Johns Hopkins University Press
  • The Effect of the COVID-19 Pandemic on Use of Select Child Health Services in Kenyan Hospitals
Abstract

Introduction. Kenya reported its first case of coronavirus disease (COVID-19) in March 2020. Pandemics may disrupt provision of essential health services. This study sought to find out if the COVID-19 outbreak had any effect on reported paediatric workload in Kenya. Methods. Aggregate workload data for 12 months before COVID-19 outbreak and 12 months of the COVID-19 outbreak were extracted from the Kenya Health Information System and negative binomial regression conducted. Results. A significant decline was observed across all indicators. Paediatric clinics attendance declined by 36%, paediatric admissions by 31.4%, outpatient attendance by 28.7%, and child wellness clinics attendance by 10.3%. In outpatient attendance, the five conditions with the highest attendance reported a decline ranging from 17.3% to 33.8%. Conclusion. COVID-19 partially disrupted essential health services among children in Kenya. Children in need of specialized treatment were more disadvantaged.

Key words

Kenya, COVID-19, paediatric, health care

Kenya reported its first coronavirus disease (COVID-19) case on March 13, 2020.1 The government immediately implemented containment measures. These included the regular hand-washing with water and soap or using alcohol-based sanitizers, maintaining social distance, encouraging people to stay at home if they felt unwell with respiratory symptoms, suspension of public gatherings, mandatory wearing of face masks in public, closure of all educational institutions, and travel restrictions. More measures were implemented later. These included a nationwide dusk-to-dawn curfew and lockdown in counties with the highest cases.1 By mid May 2022, a total of 324,026 COVID-19 cases had been reported as well as 5649 fatalities.2 Kenya started vaccinating its adult population against COVID-19 pandemic in March 2021, and its teenage population in November 2021. Priority was initially given to the elderly, health workers, teachers, and security personnel. The goal is to fully vaccinate 19 million adults or 70% of its adult population by June 2022. By mid-May 2022, 30.7% of the adult population had been fully vaccinated. By mid-May 2022, 18 million doses of COVID-19 vaccines had been administered. These were administered as follows: 16 million among adults, 1.3 million among the 15–17 years cohort, 32000 among the 12–15 years cohort, and 0.3 million booster doses.2 [End Page 326]

Figure 1. Outpatient attendance among infants pre and during COVID-19 outbreak in Kenya.
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Figure 1.

Outpatient attendance among infants pre and during COVID-19 outbreak in Kenya.

During an epidemic or pandemic, health systems in lower-income countries tend to have challenges coping with the increased workload due to the pandemic, and provision of essential health services may be negatively affected. This has been attributed to demand and supply factors. Demand factors deter people from accessing readily available health services. They include not seeking health care due to fear of being infected in health facilities, financial difficulties due to an outbreak, and measures imposed on the population movement (e.g., curfews may limit access to health services). Supply factors, on the other hand, make the health care system unable to fully provide health services. This may be due to insufficient staff, insufficient personal protective equipment for health workers; suspension of elective care, and disruption of the supply chain.3,4 In Kenya, the COVID-19 outbreak has been shown to disrupt HIV/AIDS services with a 56% decline in uptake of services reported.3 The World Health Organization reported that, on average, 40% of African countries reported disruption across reproductive, maternal, newborn, child, and adolescent health services as a result of the COVID-19 pandemic.4 Studies on the effect of the COVID-19 pandemic on pediatric health services have been done but with a focus on high-income countries.5,6 These countries had a high burden of COVID-19–related morbidity and mortality. Kenya and other sub-Saharan countries had a relatively low burden of COVID-19–r elated morbidity and mortality. However, these countries have a high global burden of communicable diseases such as HIV infection, malaria, tuberculosis, pneumonia, meningitis, and measles. They also have a high burden of non-communicable diseases such as diabetes, asthma, cancer, undernutrition and sickle cell disease. This is further compounded by [End Page 327] underfunded health systems and limited access to care.7 This study sought to explore if there were changes in infant outpatient attendance, pediatric inpatient admissions, pediatric clinic attendance and child wellness clinic attendance in Kenyan hospitals during the COVID-19 pandemic.

Methods

The study design was retrospective, cross-sectional. Monthly workload data were extracted from the Kenya Health Information System website (https://hiskenya.org). In 2011, Kenya adopted the District Health Information Software 2 (DHIS2) for reporting health facility data. This is a free and open-source web-based reporting software. Health facilities report data on disease, commodities and workload through the DHIS2.8 It is structured by administrative units with health facilities assigned to the 47 counties that make up Kenya. In 2022, a total of 14,421 health facilities were reporting in the DHIS2. These comprise 1,142 faith-based facilities; 6,051 privately owned; and 7,228 government owned ((https://hiskenya.org). Data are collected through a paper-based system of registers, tally sheets, and monthly data reporting forms. These are then keyed into the DHIS2 by health records and information officers who have access to the DHIS2. The DHIS2 stores facility-level data monthly and can aggregate data by different administrative levels (e.g., county and country).8 The study used two reporting tools. These are the services workload reporting tool and the outpatient summary for the under five years cohort. The latter provides a summary of all new cases seen in outpatient clinics. These new cases are categorized according to the disease or condition diagnosed. Monthly means of the five diseases with the highest outpatient attendance were extracted. The services workload reporting tool is divided into various sections. From the general outpatient or filter clinic attendance, attendance for the younger than five years cohort was extracted. This is normally listed as new clients and re-visits. These are tallied separately for males and females and then added together to give a total figure. The total figure was extracted as well as figures for monthly male and female outpatient attendance.

