key: cord-0980472-lhrszuye authors: Workicho, Abdulhalik; Kershaw, Meghan J; Berhanu, Lioul; Kebede, Mebit; Kennedy, Eileen title: Essential Health and Nutrition Service Provision During the COVID-19 Pandemic: Lessons from Select Ethiopian Woredas date: 2021-03-18 journal: Curr Dev Nutr DOI: 10.1093/cdn/nzab024 sha: 5a4ae776fbe72ed3f79f64729034083292093822 doc_id: 980472 cord_uid: lhrszuye The world has faced a public health emergency due to the emergence of the COVID-19 pandemic. A cross-sectional study with mixed methods was conducted to review the status of maternal and child health care and nutrition service delivery during the early months of the pandemic in woredas (districts) targeted by the Growth through Nutrition Activity, a multi-sectoral nutrition project, in Ethiopia. Comparison to the previous year showed some decline in key maternal and child health and nutrition services, with more pronounced effects during the early months of March and April before coordinated effort and standard guidance were well established. A recovery of most services was likely due in no small part to a range of mitigation interventions implemented by respective health workers and institutions, supervising government organizations, and through support from non-governmental organizations. The world has faced a public health emergency due to the emergence of the COVID-19 pandemic. A cross-sectional study with mixed methods was conducted to review the status of maternal and child health care and nutrition service delivery during the early months of the pandemic in woredas (districts) targeted by the Growth through Nutrition Activity, a multi-sectoral nutrition project, in Ethiopia. Comparison to the previous year showed some decline in key maternal and child health and nutrition services, with more pronounced effects during the early months of March and April before coordinated effort and standard guidance were well established. A recovery of most services was likely due in no small part to a range of mitigation interventions implemented by respective health workers and institutions, supervising government organizations, and through support from non-governmental organizations. The world has faced an unprecedented crisis as a result of the COVID-19 pandemic, the full impact of which is only beginning to be understood (1). In the past year, national governments adopted a variety of response actions including aggressive measures aimed at containing new infections and halting spread of the coronavirus (2). These critical efforts to mitigate the pandemic have resulted in profound effects globally, but most significantly in low-and middle-income countries. Ethiopia confirmed its first COVID-19 case in March 2020. The goverment declared a state of emergency on April 8 th , with measures to prevent transmission including travel restrictions, border closure, suspension of public gatherings, closure of schools and universities, and requirements for social distancing. The effects of these mitigation strategies on the country's health sector were expected to be significant but remain unclear (3) (4) (5) (6) (7) (8) . The Feed the Future Ethiopia Growth through Nutrition Activity, funded by USAID, is a multi-sectoral project aimed at improving the nutritional status of women, children and adolescents in Ethiopia. Working in four key regions, Growth through Nutrition has been supporting the health system primarily through enhancing the coverage and quality of maternal and child health services, focusing on quality improvements of priority health and nutrition services at Primary Health Care Units (PHCU) comprised of district-level health centers (HCs) and smaller local level health posts (HPs). Given likely challenges to the health system due to the burden of the disease and the governmentmandated mitigation strategies, the provision of health and nutrition services was anticipated to be challenged by staff redeployment to provide COVID-19 relief, closures of health facilities or services, and supply-chain difficulties limiting provision of care, as well as reductions in outpatient care attendance due to fear, lockdowns and financial difficulties (9) . In recognition of the burden of the pandemic on the health sector, in April 2020, the Ethiopian Federal Ministry of Health (FMoH) developed national guidelines for managing COVID-19. The national guidelines set standards for surveillance, tracing protocols, COVID treatment centers, as well as health center preparedness, community engagement and maintaining essential services during the pandemic (10). This study reviewed data from PHCUs on the provision of maternal and child health service delivery during the first five months of the COVID-19 pandemic in Ethiopian woredas (districts) targeted by the Growth through Nutrition Activity in order to better understand changes in service provision and areas for improved response and mitigation. The study was conducted in four regions of Ethiopia: Tigray, Amhara, Oromia and Southern Nations Nationalities and Peoples (SNNP) regions. Four woredas in each of the four regions were purposively selected. The criteria for woreda selection included: support from Growth through Nutrition, reported cases of COVID-19, and no other recent, major natural or man-made shocks that had significantly disrupted routine health services. A total of sixteen rural PHCUs were selected (one per woreda), which included sixteen health centers and sixteen health posts. However, only fifteen health centers were included in the final sample as one center had temporarily closed due to staff infection with COVID-19. The study applied a cross-sectional study design including both quantitative and qualitative data Due to COVID-19 precautions, interviews and data collection were done remotely over the phone in August 2020. The study received ethical review by the Tufts University IRB and letters of support from the respective Regional