 pandemic on access to healthcare in LMICs, as well as plausible strategies that can be put in place to ensure that the delivery of healthcare is not halted. In order to mitigate the devastating effect of the COVID‐19 pandemic on the already weak health systems in LMICs, it is much necessary to reinforce and scale up interventions and proactive measures that will ensure that access to healthcare is not disrupted even in course of the pandemic.

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Content may be subject to copyright.

Received: 17 July 2020

Revised: 16 August 2020

Accepted: 19 August 2020

DOI: 10.1002/hpm.3067

PERSPECTIVE

Impact of COVID‐19 on access to healthcare in

low‐and middle‐income countries: Current

evidence and future recommendations

Melody Okereke

|Nelson Ashinedu Ukor

Yusuff Adebayo Adebisi

|Isaac Olushola Ogunkola

Eseosa Favour Iyagbaye

|Greatman Adiela Owhor

Don Eliseo Lucero‐Prisno III

Faculty of Pharmaceutical Sciences,

University of Ilorin, Ilorin, Nigeria

Faculty of Pharmaceutical Sciences,

University of Port Harcourt, Choba, Nigeria

Faculty of Pharmacy, University of Ibadan,

Ibadan, Nigeria

Department of Public Health, University of

Calabar, Calabar, Nigeria

Faculty of Pharmacy, University of Benin,

Benin City, Nigeria

Department of Global Health and

Development, London School of Hygiene and

Tropical Medicine, London, UK

Correspondence

Melody Okereke, Faculty of Pharmaceutical

Sciences, University of Ilorin, Ilorin, Nigeria.

Email: melokereke30@gmail.com

Abstract

The COVID‐19 pandemic continues to be a major public

health threat globally and low‐and middle‐income

countries (LMICs) are not an exception. The impact of the

COVID‐19 pandemic is far‐reaching on many areas

including but not limited to global health security, eco-

nomic and healthcare delivery with a potential impact on

access to healthcare in LMICs. We evaluate the impact of

the COVID‐19 pandemic on access to healthcare in LMICs,

as well as plausible strategies that can be put in place to

ensure that the delivery of healthcare is not halted. In

order to mitigate the devastating effect of the COVID‐19

pandemic on the already weak health systems in LMICs, it

is much necessary to reinforce and scale up interventions

and proactive measures that will ensure that access to

healthcare is not disrupted even in course of the pandemic.

KEYWORDS

access, coronavirus, COVID‐19, healthcare, LMICs, pandemic

COMMENTARY

According to the income classiﬁcation of the World Bank, low‐income economies are classiﬁed as those with gross

national income (GNI) per capita of $1.025 whereas lower middle‐income economies are listed as those with GNI

per capita within $1.026 and $3.995.

Although GNI is not the heartbeat of a good health system, it is broadly

viewed as a major determinant of health outcomes with a corresponding impact on access to healthcare. This is

because access to healthcare is a multifaceted and intricate prospect. Equitable and fair access to healthcare is an

essential target for all countries, but especially difﬁcult and increasingly complex in low‐and middle‐income

countries (LMICs) given the heavy burden of healthcare needs and severely under‐resourced healthcare

frameworks and systems. The sustainable development goal 3 was established to ensure equitable access to quality

healthcare services worldwide. However, this target has been grossly interrupted ever as the emergence of the

coronavirus disease, also known as COVID‐19, globally and low and middle‐income countries have been invariably

affected. This unprecedented event has placed even more burden on the already fragile health systems in LMICs

with a potential impact on access to healthcare services.

ACCESS TO HEALTHCARE IN LMICs BEFORE THE EMERGENCE OF COVID‐19

Before the emergence of the COVID‐19 pandemic globally, access to healthcare has been seen to vary as various

countries have different healthcare provisions. Although some countries already have good existing health systems

and accessible health frameworks, others have been suffering several setbacks such as LMICs. Access to optimal

healthcare has also been a major socio‐economic issue in LMICs. For certain areas, the shortage of adequate health

services is exacerbated by the prevalence of inequalities in the allocation of public health institutions. Individuals

living in LMICs have comparatively uneven access to quality health services than their counterparts in high‐income

countries.

Before the emergence of the COVID‐19 pandemic in Africa, LMICs accounted for more than 70% global disease

burden, but less than 15% of global health spending.

LMICs have a lesser density of health workers and availability of

hospital beds per population; this decreases the availability of health services to the poor. Evidence shows that high‐

income countries spend many times more on health, and the majority of the health ﬁnances available in poorer

countries are usually out‐of‐pocket expenditure.