Paediatric clinic attendance was extracted from the special clinics attendance section. It is listed as new clients and re-visits and these are added together to give a total figure. Child wellness clinic attendance was extracted from the maternal child health and family planning client attendance section. This is also listed as new clients and re-visits. These two figures are added together to give a total figure. From the inpatient services workload section, the figure for paediatric admissions was extracted.

This study did not seek ethical clearance because it used aggregated data, and data from the Kenya Health Information System are normally de-identified.

The study compared data for 12 months before the COVID-19 outbreak and the first 12 months of the COVID-19 outbreak. The former period was from April 2019 to March 2020. The latter period was April 2020 to March 2021. Negative binomial regression was done for each by male and female. The analysis incorporated Huber-White sandwich estimators, seasonal fixed effects, and the default dispersion model in STATA (Stata Statistical Software: Release 13). The estimated effect of COVID-19 [End Page 328]

Figure 2. Paediatric clinic attendance pre and during COVID-19 outbreak in Kenya.
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Figure 2.

Paediatric clinic attendance pre and during COVID-19 outbreak in Kenya.

pandemic was derived as the coefficient. This was then converted to a percentage, together with the 95% confidence interval values.9 Time was coded into two categories (i.e., before and during COVID-19 outbreak). A priori determinations were made for significance levels of .05.

Results

Paediatric clinic attendance declined by 36% (p=.00 95% CI 43%–29%), paediatric admission declined by 31.4% (p=.00 95% CI 34.8%–27.9%), outpatient attendance declined by 28.7 % (p=.00 95% CI 35.5%–22.3%), and child wellness clinic attendance declined by 10.3 % (p=.01 95% CI 13.4%–7.9%.). As for absolute numbers, mean monthly outpatient attendance had the highest figure at 1.66 million pre-Covid. This declined to close to 1.2 million during the COVID pandemic (Figure 1). For outpatient attendance, declines ranging between 17.3% and 33.8% were observed among the top five conditions with highest attendance. Upper respiratory tract infections and tonsillitis had the highest declines of 33.8% and 33.3–% respectively. Monthly male outpatient attendance declined by 29.9%, and female outpatient attendance declined by 28.9% (Figure 2). The graphs for workload indicators (Figures 3&4) show a sharp decline after the COVID-19 pandemic was declared a national emergency. This is followed by a rise in use of health services, and another decline occurs as the year 2020 comes to an end. This is followed by a rise in use of health services. [End Page 329]

Figure 3. Inpatient admissions pre- and during COVID-19 outbreak in Kenya.
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Figure 3.

Inpatient admissions pre- and during COVID-19 outbreak in Kenya.

Figure 4. Child Welfare Clinic attendance pre and during COVID-19 outbreak in Kenya.
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Figure 4.

Child Welfare Clinic attendance pre and during COVID-19 outbreak in Kenya.

[End Page 330]

Discussion

The study shows that use of child health services declined by between 10.3–36 % during the COVID-19 period. Paediatric clinic attendance declined the most. Paediatric clinics are run by paediatricians or clinical officers who have specialized in paediatrics and are mostly held in level 4 hospitals and above. These include county referral hospitals and national referral hospitals. Patients are normally referred to these clinics either from the outpatient clinics or the inpatient (e.g., after discharge and also from lower-level health facilities). A decline in outpatient and admissions may have directly contributed to a decline in paediatric clinic attendance. After the COVID-19 outbreak, the Ministry of Health released guidelines on the continuity of essential health care. Paediatric guidelines emphasized staying away from hospitals for non-urgent matters to reduce transmission by minimizing exposure.10 One example of an non-urgent matter is a routine paediatric outpatient visit. Those in need of a refill for medication of a chronic nature were urged to send a designated caregiver to the hospital alone for a refill. The guidelines further stated that routine immunization would continue with caregivers urged to utilize levels 2 and 3 health facilities to reduce exposure of children and caregivers. High volume facilities (i.e., level 4) were encouraged to continue with immunization. To reduce risk, they were required to set up a separate space for it. There was another circular issued to county governments on March 25th 2020, advising them to cancel all elective surgical procedures in county hospitals except for obstetric cases to redirect resources towards combating the COVID-19 pandemic.11 These actions may have reduced the use of child health services.

