Pulse survey on continuity of essential health services

Pulse survey on continuity of

essential health services

during the COVID-19 pandemic

Key informant findings from 135 countries, territories and areas

Quarter 1 2021

Reporting period: 3 months preceding date of survey submission

Global results – as of 16 April 2021

Round 2: National pulse survey on continuity of EHS during the COVID-19 pandemicQ1 2021: January – March

Use:

Gain rapid snapshot of

changes and challenges in

service delivery/utilization

Modular approach:

integrates all WHO pulse surveys

into comprehensive approach

targeting different key informants

in Ministry of Health

Timeline:

Q1 2021 (Jan- March 2021).

Results reflect situation

3 months preceding submission.

Contributes to quarterly

WHO SPRP monitoring 2021:

indicators for Pillar 9: Maintaining essential health services and systems (Proportion of countries reporting disruption to essential health services during COVID-19 pandemic) and Pillar 2: Risk communication, community engagement and infodemic management (Proportion of countries with capacities to track and address infodemic and health misinformation)

Results should be used

at country level to

support policy and planning

dialogue to identify critical

bottlenecks and priorities,

recommend mitigation

approaches/solutions, and

guide resource investments as

pandemic progresses.

https://www.swissphilanthropy.ch/wp-content/uploads/2021/02/WHO-COVID_19-Strategic-Preparedness-and-Response-Plan-2021.pdf

Round 2: National pulse survey on continuity of EHS during the COVID-19 pandemicQ1 2021: January – March

Limitations:

• Reporting bias (self-reported key informant data)

• Type/mix of key informants across multiple survey sections

• Process of completion (individual survey section submissions vs. coordinated and validated

responses across survey sections)

• National level data does not reflect subnational variability within countries

• Response rates varied across regions, limiting extent of possible regional comparisons

• Different quantity and combination of participating countries introduces potential bias into survey

round 1 and round 2 global comparisons

Key questions the national pulse survey helps to answer

Policies and planning

• Have countries identified a core set

of EHS to be maintained during the

pandemic?

• Have countries designated a

national focal point for maintaining

EHS?

• Have countries allocated additional

funding for maintaining EHS?

Strategic changes to service delivery and public health activities

• Have countries limited or suspended access to service delivery platforms (e.g. outpatient, inpatient, emergency, community-based, etc.)?

• Have countries limited or suspended essential public health functions/activities (e.g. surveillance, emergency preparedness, research, etc.)?

Disruptions to tracer services

• Have countries limited or suspended access to service delivery platforms (e.g. outpatient, inpatient, emergency, community-based, etc.)?

• Have countries limited or suspended essential public health functions/activities (e.g. surveillance, emergency preparedness, research, etc.)?

Reasons for disruptions

• What are the main supply-side reasons for service disruptions?

• What are the main demand-side reasons for service disruptions?

Mitigation strategies

• What approaches are being used by countries to overcome service disruptions?

• What approaches are being used to ensure access to care for vulnerable groups?

• How are digital technologies being used to mitigate service disruptions?

Information tracking

• Are countries regularly monitoring and tracking continuity of EHS and the implementation of mitigation strategies?

• Are countries tracking the infodemic and misinformation?

Country priorities and needs

• What are countries’ most urgent priority needs and TA requirements for maintaining EHS?

National pulse survey on disruptions to essential health services: 2nd round response rates

Key informant responses from 135 countries/territories between January-March 2021

Note: The survey was sent to 216 countries, territories and areas. Response rates are calculated based on contexts where services are relevant.

Malaria section is considered relevant in 92 contexts and NTDs section is considered relevant in 104 contexts. Responses were tracked only in these settings.

Overall response rates Survey section response rates

Complete survey

submission

(submission of all

relevant sections)

N (%)

Complete + partial

survey

submissions

(submission of at

least 1 section)

N (%)

Section 1.

Health system

functions and

cross-cutting

services

N (%)

Section 2.

Reproductive,

maternal,

newborn, child

and adolescent

health and

nutrition

N (%)

Section 3.

Immunization

N (%)

Section 4.

HIV and

hepatitis

N (%)

Section 5.

TB

N (%)

Section 6.

Malaria

N (%)

Section 7.

Neglected

tropical

diseases

N (%)

Section 8.

Non-

communicable

diseases

N (%)

Section 9.

Mental,

neurological,

and substance

use disorders

N (%)

AFR 30 (65%) 40 (85%) 36 (77%) 38 (81%) 33 (70%) 35 (74%) 35 (74%) 32 (74%) 33 (75%) 38 (81%) 37 (79%)

AMR 16 (30%) 29 (54%) 25 (46%) 29 (54%) 23 (43%) 22 (41%) 23 (43%) 11 (65%) 11 (52%) 28 (50%) 27 (50%)

EMR 15 (68%) 21 (95%) 17 (77%) 19 (86%) 19 (86%) 17 (77%) 16 (73%) 8 (100%) 10 (83%) 19 (86%) 20 (91%)

EUR 12 (23%) 23 (43%) 16 (30%) 18 (34%) 21 (40%) 19 (36%) 19 (36%) 1 (20%) 1 (25%) 18 (34%) 18 (34%)

SEAR 8 (73%) 9 (82%) 9 (82%) 8 (73%) 9 (82%) 9 (82%) 8 (73%) 7 (78%) 6 (75%) 9 (82%) 8 (73%)

WPR 7 (24%) 13 (45%) 9 (31%) 9 (31%) 7 (24%) 10 (34%) 11 (38%) 8 (80%) 9 (60%) 9 (31%) 11 (38%)

Global 88 (41%) 135 (63%) 112 (52%) 121 (56%) 112 (52%) 112 (52%) 112 (52%) 67 (73%) 70 (67%) 121 (56%) 121 (56%)

Despite some evidence of service

restoration, over one year into the

COVID-19 pandemic, substantial

disruptions to essential health

services persist across the globe.

