PLOS GLOBAL PUBLIC HEALTH
RESEARCH ARTICLE
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Citation: Mebratie AD, Nega A, Gage A, Mariam
DH, Eshetu MK, Arsenault C (2022) Effect of the
COVID-19 pandemic on health service utilization
across regions of Ethiopia: An interrupted time
series analysis of health information system data
from 2019–2020. PLOS Glob Public Health 2(9):
e0000843. https://doi.org/10.1371/journal.
pgph.0000843
Editor: Prashanth Nuggehalli Srinivas, Institute of
Public Health Bengaluru, INDIA
Received: March 3, 2022
Accepted: August 16, 2022
Published: September 12, 2022
Copyright: © 2022 Mebratie et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The data used for this
study were obtained from the Ethiopian District
Health Information System 2. These data are
exclusively owned by the Ministry of Health of
Ethiopia. Regional-level data used in this analysis
can be made available at the discretion of the
Ministry for academic research purposes. Other
would be able to access these data in the same
manner as the authors of this article and authors
did not have any special access privileges that
PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000843 September 12, 2022
Effect of the COVID-19 pandemic on health
service utilization across regions of Ethiopia:
An interrupted time series analysis of health
information system data from 2019–2020
Anagaw Derseh Mebratie ID1*, Adiam Nega1, Anna Gage ID2, Damen Haile Mariam1, Munir
Kassa Eshetu3, Catherine Arsenault ID2
1 School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia, 2 Department of Global Health
and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America,
3 Minister’s Office, Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
* anagaw.derseh@aau.edu.et
Abstract
The spread of COVID-19 and associated deaths have remained low in Ethiopia. However, the
pandemic could pose a public health crisis indirectly through disruptions in essential health
services. The aim of this study was to examine disruptions in health service utilization during
the first nine months of the COVID-19 pandemic across 10 regions in Ethiopia. We analyzed
utilization of 21 different health services across all of Ethiopia (except the Tigray region) for
the period of January 2019 to December 2020. Data were extracted from the Ethiopian district
health information system (DHIS2). Monthly visits in 2020 were graphed relative to the same
months in 2019. Interrupted time series analysis was used to estimate the effect of the pan-
demic on service utilization in each region. We found that disruptions in health services were
generally higher in urban regions which were most affected by COVID. Outpatient visits
declined by 52%, 54%, and 58%, specifically in Dire Dawa, Addis Ababa and Harari, the three
urban regions. Similarly, there was a 47% reduction in inpatient admissions in Addis Ababa.
In agrarian regions, the pandemic caused an 11% to 17% reduction in outpatient visits and a
10% to 27% decline in inpatient admissions. Visits for children with diarrhea, pneumonia and
malnutrition also declined substantially while maternal health services were less affected. Our
study indicates that disruptions in health services were more pronounced in areas that were
relatively harder hit by the pandemic. Our results show that the Ethiopian health system has a
limited capacity to absorb shocks. During future waves of COVID or future pandemics, the
Ethiopian health system must be better prepared to maintain essential services and mitigate
the indirect impact of the pandemic on public health, particularly in urban areas.
Introduction
In a time of crisis, health systems need to both respond to the outbreak and maintain the provi-
sion of other essential health services. The spread of COVID-19 across African countries in
2020 and its direct health impacts were not as severe as many had feared. In Ethiopia, only
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PLOS GLOBAL PUBLIC HEALTH
others would not have. Requests for data may be
addressed to the Policy Planning, Monitoring and
Evaluation Directorate of the Ministry of Health of
Ethiopia. Email: solomon.kassahun@moh.gov.et,
Telephone number: +251115517011, P O Box:
1234, Addis Ababa, Ethiopia.
Funding: ADM, AN, DHM and CA received funding
from the Grand Challenges International COVID-19
Data Alliance (ICODA) pilot initiative, delivered by
Health Data Research UK and funded by the Bill &
Melinda Gates Foundation and the Minderoo
Foundation (grant number INV-017293). CA, DHM
and MKE also acknowledge funding from QuEST
network funded by the Bill and Melinda Gates
Foundation (grant INV-005254). The funders did
not have any role in study design, data collection,
data analysis, or preparation of the manuscript for
publication.
Competing interests: The authors have declared
that no competing interests exist.
PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000843 September 12, 2022
Health service utilization in Ethiopia during the COVID-19
1,054 COVID cases per million were reported and only 16 people per million died from the
condition in 2020 [1]. However, there is a growing concern that by disrupting essential health
services, the pandemic could have important consequences on population health [2, 3]. A
reduction in utilization of essential health services could have long-term effects by increasing
chronic illnesses, disability or preventable mortality [4]. In addition, certain population groups
risk being systematically more affected resulting in widening health inequalities.
The Ethiopian health system, which has historically been under-funded and under-
resourced, may be particularly vulnerable during the COVID-19 pandemic. The pandemic
could result in worse health outcomes due to reduced service provision, declines in quality of
care, or poorer healthcare seeking behavior. Other health systems have reported lower volumes
of non-COVID-19 patients and critical declines in preventive services such as immunizations
[5]. Before the pandemic, access to quality care was already a challenge in Sub-Saharan Africa.
Health providers performed less than half of the most basic elements of recommended care
and facilities often lacked necessary equipment and supplies [6].
Ethiopia was able to prevent widespread transmission of COVID-19. After the first case was
reported in mid-March 2020, the government declared a five-month national state of emer-
gency starting April 8th, 2020. Restrictions on large gatherings and movement were imposed,
most civil servants were asked to work from home, and the closure of schools was ordered.
The government also suspended flights to 120 countries and granted a pardon to 20,402 pris-
oners to reduce overcrowding in prisons [7]. The country also put in place a 14-day mandatory
quarantine and COVID test for inbound travelers. Mass media communication campaigns
were developed to promote hand washing, mask wearing, and social distancing. When
COVID continued to spread in Addis Ababa and other urban areas, the government imposed
mandatory facemasks in public places and reduced the number of passengers allowed in public
transports. Night clubs, concerts, cinema houses, churches and mosques were also closed, and
sport events were cancelled in the capital. In addition, the Ethiopian Federal Ministry of Health
and its technical arm, the Ethiopian Public Health Institution, established a surveillance mech-
anism as per WHO recommendations to regularly check the status of COVID-19 in the popu-
lation and disseminate health-related information [8].
Some of the COVID-19 prevention measures taken in Ethiopia could have had adverse
impacts on the utilization of essential health services. Prior to the pandemic, health care utiliza-
tion and health outcomes were relatively poor in Ethiopia compared to other countries. For
example, only 48% of women gave birth in health facilities, and the newborn mortality rate
was 30 per 1,000 live births [9]. Health intervention coverage and health outcomes also varied
widely across regions in the country, with stark disparities between the capital and other areas.
The conversion of selected health facilities into COVID-19 treatment centers and the rede-
ployment of health workers to COVID-19 treatment centers could have also reduced access to
and provision of essential health services [10]. Moreover, due to limited understanding about
the disease and limited preparedness of health facilities, the community could fear being
exposed to the virus while visiting health facilities and avoid or delay seeking care. Moreover,
the pandemic could severely affect some segments of the population and increase health
inequalities.
Although increasing attention is being paid to assess how health systems should respond to
the pandemic, less is known about the effect of the pandemic on non-COVID health services.
Previous analyses have quantified the effect of COVID on health service utilization in Ethiopia
at the national level, but there is limited evidence on whether these effects have differed across
sub-national areas or across different types of services [11]. Our study assesses the trends in a
range of essential health services during the first nine months of the COVID-19 pandemic
across regions in Ethiopia and identifies the worst and least affected regions.
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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Materials and methods