The enforced curfew and lockdown may have hindered access to health services. Only expectant mothers were issued with curfew passes.12 Parents and caregivers with little children may have experienced challenges accessing health care, especially during the curfew periods. The pandemic also had adverse economic effects on livelihoods. These include job losses in the education, transport, aviation, and hospitality sectors. Loss of income deters people from seeking health care as they may lack health insurance or be unable to cover out-of-pocket expenses (e.g., transport). A survey in five informal settlements in Nairobi found that 10% of respondents were foregoing medical services during the COVID-19 period.13 The main reason for foregoing medical services was the inability to afford them (52%), fear of contracting COVID-19 (17%), and closure of health facilities (12%). The main medical care they were foregoing was for acute illness (21%), routine health services (20%), malaria (16%), immunization (16%) and nutrition (16%).

Child wellness clinics recorded the least decline. These conduct growth-monitoring, nutritional support, immunization, deworming, vitamin A supplementation, and provision of select public health goods such as insecticide-treated nets and oral rehydration solution sachets. These clinics are found in all health facilities starting from level 2. It is likely that those who initially sought these services from higher-level facilities pre-COVID-19 outbreak may have opted to visit lower-level facilities like dispensaries. These may have been perceived to be less risky as they were not handling COVID-19 patients. Providing some services at the child wellness clinic does not necessarily [End Page 331] require a trained health care worker. Community health volunteers can provide some (e.g., weight monitoring and deworming). The graphs for workload indicators (Figures 3&4) show a sharp decline immediately when COVID-19 was declared a national emergency. This may be attributed to people staying away from health facilities as advised. This is followed by an increase and another sharp decline towards the end of 2020. In Kenya, detected COVID-19 cases peaked in early August 2020 because of the relaxation of containment measures. The second and third COVID-19 waves occurred in mid-November 2020 and in March 2021. The second wave may have caused the second sharp decline as people tended to keep away from health facilities during the waves.14 In Mozambique, health workers reported a decline in child consultations at the start of the COVID-19 pandemic.15 Concerning gender, outpatient attendance declined more or less the same across males and females.

It is also possible that measures put in place to control the COVID-19 pandemic may have reduced childhood illnesses resulting in a decline in health care utilization. Promotion of hand-washing with soap and water as part of COVID-19 prevention may have reduced respiratory illnesses and water and sanitation-related illnesses (e.g., diarrhoea among infants). The closure of schools may have minimized contagious diseases, which tend to easily spread among school going children contributing to decreased hospital attendance. On March 15, 2020, Kenya's ministry of education closed all 30,000 primary and secondary schools indefinitely to prevent spread of COVID-19. Tertiary-level education institutions were also closed. This interrupted the studies of 18 million pre-primary, primary, and secondary school students. Schools partially reopened in November for select classes. The selected classes were the ones were supposed to be sitting for their national exams and consisted of three groups, grade four and standard eight pupils in primary schools and form four students in secondary schools. The remaining students resumed their studies in January 2021.16 Among outpatient attendance, the highest decline was for upper respiratory tract infections and tonsillitis. Closure of schools may have partly contributed to this decline.5

The World Health Organization reported that essential services were disrupted in lower-income countries due to COVID-19.3 Most service disruptions were partial, defined as 5–50% change in service use or disruption. Services affected include essential services for communicable diseases and non-communicable diseases; mental health; reproductive, maternal, newborn, child, and adolescent health; and nutrition services. This study found that partial disruption occurred among child health services in Kenya. This disruption may have extended to other health services in Kenya as a study found that admissions in Kenyan county hospitals recorded a notable decline after the COVID-19 outbreak compared with previous years.17 In Brazil, the COVID-19 pandemic did not significantly affect immunization of children at the national level with under vaccination observed before and during the pandemic.18

A decline in utilization of paediatric health services is not an indicator of improved health among infants. Given the high burden of communicable diseases in Kenya, there is the likelihood that some infants in need of specialized paediatric care may have been disadvantaged. This may also include children living with disabilities and chronic conditions. Caregivers may have sought care from informal healthcare providers like unlicensed pharmacies and herbalists. This study would recommend a follow up on paediatric [End Page 332] mortality during the COVID-19 pandemic. This would shed more light on whether the decline in healthcare utilization was accompanied by a reduction in infant mortality. In future epidemics, policy makers should ensure specialized paediatric services run uninterrupted as well as promptly inform caregivers how to access these services.

The study has some limitations. Reporting systems may be liable to have missing data (e.g., as a result of under-reporting and misreporting). A designated caregiver visiting the hospital alone for a medication refill for a child may only have been captured at the pharmacy and not the outpatient filter clinic. Another possible factor is that record-keeping for routine activities may not be a priority in a pandemic.

Conclusion

The COVID-19 outbreak disrupted the uptake of essential health services among children in Kenya with paediatric clinics most affected. Children in need of specialized treatment were more disadvantaged.

John Njuguna

JOHN NJUGUNA is a Public Health Officer working in Mukurwe-ini sub-County, Kenya.

Please address all correspondence to John Njuguna: Mukurwe-ini sub-County Public Health Office, P.O. Box 112-10103, Mukurweini, Kenya; Email: jowanju2002@gmail.com.

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