Disruptions to essential health services are still geographically widespread across the globe

Denominator: represents responses from countries/territories that responded to at least one survey section and consented to data sharing agreement. Percentage of countries reporting disruptions may not add up to exactly 100% due to rounding. Services include: primary care, emergency and critical

care, surgical care, rehabilitation, palliative care, long-term care, auxiliary services, and tracer services for reproductive, maternal, newborn, child and adolescent health and nutrition, immunization, communicable diseases, noncommunicable diseases, neglected tropical diseases, and mental,

neurological and substance use disorders

9% of countries reported disruptions

in 75-100% of services






in less than 25% of services

Only 6% of countries reported

no disruptions

94% of responding countries (n= 135)

experienced a disruption to some extent

94%

t

On average, countries reported disruptions to more than one third of services

1/3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

GNB PHL PER TLS IDN UGA PNG MEX SDN SWZ TCD ITA BOL AGO ALB SSD DOMBRA LBN HND SLB BLZ SLV UKR CMR PAN BHS ARG GBRMDG PRY MOZ PRT LCA IRQ HTI CIV LSO MRT WLS JOR SUR COM SEN MWI CHL MYS KEN STP THA TGO COG YEM GHAMAR ZAF ZMB GTM LKA PYF SYC BWAGEO IRN GIN BGR PAK ERI GMB CZE SCT GRD VCT AUT NER GAB ECU FRA DMA PSE LAO SYR TUN CRI LBR CPV JAM ETH VUT MDA URY BGDOMN BEN BMU FIN QAT VGB EGY AUS NAM LVA MDV BRN FJI NPL SOM HRV ARE AFG KAZ CYM HUN ARM BTN SAU KWT COD BDI EST RWADNK CAF DJI NIC BHR KOR MUS TKM CUB CHN BFA PRK

Per

cen

tag

e o

f se

rvic

es

Country/territory

Percentage of services disrupted per country (number of tracer services = 63)

50% or more disrupted 26-50% disrupted 5-25% disrupted

Global average: 38%

Denominator: represents responses from countries/territories that responded to at least one survey section and consented to data sharing agreement. Percentage of countries reporting disruptions may not add up to exactly 100% due to rounding. Services include: primary care, emergency and critical care,

surgical care, rehabilitation, palliative care, long-term care, auxiliary services, and tracer services for reproductive, maternal, newborn, child and adolescent health and nutrition, immunization, communicable diseases, noncommunicable diseases, neglected tropical diseases, and mental, neurological and

substance use disorders

Overall, primary care and rehabilitative, palliative and long-term care are more predominantly affected

t

of countries reported

disruptions to essential

primary care services

t

of countries reported disruptions to rehabilitative, palliative and long-term care

41%48%…with likely implications for the most vulnerable

populations, such as older persons and people living with chronic conditions

and disabilities

Overall, primary care and rehabilitative, palliative and long-term care are more predominantly affected

Denominator: excludes “Not applicable” or “Do not know” responses.

19%

24%

14%

29%

22%

6%

9%

4%

13%

9%

3%

8%

3%

6%

5%

27%

41%

22%

48%

35%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Auxiliary services

Rehabilitative, palliative and long-term care

Emergency, critical, and operative care

Primary care

AVERAGE DISRUPTION

Percentage of countries

Average percentage of disruptions across integrated service delivery channels (n=112)

5-25% disrupted 26-50% disrupted More than 50% disrupted

Potentially life-saving emergency, critical and operative care interventions disrupted in about 20% of countries, likely resulting in substantial near-term impact on health outcomes


29%

32%

30%

35%

24%

26%

14%

27%

21%

12%

15%

14%

15%

11%

8%

7%

24%

29%

22%

22%

19%

20%

18%

13%

16%

15%

9%

17%

8%

4%

13%

4%

5%

2%

3%

2%

1%

4%

2%

9%

13%

8%

5%

6%

5%

6%

6%

6%

8%

4%

7%

2%

3%

25%

2%

2%

1%

0%

1%

0%

0%

0%

8%

10%

7%

8%

3%

3%

3%

48%

54%

53%

48%

48%

36%

22%

65%

27%

19%

18%

18%

19%

13%

12%

9%

41%

53%

36%

35%

27%

28%

27%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

AVERAGE DISRUPTION OF PRIMARY CARE

Routine scheduled visits (n=98)

Health promotion services (n=96)

Referrals to specialty care (n=91)

Visits for undifferentiated symptoms (n=90)

Prescription renewals for chronic medications (n=97)

AVERAGE DISRUPTION OF EMERGENCY, CRITICAL, AND OPERATIVE CARE

Elective surgeries (n=100)

Emergency referrals for time-sensitive conditions (n=95)

Inpatient critical care services (n=94)

Emergency surgeries (excluding obstetric) (n=93)

Acuity-based triage in emergency units (n=95)

Ambulance services at the scene (n=100)

Emergency obstetric surgeries (n=96)

24-hour emergency room/unit services (n=94)

Urgent blood transfusion services (n=93)

AVERAGE DISRUPTION OF REHABILITATIVE, PALLIATIVE, AND LONG-TERM CARE

Rehabilitation services (n=89)

Palliative services (n=74)

Long-term care services (n=74)

AVERAGE DISRUPTION OF AUXILIARY SERVICES

Radiology services (n=97)

Laboratory services (n=97)

Pri

mar

y ca

reE

mer

gen

cy, c

riti

cal,

and

op

erat

ive

care

Reh

abili

tati

ve,

pal

liati

ve a

nd

lon

g-t

erm

car

eA

uxi

liary

serv

ices


Service disruptions across integrated service delivery channels (n=112)

5-25% disrupted

26-50% disrupted

More than 50% disrupted

65% also reporting disruptions in elective surgeries, with accumulating consequences as the pandemic is prolonged

Substantial disruptions span across all major health areas

Most frequently disrupted servicesare for mental, neurological, and

substance use disorders and neglected tropical diseases

(reported in more than 40% of countries)

Services across other health areas are also

disrupted in more than 1/3 of countries

>1/3>40%

Substantial disruptions span across all major health areas


24%

22%

23%

19%

15%

23%

21%

9%

7%

8%

8%

11%

13%

9%

3%

8%

5%

9%

19%

10%

9%

35%

36%

37%

37%

44%

45%

39%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Reproductive, maternal, newborn, child and adolescent health and nutrition (n=121)

Communicable diseases (n=128)