Study setting
Ethiopia is the second most populous country in Africa with more than 114 million estimated
population size in 2020 [12, 13]. Over the last two decades, in order to improve health out-
comes, the country has given due attention to improve the health system and made consider-
able investments to expand access to health services. According to a report by the Ministry of
Health (2019), Ethiopia has 16,660 health posts, 3,622 health centers, and 266 public hospitals.
Moreover, there are 7,576 clinics and 62 hospitals owned by the private sector [14]. Conse-
quently, primary health service coverage, as measured by access to a health facility within a
two-hour walk, has incresed from 51% in 2001 to 98% in 2016 [15].
Despite the recent progress made in expanding access to essential health services, there are
notable variations in spatial distribution of healthcare infrastructure across regions in Ethiopia.
People in rural and pastoralist areas generally have limited access to services compared to
urban residents. According to the 2019 Health and Health Indicators report by the Federal
Ministry of Health, the average number of people served per one hospital in Addis Ababa is
164,998 and 48,583 in Harari. On the other hand, one hospital in Afar, Oromia and Somali
serve on average 331,468, 302,757 and 581,126 people, respectively [16, 17]. Furthermore, pri-
vate clinics are largely concentrated in urban areas. Similarly, the number of nurses per
100,000 population is 162, 155 and 123 in Gambella, Harari and Addis Ababa compared to
only 4.8, 5.1 and 5.5 in Oromia, Somali and Amhara. The number of medical doctors per
100,000 population ranges from 2.6 in Oromia to 24.1 in Harari. The corresponding figure for
Addis Ababa is 13.9 [16, 18].
Service utilization also varies across regions. In 2019, outpatient attendance per capita per
year in urban areas ranged from 1.15 to 1.74. In contrast, outpatient attendance was lowest in
pastoralist regions namely Afar (0.36) and Somali (0.21) [16, 19].

