key: cord-0810554-em8ia5pf
authors: Gadsden, Thomas; Downey, Laura E; Vilas, Victor Del Rio; Peiris, David; Jan, Stephen
title: The impact of COVID-19 on essential health service provision for noncommunicable diseases in the South-East Asia region: A systematic review
date: 2022-05-05
journal: The Lancet Regional Health - Southeast Asia
DOI: 10.1016/j.lansea.2022.04.006
sha: dc9673a8bbfc84ac1826347e487d684415adfed5
doc_id: 810554
cord_uid: em8ia5pf

Background COVID-19 has had a profound impact on the health systems of the 11 countries of the WHO South East Asia Region. We conducted a systematic review of studies that used quantitative and comparative approaches to assess the impact of the pandemic on the service provision of four noncommunicable diseases (NCDs) (cancer, cardiovascular disease, chronic respiratory diseases, and diabetes) in the region. Methods A systematic search was conducted in PubMed, Embase, MedRxiv, and WHO COVID-19 databases in December 2021. The quality of studies was evaluated using the Joanna Briggs Institute Critical Appraisal Checklist and the ROBINS-I risk of bias tool. A narrative synthesis was conducted following the ‘synthesis without meta-analysis’ reporting guidelines. The review was registered with PROSPERO (CRD42020187629) and reported according to PRISMA guidelines. Findings Two review authors independently screened 5,397 records with 31 studies included, 26 which were cross-sectional studies. Most studies (n=24, 77%) were conducted in India and 19 (61%) were single-site studies. Compared to a pre-pandemic period, 10/17 cancer studies found a >40% reduction in outpatient services, 9/14 cardiovascular disease found a reduction of 30% or greater in inpatient admissions and 2 studies found diagnoses and interventions for respiratory diseases reduced up to 78.9% and 83.0%, respectively. No eligible studies on the impact of COVID-19 on diabetes services were found. Interpretation COVID-19 has substantially disrupted the provision of essential health services for NCDs in the WHO South East Asia Region, particularly cancer and cardiovascular disease. This is likely to have serious and potentially long-term downstream impacts on health and mortality of those living with or at risk of NCDs in the region. Funding This work was supported by the WHO Sri Lanka Country Office.

Background: COVID-19 has had a profound impact on the health systems of the 11 countries of the WHO South East Asia Region. We conducted a systematic review of studies that used quantitative and comparative approaches to assess the impact of the pandemic on the service provision of four noncommunicable diseases (NCDs) (cancer, cardiovascular disease, chronic respiratory diseases, and diabetes) in the region. were single-site studies. Compared to a pre-pandemic period, 10/17 cancer studies found a >40% reduction in outpatient services, 9/14 cardiovascular disease found a reduction of 30% or greater in inpatient admissions and 2 studies found diagnoses and interventions for respiratory diseases reduced up to 78.9% and 83.0%, respectively. No eligible studies on the impact of COVID-19 on diabetes services were found.

Interpretation: COVID-19 has substantially disrupted the provision of essential health services for NCDs in the WHO South East Asia Region, particularly cancer and cardiovascular disease. This is likely to have serious and potentially long-term downstream impacts on health and mortality of those living with or at risk of NCDs in the region.

Funding: This work was supported by the WHO Sri Lanka Country Office.

Evidence before this study

The COVID-19 pandemic has placed enormous strain on health systems in the South East Asia region (SEAR), with the WHO PULSE survey estimating that up to 60% of essential services have been at least partially disrupted. Disruptions in access to noncommunicable disease (NCD) services may lead to delayed diagnosis and advanced disease, potentially setting back hardfought gains in NCD control across the region. However, no comprehensive analysis of quantitative evidence documenting the displacement of NCD services from the SEAR has been undertaken to date.

This study represents the first systematic review and evidence synthesis of published evidence to estimate the quantitative impact of the COVID-19 pandemic on essential service provision for NCDs in the SEAR. We document that the pandemic substantially disrupted the provision of health services for NCDs, and in particular -cancer and cardiovascular disease, across multiple SEA countries. All aspects of NCD care, including screening, diagnosis, treatment, palliative care, and follow-up management were reduced during the pandemic. We did not identify any relevant studies in Bhutan, North Korea, Maldives, Myanmar, Thailand, or Timor-Leste, nor for services related to the diagnoses, treatment, or management of diabetes.

