COVID-19 pandemic disrupts sexual and reproductive health services in Sub-Saharan Africa

A recently released report has laid bare the impact of the COVID-19 pandemic in five sub-Saharan African (SSA) countries—Burkina Faso, Ethiopia, Kenya, Malawi, and Uganda- demonstrating how availability, accessibility, and utilization of sexual and reproductive health (SRH) services faced significant disruptions.

The report says, government-imposed lockdowns and pandemic response policies exacerbated existing healthcare challenges, particularly for vulnerable groups such as young women, adolescents, and sexual and gender minorities.

The study was led and carried out by a consortium of organisations the African Population and Health Research Center (APHRC), Amref Health Africa, Centre for Reproductive Rights (CRR), Ipas Africa Alliance, Network for Adolescent and Youth of Africa (NAYA), Reproductive Health Network Kenya (RHNK) and Planned Parenthood Global (PPG).

The report was titled: “Impact of the COVID-19 Pandemic on Sexual and Reproductive Health Services in Burkina Faso, Ethiopia, Kenya, Malawi and Uganda,” and released in April 2021.

Findings from the study, which surveyed 3,473 women and girls and 466 healthcare providers, show that many were unable to access critical services such as contraception, antenatal care, post-abortion care (PAC), and HIV/AIDS management.

The report says that restrictions led to the closure of health facilities, some of which were converted into COVID-19 treatment centers, forcing patients to travel longer distances for SRH services.

Increased transportation costs, fear of contracting the virus, and occasional negative attitudes of healthcare providers further hindered access.

As a result, some women and girls delayed seeking medical care, turned to self-medication, or sought help from traditional healers and birth attendants.

Healthcare providers also reported a decline in the availability of SRH services due to supply shortages, staff redeployment, and facility closures. Many healthcare professionals were reassigned to COVID-19 units, while others fell ill or were unable to work, leading to reduced service delivery.

According to the report, the absence of trained personnel and a lack of essential supplies led to a decrease in contraceptive availability, antenatal care, and gender-based violence services.

Despite these challenges, some health facilities implemented innovative measures to maintain SRH services, including telemedicine, self-care approaches, adjusted service hours, and revised referral systems.

However, the report highlights that unmet contraceptive needs and disrupted maternal and HIV/AIDS care continue to result in poor health outcomes.

The report underscores the need for governments to adopt balanced, multisectoral responses that prioritize sexual and reproductive health needs while addressing pandemic-related challenges. Experts call for policies that ensure the continuity of essential health services, especially for the most vulnerable populations.

Continuity of SRH services during COVID 19

The report indicates that different countries adopted various strategies to ensure continuity of services during the pandemic.

National guidelines and policies informed most approaches, including provider training on handling COVID-19 and the provision of personal protective equipment (PPE) and sanitisers, among others.

In Uganda, the government made repeated public announcements to emphasise that health facilities were open and that normal services were still available at the facilities despite the pandemic.

There were also supervisory visits by Ministry of Health officials to ensure that the health workers needed to provide these services were in place in all the facilities. Qualitative data revealed fragmentation in the training of health providers.

Priority was given to providers working in public health facilities, while some in private sector and CSO facilities were neither trained nor supplied with usable formats of the policies and guidelines established by the government.

Several factors influenced whether there was continuity in the provision of services, and these centered on the safety both of clients and of health providers.

Strategies implemented to ensure safety included the use of PPE, checking the temperature of clients on arrival, careful handwashing, wearing masks and using well-ventilated rooms, improving social distancing by spacing out seats for clients, and booking fewer clients for

Burkina Faso and Ethiopia had the highest percentage of health facilities with staff trained in handling COVID-19 patients, 74% and 75%, respectively.

At the time of the survey, Ethiopia had the highest number of facilities supplied with PPE (84%), followed by Kenya (77%).

Virtually all facilities enforced sanitisation and social distancing measures. Limiting the number of patients allowed to visit facilities was a practice imposed more frequently in Kenya (64%) and Uganda (54%) than in the other countries.

Measures taken by health facilities to address COVID-19 risks

In Uganda, the government made repeated public announcements to emphasise that health facilities were open and that normal services were still available at the facilities despite the pandemic. There were also supervisory visits by Ministry of Health officials to ensure that the health workers needed to provide these services were in place in all the facilities.

Data revealed fragmentation in the training of health providers. Priority was given to providers working in public health facilities, while some in private sector and CSO facilities were neither trained nor supplied with usable formats of the policies and guidelines established by the government.