These incidences will invariably result in poor access to healthcare

in these countries. Ever as the emergence of the COVID‐19 pandemic in Africa, it has had its toll on LMICs as the

mortality rate of the pandemic has experienced a dramatic rise over time and is increasingly alarming. This can

potentially exert pressure on already fragile health systems in LMICs with a resultant impact on healthcare providers.

KEY SECTORS OF HEALTH SYSTEMS AFFECTED BY COVID‐19 AND IMPACT ON

HEALTHCARE PROVIDERS

A stable and functional health system is built on a variety of factors, including skilled healthcare personnel, well‐

maintained facilities and infrastructural frameworks, and adequate availability of personal protective equipment

(PPE) and medicines. In Africa, health systems have been surmounted with the various challenges posed by previous

disease outbreaks such as Ebola, Zika virus, H1N1 pandemic

and the present COVID‐19 pandemic. As the COVID‐19

pandemic broke out in Africa, various sectors of health systems in LMICs have been threatened including pharmacy

clinical, and hospital

sectors respectively. This will have grave consequences on the delivery of healthcare services in

several LMICs in Africa as a strengthened health system is essential for ensuring better health outcomes.

To further enhance better health outcomes and strengthen inter‐sectoral collaboration in light of this present

pandemic in LMICs, the role of pharmacy practice as a major component and driver of the health system is crucial

OKEREKE ET AL.

but this is not without challenges. Due to the lockdown policies caused by COVID‐19 to reduce the incidence of

transmission, pharmacy practice in Africa has suffered several setbacks in optimal healthcare delivery as the

pandemic has had a potential impact on drug supply, availability, affordability and movement of pharmacists and

pharmacy workers.

Before the emergence and spread of COVID‐19, pharmacists have usually been the ﬁrst point

of contact by patients in need of healthcare services

but with the present situation of the pandemic, pharmacists in

several LMICs in Africa are reluctant to address the needs of patients due to fear of disease contraction.

The effect

of the COVID‐19 pandemic on pharmacy practice in Africa has become very pronounced. Also, the supply chain of

medicines, pharmaceutical products and PPE were greatly affected by the lockdown policy.

This also weighed on

the quality of health service afforded to LMICs' populations. A possible implication is that this would have a

signiﬁcant impact on the standard of healthcare delivery in LMICs.

Globally, the COVID‐19 pandemic has affected clinical and hospital practices

and LMICs are not an exception.

Although occasional cancellation of surgeries has been experienced in the past,

the current COVID‐19 pandemic

has placed more unprecedented implications for patients requiring surgical attention during these times. For

instance, rather than reinforcing the need for the mobilization of surgical resources needed for surgical operations,

the growing demand for ventilators, hospital space and manpower, coupled with the lockdown policies is restricting

surgical services from extending to critical patients and areas where they are essentially required. This has

invariably affected millions of surgical patients worldwide. Of great concern also is the safety of medical doctors

and surgeons who are on the frontline in course of the COVID‐19 pandemic. Proper PPE is an absolute must but

has proven to be a global concern with complex and volatile supply chains and distribution networks globally. This is

an area worth exploring in order to minimize the risks of occupational hazards in the course of healthcare delivery.

Consequently, when healthcare providers have been grossly affected by the COVID‐19 pandemic, then there are

tendencies that patients in dire need of healthcare would suffer several setbacks in accessing these healthcare

services.

COVID‐19 AS A BARRIER TOWARDS ACCESSING HEALTH SERVICES BY

PATIENTS SUFFERING FROM CHRONIC DISEASES IN LMICs

Every year, 15 million individuals between the ages of 30 and 69 years die from non‐communicable diseases

(NCDs).

More than 85% of such ‘premature’ deaths arise in LMICs such as India and Nigeria due to cardiovascular

diseases (17.9 million), followed by cancer (9.0 million), respiratory diseases (3.9 million) and diabetes (1.6 million).

COVID‐19 may have a detrimental effect on NCD outcomes for adults and children across many systems including

increased vulnerability to COVID‐19 infection and higher mortality levels amongst patients living with NCDs;

delays in detection of NCDs progressing to more severe forms of the disease; discontinued or interrupted therapy

of NCDs; an upsurge in behavioural risk factors and increased usage of dangerous substances.

Globally, two‐thirds

of countries conﬁrmed that NCD programs were being included in their national COVID‐19 readiness and response

plans.

