A new report by the Global Fund to Fight AIDS, Tuberculosis and Malaria shows that the COVID-19 pandemic has greatly interrupted health systems and health service delivery for communicable diseases such as HIV, tuberculosis (TB) and malaria in low- and middle-income countries in Africa and Asia in 2020. The report, which provides a summary of the impact of the pandemic on 502 health facilities (HFs) throughout Africa and Asia, was launched on 13 April 2021. In 2020, COVID-19 exploded into our world in a manner that was previously unimaginable. To date, it has infected more than 135 million people, killed over 2.9 million people, and is projected to plunge up to 115 million people into extreme poverty. As countries have gone into lockdown, gender-based violence has increased, unemployment has soared, and access to health care for the poorest and most vulnerable has been affected. COVID-19 has made people less likely to seek health care because they are afraid of being infected with the virus. Fear and uncertainty surrounding the virus have also increased stigma and discrimination. Frontline workers without enough access to personal protective equipment (PPE) risk their lives to treat patients, as COVID-19 propels already fragile health systems to the verge of collapse. The report highlights the urgent need to scale up the mitigating measures that HFs have had to adopt to be able to continue the battle against HIV, TB and malaria, to substantially increase the delivery of critical supplies for the COVID-19 response, and prevent health care systems and community responses from being pushed to the brink of disintegration.   The report examines patterns of disruption caused by COVID-19, as well as the adaptive measures that the Global Fund-supported programs have taken to respond to these challenges. The report’s ‘snapshots’ are primarily based on data collected and aggregated through Programmatic Spot Checks recording information from April to September 2019 (Q2/Q3 2019) and from April to September 2020 (Q2/Q3 2020) across 502 health facilities in 32 countries. Based on these country portraits, the Global Fund has assembled a picture of the extent of the interruption to health services for HIV, TB and malaria, and of how HFs have responded. Countries providing more than 80% of the range of target services across HIV, TB and malaria were selected for spot checks. Peter Sands, the Global Fund’s Executive Director, said: “This snapshot underscores the scale of the challenge. HIV prevention has been knocked backwards. With the dramatic drop in case management for malaria, we face a real risk of a spike in mortality. Much of the progress we’ve made to close the gap on finding “missing” people with TB has been reversed. The stark truth is that we will see more incremental deaths from HIV, TB and malaria in 2021 as a consequence of the disruption caused by COVID-19 in 2020.” As COVID-19 rapidly spread in 2020, outpatient consultations at HFs declined considerably compared to 2019. All surveyed HFs describe changes in attendance, highlighting the widespread reach of COVID-19 and its impact. The main reason patients were no longer coming to facilities was due to their fear of catching COVID-19, according to 85% of facilities surveyed (Figure 1). Patients were also no longer able to reach HFs because of disruption to public transportation services, as well as lockdown and orders to stay at home, trends being slightly more acute in urban settings. Some patients also delayed seeking care, while others no longer visited clinics due to changes in recommendations for mild illness and elective care. Overall, HFs appear to have put considerable effort into keeping services open, despite the difficult circumstances. Where this was not possible, facilities redirected patients to and from other facilities, and some specific services were reduced or no longer offered, which affected patient attendance. Other factors influencing patient access to services included more patients presenting with respiratory infection symptoms and other services being disrupted. In addition, as everyone’s focus became consumed by COVID-19, there was a reduction in general health communication campaigns to encourage people to seek out health care.

Figure 1. Breakdown of reasons for the change in patient attendance from April to September 2020, organized into facility reasons and community reasons, according to the perception of staff interviewed in spot-checks across 32 countries

The report outlines how data collected between April to September 2020, relative to the same sixth-month period in 2019, shows the following bleak results:

• HIV testing dropped by 41%.
• TB referrals – where patients suspected of having TB are referred to the next step of diagnosis and treatment – declined by 59%.
• Malaria diagnoses decreased by 31%.
• Antenatal care (ANC) visits fell by 43%.

The change in attendance and access to services is of concern for mothers and children. Early childhood is a particularly vulnerable time for health issues, and the impact of COVID-19 does not escape the young. First ANC visits fell by 5% across Africa, and by a colossal 66% across facilities surveyed in the seven countries across Asia. Services for children under five were also badly impacted by the pandemic. Facilities across Africa experienced a decrease of 23% in consultations for under-5 services in 2020 compared to 2019, while in seven countries across Asia these services fell 74%, resulting in significantly fewer children being seen by health care workers and receiving lifesaving care. If mothers' and children’s access to essential health services is reduced, mortality among children under 5 could be expected to rise. The spot checks also highlighted a critical lack of tests, treatments, and personal protective equipment (PPE) needed to fight COVID-19, particularly in Africa:

• Only 45% of HFs surveyed had enough essential PPE items for their health workers, including masks, disinfectants, gloves, and hand sanitizer.
• Across the 24 countries in Africa that were surveyed, only 11% of HFs could conduct COVID-19 antigen rapid diagnostic tests, and only 8% could conduct polymerase chain reaction (PCR) tests.

However, the portrait painted by the report also shows that countries that implemented measures to counter the impact of COVID-19 on health service continuity and adapt services to the new ‘normal’ fared better than those that did not adapt. More than two-thirds (68%) of facilities surveyed adopted at least one adaptive measure, such as providing HIV and TB patients with long-term, multi-month dispensing for medicines, or switching to a door-to-door delivery system for mosquito nets and preventive malaria medicines. These successful revisions to service disruption by COVID-19 need to be further investigated, scaled up and tailored to local contexts. As the world’s largest multilateral provider of grants for health systems, the Global Fund is uniquely positioned to help countries respond to the COVID-19 pandemic and diminish the knock-on impact on HIV, TB and malaria. It responded immediately to the pandemic, awarding just under $1 billion through its COVID-19 Response Mechanism (C19RM). It also put in place additional grant flexibilities to support country responses to COVID-19, strengthen their systems for health and adapt their HIV, TB and malaria programs: in such a way mitigating the pandemic’s impact on the three diseases in more than 100 countries. Through the Access to COVID-19 Tools (ACT) Accelerator, the ground-breaking global collaboration to fast-track the development and production of, and equitable access to, COVID-19 tests, treatments and vaccines, the Global Fund is now the primary channel for providing grant support to low- and middle-income countries on tests, treatments (including medical oxygen), PPE and health system strengthening. For the Global Fund to fulfil its responsibility to the ACT-Accelerator and regain lost progress against HIV, TB and malaria, an additional $10 billion is needed. To date in 2021, the Global Fund has raised $3.7 billion. The report concludes that this snapshot of country responses to the pandemic provides an indicative progress update that shows that COVID-19 has had a devastating impact on the continuity of HIV, TB and malaria services between April and September 2020. Data from the reporting facilities shows that there are important gaps that need to be urgently addressed. As outbreaks of the virus flare-up in different regions and new variants emerge and circulate, the pandemic will continue to impact health services and overburden systems for health if we do not step up our response. “In most low- and middle-income countries, the crisis is far from over, with infections and deaths from COVID-19 continuing to increase, and the knock-on impact on HIV, TB and malaria continuing to escalate,” said Peter Sands. “To regain the ground lost on the three epidemics in 2020 and to step up the fight against COVID-19, we have to massively scale up adaptation programs, increase access to COVID-19 tools, and shore up systems for health so they don’t collapse”.