The international community is mobilising to limit the spread of severe acute respiratory syndrome coronavirus 2 and reduce mortality from COVID-19. As of May 1, 2020, more than 237 000 people have died from COVID-19, and estimates of future deaths number in the millions. Governments are responding at local, national, regional, and global levels, and health officials are developing guidance for health systems and the public. In weighing their options, policy makers must consider not only the immediate health effects of the pandemic but also the indirect effects of the pandemic and the response to it. An analysis of the 2014 outbreak of Ebola virus in west Africa showed that the indirect effects of the outbreak were more severe than the outbreak itself. Although mortality rates for COVID-19 appear to be low in children and in women of reproductive age, these groups might be disproportionately affected by the disruption of routine health services, particularly in low-income and middle-income countries (LMICs).
In past epidemics, health systems have struggled to maintain routine services and utilisation of services has decreased. As WHO notes, “People, efforts, and medical supplies all shift to respond to the emergency. This often leads to the neglect of basic and regular essential health services. People with health problems unrelated to the epidemic find it harder to get access to health care services.” A study of the 2014 epidemic of Ebola virus disease estimated that, during the outbreak, antenatal care coverage decreased by 22 percentage points, and there were declines in the coverage of family planning (6 percentage points), facility delivery (8 percentage points), and postnatal care (13 percentage points). Qualitative studies suggest that these reductions were due to fear of contracting Ebola virus at health facilities, distrust of the health system, and rumours about the source of the disease. During the 2003 severe acute respiratory syndrome epidemic, ambulatory care decreased by 23·9% in Taiwan and inpatient care decreased by 35·2%. Simulated models of influenza pandemics also predict reductions in utilisation of health services.