Immunization (n=112)

Noncommunicable diseases (n=121)

Neglected tropical diseases (n=109)

Mental, neurological and substance use disorders (n=121)

AVERAGE DISRUPTION OF PROGRAMME SPECIFIC AREAS


Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions across tracer service areas


Countries in high income group reported fewer service disruptions compared to countries in other income groups


24%

11%

18%

36%

27%

9%

3%

13%

7%

13%

3%

3%

5%

3%

0%

35%

17%

36%

46%

40%

0% 10% 20% 30% 40% 50% 60%

Global (n=121)

High income (n=30)

Upper middle income (n=34)

Lower middle income (n=32)

Low income (n=25)

Percent of countries

Average percentage of countries reporting disruptions to reproductive, maternal, newborn, child and

adolescent health and nutrition services by income group


23%

11%

35%

23%

20%

8%

7%

14%

6%

8%

5%

5%

8%

2%

8%

37%

23%

56%

31%

35%

0% 10% 20% 30% 40% 50% 60%

Global (n=112)

High income (n=32)



Low income (n=22)


Average percentage of countries reporting disruptions to immunization services by income

group


19%

5%

24%

21%

28%

8%

6%

8%

14%

3%

9%

8%

13%

10%

3%

37%

20%

45%

45%

33%

0% 10% 20% 30% 40% 50% 60%

Global (n=121)

High income (n=35)



Low income (n=25)


Average percentage of countries reporting disruptions to noncommunicable disease services by income group


15%

3%

9%

22%

20%

11%

14%

10%

14%

1%

19%

5%

25%

17%

25%

44%

22%

44%

54%

46%

0% 20% 40% 60% 80% 100% 120%

Global (n=109)

High income (n=27)



Low income (n=21)


Average percentage of countries reporting disruptions to neglected tropical disease services by

income group


22%

15%

28%

24%

23%

9%

5%

11%

11%

8%

7%

6%

9%

8%

5%

38%

26%

48%

42%

36%

0% 50% 100%

Global (n=135)

High income (n=35)

Upper middle income(n=37)

Lower middle income(n=37)

Low income (n=26)


Percentage of countries reporting disruptions across

tracer service areas by income group

5-25% disrupted 26-50% disrupted

More than 50% disrupted

23%

18%

36%

18%

17%

13%

6%

12%

22%

13%

10%

7%

11%

10%

10%

45%

31%

59%

50%

39%

0% 10% 20% 30% 40% 50% 60%

Global (n=121)

High income (n=29)



Low income (n=24)


Average percentage of countries reporting disruptions to mental, neurological, and substance

use disorder services by income group


21%

29%

27%

20%

22%

7%

5%

9%

6%

5%

8%

6%

7%

12%

4%

36%

40%

44%

37%

31%

0% 10% 20% 30% 40% 50% 60%

Global (n=129)

High income (n=35)



Low income (n=23)


Average percentage of countries reporting disruptions to communicable disease services by

income group


Disruptions to mental, neurological and substance use disorders (MNS) span the full continuum of care

From prevention and promotion: school mental health programmes and

suicide prevention programmes

To diagnostics and treatments neuroimaging

and neurophysiology, psychotherapy, counselling

and psychosocial interventions, and

prescriptions

For life-saving emergency care: management of emergency MNS

manifestations, critical harm reduction services, overdose prevention and

management programmes

For the most vulnerable populations: older adults, children, and adolescents

with mental health conditions or disabilities


Disruptions to mental, neurological and substance use disorders (MNS) span the full continuum of care

School mental health programmes (66%) and psychotherapy, counselling and psychosocial

intervention (54%) are among the most predominantly disrupted services across all service areas

23%

23%

16%

21%

20%

31%

22%

26%

15%

29%

7%

11%

13%

16%

15%

14%

15%

13%

11%

17%

5%

5%

2%

7%

4%

9%

8%

9%

40%

7%

34%

39%

32%

44%

39%

53%

45%

48%

66%

54%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Overdose prevention and management programmes (n=44)

Critical harm reduction services (n=44)

Prescriptions for MNS disorder medicines (n=91)

Suicide prevention programmes (n=57)

Management of emergency MNS manifestations (n=94)

Neuroimaging and neurophysiology (n=58)

Services for children/adolescents with mental health conditions or disabilities (n=86)

Services for older adults with mental health conditions or disabilities (n=85)

School mental health programmes (n=53)

Psychotherapy interventions for MNS disorders (n=95)


Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions in services for mental, neurological and substance use disorders

5% to 25% disrupted 26% to 50% disrupted More than 50% disrupted

Nearly half of countries reported disruptions to one of more services for noncommunicable diseases

Cancer screening

and treatment services are

among the most disrupted

services

t

1/3 of more countries

also reporting disruptions to

hypertension management,

diabetes management, and

asthma services

Time-sensitive services for urgent dental care and

cardiovascular emergencies are also affected

1/3

Nearly half of countries reported disruptions to one of more services for noncommunicable diseases


11%

15%

18%

21%

24%

27%

20%

19%

7%

8%

6%

7%

11%

9%

10%

8%

2%

7%

9%

14%

7%

8%

19%

9%

20%

30%

32%

42%

42%

45%

49%

37%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Cardiovascular emergencies (n=91)

Asthma services (n=87)

Cancer Treatment (n=90)

Urgent dental care (n=85)

Diabetes and Diabetic Complications Management (n=97)

Hypertension Management (n=95)

Cancer screening (n=86)

AVERAGE DISRUPTION IN SERVICE GROUP


Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions in noncommunicable disease services


Disruptions in immunization services


24%

21%

23%

7%

10%

8%

3%

8%

5%

34%

39%

37%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Routine facility-based immunization services (n=103)

Routine outreach immunization services (n=89)



Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions inimmunization services


t

More than one third of countries reported disruptions to both routine facility-based

and outreach immunization services

1/3

Disruptions in services for reproductive, maternal, newborn, child and adolescent health and nutrition