Inclusion was recorded by 72% of high‐income countries compared to 42% of low‐income countries with a

primary focus on cancer, diabetes, chronic respiratory disorders and cardiovascular diseases.

The nature of COVID‐19 may make some NCDs more difﬁcult to recognize. For example, COVID‐19 has been

associated with cardiovascular complications that can make the accurate diagnosis of myocardial infarction

increasingly complex. Patients with existing chronic respiratory disorders such as chronic obstructive pulmonary

disease, asthma, inﬂuenza, and so on. Often ﬁnd it difﬁcult to recognize when immediate medical attention can be

pursued as such diseases have very common symptoms to COVID‐19.

Combining all the evidence published and

recorded so far, and keeping in mind the current COVID‐19 scenario, it is evident that the COVID‐19 pandemic

would further intensify the global NCD crisis, especially in LMICs. Efforts need to be increased in LMICs to ensure

effective pandemic containment because the region faces a double burden of infectious and non‐infectious diseases

and most of all, its weak healthcare systems.

11,12

OKEREKE ET AL.

CONCLUSION AND FUTURE RECOMMENDATIONS

The COVID‐19 pandemic continues to be a major public health threat globally and LMICs are not exempted from

this threat. The impact of the COVID‐19 pandemic is far‐reaching on many areas including but not limited to global

health security, economic and healthcare delivery in LMICs. Responses have been mounted towards effective

containment of the pandemic. However, national health authorities and other stakeholders in LMICs must continue

to ensure that access to quality healthcare services is not disrupted. Innovations are more needed than ever and

LMICs need to continue to devise means to ensure country‐compatible measures and policies in the ﬁght against

COVID‐19. There is also the need for a unique approach to ensure a proactive response in LMICs. Early isolation of

infected persons, cross‐border knowledge sharing, effective contact tracing, standard reporting and reliable

surveillance system, increased testing capacity, cross‐border cooperation and collaboration in LMICs, effective

community engagement and infection prevention and control measures, including maintaining physical distance and

proper hand and cough etiquette/respiratory hygiene should continue to be prioritized in LMICs. With this, the

burden on the already fragile healthcare systems in LMICs would be lessened. This will provide the opportunity to

respond adequately to the unprecedented COVID‐19 pandemic in LMICs and still ensure that healthcare delivery is

not disrupted.

ACKNOWLEDGEMENTS

We appreciate the reviewers for their insightful comments.

CONFLICT OF INTEREST

The authors declared no conﬂicts of interest.

AUTHOR CONTRIBUTIONS

The concept for this commentary was developed by Melody Okereke. Melody Okereke, Nelson Ashinedu Ukor,

Isaac Olushola Ogunkola, Eseosa Favour Iyagbaye, Greatman Adiela Owhor developed the draft and Melody

Okereke prepared the manuscript. Yusuff Adebayo Adebisi and Don Eliseo Lucero‐Prisno III assisted with data

collection, revision of the draft and language edits. All the authors have read and agreed to the ﬁnal manuscript.

ORCID

Melody Okereke https://orcid.org/0000-0003-2533-6785

Yusuff Adebayo Adebisi https://orcid.org/0000-0002-2381-0984

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How to cite this article: Okereke M, Ukor NA, Adebisi YA, et al. Impact of COVID‐19 on access to

healthcare in low‐and middle‐income countries: Current evidence and future recommendations. Int J Health

Plann Mgmt. 2020;1–5. https://doi.org/10.1002/hpm.3067

OKEREKE ET AL.

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Full-text available

Jul 2020

COVID-19 is an unprecedented pandemic posing major threat to global public health. In the past decades of years or so, one could have heard of how dangerous it is to be virtually reliant on medicine supply from other countries. Nonetheless, no action was taken because it seemed to many that the global trade system was operational and Nigerians as well as citizens of African countries appear to have sufficient supply of the medications required at quite appealing cost. Currently in 2020, this apprehension has revolved from an imaginary problem to an actual challenge that might have consequences for millions nationwide due to COVID-19 pandemic. Now, African countries can realize that putting all our eggs in one basket was not such a good idea. In Nigeria, over 70% of the prescribed medications are produced from active ingredients (API) primarily sourced from firms in China and India. Access to medicine is an integral part of healthcare systems, uninterrupted access to medicine is much needed and essential for the well-being of the population. We are now approaching the conclusion that it is more reasonable to probably invest a little more to resuscitate a domestic pharmaceutical synthesis and herbal medicine research capacity in Nigeria and across African countries to improve public health.

