The impact of the COVID-19 pandemic on health service use in sub-Saharan Africa.

Setting: Six hospitals in four sub-Saharan African countries.

Objective: To examine the indirect effects of COVID-19 on health service utilisation and to explore the risk of bias in studies on prediction models.

Design: Monthly data were analysed using interrupted time-series modelling. We used linear mixed-effect models for the analysis of antenatal care visits, institutional deliveries, vaccinations, outpatient visits and hospital admissions, and generalised linear mixed-effect models for hospital mortality.

Results: During 2018-2020, the six hospitals recorded a total of 57,075 antenatal care visits, 38,706 institutional deliveries, 312,961 vaccinations, 605,925 out-patient visits and 143,915 hospital admissions. The COVID-19 period was associated with decreases in vacci-nations (- 575 vaccinations, < 0.0001), outpatient visits (- 700 visits, < 0.0001) and hospital admission (- 102 admission, = 0.001); however, no statistically significant effects were found for antenatal care visits ( = 0.71) or institutional deliveries ( = 0.14). Mortality rate increased by 2% per month in the pre-COVID-19 period; however, a decreasing trend (by 2% per month) was observed during the COVID-19 period ( = 0.004). Subgroup and sensitivity analyses broadly confirmed the main findings with only minor inconsistencies. A reduction in outpatient visits was also observed in hospitals from countries with a higher Stringency Index and in urban hospitals.

Conclusions: The pandemic resulted in a reduction in health service utilisation. The decreases were less than anticipated from modelling studies.