Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: a longitudinal cohort study

Objectives

Public health interventions designed to interrupt COVID-19 transmission could have deleterious impacts on primary healthcare access. We sought to identify whether implementation of the nationwide lockdown (shelter-in-place) order in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN).

Design

Prospective, longitudinal cohort study

Setting

Data were analyzed from the Africa Health Research Institute Health and Demographic Surveillance System, which includes prospective data capture of clinic visits at eleven primary healthcare clinics in northern KwaZulu-Natal

Participants

A total of 36,291 individuals made 55,545 clinic visits during the observation period.

Exposure of Interest

We conducted an interrupted time series analysis with regression discontinuity methods to estimate changes in outpatient clinic visitation from 60 days before through 35 days after the lockdown period.

Outcome Measures

Daily clinic visitation at ambulatory clinics. In stratified analyses we assessed visitation for the following sub-categories: child health, perinatal care and family planning, HIV services, noncommunicable diseases, and by age and sex strata.

Results

We found no change in total clinic visits/clinic/day from prior to and during the lockdown (–6.9 visits/clinic/day, 95%CI –17.4, 3.7) or trends in clinic visitation over time during the lockdown period (–0.2, 95%CI –3.4, 3.1). We did detect a reduction in child healthcare visits at the lockdown (–7.2 visits/clinic/day, 95%CI –9.2, –5.3), which was seen in both children <1 and children 1–5. In contrast, we found a significant increase in HIV visits immediately after the lockdown (8.4 visits/clinic/day, 95%CI 2.4, 14.4). No other differences in clinic visitation were found for perinatal care and family planning, non-communicable diseases, or among adult men and women.

Conclusions

In rural KZN, the ambulatory healthcare system was largely resilient during the national-wide lockdown order. A major exception was child healthcare visitation, which declined immediately after the lockdown but began to normalize in the weeks thereafter. Future work should explore efforts to decentralize chronic care for high-risk populations and whether catch-up vaccination programs might be required in the wake of these findings.

What is already known on this topic?

• Prior disease epidemics have created severe interruptions in access to primary care in sub-Saharan Africa, resulting in increased child and maternal mortality

• Data from resource-rich settings and modelling studies have suggested the COVID-19 epidemic and non-pharmacologic measures implemented in response could similarly result in substantial barriers to primary health care access in the region

• We leveraged a clinical information system in rural KwaZulu-Natal to empirically assess the effect of the COVID-19 epidemic and a nationwide lockdown in South Africa on access to primary care

What this study adds?

• Access to primary healthcare was largely maintained during the most stringent period of the COVID-19 lockdown in South Africa, with the exception of a temporary drop in child health visits

• Creative solutions are needed for sustaining child vaccination programs, and protecting high-risk individuals from risk of nosocomial transmission in resource-limited settings