POVERTY & EQUITY NOTES MARCH 2021 · NUMBER 38 Barriers to Accessing Medical Care in Sub-Saharan Africa (SSA) in Early Stages of COVID-19 Pandemic Rachel Swindle, David Newhouse 1 Eighty-two percent of respondents in a sample of Sub-Saharan African (SSA) countries were able to access medical care despite the COVID-19 pandemic. Of the remaining 18 percent, about one-third reported that the COVID-19 pandemic impaired their access, either due to lockdown restrictions, facility closures, or fear of contracting the virus. “Lack of money� was by far the most frequently reported barrier to accessing care across countries, especially for food-insecure households, two-thirds of which cited “lack of money� as the main healthcare access constraint. Continued monitoring can help shed light on who is most at risk of not being able to access healthcare during crises. This note makes use of newly harmonized data to respondent reports that they are unable to access needed summarize reasons why respondents in 11 SSA care, and data are only harmonized if the recall period countries were unable to access medical care during matches the required past 7 days. early COVID-19 stages. It draws on High-Frequency Phone Surveys (HFPS) fielded by National Statistics Table 1: Variable Definitions Offices with World Bank support. As of November 2020, Variable Name Definition 11 SSA countries had COVID HFPS harmonized datasets: access_the_services HH has been able to access medical services in Central African Republic (CAF)2, Ethiopia (ETH), Ghana the past 7 days when needed (Y/N) If response is “no�, interviewer proceeds with (GHA), Kenya (KEN), Madagascar (MDG), Mali (MLI), asking the respondent for the reason they were Malawi (MWI), Nigeria (NGA), Senegal (SEN), South Sudan unable to access care. (SSD), and Zambia (ZMB). These HFPSs were fielded acce_he_1 Reason: lack of money acce_he_2 Reason: no medical personnel available between April and July 2020 and contain multiple waves acce_he_3 Reason: medical facility was full from several countries.3 acce_he_4 Reason: medical facility was closed acce_he_5 Reason: hospital/clinic did not have enough supplies or tests HPFS Methodology acce_he_6 Reason: afraid/concerned about catching COVID19 acce_he_7 Reason: restrictions (stay-at-home, travel The World Bank supported HFPSs in a number of restrictions) countries to track COVID-19-related data. Table 1 acce_he_8 Reason: lack of transportation outlines the variables collected and harmonized to acce_he_9 Reason: OTHER access_the_other Description of reason HH was unable to access measure the reasons cited for inability to access medical medical treatment. care. These questions are only asked if the survey 1 The authors thank Johan Mistiaen, Benu Bidani, and Nobuo Yoshida for support and useful comments, and Jakub Kakietak, Julia Dayton, and Nick Stacey for useful comments and discussions. 2 Central African Republic (CAF) survey includes only Bangui (capital) and Bimbo. 3 All countries listed include the first wave of surveys, which were fielded predominantly in the months of April, May, and June (2020). Ethiopia (ETH) and Mali (MLI) also include a second wave of survey data from May, June, and July (2020). Nigeria (NGA) includes three waves of data with interviews conducted in April and May (wave 1), June (wave 2), and July (wave 3). Time periods between survey waves vary by country but on average there are about 4-6 weeks between interviews. In most of SSA, the sample was drawn from the where each country mean (and wave if applicable) is respondents of a previous nationally representative calculated using weights provided by the national statistics household survey. HFPS datasets are weighted by office. Note that because some surveys allow respondents household, adjusted to correct for exclusion of households to cite more than one reason for inability to access care, that lack phones from the sample. Phone survey the sum of the reasons cited is greater than “100�. respondents are largely heads of the households and their spouses.4 Figure 1: Health Care Inaccessibility in SSA Region, Estimates are raw averages of survey-weighted country means. Survey Findings Within the countries included in this analysis, the vast majority (82%) of respondents in need of medical care were able to access appropriate facilities or personnel to obtain treatment.5 Among the respondents who were unable to access care, “lack of money� was the most commonly cited obstacle. Almost one-third of survey respondents reported COVID-related reasons for not accessing care (9% cited lockdowns, 6% cited facility closures, 14% cited fear of COVID-19). Figure 1 displays an overview of reasons for not accessing care in the region, while Figure 2 describes findings by country and survey wave. All estimates represent simple averages of survey-weighted means, Figure 2: Breakdown of Inaccessibility Reasons by Country and Survey Wave CAF Wave 1 ETH Wave 1 ETH Wave 2 GHA Wave 1 KEN Wave 1 Country Code and Survey Wave MDG Wave 1 MLI Wave 1 MLI Wave 2 MWI Wave 1 NGA Wave 1 NGA Wave 2 NGA Wave 3 SEN Wave 1 SSD Wave 1 ZMB Wave 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% Reason(s) Reported for Inaccessibility, Survey-Weighted Means Lack of money No medical personnel Facility was full Facility was closed Hospital had insufficient supplies Fear of catching Covid-19 Stay-at-home orders Lack of