Over 40% of countries report

disruptions to family planning

and contraception and

malnutrition services

t

Over a third report disruptions to

antenatal care and postnatal care,

critical health services to ensure that

pregnant women and newborns

survive and remain healthy

Although a third of countries report reductions in sick child visits, further information is needed

to understand if this reflects actual disruptions or if children are less likely

to become ill due to measures put in place to prevent the spread of COVID-19

?>1/3>40%


Disruptions in services for reproductive, maternal, newborn, child and adolescent health and nutrition

18%

17%

24%

23%

32%

26%

24%

25%

24%

6%

9%

7%

7%

5%

10%

13%

14%

9%

1%

1%

2%

4%

2%

3%

4%

5%

3%

25%

28%

33%

34%

39%

39%

41%

44%

35%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Facility-based births (n = 104)

Safe abortion and post-abortion care (n=75)

Postnatal care for women and newborns (n=101)

Sick child services (n=101)

Antenatal care (n=110)

Intimate partner and sexual violence prevention and response (n=61)

Management of moderate and severe malnutrition (n=92)

Family planning and contraception (n=104)



Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions in reproductive, maternal, newborn, child and adolescent health and nutrition services


Disruptions in services for communicable disease services

Over half of countries report disruptions to

TB diagnosis and treatment.

HIV testing and prevention services also

disrupted in nearly half of countries

40%

Nearly 40% of countries are reporting

disruptions to one or more malaria services

(including diagnosis and treatment services

and prevention campaigns)

1/2

Disruptions in services for communicable disease services


13%

18%

13%

10%

19%

27%

22%

25%

29%

30%

29%

21%

1%

2%

10%

10%

7%

2%

4%

4%

9%

12%

16%

7%

3%

4%

2%

10%

7%

10%

12%

13%

9%

7%

6%

8%

17%

25%

25%

30%

33%

39%

39%

43%

46%

49%

51%

36%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Continuation of established ARV treatment (n=98)

Initiation of new ARV treatment (n=93)

Outbreak detection and control (for non-COVID diseases) (n=91)

Seasonal malaria chemoprevention (n=10)

Indoor residual spraying (n=43)

Malaria diagnosis and treatment (n=59)

Insecticide-treated-mosquito nets (n=49)

Hepatitis B and C diagnosis and treatment (n=75)

HIV prevention services (n=93)

HIV testing services (n=99)

TB diagnosis and treatment (n=98)



Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions in communicable disease services


Disruptions in services for neglected tropical diseases (NTDs)


tThe most predominant disruptions

were to large scale preventive chemotherapy campaigns, community

awareness/health education campaigns, and support for self-care,

rehabilitation and psychosocial services for patients with chronic NTDs

14%

13%

15%

19%

16%

13%

15%

6%

8%

15%

13%

13%

10%

11%

8%

10%

12%

21%

23%

37%

19%

28%

30%

42%

52%

52%

60%

44%

0% 20% 40% 60% 80% 100%

Prescriptions for NTD medicines (n=64)

Surgical procedures for NTDs (n=40)

Diagnosis, treatment and care for NTDs (n=74)

Support for self-care, rehabilitation and psychosocial services forpatients with chronic NTDs (n=48)

Community awareness and health education campaigns for NTDs(n=69)

Large scale preventive chemotherapy campaigns for NTDs (n=62)



Ess

enti

al h

ealt

h s

ervi

ce

Percentage of countries reporting disruptions in neglected tropical disease services


Service disruptions are perceived to be caused by a mix of supply and demand side factors

Health workforce-related issues are among the most commonly reported supply-side reasons linked to staff deployment to COVID-19 relief and insufficient staff availability. Cancellation of elective care and changes to treatment policies are also reported as reasons for disruptions.

Most common demand-side reasons included: community fear/mistrust, decreases in OPD volume due to patients not presenting, travel restrictions and financial difficulties during the pandemic.

In some countries, measures for COVID-19 control may be contributing to increased barriers to accessing care (e.g. fear of getting infected, limited personal protective equipment or access, limitations in movement, loss of income, increased financial burden).

Supply chain systems are also disrupted in nearly 1/3 of countries.

1/3


Service disruptions are perceived to be caused by a mix of supply and demand side factors

12%

14%

16%

19%

22%

26%

35%

47%

66%

36%

43%

57%

57%

0% 10% 20% 30% 40% 50% 60% 70%

Closure of outpatient services as per government directive (n=112)

Closure of population level screening programmes (n=111)

Closure of outpatient clinics (n=112)

Inpatient services/hospital beds not available (n=111)

Unavailability/Stock out of essential medicines (n=111)

Insufficient Personal Protective Equipment (PPE) available (n=111)

Changes in treatment policies for care seeking behaviour (n=111)

Travel restrictions hindering access to the health facilities (n=112)

Financial difficulties during outbreak/lock down (n=112)

Decrease in inpatient volume due to cancellation of elective care (n=112)

Decrease in outpatient volume due to patients not presenting (n=111)

Community fear/mistrust in seeking health care (n=112)

Insufficient staff availability (due to deployment to provide COVID-19 relief or other) (n=112)


Reasons for service disruptions (n=112)

Demand side factor Supply side factor

To some extent, disruptions may be attributed to intentional scaling back or modifications to service delivery in the context of COVID-19

One-third or more countries have limited or suspended community-based, mobile care, outpatient, inpatient and delivery platforms

15%>1/3Emergency and pre-emergency platforms

also limited in 15% of countries

To some extent, disruptions may be attributed to intentional scaling back or modifications to service delivery in the context of COVID-19


38% 41% 38% 35%

15% 16%

7% 4%

0%1%

1% 0%

45% 45%

38%36%

16% 16%

0%

10%

20%

30%

40%

50%

60%

70%

Mobile clinics (n=86) Community based care(n=103)

Outpatient services (n=108) Inpatient services (n=107) Prehospital emergency careservices (n=105)

Emergency unit services(n=106)

Per

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Service delivery platform

Government policies in relation to service delivery platforms (n=112)

Limited access Suspended

In high income countries, disruptions are more frequently the result of strategic suspensions or modifications as compared to countries in other income groups

51%62%

55%47% 43%

43% 26% 41%46% 52%

6%12%

4% 7% 4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global (n=132) High income (n=32) Upper middle income (n=38) Lower middle income (n=36) Low income (n=26)