COVID-19: Community Pharmacy Practice in Africa

Article

Full-text available

Jun 2020

In the 21st century, the world has seen a fair share of widespread infectious disease outbreaks that thrusts healthcare workers at the frontline, putting their expertise to work in containing them. The position of the pharmacists had been utilized in such crises with their role shifting from a product-centered to patient-centered care (1). Pharmacists are an essential part of healthcare team that performs exceptional roles in the containment of the earlier pandemics and global health crisis including Ebola and Zika. During the H1N1 influenza pandemic, community pharmacies were recognized by patients as con- venient locations to receive pandemic influenza vaccinations and in course of the 2010 to 2011 influenza season, 18.4 percent of adult influenza vaccines were administered in community pharmacies, this further reinforces the much-needed role pharmacists can play in responding to health emergencies. It has been reported that 93 percent of pharmacists would be willing to report to work in course of a future disease outbreak such as COVID-19. Engagement of pharmacists in pandemics is vital due to their spe- cialized knowledge in ensuring and supporting effective responses to diseases outbreak.

Proposed Model for Hospital and Community Pharmacy Services During COVID-19 Pandemic in Nigeria

Article

Full-text available

Jul 2020

In December 2019, a novel coronavirus called Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) has been implicated as the virus that causes the coronavirus diseases (COVID-19). On 11 March 2020, the World Health Organization declared the outbreak a pandemic after it has progressively spread to many countries around the world. Current evidence has shown that COVID-19 is transmitted through respiratory droplet spread or droplet nuclei that have settled on surfaces or via close contact. During the incubation period (2 – 14 days), infected persons are asymptomatic but have the ability to transmit the virus to other people. These characteristics of COVID-19 are a potential threat to a widespread infection at the community level. COVID-19 pandemic has caused virtually all aspect of the human life to experience unprecedented transformation with major threat to global health security as well as the global economy. In addition, healthcare professionals including pharmacists are at significant risk of contracting COVID-19. This letter emphasizes the proposed model for community and hospital pharmacy services amid this pandemic in Nigeria and this can be adapted to other resource-limited settings.

Current efforts and challenges facing responses to 2019-nCoV in Africa

Article

Full-text available

May 2020
Health Res Pol Syst

The novel coronavirus is a pandemic that has started to creep into Africa thus making the virus a truly global, health security threat. The number of new 2019-nCoV cases has been rising in Africa, though currently lower than the cases reported outside the region. African countries have activated their Emergency Operations Centres to coordinate responses and preparedness activities to the pandemic. A series of measures such as restricting travel, case detection and contact tracing, mandatory quarantine, guidance and information to the public among other efforts are being implemented across Africa. However, the presence of porous borders, the double burden of communicable and non-communicable diseases, poverty, poor health literacy, infodemic and family clustering, and most of all, weak health systems, may make containment challenging. It is important for African countries to continue to intensify efforts and address the challenges to effectively respond to the uncertainty the pandemic poses.

The consequences of the COVID-19 pandemic on mental health and implications for clinical practice

Article

Full-text available

Apr 2020

The consequences of the COVID-19 pandemic on mental health and implications for clinical practice - Andrea Fiorillo, Philip Gorwood

Elective surgical case cancellation in the Veterans Health Administration system: Identifying areas for improvement

Article

Nov 2009

This study evaluated elective surgical case cancellation (CC) rates, reasons for these cancellations, and identified areas for improvement within the Veterans Health Administration (VA) system. CC data for 2006 were collected from the scheduling software for 123 VA facilities. Surveys were distributed to 40 facilities (10 highest and 10 lowest CC rates for high- and low-volume facilities). CC reasons were standardized and piloted at 5 facilities. Of 329,784 cases scheduled by 9 surgical specialties, 40,988 (12.4%) were cancelled. CC reasons (9,528) were placed into 6 broad categories: patient (35%), work-up/medical condition change (28%), facility (20%), surgeon (8%), anesthesia (1%), and miscellaneous (8%). Survey results show areas for improvement at the facility level and a standardized list of 28 CC reasons was comprehensive. Interventions that decrease cancellations caused by patient factors, inadequate work-up, and facility factors are needed to reduce overall elective surgical case cancellations.

COVID-19 and non-communicable diseases (NCDs): questions and answers

Ncd Alliance

NCD Alliance. COVID-19 and non-communicable diseases (NCDs): questions and answers. https://ncdalliance.org/ resources/covid-19-and-noncommunicable-diseases-ncds-questions-and-answers. Accessed July 15, 2020.