Study design and timelines

We conducted an interrupted time series study using health management information system data
to address the research objective. Two years of essential service data for the period of Tirr 1,2011to
Tahsas 30, 2013 (Equivalent to January 9, 2019 to January 8, 2021) was used for the analysis.

Data source
The data were extracted from the Ethiopian District Health Information System 2 (DHIS2)
and provided by the Ethiopian Ministry of Health. The study covers 8 regions (Afar, Amhara,
Oromia, Somali, SNNP, Gambella, Harari and Benishangul Gumz) and 2 city administrations
(Addis Ababa and Dire Dawa) in Ethiopia. The study excludes Tigray region because services
utilization data were missing for the last three months of the study period (between October
and December, 2020) due to the ongoing conflict in the region.
The dataset combined facility-level and woreda (district)-level data: facility-level informa-
tion was available for tertiary and secondary hospitals and private facilities and for all facilities
in the capital, Addis Ababa. Data from other public facilities (primary hospitals, health centers
and health posts) were aggregated and reported by woreda health offices in all regions except
in the capital, Addis Ababa.

Outcome measures
We assessed utilization for various types of health services including maternal health services,
child vaccinations, inpatient and outpatient care and family planning service (See Table D in

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

S1 Appendix). We analyzed the absolute number of monthly visits or services provided rather
than service coverage indicators (i.e., proportion of target population who received a specific
service) as the later can be unreliable because they depend on estimated target population sizes
as denominators.

Data cleaning
Using DHIS2 data during the pandemic could face challenges with data completeness and
reporting delays. To ensure that our dataset included a stable number of facilities reporting
each month, we included (for each indicator) only health facilities (or woreda health offices)
that reported non-missing values for at least 15 months out of 24. This threshold was chosen
because it best balanced the need for stable reporting without excluding too much data.
Second, positive outliers were identified and replaced to missing. Outliers are utilization
counts greater than 3.5 standard deviation from the facility mean over 24 months. Negative
outliers (values lower than 3.5 standard deviations from the mean), were not removed as utili-
zation may have reasonably decreased during the pandemic to low levels. Finally, datasets
were compared before and after the two steps mentioned above to make sure that the data
cleaning did not bias the dataset. Then the sum of each indicator in the raw vs. cleaned dataset
was compared to ensure that cleaning procedures did not exclude too much data. Further
details on data cleaning and data validation procedures were published previously [11].