Per

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ervi

ces

Percent of disruptions to tracer services due to intentional modifications by income group

Disruptions due to intentional service modifications Disruptions due to other causes Unknown cause

Services included for: emergency and critical care, rehabilitative and palliative care, reproductive, maternal, newborn, child and adolescent health and nutrition, immunization, communicable diseases, noncommunicable diseases, neglected tropical diseases, and mental,

neurological and substance use disorders

Nearly half of countries have scaled back at least one essential public health function or activity, including population-based services

of countries have scaled back population-based disease

prevention, health promotion and health protection activities

t

of countries have scaled back research activities

of countries have scaled back communications and social

mobilization activities

>40% 43% 27%


Nearly half of countries have scaled back at least one essential public health function or activity, including population-based services

45%39% 41% 38%

25%

14% 12%

2%

4% 2%2%

2%

0%0%

47%43% 43%

40%

27%

14%12%

0%

10%

20%

30%

40%

50%

60%

70%

Disease preventionpopulation-based activities

(n=109)

Health promotion-basedactivities (n=109)

Public health research(n=96)

Health protection (n=100) Communications and socialmobilization activities for

health (n=105)

Surveillance and response(n=105)

Emergency preparednessand response (n=106)

Per

cen

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Essential public health function

Government policies in relation to essential public health functions and activities

Limited Suspended

Notwithstanding the sustained

global disruptions, the

magnitude and extent of

disruptions within countries

has decreased

Note: represents global findings from all countries that responded to either round 1 or 2 of survey. Round 1 data sourced from 2020 WHO surveys on disruptions to Essential health services, Noncommunicable diseases, and Mental, neurological and substance use disorder during the COVID-19 pandemic.

Denominator: excludes “Not applicable” or “Do not know” responses. 35 tracer services included in both survey rounds include services for: emergency and critical care, rehabilitative and palliative care, reproductive, maternal, newborn, child and adolescent health and nutrition, immunization, communicable

diseases, noncommunicable diseases, neglected tropical diseases, and mental, neurological and substance use disorders.

Decrease in reported disruptions in countries participating in either survey round: just over a third of services are currently affected, compared to half in 2020Moreover, fewer countries are reporting complete disruptions to 75-100% of services

95% of countries reported some level of disruption to services

• 24% of countries reported disruptions in 75–100% of services



• 16% of countries reported disruptions in less than 25% of services

5% of countries reported no service disruptions







0%

20%

40%

60%

80%

100%

ITA GNB TLS PER IDN UGA PHL TCD SWZ MEX BOL SDN MRT LBN BRA BLZ ARG PNG IRQ AGO SLB UKR DOM SLV HND ALB SSD COM CMR MOZ MDG BHS CIV LCA HTI SEN PAN ZMB CHL BWA PYF GT M STP LAO WLS LSO ECU PRY MWI JOR GMB THA KEN GIN ZAF BGR TGO YEM MAR SYC GAB NER MYS CZE SCT JAM FRA PSE GHA ERI IRN LKA SYR GRD GBR TUN COG VCT AUT PAK GEO VUT NAM SUR OMN FIN AFG CRI VGB SOM MDA AUS LBR EGY CPV ETH QAT FJI HRV NPL COD URY BMU SAU BGD BRN KAZ HUN BEN KWT DMA CYM ARM LVA CAF ARE BTN NIC BDI MDV PRT KOR DJI BFA CHN MUS EST PRK RWA DNK BHR TKM CUB

Per

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tag

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Country/territory

Round 2 (Q1 2021) Percentage of 35 tracer services disrupted per country (n=135)

Global: 36%

0%

20%

40%

60%

80%

100%

IND LBY USA GNB UGA COM MDG LSO GMB TUN GEO GIN NPL DJI CMR ZWE GNQ SEN PAK SWZ STP MLI HTI BLZ SLE PHL TCD TGO KAZ POL BGD SDN JAM ETH YEM PER IRL MNE NAM MKD NGA GUY PLW FRA MMR CIV CHN BRB KGZ UKR THA COG BFA HND IRQ IDN EGY KEN MDA MAR HUN NLD ITA GAB OMN MUS ROU NER HRV BRA ARE JOR MCO LTU BGR DMA EST BEN VEN ZAF MEX ECU GRD BOL SVK LBR NZL LBN DOM SSD AGO PNG ALB CZE TUR GRC GT M JPN QAT SUR MRT LKA TLS MOZ SLB SWE CHL KWT NOR MLT CPV FIN FJI ARM SGP UZB MWI RUS SVN BLR PSE BIH LAO IRN AUT WSM MHL SOM PRK ZMB VUT KHM TZA CYP DZA BHS COK LCA BRN LVA MNG SYC GHA NRU AUS PAN ESP TON KIR COL SAU NIU VNM TTO VCT RWA ARG ISL MYS KNA PRY URY ATG DEU DNK FSM BEL CRI AND SYR BWA SMR ERI MDV ISR TUV AZE CHE COD BTN NIC BHR TKM CUBPer

cen

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Country/territory

Round 1 (Q2-Q3 2020) Percentage of 35 tracer services disrupted per country (n=187)

Global: 50%

https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1

https://www.who.int/publications/i/item/ncds-covid-rapid-assessment

https://www.who.int/publications/i/item/978924012455

Note: represents findings from all countries that responded to both rounds 1 and 2 of survey. Round 1 data sourced from 2020 WHO surveys on disruptions to Essential health services, Noncommunicable diseases, and Mental, neurological and substance use disorder during the COVID-19 pandemic.

Denominator: excludes “Not applicable” or “Do not know” responses. 35 tracer services included in both survey rounds include services for: emergency and critical care, rehabilitative and palliative care, reproductive, maternal, newborn, child and adolescent health and nutrition, immunization, communicable

diseases, noncommunicable diseases, neglected tropical diseases, and mental, neurological and substance use disorders.

Comparing service disruptions in countries that participated in both survey rounds, a drop in disrupted services is still seen from 54% in 2020 to 37% in 2021Quantity of disruptions reported in countries has also decreased.