Our findings demonstrate that essential services for a range of NCDs were substantially disrupted by the COVID-19 pandemic across the SEAR. The downstream effects of these disruptions are potentially dire and could result in delayed diagnoses, faster disease progression, and ultimately -higher rates of mortality. Further research is required to understand the impact of subsequent waves of COVID-19 infection on NCD service provision, effective strategies to recover and protect disrupted services, and how countries across the SEAR can utilise this evidence towards informing policy for building more resilient health systems for future pandemic preparedness.

The COVID-19 pandemic has placed enormous strain on health systems globally, and there is increasing evidence from numerous settings that it has impacted adversely on the provision of a wide range of essential health services. 1 Management of the COVID-19 pandemic is particularly challenging for the 11 countries in the WHO South East Asia (SEA) Region, which has the lowest level of health spending of all WHO Regions at less than 5% on average. 2, 3 The SEA Region is home to over a quarter of the world's population and comprises eleven countries: Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. The pandemic toll in SEA Region has been severe -the region had experienced approximately one-fifth of global COVID-19 cases as of June 11, 2021. 3 Besides its direct impact on health, COVID-19 has indirectly impacted health services due to lockdowns and other public health policies such as voluntary social distancing. In turn, these have led to decline in service utilization. The WHO PULSE survey on the continuity of essential health services during the COVID-19 pandemic has now published two rounds of information captured from 2020 and 2021. 4, 5 According to the WHO Pulse survey conducted in 2020, 77% of all countries have experienced health service disruptions to some extent 4 . The services that were most frequently disrupted were routine immunization, noncommunicable disease (NCD) diagnosis and treatment, family planning and contraception, treatment for mental health disorders, antenatal care and cancer diagnosis and treatment. On average, close to 60% of essential services were at least partially disrupted in the SEA Region. 4 Prior to the pandemic, all countries in the region had made improvement according to the WHO overall essential health service coverage index with the regional average increasing from 49% in 2010 to 63% in 2020. 3 The largest progress was made in Indonesia, where the service coverage index increased by 18 percentage points. 3 However, progress was largely uneven: the biggest gains were made in providing infectious diseases-related services, such as tuberculosis treatment and HIV antiretroviral therapy, while improvements related to noncommunicable diseases (NCDs) have been less rapid. In addition to being considered at higher risk for worse outcomes from COVID-19, people with NCDs may also experience disruptions or delays in access to health services due to mitigation measures such as national lockdowns.

NCDs account for an estimated 8.5 million deaths annually in the WHO SEA Region. 6 In India for instance, NCDs present a substantial burden to the health system, and it is estimated that 35% of all outpatient visits to hospitals in 2004 were for NCDs, and 40% of hospitalizations. 7 The continued increase in NCDs and chronic care conditions necessitates available, accessible, and affordable NCD health services yet the impact of the COVID-19 pandemic on service provision threatens to slow down progress and even reverse the gains in controlling NCDs.

We review the published quantitative evidence on the impact of COVID-19, compared to prepandemic data, on the provision of essential prevention, detection, treatment, and management services for NCDs across the SEA Region. We focus on four NCDs selected on the basis that they have the highest burden of disease in adults in the region, accounting for over 80% of all premature NCD deaths: cardiovascular diseases and stroke, cancers, chronic respiratory diseases, and diabetes. 6 This review also characterizes the various policy responses implemented across the region and their impact on health service provision during the COVID-19 pandemic.

A systematic review was conducted to identify quantitative evidence regarding the provision of essential health service for NCD services in each of the 11 countries within the SEA Region. The review was prospectively registered with PROSPERO (CRD42020187629) and reported according to PRISMA guidelines.

Between 1st and 15th of December 2021, we electronically searched the following databases: Ovid Medline, Embase and Global Health. The search included relevant medical subject heading terms, keywords, and word variant for NCDs, service disruption, COVID-19 and countries that belong to the SEA Region. The search was limited to English language sources published from 2020 to the time of the search. The complete search strategy is available in supplementary file 1. Additional nonstructured searches for grey literature were conducted in the WHO COVID-19 database and a pre-print database (e.g., https://www.medrxiv.org/).