Several factors influenced whether there was continuity in the provision of services, and these centered on the safety both of clients and of health providers.

Strategies implemented to ensure safety included the use of PPE, checking the temperature of clients on arrival, careful handwashing, wearing masks and using well-ventilated rooms, improving social distancing by spacing out seats for clients, and booking fewer clients for scheduled clinic visits such as in MCH, FP, and Comprehensive Care Center (CCC) units.

“Nevertheless, the operations of health providers were impeded in both Uganda and Kenya, due to difficulties in accessing standard COVID-19 equipment and procedures; adequate PPE and essential sanitizers were either simply not available or were costly to obtain,” the study revealed.

While governments focused on supplying SOP equipment to public health facilities, some participants decried delays or unavailability that resulted in a lack of services.

Reasons why some services were not available

The report adds that virtually all health providers in Burkina Faso reported that they did not offer PAC services. This was due to a lack of commodities (stockouts) and the absence of trained healthcare staff. In the same breath, some said they did not offer CAC services due to the lack of commodities, the occurrence of COVID-19 in the facility, and an absence of patients.

In Uganda, a large majority of healthcare providers reported not offering PAC (83%) and CAC (74%) services because of commodity stock outs; only a few reported the lack of trained staff and PPE as their reasons for not making these services available.

In Kenya, commodity stock outs were the main reason health providers stopped offering PAC and CAC services in some of their facilities.

It was only in Ethiopia that the main reason given for not offering PAC and CAC services was the lack of trained staff and absence of patients needing the service.

Uptake of SRH Services by clients before and during the pandemic

The study revealed that overall, there was a general decline in the uptake of services. Contraceptives were the most sought-after service (45.9%) across the four countries, followed by antenatal care (40.4%); at 3.1%, PAC services were the least sought after.

Nearly half of all women and girls participating in our survey came to the facility seeking contraceptives (40%) and antenatal care (26%).

“Survey participants in Burkina Faso and Kenya attributed the decrease in utilization of SRH services to fear of contracting COVID-19, fear of testing positive for the virus, and fear of isolation or quarantine if confirmed positive,” reads the report.

“Other reasons given include self-medication, such as with over-the-counter or herbal medicines, a lack of income, the loss of employment, an inability to pay for services, and government pandemic prevention measures (social distancing, stay-at-home or lockdown orders, and curfews),” it adds.

The report added that in Kenya, Malawi, and Uganda, clients reported that health providers treated them harshly and had negative attitudes towards patients who were seeking health services regarded as non-essential.

This attitude by health providers was likely the result of their efforts to reinforce government COVID-19 prevention measures, added the report.

Key recommendations

• Responding to public health emergencies, especially those of high risk to humans may require drastic control measures, but the responses adopted need to be balanced against other public health needs and priorities, such as SRH.
• A multisectoral approach should be used when developing and implementing government policies and guidelines in response to pandemics and other health crises through a collective action strategy that ensures the preservation of SRH services. The policies and guidelines that result need to be continuously reviewed in order to respond effectively to evolving needs, trends, challenges, and developments.
• There is need for all countries to invest in telemedicine approaches to ensure access to SRH services for all. These include enhancing the capacities of providers in telemedicine and establishing the necessary frameworks and eliminating structural barriers to expanding access to SRH services that are in line with universal health coverage (UHC) goals.
• There is a compelling need for Ministries of Health to develop self-care guidelines, and while doing so remove regulatory barriers to self-care to ensure a smooth rollout in all countries.
• There is a need to strengthen and utilize community health outreach and interventions to enhance access to health information and services. This should include the use of community health workers and community-based distributors of FP commodities to address the challenges created by stock outs.
• Governments should ensure sustainable and resilient supply chain management systems for SRH commodities for public and private health facilities. Governments should support private facilities (with SRH supplies and commodities) since they serve a significant proportion of the population and are able to reach disadvantaged sub-populations.
• Governments should adopt a holistic response and recovery strategy that considers the impacts in different socioeconomic sectors at various stages of the pandemic.
• Health facilities should institutionalize inclusive, continuous, consistent, and client-friendly training and sensitization of health care providers in the delivery of SRH services, even during pandemics.
• To ensure the continuity of services, healthcare providers need to be protected, both from the pandemic (through the provision of essential PPE) and from broad social and economic fears, as well as the psychological stress that comes from operating in such crisis contexts.
• Sexual and reproductive health funders and partners need to increase funding and support for SRH services, while improving the resilience of supply chains and services during the crisis.