Data analysis
For the analysis, service volumes were aggregated at the regional level on a monthly basis. We
first presented results descriptively using trend graphs showing the volume of each service dur-
ing COVID compared to the same month pre-COVID, by region. Second, interrupted time
series analysis (ITSA) was used to estimate the level and slope change during the first nine
months of the pandemic. April 2020 was used as the interruption period. In addition, to the
regional-level estimates, we also repeated the analysis by aggregating services by region type.
We categorized the regions and city administrations into three groups. These included urban
regions (Addis Ababa, Dire Dawa, and Harari), agrarian regions (Amhara, Oromia and
SNNP) and pastoralist regions (Benishangul-Gumuz, Gambella, Afar and Somali). These
region types are widely used in Ethiopia for policy making and research. To compare coeffi-
cients from linear models across regions and health services, we created a relative level change
estimate by dividing the estimate for the level change by the average service volume in the pre-
COVID period (from January 2019 to March 2020).
The interrupted time series analysis predicts two types of coefficients indicating the effect
of the pandemic on utilization of care for each type of health service. The first one is a level
change in volume of visits showing the monthly average service visits immediately after the
declaration of the pandemic in April 2020 minus the monthly average visits during pre-
COVID-19. The second estimate is a slope change in healthcare use that indicates the magni-
tude of change in the volume of monthly average service utilization during COVID-19 period
until the end of 2020. In the ITSA, estimates were considered to be statistically significant if
the p-value � 0.05. All analyses were conducted using Stata version 16.0 (StataCorp, College
Station, Texas 77845 USA).
We also conducted two sensitivity analysis to confirm consistency of the estimates. First, we
used a prais regression model where the errors are assumed to follow a first-order autoregres-
sive process to check whether results were consistent. We also repeated the analysis by includ-
ing dummies for quarters of the year in order to account for seasonality (potential changes in
demand for services at different times of the year).

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Ethics
This study was conducted using secondary data accessed from the Ethiopian DHIS-2. The Fed-
eral Ministry of Health approved the research project. In addition, ethical approval and clear-
ance was obtained from the Institutional Review Board of the College of Health Science of
Addis Ababa University (IRB-CHS). We received de-identified and anonymized data from
DHIS2. Data were not copied from or removed from the data repository prepared by the Har-
vard T.H. Chan School of Public Health without prior permission from the local country PI
and they were not shared with anyone except the members of the research team at Harvard
University and Addis Ababa University.

Results
We analyzed a total of 21 types of health services included in the Ethiopian DHIS2. Table A in
S1 Appendix shows the number of units (facilities, Woredas or primary health center units)
included in the study across regions. The majority of facilities are found in Oromia, the largest
region in Ethiopia, followed by the Southern Nations, Nationalities and People’s (SNNP)
region.
Relative service utilization (service volume in 2020 compared to the same month in 2019)
across the three region types are shown in Figs 1–3. Estimates for the immediate level and the
slope change during the pandemic with confidence intervals and p-values are reported in
Tables 1–3. In these tables, the level change estimates indicate the effect of the pandemic
immediately following the declaration of the pandemic while the slope change refers to the
monthly change in visits during the pandemic period until the end of 2020. For improved
interpretability, the relative level change as compared to the average in the pre-COVID-19
period is also reported.

Overall utilization of health services

Fig 1 shows the trends in outpatient visits, inpatient admissions and emergency room visits in
2020 compared to 2019. Between April and June 2020, outpatient visits were substantially
lower in urban regions (Addis Ababa, Dire Dawa and Harari). In June 2020, the volume of out-
patient visits in these urban regions was only 60% on average of that in June 2019. In pastoral

Fig 1. Overall service utlization in 2020 compared to 2019 by region type.

https://doi.org/10.1371/journal.pgph.0000843.g001

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Fig 2. Reproductive and maternal health services in 2020 compared to 2019 by region type.
https://doi.org/10.1371/journal.pgph.0000843.g002

regions (Afar, Gambella, Benishangul-Gumuz and Somali), outpatient care continued to fall
until November 2020. In agrarian regions (that is Amhara, Oromia and SNNP), outpatient vis-
its did not appear to be affected. Similarly, there were declining trends in emergency room vis-
its and inpatient admissions during the first few months of the pandemic. Overall, reductions
in these three services were relatively higher in urban areas.

