The changes in health service utilisation in Malawi during the COVID-19 pandemic

Bingling She*, Tara D. Mangal, Anna Y. Adjabeng, Tim Colbourn, Joseph H. Collins, Eva Janoušková, Ines Li Lin, Emmanuel Mnjowe, Sakshi Mohan, Margherita Molaro, Andrew N. Phillips, Paul Revill, Robert Manning Smith, Pakwanja D. Twea, Dominic Nkhoma, Gerald Manthalu, Timothy B. Hallett

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Introduction The COVID-19 pandemic and the restriction policies implemented by the Government of Malawi may have disrupted routine health service utilisation. We aimed to find evidence for such disruptions and quantify any changes by service type and level of health care. Methods We extracted nationwide routine health service usage data for 2015–2021 from the electronic health information management systems in Malawi. Two datasets were prepared: unadjusted and adjusted; for the latter, unreported monthly data entries for a facility were filled in through systematic rules based on reported mean values of that facility or facility type and considering both reporting rates and comparability with published data. Using statistical descriptive methods, we first described the patterns of service utilisation in pre-pandemic years (2015–2019). We then tested for evidence of departures from this routine pattern, i.e., service volume delivered being below recent average by more than two standard deviations was viewed as a substantial reduction, and calculated the cumulative net differences of service volume during the pandemic period (2020–2021), in aggregate and within each specific facility. Results Evidence of disruptions were found: from April 2020 to December 2021, services delivered of several types were reduced across primary and secondary levels of care–including inpatient care (-20.03% less total interactions in that period compared to the recent average), immunisation (-17.61%), malnutrition treatment (-34.5%), accidents and emergency services (-16.03%), HIV (human immunodeficiency viruses) tests (-27.34%), antiretroviral therapy (ART) initiations for adults (-33.52%), and ART treatment for paediatrics (-41.32%). Reductions of service volume were greatest in the first wave of the pandemic during April-August 2020, and whereas some service types rebounded quickly (e.g., outpatient visits from -17.7% to +3.23%), many others persisted at lower level through 2021 (e.g., under-five malnutrition treatment from -15.24% to -42.23%). The total reduced service volume between April 2020 and December 2021 was 8 066 956 (-10.23%), equating to 444 units per 1000 persons. Conclusion We have found substantial evidence for reductions in health service delivered in Malawi during the COVID-19 pandemic which may have potential health consequences, the effect of which should inform how decisions are taken in the future to maximise the resilience of healthcare system during similar events.

Original languageEnglish
Article numbere0290823
Number of pages15
Issue number1
Publication statusPublished - 17 Jan 2024

Bibliographical note

Funding Information:
This research is funded by the The Wellcome Trust. For authors (B. She, T. D. Mangal, A. Y. Adjabeng, M. Molaro and T. B. Hallett) at Imperial College London, this award is jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This research is greatly supported by Malawi Ministry of Health and Population, who gave permission to access data in DHIS2 system and provided invaluable advice on the research. We would like to thank Elsie Kasambwe, Andreas Jahn and their team in the Department of HIV & AIDS and Viral Hepatitis, Ministry of Health and Population, Malawi, for sharing HIV-related service data. We would also like to thank Margaret L. Prust and Stephanie Heung from Clinton Health Access Initiative, Inc., for their advice on data extraction and interpretation in DHIS2 system.

Publisher Copyright:
© 2024 She et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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