Health Bureaus. Based on data collected from PHCUs, almost all representatives reported that service delivery and utilization of health/nutrition services had been affected by the COVID-19 pandemic (14 HCs). Although According to respondents, several mitigation strategies were put in place to offset the negative effects on health service delivery and utilization, with a strong emphasis on awareness creation for the community. The awareness creation focused on two main messages, stressing community-level prevention techniques for COVID-19, and messaging focused on COVID-19 prevention techniques to use when coming to health centers. In order to expand the cadre of people who could inform communities and households, volunteers were recruited from university students, frontline community workers, religious leaders, and others. At the same time, other strategies to reach households included providing counseling over the phone and health extension workers initiating a home-visit program. This approach is captured in the following: "We are giving door-to-door awareness creation services. On the other hand, we have created awareness to the community and health extension workers about how to resume activities which request gathering of people by fulfilling all necessary prevention mechanisms including social distance in place… We have made telephone counseling service available to mothers for maternal and child health services." (KI from Health Center in Tigray). "We tried to make health workers to create awareness door-to-door. We tried to give door-todoor service for activities which are possible to provide at the household level." (KI with HEW from Oromia). Routine health services in general, and maternal and child health and nutrition services in particular, for the most part showed some decline in comparison to the same time period in the previous year in the study areas. Most of the declines in utilization of services occurred in the early period of the pandemicfrom March to April 2020 -when coordinated efforts and standard guidance were in the early stages, but most services had recovered by end of July. Initial concern and lack of awareness of the nature of COVID-19 was reported as a significant factor associated with lower utilization of health services. Another major influence that negatively affected health care service was the prohibition of mass gatherings combined with travel restrictions. The higher rates of Vitamin A supplementation in 2020 may have been due to the transition of supplementation from facility-based to outreach, home-based service. The mitigation efforts of the government and other agencies did appear to be effective, to a certain extent, in reversing downward trends in service utilization. The awareness creation efforts at the community level improved health seeking behavior of households. These activities were also very much in line with the guidance from the FMoH to spread information on basic infection prevention and guide safe care-seeking behavior (10). This, along with other adaptive measures such as virtual counseling and house-to-house visits, helped offset some of the challenges in obtaining or delivering services. Another key lesson learned was the importance of redesigning the provision of services which required mass gatherings by limiting the number of participants and simultaneously increasing the number of events to deliver health care activities. While health providers reported that modifications have been successful in reviving services, continued support to ensure that adequate funding and supplies are available for modified services and directly reaching communities and households will be important to sustain ongoing efforts and ensure the health system can continue to meet community needs as the COVID-19 pandemic continues. One of the study limitations was potential quality issues in the health data collected from health facilities. As the data were collected over the phone, it was also verified with copies of the original records to the extent possible, but studies of Ethiopian health facility monitoring data have identified high rates of inaccuracies in records (11) (12) . While the original study design also included records from 2018, poor quality and incompleteness of the 2018 data made it unusable The study was thus not able to identify normal annual variation patterns for comparison. Another limitation of the study was that the representatives selected for both the quanitative and the qualitative data collection were likely to have Report of the WHO-China Joint Mission on Coronavirus Disease United Nations Economic Commission for Africa. COVID-19 lockdown Exit Strategies for Africa United Nations Ethiopia. Socio-economic impacts of COVID-19 in Ethiopia What is the role of Primary Health Care in the COVID-19 pandemic? Estimating the Indirect Health Impacts of COVID-19 in Ethiopia Immediate Impacts of COVID-19 Pandemic on Essential MNCH Services in Selected Health Facilities in Ethiopia The Indirect Impact of COVID-19 Pandemic on Maternal and Child Mortality in Ethiopia: A Modelling Study Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study 90% of countries report disruptions to essential health services since COVID-19 pandemic. Version current 31 Addis Ababa: FMoH 2020 Assessing Community Health Information Systems: Evidence from Child Health Records in Food Insecure Areas of the Ethiopian Highlands. Matern Gaps in Team Communication About Service Statistics Among Health Extension Workers in Ethiopia: Secondary Data Analysis The authors' would like to acknowledge the contributions of Rahel Gizaw, Zenebu Yimam, and Cherinet Abuye in providing feedback on the research design and manuscript. The authors' responsibilities were as follows-AW, MJK, LB, MK, EK: designed the research; AW, MJK, EK wrote the manuscript; AW collected and analyzed the data; and all authors: read and approved the final manuscript.