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SETTING: Six hospitals in four sub-Saharan African countries.OBJECTIVE: To examine the indirect effects of COVID-19 on health service utilisation and to explore the risk of bias in studies on prediction models.DESIGN: Monthly data were analysed using interrupted time-series modelling. We used linear mixed-effect models for the analysis of antenatal care visits, institutional deliveries, vaccinations, outpatient visits and hospital admissions, and generalised linear mixed-effect models for hospital mortality.RESULTS: During 2018–2020, the six hospitals recorded a total of 57,075 antenatal care visits, 38,706 institutional deliveries, 312,961 vaccinations, 605,925 out-patient visits and 143,915 hospital admissions. The COVID-19 period was associated with decreases in vacci-nations (− 575 vaccinations, P < 0.0001), outpatient visits (− 700 visits, P < 0.0001) and hospital admission (− 102 admission, P = 0.001); however, no statistically significant effects were found for antenatal care visits (P = 0.71) or institutional deliveries (P = 0.14). Mortality rate increased by 2% per month in the pre-COVID-19 period; however, a decreasing trend (by 2% per month) was observed during the COVID-19 period (P = 0.004). Subgroup and sensitivity analyses broadly confirmed the main findings with only minor inconsistencies. A reduction in outpatient visits was also observed in hospitals from countries with a higher Stringency Index and in urban hospitals.CONCLUSIONS: The pandemic resulted in a reduction in health service utilisation. The decreases were less than anticipated from modelling studies.

Introduction The last two decades saw an extensive effort to design, develop and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low- and middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative evaluation tool to assess the performance of health services provision for communicable diseases in three sub-Saharan African countries. Material and methods A total of 42 indicators, 14 per each communicable disease care pathway, were developed. A sub-set of 23 indicators was included in the evaluation process. The communicable diseases care pathways were developed for Tuberculosis, Gastroenteritis, and HIV/AIDS, including indicators grouped in four care phases: prevention (or screening), diagnosis, treatment, and outcome. All indicators were calculated for the period 2017–2019, while performance evaluation was performed for the year 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda. Results Substantial variability was observed over time and across the four different districts. In the Tuberculosis pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase. Conclusions The bottom-up approach and stakeholders’ engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation, outcomes measurement and accountability in settings characterised by multiple healthcare service providers.

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Background Mainstream medical education remains largely focused on national health issues. Therefore, in order to expose medical students to international health issues, it is beneficial to facilitate international medical electives. Methods This article describes the Junior Project Officer (JPO) program, a medical experience based on clinical electives in Sub-Saharan Africa, supported by a Non-Governmental Organisation (NGO). Residents spend 6 months as part of a multidisciplinary medical team in Africa. A post-elective online survey was administered to all who participated in the program in the period 2002–2020. The questionnaire comprised three domains: (i) general and pre-departure information; (ii) the experience; (iii) the post-experience. Results Questionnaires were received from 157/241 subjects, a response rate of 65%. The most common specialties were pediatrics, public health, and internal medicine. Of all, 87% carried out clinical activities; 45% also worked in the management of health services, and 60% carried out research activities. About 64% reported difficulties linked to a lack of equipment, different ways of working (57%), and exposure to situations for which they did not feel technically prepared (56%). In 25% of cases, residents reported that their school’s attitude to their doing the elective was not positive: upon their return, over 50% felt that their experience was not sufficiently valued by their institution. Respondents considered the experience important for professional and personal growth (93% and 80% respectively ). Forty-two participants (27%) reported that the experience had a significant impact on their future career choices. Conclusion Despite the difficulties encountered, a well-structured experience in international health can have a positive impact on residents, professionally and personally. Key factors behind the positive outcomes are the substantial length (6 months) of the experience, and the long term working relationships between the sending and receiving institutions. The schools in Italy that provide the students for the electives need to see more evidence that international electives are worth the investment.