0%

20%

40%

60%

80%

100%

KOR GNB UGA COM MDG LSO GMB TUN GEO GIN NPL DJI CMR SEN PAK SWZ STP HTI BLZ PHL TCD TGO KAZ BGD SDN JAM ETH YEM PER NAM FRA CIV CHN UKR THA COG BFA HND IRQ IDN EGY KEN MDA MAR HUN ITA GAB OMN MUS NER HRV BRA ARE JOR BGR DMA EST BEN ZAF MEX ECU GRD BOL LBR LBN DOM SSD AGO PNG ALB CZE GT M JPN QAT SUR MRT LKA TLS MOZ SLB SWE CHL KWT CPV FIN FJI ARM MWI BDI PSE LAO IRN AUT SOM PRK ZMB VUT BHS LCA BRN LVA SYC GHA AUS PAN SAU VCT RWA ARG MYS PRY URY DNK CRI SYR BWA ERI MDV COD BTN NIC BHR CUB TKM

Per

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Country/territory

Round 1 (Q2-Q3 2020)Percentage of 35 tracer services disrupted per country (n=125)

Global: 54%

0%

20%

40%

60%

80%

100%

ITA GNB TLS PER IDN UGA PHL TCD SWZ MEX BOL SDN MRT LBN BRA BLZ ARG PNG IRQ AGO SLB UKR DOM HND ALB SSD COM CMR MOZ MDG BHS CIV LCA HTI SEN PAN ZMB CHL BWA GT M STP LAO LSO ECU PRY MWI JOR GMB THA KEN GIN ZAF BGR TGO YEM MAR SYC GAB NER MYS CZE JAM FRA PSE GHA ERI IRN LKA SYR GRD TUN COG VCT AUT PAK GEO VUT NAM SUR OMN FIN CRI SOM MDA AUS LBR EGY CPV ETH QAT FJI HRV NPL COD URY SAU BGD BRN KAZ HUN BEN KWT DMA ARM LVA ARE BTN NIC KOR BDI MDV DJI BFA CHN MUS EST PRK RWA DNK BHR CUB TKMPer

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Country/territory

Round 2 (Q1 2021)Percentage of 35 tracer services at least partially disrupted

per country (n=125)

Global: 37%




Note: represents global findings from all countries that responded to either round 1 or 2 of survey. Round 1 data sourced from 2020 WHO surveys on disruptions to Essential health services, Noncommunicable diseases, and Mental, neurological and substance use disorder during the COVID-19 pandemic.


Emergency and critical care services include: 24-hour emergency room/unit services; urgent blood transfusion services; inpatient critical care services; and emergency surgery.

Reproductive, maternal, newborn, child and adolescent health and nutrition services include: family planning and contraception; antenatal care; facility-based births; sick child services; and management of malnutrition.

Immunization services include: facility-based routine immunization; and outreach routine immunization.

Communicable disease services include: Outbreak detection and control (non-COVID); continuation of established antiretroviral treatment; malaria diagnosis and treatment; ITN malaria prevention campaigns; IRS malaria prevention campaigns; and SMC malaria prevention campaigns.

Noncommunicable disease services include: cancer diagnosis and treatment; hypertension management; diabetes management; and asthma services.

mental, neurological, and substance use disorders (MNS) services include: MNS emergency services; counselling for MNS disorders; medicines for MNS disorders; services for children and adolescents; services for older adults; school mental health programmes; suicide prevention programmes; overdose

prevention programmes; and critical harm reduction services.

Rehabilitative and palliative care services include: rehabilitation services; palliative services.

Average percentage of countries reporting disruptions dropped across all tracer service areasCountries participating in either survey round

*view report to see changes in disruptions to individual tracer services.

17% 14%

47%

33%

50%

31%

46%

26%

45%

27%39% 35%

54%

36%3%1%

3%

3%

12%

5%

9%

7%

3%

8%

20%

10%

12%

8%

20%15%

51%

37%

62%

37%

55%

33%

48%

35%

59%

45%

65%

45%

0%

10%

20%

30%

40%

50%

60%

70%

Round 1(n=129)

Round 2(n=112)

Round 1(n=129)

Round 2(n=121)

Round 1(n=129)

Round 2(n=112)

Round 1(n=129)

Round 2(n=124)

Round 1(n=164)

Round 2(n=121)

Round 1(n=130)

Round 2(n=121)

Round 1(n=164)

Round 2(n=121)

Emergency, criticaland operative care

RMNCAH andnutrition

Immunization Communicablediseases

Noncommunicablediseases

Mental,neurological andsubstance use

disorders

Rehabilitative andpalliative care

Pe

rce

nta

ge

of

co

un

trie

s

Round 1 vs. Round 2 comparison: Service disruptions by tracer service area

5-50% disrupted More than 50% disrupted




Note: represents findings from all countries that responded to both rounds 1 and 2 of survey. Round 1 data sourced from 2020 WHO surveys on disruptions to Essential health services, Noncommunicable diseases, and Mental, neurological and substance use disorder during the COVID-19 pandemic.


Emergency and critical care services include: 24-hour emergency room/unit services; urgent blood transfusion services; inpatient critical care services; and emergency surgery.

Reproductive, maternal, newborn, child and adolescent health and nutrition services include: family planning and contraception; antenatal care; facility-based births; sick child services; and management of malnutrition.

Immunization services include: facility-based routine immunization; and outreach routine immunization.

Communicable disease services include: Outbreak detection and control (non-COVID); continuation of established antiretroviral treatment; malaria diagnosis and treatment; ITN malaria prevention campaigns; IRS malaria prevention campaigns; and SMC malaria prevention campaigns.

Noncommunicable disease services include: cancer diagnosis and treatment; hypertension management; diabetes management; and asthma services.

mental, neurological, and substance use disorders (MNS) services include: MNS emergency services; counselling for MNS disorders; medicines for MNS disorders; services for children and adolescents; services for older adults; school mental health programmes; suicide prevention programmes; overdose

prevention programmes; and critical harm reduction services.

Rehabilitative and palliative care services include: rehabilitation services; palliative services.

Average percentage of countries reporting disruptions dropped across all tracer service areasCountries participating in both survey rounds

*view report to see changes in disruptions to individual tracer services.