We limited eligibility to studies where one of the primary objectives was to determine the impact of the COVID-19 pandemic on the provision of health services for one or more of the NCD conditions of interest. Articles were included if the title and/or abstract indicated the report of results using quantitative and comparative approaches (i.e., 2020/21 estimates compared to 2019 and prior) that examine the impact of COVID-19 on the provision of any health service related to the prevention, diagnosis, treatment, or management for one of the four NCDs of interest in a SEA setting. Studies were excluded if they did not contain data from one of the listed countries, did not include a NCD of interest, were published outside the specified date range, contained only qualitative results, or did not include comparison groups.

Abstracts and potentially relevant full-texts were reviewed independently by two authors (TG and LD) with any conflicts resolved by consensus. Duplicates were removed from the initial search.

Thereafter, full-texts of potentially relevant studies were reviewed to determine eligibility for inclusion. A full list of inclusion and exclusion criteria for the studies is provided in table 1. All articles identified in the searches were imported into the Covidence systematic review software (version 2, Veritas Health Innovation, Melbourne, VIC, Australia), and title and abstract screening, full-text review, data extraction, and quality assessment were all performed in Covidence. 

The methodological quality of the included studies was evaluated using validated tools for each study design. For cross-sectional before-after studies we used the six-item Joanna Briggs Institute (JBI) Critical Appraisal Checklist for analytical cross-sectional studies. The JBI is an international, membership-based research and development organization within the Faculty of Health Sciences at the University of Adelaide. The instrument was developed by the JBI before being reviewed by an international methodological group. For cohort or case control studies we used the ROBINS-I [9] risk of bias tool, as recommended by the Cochrane Collaboration to assess non-randomized studies of interventions. Quality appraisal was undertaken by a single reviewer (TG) and any points of uncertainty were addressed through discussion and consensus with a second reviewer (LD).

Data were extracted in Covidence by two reviewers (TG, LD) using a standard template that was modified to include key parameters of interest. The following data were extracted: country; condition of interest; service of interest; study design; sampling period; % change in service delivery metrics from pre-COVID to peri-COVID. Essential health services were divided into the following categories of interest, in line with patient pathways of care: outpatient services (e.g., presentation rates), inpatient services (e.g., admission rates), diagnosis and case finding, pharmacological services, condition management and follow-up services. The following COVID-19 related information was also extracted from papers where possible: whether data collection coincided with a 'peak' of infection and/or lockdown; whether any service protection/mitigation measures were in place during the period of data collection; the reported efficacy of the mitigation measures; and reported consequences of forgone or displaced health services as a consequence of COVID-19.

Given the heterogeneity in setting, population, condition, and service area, a meta-analysis was not undertaken. A narrative synthesis was conducted following the 'synthesis without meta-analysis (SWIM)' in systematic review reporting guidelines to explore, describe, and interpret key findings related to the impact of COVID-19 on the provision of essential health services for NCDs during 2020 and 2021 in the SEA Region.

This study was funded by the World Health Organisation Sri Lanka (WHO-SL) Country Office. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The WHO-SL office and the WHO South East Asia Regional Office (WHO-SEARO) have reviewed and approved this manuscript for publication.

TG is supported by a university post graduate award from the University of New South Wales. VDRV receives a salary from the World Health Organisation South East Asia Regional Office. DP and SJ are both supported by individual investigator grants from the Australian National Health and Medical Research Council.

Ethical approval was not required for this review as all information collected was available in the public domain.

An initial 8,601 papers were identified through a database search and 9 through the grey literature. 5 ,397 records remained after duplicates were removed. 74 were relevant for full-text review and 31 met the inclusion criteria for systematic review ( Figure 1 ). Forty-three studies were excluded.

Primary reasons for exclusion included the study setting outside SEA (n=21), conference abstract or poster presentation (n=9) inappropriate study design (i.e., not comparative; n=6) and reporting on outcomes outside of the scope of this review (n=6). 22 Additionally, one study reported on disruptions to both cancer and cardiovascular services 21 and one on disruptions to diagnostic procedures for cancer, cardiovascular and respiratory diseases. 20 There was one report using a national registry, 11 multi-site studies and the remaining 19 were single-site studies.

Nearly all studies were cross-sectional in nature (n=30), though different study design labels were applied including 'ambi-directional' cohort study, 29 prospective mixed-quantitative methods study 33 and emulated natural interrupted time series. 37 One study was a retrospective matched cohort study where clusters of geographic districts were exposed to a different form of follow-up provision. 31 Eighteen studies compared a period of time during the COVID-19 pandemic, often during lockdown, with the corresponding period in the prior year (i.e., 2019) while nine studies obtained a comparison group from a period immediately preceding the pandemic or lockdown. Sample sizes varied from 50 to 41,832 (Table 2 ).