transportation 4 More information about the high frequency phone surveys can be 5 Survey weights used in all calculations. found in Khamis et. al., 2021. March 2021 · Number 38 2 Respondents in urban areas were much more likely Households who reported food insecurity were far to cite “fear of catching COVID-19� as a reason to not more likely to cite resource constraints as barriers to seek care (Figure 3). Overall, rural survey respondents access. The COVID HFPSs do not measure consumption tend to report slightly higher rates of ability to access or welfare status, but they do ask a series of questions to care (85%) than urban respondents (84%). While lack of measure incidence of food insecurity. Data on whether financial resources remains a dominate barrier to seeking an adult member of a household skipped a meal in the care, people in urban areas cite fears of contracting 30 days preceding the survey provides a proxy measure COVID-19, facility closures, and stay-at-home orders of welfare. Households that did not report skipped meals more often than rural inhabitants. Rural households are were more likely to be able to access care (91%) also more likely to report transportation limitations as a compared to households where adults did skip meals reason for not obtaining care. (84%). Figure 4 shows that when they were unable to access care, households without skipped meals were Figure 3: Health Care Access and Urban/Rural Dwelling more likely to cite stay-at-home orders or lack of medical Location, Raw averages of survey-weighted country means personnel as reasons to not seek care. Households with adults skipping meals, meanwhile, were more likely to Lack of transportation report they did not seek care because of insufficient Stay-at-home orders financial resources. These households were also more Fear of catching Covid-19 likely to report that they could not access care because the facility was closed. These findings highlight Hospital had insufficient supplies disparities in service accessibility between families Facility was closed experiencing one measure of food insecurity (adults Facility was full skipping meals) and households where adults did not have to skip meals. No medical personnel Lack of money Figure 4: Health Care Access and Food Insecurity, Raw 0% 10% 20% 30% 40% 50% 60% averages of survey-weighted country means Urban Rural Lack of transportation In Ghana, Senegal, Ethiopia, and Malawi, “fear of Stay-at-home orders contracting COVID-19� was also more frequently Fear of catching Covid-19 cited as a reason for not seeking medical care. These countries are slightly more urban than others in this Hospital had insufficient supplies sample, which might help to explain this finding. Facility was closed Compared to those residing in rural areas, urban- dwellers more often report concerns over catching Facility was full COVID-19 as obstacles to seeking medical care. More No medical personnel densely populated areas might be predisposed to having Lack of money higher numbers of confirmed COVID-19 cases, but further research could explore the trends between 0% 10% 20% 30% 40% 50% 60% confirmed cases in a given area and propensity to cite fear of disease as a prohibitive factor in the ability to Adults in household skipped meals satisfy medical needs. No adults in household skipped meals March 2021 · Number 38 3 One possible uses of this data include exploring the Implications Going Forward connection between perceptions and behaviors; such as perceptions about how “fear of catching COVID� As the COVID-19 pandemic progresses, these influence “accessing care�, for instance, and how these preliminary findings highlight the importance of perceptions and preferences change in response to monitoring both (a) people’s ability to access needed factors like mobility restrictions, public information medical care, and (b) the nature of constraints to campaigns, and frustration with restrictions. accessing care. Monitoring changes in self-reported reasons for service inaccessibility over the course of the Further research could also explore the long-term pandemic and the aftermath of this public health crisis can consequences of being unable to access medical shed light on who is most at risk of experiencing reduced treatment. Inability to access healthcare can negatively access to medical care during a shock. Profiling the health indicators, such as increased disability rates and characteristics of higher-risk people and communities lower life expectancies, as well as have economic impacts, enables policymakers and aid organizations to better including depleted assets and a decline in labor force target cash and in-kind relief measures for both the participation. ongoing COVID as well as future crises. ABOUT THE AUTHORS Rachel Swindle is a consultant in the World Bank’s Poverty and Equity Global Practice. E: rswindle@worldbank.org//res128@georgetown.edu David Newhouse is Senior Economist in the World Bank’s Poverty and Equity Global Practice . E: dnewhouse@worldbank.org This note series is intended to summarize good practices and key policy findings on Poverty-related topics. The views expressed in the notes are those of the authors and do not necessarily reflect those of the World Bank, its board, or its member countries. Available for download at the World Bank Publications, Documents & Reports site. March 2021 · Number 38 4