19%11%

49%36%

46%

30%43%

30%

48%

29%38% 36%

50%37%4%

1%

3%

2%

11%

5%

9%

7%

3%

7%

23%

8%

15%

7%

23%

13%

53%

38%

57%

35%

52%

38%

51%

36%

61%

44%

66%

44%

0%

10%

20%

30%

40%

50%

60%

70%

Round 1(n=75)

Round 2(n=75)

Round 1(n=79)

Round 2(n=79)

Round 1(n=75)

Round 2(n=75)

Round 1(n=75)

Round 2(n=75)

Round 1(n=101)

Round 2(n=101)

Round 1(n=82)

Round 2(n=82)

Round 1(n=101)

Round 2(n=101)

Emergency, criticaland operative care

RMNCAH andnutrition

Immunization Communicablediseases

Noncommunicablediseases

Mental,neurological andsubstance use

disorders

Rehabilitative andpalliative care

Pe

rce

nta

ge

of

co

un

trie

s

Round 1 vs. Round 2 comparison: Service disruptions by tracer service area

5-50% disrupted More than 50% disrupted




t

Disruptions due to insufficient PPE and other health products availability have decreased since 2020

Note: represents findings from all countries that responded to either round 1 or 2 of survey.


78%

69%

61%

53%

43%

40%

36%

36%

34%

31%

30%

14%

57%

47%

66%

36%

26%

14%

35%

16%

43%

12%

22%

19%

0% 20% 40% 60% 80% 100%

Decrease in outpatient volume due to patients not presenting

Decrease in inpatient volume due to cancellation of elective care

Insufficient staff availability (due to staff deployment to provide COVID-19 relief or other)

Government or public transport lockdowns hindering access

Insufficient PPE available for health care providers

Closure of population level screening programs

Changes in treatment policies

Closure of outpatient disease specific consultation clinics

Financial difficulties during outbreak/lock down

Closure of outpatient services as per government directive

Unavailability/Stock out of health products at health facilities

Inpatient services/hospital beds not available


Round 1 vs. Round 2 comparison: Reasons for service disruptions

Round 1 (n=129) Round 2 (n=112)

Insufficient PPE availability has decreased from 43% to 26% of countries compared to Q3 2020

Unavailability and stock outs of health products have decreased from 30% to 22% of countries compared to Q3 2020

Countries participating in either survey round

t

Disruptions due to insufficient PPE and other health products availability have decreased since 2020

Note: represents findings from all countries that responded to either round 1 or 2 of survey.


Insufficient PPE availability has decreased from 52% to 28% of countries compared to Q3 2020

Unavailability and stock outs of health products have decreased from 36% to 19% of countries compared to Q3 2020

Countries participating in both survey rounds

73%

68%

62%

52%

38%

33%

39%

45%

24%

36%

21%

57%

48%

61%

36%

28%

11%

33%

17%

40%

12%

19%

16%

0% 20% 40% 60% 80%

Decrease in outpatient volume due to patients not presenting

Decrease in inpatient volume due to cancellation of elective care

Insufficient staff availability (due to staff deployment to provide COVID-19 relief or other)

Government or public transport lockdowns hindering access

Insufficient PPE available for health care providers

Closure of population level screening programs

Changes in treatment policies

Closure of outpatient disease specific consultation clinics

Financial difficulties during outbreak/lock down

Closure of outpatient services as per government directive

Unavailability/Stock out of health products at health facilities

Inpatient services/hospital beds not available


Round 1 vs. Round 2 comparison: Reasons for service disruptions

Round 1 (n=75) Round 2 (n=75)

Gains and partial rebound in

service provision likely due to

implementation of

recommended policies and

strategies for maintaining

essential health services.

Most countries have implemented policies and plans on continuity of essential health services

of countries have defined essential health services to be maintained

during the COVID-19 pandemic in a national policy or plan

t

have designated a national focal point responsible for continuity of essential

health services during the COVID-19 pandemic

have allocated additional funding to support maintenance of essential health services

87% 82% 62%

Increased from 70% in Q3 2020 No change since Q3 2020

Recommended strategies to restore or adapt service delivery being implemented by many countries


t

Over half of countries report using community communications, triaging, staff recruitment and provision of home-based care to adapt service delivery during disruptions

Novel approaches to prescribing and dispensing medicines, supply chain and telemedicine deployment are also among the most frequently used approaches to restore service delivery

67%

60%

56%

54%

51%

48%

40%

40%

38%

35%

31%

31%

29%

25%

5%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Community communications (n=112)

Triaging to identify priorities (n=112)

Recruitment of additional staff (n=111)

Redirection of patients to alternate care sites (n=112)

Provision of home-based care where appropriate (n=112)

Telemedicine deployment to replace in-person consults (n=112)

Self-care interventions where appropriate (n=112)

Novel prescribing approaches (n=112)

Task shifting / role delegation (n=111)

Novel dispensing approaches for medicines (n=112)

Catch-up campaigns for missed appointments (n=112)

Novel supply chain management and logistics approaches (n=111)

Integration of several services into single visit (n=112)

Expanding facility hours (n=111)

Government removal of user fees (n=111)


Ap

pro

ach

es

Approaches for overcoming disruptions

Many countries are using telehealth technologies to mitigate disruptionsHigh income countries more frequently report use of telehealth technologies to support service delivery


17%

22%

28%

28%

30%

32%

37%

40%

43%

49%

49%

0% 20% 40% 60%

Eye care consultations (n=111)

Family planning counselling (n=112)

Imaging diagnostics (n=111)

Prenatal care consultations (n=112)

Emergency care consultations (n=112)

Child health consultations (n=112)

Mental health consultations (n=112)

Chronic care consultations (n=111)

Pharmacy and medication refills (n=112)

Primary care consultations (n=112)

Scheduling appointments (n=112)


Percentage of countries reporting use of telehealth technologies to support service delivery

64%

96%

66% 65%

29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of countries reporting use of any telehealth

Per

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Percentage of countries reporting use of telehealth technologies to support service delivery

Global (n=112) High income (n=25) Upper middle income (n=32)

Lower middle income (n=31) Low income (n=24)

