Providers' experience on essential health services in primary healthcare units of Ethiopia during COVID-19: a qualitative study on impact and response.

Aim: The objective of this study was to explore how selected sub-national (provincial) primary healthcare units in Ethiopia responded to coronavirus disease 2019 (COVID-19) and what impact these measures had on essential health services.

Background: National-level responses against the spread of COVID-19 and its consequences are well studied. However, data on capacities and challenges of sub-national health systems in mitigating the impact of COVID-19 on essential health services are limited. In countries with decentralized health systems like Ethiopia, a study of COVID-19 impacts on essential health services could inform government bodies, partners, and providers to strengthen the response against the pandemic and document lessons learned.

Methods: We conducted a qualitative study, using a descriptive phenomenology research design. A total of 59 health leaders across Ethiopia's 10 regions and 2 administrative cities were purposively selected to participate in key informant interviews. Data were collected using a semi-structured interview guide translated into a local language. Interviews were conducted in person or by phone. Coding of transcripts led to the development of categories and themes, which were finalized upon agreement between two investigators. Data were analysed using thematic analysis.

Findings: Essential health services declined in the first months of the pandemic, affecting maternal and child health including deliveries, immunization, family planning services, and chronic disease services. Services declined due to patients' and providers' fear of contracting COVID-19, increased cost of transport, and reallocation of financial and human resources to the various activities of the response. Authorities of local governments and the health system responded to the pandemic immediately, capitalizing on multisectoral support and redirecting resources; however, the intensity of the response declined as time progressed. Future investments in health system hardware - health workers, supplies, equipment, and infrastructure as well as carefully designed interventions and coordination are needed to shore up the COVID-19 response.