Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study

Abstract

Background Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. Methods We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. Results In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. Conclusions Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Measuring supply-side service disruption: a systematic review of the methods for measuring disruption in the context of maternal and newborn health services in low and middle-income settings

“…The characteristics of the 28 included studies are listed in online supplemental appendix 2. Studies were carried out in: Bangladesh,26 Ethiopia,27 28 India,29–34 Indonesia,35 36 Iran,37 38 Nepal,39 40 Nigeria41–44, and Uganda 45 46. Three studies included multiple LMIC countries,14 47 48 and four included both HICs and LMICs 49–52.…”

“…Most studies (n=18) used qualitative methods to collect data about supply-side disruption28 30 31 33–37 40–47 49 50; one study involved a qualitative media analysis 32. Seven studies were based on quantitative methods,14 26 27 29 38 48 52 and two used both qualitative and quantitative methods 39 51. Most studies (n=14) involved participation from service-providers (eg, nurses, midwives, obstetricians, community health workers, policy-makers),14 29 30 35 40 42–44 47–52 while 11 involved service users,27 31–34 36–39 45 46 and 3 included both groups 26 28 41…”

Integrating an algorithmic and health systems thinking approach to improve the uptake of government antenatal nutrition services in Vidisha, Madhya Pradesh (India), 2018 to 2021

“…These findings also obtain support from some of the other small-area studies which report that COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh ( Nguyen et al , 2021 ). In fact, the analyses of district-level data also reveal that delivery of maternal and child health services was disrupted to a great extent though it was quickly restored after the lockdown period from March to June 2020 ( Avula et al. , 2022 ).…”

Achieving Universal Health Coverage in Low- and Middle-Income Countries: Challenges for Policy Post-Pandemic and Beyond

“… 11 Majority of Indian districts witnessed >50% of antenatal care and child immunization services disrupted during December 2019 to April 2020. 12 From March to July 2020, COVID-19 led service disruptions in eight Sub-Saharan African countries (ie, Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia) resulted in a cumulative shortfall of 0.32 million doses of pentavalent vaccinations. 13 Another study reported a decline in first antenatal visits ranging from 18% to 32% across LMICs.…”