Among analytical cross-sectional studies, 21 were considered moderate quality 8-14, 17-20, 23, 25, 27-29, 32, 33, 36-38 and 9 low quality. 15, 16, 21, 22, 24, 26, 30, 34, 35 The majority of studies outlined clear time periods for comparison, the study setting, outcomes for measurement and their data source. Comparatively, sample size was not reported in 12 studies, and studies commonly did not explain their statistical analysis methods nor provide confidence intervals. Only one study -the retrospective matched cohort study -controlled for confounding and was found to have a moderate risk of bias. 31 None of the included studies were scored a high methodological quality. Results of the quality assessment are contained in supplementary file 2.

Of the 17 studies that assessed disruptions to cancer related health services, 13 were conducted in India ( Table 3 ). The majority (n=11) assessed services provision in tertiary oncology departments (for all types of cancer) while others focused specifically on cervical (n=1), paediatric (n=1), oral (n=1), blood (n=1), gastrointestinal (n=1) and head and neck (n=1) cancers.

Studies commonly reported on multiple services of interest. Eleven reported on outpatient services, of which 10 found a >40% reduction in service delivery post the onset of COVID-19 as compared to a pre-pandemic period (range 8 to 80%). Seven studies reported on inpatient admissions finding reductions ranging from 14.4 to 61.6%. To some extent, the magnitude of service reduction reported, depended on the timeline of the study. Studies that only analysed service provision during a lockdown period were likely to report higher reductions than those that covered the whole of 2020.

For instance, in Bangladesh the national cervical cancer screening program dropped 94.9% in the first month of the lockdown yet only 14.1% across the whole year. 9 Of these 17 studies, only two reported on the impact of mitigation measures to maintain service provision during the pandemic. 18, 23 In the absence of any national guidelines in India, Mallick and colleagues prioritised radiotherapy treatment for oncology patients, continued services for patients already undergoing treatment and deferred new starts for adjuvant therapy. 23 Additionally, a staff rotation policy was implemented to ensure that human resources could be redeployed to prevent delays and deliver full services for those with the highest priority. Although outpatient consultations dropped by 58% during lockdown, more than 90% of high-priority cancer treatments (specifically radiotherapy and chemotherapy) were implemented as planned.

Similarly, Hewamana documented mitigation strategies used in a tertiary blood cancer centre in Sri Lanka. 18 These included triaging patients via telephone prior to attendance, monitoring patients following discharge via telephone to reduce attendance, and providing prophylaxis and oral antibacterial medications to minimize presentations. Compared to same period in 2019, the number of outpatient services reduced by 8% (p=0.002, 95% CI: 6.2 to 9.5%) during the pandemic period, while inpatient admissions decreased by 26% (p=0.002, 95% CI: 22.9 to 30.3%).

Fourteen studies assessed the impact of the pandemic on cardiovascular related services -11 were conducted in India, and one each in Bangladesh, Indonesia, and Sri Lanka (Table 4) Nine studies reported gender disaggregated data, four of which reported large discrepancies in access by gender. Two multi-site studies in India found a reduction in the proportion of women accessing cardiovascular care during the COVID-19 pandemic. Among four hospitals during lockdown the proportion of women accessing cardiovascular services reduced from 28.1 to 11%; 12 and among two hospitals patients admitted with acute heart failure during the lockdown were more commonly male (82.6 vs 71.6%; p value <0.02); 13 Two other studies reported low levels of females patients before and during the pandemic. A cross-sectional analysis of 187 Indian hospitals reported that across 2019 and 2020 only 21.6% (9,018/41,832) of hospitalised patients with acute myocardial infarction were female; 37 similarly, of 324 patients undergoing primary angioplasty in a tertiary care hospital in Jakarta, Indonesia, approximately 90% were male. 38 Only one study examined the impact of the pandemic on the availability of condition management and follow-up services. Reddy et al (2021) examined whether the decentralization of hypertension follow-up services improved continuity of care for hypertensive patients and helped to mitigate disruption during the pandemic. 31 In the decentralised group, registered hypertensive patients received free medication and care from an auxiliary nurse midwife at subcentres, the most peripheral component of the primary healthcare system. In the control group, registered hypertensive patients were required to travel to the primary health centre to receive free medication and care from a nurse. During the pandemic, follow-up services under the decentralized model of care reduced by 5% compared to 51% under the centralised model. 31 Table 4 : Change in cardiovascular disease service provision by study and patient pathway

Only one study, conducted in India, examined the impact of the pandemic on access to nephrology services, specifically in terms of outpatients, inpatient admissions, and kidney transplant services.

