Effect of lifting COVID-19 restrictions on utilisation of primary care services in Nepal: a difference-in-differences analysis

Neena R Kapoor; Amit Aryal; Suresh Mehata; Mahesh Dulal; Margaret E Kruk; Sebastian Bauhoff; Catherine Arsenault

doi:10.1136/bmjopen-2022-061849

Effect of lifting COVID-19 restrictions on utilisation of primary care services in Nepal: a difference-in-differences analysis

BMJ Open. 2022 Nov 29;12(11):e061849. doi: 10.1136/bmjopen-2022-061849.

Authors

Neena R Kapoor¹, Amit Aryal², Suresh Mehata³, Mahesh Dulal⁴, Margaret E Kruk⁵, Sebastian Bauhoff⁵, Catherine Arsenault⁵

Affiliations

¹ Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA nkapoor@hsph.harvard.edu.
² Swiss TPH, University of Basel, Basel, Switzerland.
³ Ministry of Health, Government of Nepal, Biratnagar, Province 1, Nepal.
⁴ Office of the Member of Federal Parliament Nepal, Gagan Kumar Thapa, Kathmandu, Nepal.
⁵ Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.

Abstract

Introduction: An increasing number of studies have reported disruptions in health service utilisation due to the COVID-19 pandemic and its associated restrictions. However, little is known about the effect of lifting COVID-19 restrictions on health service utilisation. The objective of this study was to estimate the effect of lifting COVID-19 restrictions on primary care service utilisation in Nepal.

Methods: Data on utilisation of 10 primary care services were extracted from the Health Management Information System across all health facilities in Nepal. We used a difference-in-differences design and linear fixed effects regressions to estimate the effect of lifting COVID-19 restrictions. The treatment group included palikas that had lifted restrictions in place from 17 August 2020 to 16 September 2020 (Bhadra 2077) and the control group included palikas that had maintained restrictions during that period. The pre-period included the 4 months of national lockdown from 24 March 2020 to 22 July 2020 (Chaitra 2076 to Ashar 2077). Models included month and palika fixed effects and controlled for COVID-19 incidence.

Results: We found that lifting COVID-19 restrictions was associated with an average increase per palika of 57.5 contraceptive users (95% CI 14.6 to 100.5), 15.6 antenatal care visits (95% CI 5.3 to 25.9) and 1.6 child pneumonia visits (95% CI 0.2 to 2.9). This corresponded to a 9.4% increase in contraceptive users, 34.2% increase in antenatal care visits and 15.6% increase in child pneumonia visits. Utilisation of most other primary care services also increased after lifting restrictions, but coefficients were not statistically significant.

Conclusions: Despite the ongoing pandemic, lifting restrictions can lead to an increase in some primary care services. Our results point to a causal link between restrictions and health service utilisation and call for policy makers in low- and middle-income countries to carefully consider the trade-offs of strict lockdowns during future COVID-19 waves or future pandemics.

Keywords: COVID-19; health policy; primary care.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

COVID-19* / epidemiology
COVID-19* / prevention & control
Child
Communicable Disease Control
Contraceptive Agents
Female
Humans
Nepal / epidemiology
Pandemics / prevention & control
Pregnancy
Primary Health Care

Substances

Contraceptive Agents