The Challenge
The ongoing COVID-19 pandemic is a clear threat to the progress that health systems have made in the Global South in recent years. As governments around the world focus on their COVID-19 response, the magnitude of the impact the pandemic had- and still has- on essential health services is beginning to unfold.
There is strong evidence that the supply and demand of essential health services declines during widespread disease outbreaks: During the 2014 Ebola outbreak in West Africa, for example, it was estimated that antenatal 
care (ANC) coverage decreased by 22%. There were also declines in the coverage of family planning, institutional delivery and post-natal care.
Globally, with COVID-19 we are seeing similar disruptions to health services: amongst others, these are supply chain interruptions of essential medicines and health products as well as the diversion of health workers to support the COVID-19 response. COVID-19 also paused provision of certain services due to new social distancing requirements being put in place, including immunisation outreach and campaigns, mass drug administrations and anti-malaria bed net distributions. On the demand side, anxiety, stigma, misinformation, limitations of movement and increasing poverty reduce health seeking behaviour and the utilization of routine and essential health services.
In South Sudan, for example, Crown Agents implements the Health Pooled Fund programme, a programme which provides hundreds of thousands of citizens, especially women and children, with quality healthcare, delivering services across 80% of the country. The Global Financing Facility (GFF) estimates that disruptions in health services in South Sudan due to COVID-19 have the potential to leave 198,000 children without oral antibiotics for pneumonia, over 200,000 children without diphtheria, pertussis and tetanus (DPT) vaccinations, over 10,000 women without access to institutional deliveries, and over 30,000 fewer women receiving family planning services. As a result of disruptions in all essential services, child mortality in the country could increase by 13%.
In Zimbabwe, Crown Agents is implementing the Results-Based-Financing Programme, a national scale health programme reaching 6,6 million people in 42 rural districts, targeting 849 health facilities. The programme has contributed to over 450, 000 women accessing antenatal healthcare and over 5,500, 000 children attending growth monitor visits. As a result of the lockdown, a 51% reduction in ANC and post-natal care service utilisation has been registered in the country, including a 22% reduction in safe-birth deliveries in health facilities compared to 2019.7
How we ensure essential health services continue
As Crown Agents is playing a critical role in the provision of health services in some of the most vulnerable places in the world, such as Zimbabwe, Sierra Leone and South Sudan, we are witnessing first-hand the devastating impacts of the restricted access to basic health care. As a result, mitigating these disastrous effects and building robust and efficient healthcare systems during and beyond the COVID-19 pandemic has become a key priority across our health work globally. In response, we are taking a three-pronged approach, focusing interventions at the service delivery, health facility and community levels.
At service delivery level, we are efficiently managing logistics, procurement, and supply of essential medical commodities, including medical equipment and drugs. This way, we are ensuring that large scale health interventions continue despite reduced transport links, social distancing and shortage of supplies, amongst others.
For example, in the countries where we are implementing our ASCEND programme, which is tackling neglected tropical diseases, we have identified a series of actions and considerations for continuing mass drug administrations, including steps to ensure that programme delivery is adapted accordingly.
In Sierra Leone, through Saving Lives, a programme which supports the Government of Sierra Leone (GoSL) in improving maternal and child health, we are adjusting our distribution of free health care and nutrition supplies to make sure essential commodities are well stocked and reach health facilities as well as beneficiaries in time.
At the health facility level, we are ensuring clinics and hospitals are safe to visit by implementing infection prevention. We are also training health care workers on the use of Personal Protective Equipment (PPE) and are implementing safe protocols for the screening of incoming patients. This is being done as part of our Results-based financing (RBF) programme in Zimbabwe and our Health-Pooled-Fund in South Sudan. We are also ensuring the continuation of essential health services such as malaria testing and treatment and maternal, child and new-born health services to avoid spikes in avoidable deaths, paying close attention to rural areas where access to health care is generally poorer.
In Sierra Leone, through our Child Health and Mortality Prevention Surveillance (CHAMPS) programme, we are collecting, analysing and sharing evidence to prevent child mortality. To prevent the spread of COVID-19, we are currently providing technical assistance in COVID-19 surveillance and data management to support the resilience of local health facilities.
At community level, we are building trust by engaging communities to promote and facilitate health-seeking behaviour. To that end, we are providing community workers with messages on the continued importance of health service utilisation and communicate measures that health facilities are taking to keep patients safe.
In South Sudan, as part of our HPF programme, we have provided over 800 health facilities with risk communications materials.
In addition, we have trained over 4000 community health workers to provide communities with messaging on COVID-19 prevention and training on how to manage mild and moderate ‘flu-like’ symptoms at home. We are also strengthening water, sanitation and hygiene (WASH) infrastructure, are improving screening and triage (deciding on the treatment order of patients) and are providing training on how clinical guidelines reduce the risk of infection in health facilities.
Conclusion: Health care services and systems matter more than ever
Beyond the direct impacts of COVID-19, the pandemic has triggered a crisis in global health systems, severely undermining prospects of achieving SDG 3. This reality shows that health care services and systems matter more than ever: It is not surprising that the additional burden of planning and responding to the pandemic runs the risk of overwhelming health systems, leaving ongoing preventive care by the wayside. However, we must understand that this inevitably leads to increased secondary morbidity and mortality, particularly in vulnerable populations. Therefore, whilst we must scale up our immediate health response to curb the spread of COVID-19, we must also ensure essential health services continue, keeping progress towards SDG3 at the forefront of the global health agenda.
When we first started responding to COVID-19, we focused on immediate actions to stop the spread and meet emerging needs. We did so, like many other organisations, by procuring PPE and undertaking communication outreach activities with local communities, focused on hygiene and social distancing. Notwithstanding the attention and resources that specific COVID19 programming have required, we have worked hard with our partners to ensure that other health priorities continue to get the attention they require. In resource constrained settings such as those where we work, the need to meet both of these requirements simultaneously has been challenging, and involved difficult choices.
We therefore urge Ministries of Health around the world- and the Global Health institutions that support them- to prioritize the appropriate and safe management of existing health care services and structures. If we want to achieve SDG 3, we will need to continue to strengthen the capacity of health services now and in the future and ensure that national and global health systems can not only withstand pandemics, but also deliver on basic needs on a continuous basis, no matter the challenge.