Kute et al found reported that these measures reduced by 20%, 31% and 56%, respectively, during 2020. 22 Regarding respiratory services, Tyagi and colleagues reported that, in India, the number of interventional pulmonology procedures reduced by 83% from March 24 to July 23, 2020, compared with January 2020. 35 This review finds that the provision of NCD services in the SEA Region was substantially affected by 2 the COVID-19 pandemic. The provision of cancer services was consistently reported to be 50% less 3 when compared to the pre-pandemic period including disruptions to all aspects of care, such as 4 outpatient services, inpatient admissions, surgical procedures, and pharmacological treatments. The 5 provision of services for cardiovascular disease was similarly impacted, with 7 out of 14 studies 6 reporting >50% reductions in service provision. Evidence of the pandemic's impact on nephrology 7 and respiratory services was limited yet the available information reports service reductions ranging 8 from 20% to 83%. 9

Whilst some level of health service disruption is an expected impact of the COVID-19 pandemic, our 10 findings document a magnitude of disruption potentially greater than previously postulated. A 11 recent systematic review of disruptions in cancer care, which included studies mostly (84%) from 12 high income countries, found reductions in hospitalization rates of up to 30% compared to the pre-13 pandemic period. 39 Our findings also highlight a potentially higher level of service disruption than 14 that reported in large scale surveys, such as the WHO PULSE survey. 4, 5, 40 For example, the first 15 PULSE survey (2020) reported that much of the disruption to NCD services was incurred in 16 prevention activities with reductions in inpatient services observed to be 'generally less affected', 17 however we identified data from multiple studies in this review that highlighted substantial 18 reduction in the use of inpatient services, as well as NCD-related surgical services. 19

One of the difficulties in interpreting these findings is in disentangling the effect of such disruption 20 from supply-side and demand-side factors, the latter related to lockdowns, social distancing 21 regulations, financial burden, and fear of infection within patient populations. Based largely on data 22 from multiple studies in India, reductions in service provision appeared greatest when national 23 lockdowns were first announced, which coincided with stricter restrictions, but with less COVID- 19 24 cases. 10-13, 19, 29, 37 However, by the time India's first national lockdown ended in June 2020, case 25 numbers were rapidly increasing. As a result, anticipated rebounds in patient load were limited due 26 to continuing travel restrictions and fear of infection. 10 For instance, Jayagopal et al (2021) reported 27 a surge in patient admissions following the end of India's national lockdown in June 2020, yet this 28 was followed by another drop in late June as the number of COVID-19 cases rapidly increased. 19 29 It is worth noting that service utilisation by gender was rarely reported by studies. Three studies 30 from India found reductions in access to cardiovascular services among females, contrasted with the 31 increase in service utilisation amongst males. 12, 13, 37 This aligns with evidence of gender 32 discrimination in healthcare access in the country. 41, 42 Decision makers need to ensure that 33 disparities in access to care, particularly by gender, are not exacerbated by the pandemic and further 34 research is needed to track how access to services may have been affected across sub-populations 35 such as rural, the poor and displaced populations. 36

To our knowledge, this is the first systematic review to comprehensively assess the evidence base 37 for service disruption due to COVID-19 across the SEA Region. The study design is advantageous in 38 that it focuses on quantitative estimates of service disruption rather than commentary and 39 qualitative assessment. As such, this review provides a much needed means of validating the 40 enormous amount of commentary that has surrounded this topic and in informing policy responses. 41

The systematic search also incorporates a review of the grey literature, which is important given the 42 rapidly changing epidemiology and policy environment and the potentially slow process of academic 43 peer review. Lastly, this review was commissioned by WHO SEARO and was conducted with a rapid Furthermore, by adopting a regional perspective, our ability to analyse the contextual dynamics of 58 the pandemic as it evolved in each country was limited. This is especially relevant in relation to 59 country-specific health system configuration, quality, accessibility, and resilience, and to local 60 policies and baseline characteristics of the provision of essential health services for the prevention, 61 detection, treatment, and ongoing management of NCDs. We were also unable to make a 62 

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