Limited access and technical capacities to use telehealth technologies are the most commonly reported barriers to use in countries


19%

21%

43%

54%

58%

68%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Legal or regulatory barriers (n=111)

Security and privacy concerns (n=111)

Lack of funding to set up and implement programmes (n=111)

Limited awareness/knowledge of patients and/or providers regarding telehealthtechnologies (n=112)

Limited organizational or technical capacities to transition to use (n=112)

Limited access to telehealth technologies for patients and/or providers (n=111)


Percentage of countries reporting barriers to use of telehealth technologies

t

Two-thirds of countries are implementing approaches to ensure access to care for vulnerable groups


Many countries are implementing approaches to target specific

vulnerable groups

High- and middle-income countries are implementing these approaches

slightly more frequently

64% 64%

78%

58%54%

60%

76%69%

45%50%

58%

48%

56%

65% 63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global (n=112) High income (n=25) Upper middle income(n=32)

Lower middle income(n=31)

Low income (n=24)

Countries using approaches to ensure access to care for vulnerable groups

Identifying vulnerable groups of primary concern

Proactive governmental strategies to reach out to vulnerable groups

Use of existing networks or organizations to reach out to vulnerable groups

Most countries are actively tracking and monitoring information to support continuity of essential health services

are regularly monitoring continuity of essential health services

t

85% 86%are collecting data on comorbidities

in COVID-19 patients

65%have designated a team to track and address the infodemic and

health misinformation

56%

9%4%

18%

8%5%

(n=112)

Yes, within Ministry of Health or equivalent

Yes, within government but in another ministry

Not yet, but planning on setting up a unit

No unit, but we have staff completing these tasks

No

Don't know

75%

10%

12%

3%

(n=112)

Regularly monitoring continuation of EHS including mitigationstrategies

Monitoring continuation of EHS but not mitigation strategies

No monitoring

Don't know

86%

9%

5%

(n=110)

Yes No Don’t know


The most commonly reported country priority needs and technical assistance requirements relate to maintaining essential health services during the COVID-19 pandemic

4027

2619

1312

9888

75555

444

31111

0 5 10 15 20 25 30 35 40 45

Maintaining EHS during COVID-19

Monitoring and evaluation capacities

Health workforce strengthening

Essential health products and equipment

Telehealth technologies

Policy guidance

Service organization and models of care

COVID-19 vaccination capacities

Essential PPE supplies

Information management

COVID-19 case management capacities

Health systems strengthening and resilience

Peer learning

Risk communications and community engagement

Surveillance, case detection and containment

COVID-19 diagnostic capacities

Implementation research and learning

Screening, triage and isolation

Infection prevention and Control

Health worker safety

Immunization activities

Infrastructure

Quality improvement and safety

Number of requests made

Country priorities and technical needs (216 requests from 78 countries)

Implications for action

Despite the limitations of a key informant survey, it is reasonable to expect that even moderate interruptions to health service delivery and utilization can lead to worsened health outcomes.

t

Further information, including from subnational, health facility, and community levels should supplement findings to better quantify potential impact of disruptions over the short, medium and long term.

Urgent need for responsive health policy planning and action to orient health strategies according to rapidly evolving priorities and needs.

Further documentation and learning on which mitigation strategies and approaches work best and benefits and risks of pursuing different strategies towards recovery.

COVID-19 control strategies must be in balance with other health priorities (e.g. ensuring adequate staff are available and infection prevention and control measures are in place to protect health worker and patient safety throughout the delivery of both COVID-19 and other essential care).

WHO’s response must continue to support countries to respond to the increased strains on health systems to ensure continued access to comprehensive care for all individuals

Annex:

Participating countries,

territories and areas

WHO expresses its gratitude to all authorities and WHO country offices that supported participation in this survey

t

African region

• Angola

• Benin• Botswana• Burkina Faso• Burundi• Cabo Verde• Cameroon• Central African

Republic• Chad• Comoros• Congo• Cote d'Ivoire• Democratic

Republic of the Congo

• Eritrea• Eswatini• Ethiopia• Gabon• Gambia• Ghana• Guinea

• Guinea-Bissau• Kenya• Lesotho• Liberia• Madagascar• Malawi• Mauritania• Mauritius• Mozambique• Namibia• Niger• Rwanda• Sao Tome and

Principe• Senegal• Seychelles• South Africa• South Sudan• Togo• Uganda• Zambia

Region of the Americas

• Argentina• Bahamas• Belize• Bermuda• Bolivia (Plurinational

State of)• Brazil• British Virgin Islands• Cayman Islands• Chile• Costa Rica• Cuba• Dominica• Dominican Republic• Ecuador• El Salvador

Eastern Mediterranean region

• Afghanistan• Bahrain• Djibouti• Egypt• Iran (Islamic

Republic of)• Iraq• Jordan• Kuwait• Lebanon• Morocco• Oman

• occupied Palestinian territory, including east Jerusalem

• Pakistan• Qatar• Saudi Arabia• Somalia• Sudan• Syrian Arab Republic• Tunisia• United Arab Emirates• Yemen

• Grenada• Guatemala• Haiti• Honduras• Jamaica• Mexico• Nicaragua• Panama• Paraguay• Peru• Saint Lucia• Saint Vincent and

the Grenadines• Suriname• Uruguay

t

European region

• Albania• Armenia• Austria• Bulgaria• Croatia• Czechia• Denmark• Estonia• Finland• France• Georgia

• Hungary• Italy• Kazakhstan• Latvia• Portugal• Republic of Moldova• Sweden• Turkmenistan• Ukraine• United Kingdom of

Great Britain and Northern Ireland

South-East Asian region

• Bangladesh• Bhutan• Democratic People's Republic of Korea• Indonesia• Maldives• Nepal• Sri Lanka• Thailand• Timor-Leste

Western Pacific region

• Australia• Brunei Darussalam• China• Fiji• French Polynesia• Japan• Lao People's Democratic Republic• Malaysia• Papua New Guinea• Philippines• Republic of Korea• Solomon Islands• Vanuatu

WHO expresses its gratitude to all authorities and WHO country offices that supported participation in this survey (cont.)

Documents

Pulse survey on continuity of essential health services