Fig 3. Child health services and vaccinations in 2020 compared to 2019 by region type.
https://doi.org/10.1371/journal.pgph.0000843.g003

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Table 1. Effect of the COVID-19 pandemic on overall service utilization in each region (ITSA—Regression with Newey-West standard errors).
Region Outpatient visits Emergency room visits Inpatient admissions
Level change (95% Relative level Slope change Level change Relative level Slope change Level change Relative level Slope change
CI) change (95% CI) (95% CI) change (95% CI) (95% CI) change (95% CI)
Addis -317,757�� -54% 22,732�� -14,156�� -47% 662�� (131, -4,532�� (-6,436, -34% 497�� (224,
Ababa (-417,938, (11,793, (-18,272, 1,194) -2,627) 769)
-217,576) 33,671) -10,040)
Afar -15,157�� -25% 783 ( -380, -538 (-1,129, 53) -34% 83 (-19, 185) -287�� (-459, -27% 11(-6, 27)
(-24,084, -6,229) 1,946) -115)
Amhara -654,667�� -27% 50,757�� -26,887�� -43% 1,979�� (818, -7,702�� -35% 797�� (454,
(-918,256, (8,721, 92,793) (-32,107, 3,141) (-1,0421, -4,985) 1,140)
-391,077) -21,667)
Ben-Gum -10,886 (-32,563, -14% -1,324 (-3,999, -1,278�� (-1,859, -62% 21 (-71- 111) -448�� (-729, -33% 16 (-25, 57)
10,791) 1,351) -699) -167)
Dire Dawa -32,461�� (-4062, -52% 1,397�� (541, -4,655�� (-6,987, -98% 33 (-221, 288) -529�� (-956, -34% 83�� (24, 142)
-24294) 2,254) -2,324) -102)
Gambella -1,889 (-4,750, -13% -236 (-688, -2,020�� (-3,104, -64% -226�� (-409, -256 (-608, 96) -29% -3 (-58, 53)
972) 215) -937) -43)
Harari -15,104�� (-20,152, -58% 1,639�� (767, -951�� (-1,550, -41% 66 (-15, 146) -397�� (-737, -23% 65�� (16, 114)
-10,057) 2,511) -353) -58)
Oromia -525,620�� -24% 75,279�� -28,411�� -43% 3,567�� -13,753�� -39% 1,053�� (562,
(-733,243, (48,332, (-37,838, (2,218, 4,915) (-18,241, -9,266) 1,544)
-317,998) 102,227) -18,985)
SNNP -163,068�� -10% 33,659�� -17,880�� -33% 1,324�� (554, -6,467�� (-8,124, -37% 574�� (382,
(-250,758, -75,378) (19,638, (-23,070, 2,095) -4809) 765)
47,681) -12,691)
Somali -9,617 (-20,258, -8% -194 (-1,867, -1,120�� (-2,033, -57% 147�� (18, -1,135�� (-1,666, -23% -50 (-107, 7)
1,025) 1,478) -208) 276) -603)

Level change shows the immediate effect of the pandemic in April 2020 and slope change is the monthly change during COVID-19 until the end of 2020. Relative level
change is the immediate level change in April 2020 compared to the average during the pre-COVID period (January 2019 to March 2020). Asterisks �� indicate
statistical significance (p �0.05). SNNP is Southern Nations, Nationalities and People’s region. Ben-Gum is Benishangul-Gumuz region.

https://doi.org/10.1371/journal.pgph.0000843.t001

Results from interrupted time series regressions show that COVID-19 disrupted outpatient
visits use immediately following the declaration of the state of emergency in Ethiopia. Reduc-
tions in outpatient visits were significant at 5% level of significance in all regions except in pas-
toralist areas. Immediate effects ranged from a 10% reduction in SNNP to a 58% decline in
Harari region (Table 1). In the capital, Addis Ababa, outpatient visits declined by 54% in April
2020. The immediate effect of the pandemic was stronger in urban regions compared to agrar-
ian regions. ITSA indicates that changes in service trends during COVID were significant and
positive in most regions indicating a trend toward resumption in service use.
The volume of emergency unit attendances and inpatient admissions were also disrupted in
April 2020 (Table 1). Declines were statistically significant in all regions expect in Afar and
Gambella. In Dire Dawa, emergency unit attendances declined by 98% compared to the pre-
COVID average. Slope changes during the pandemic were significant and positive in most
regions except in Gambella where emergency unit attendances continued to decline.

Reproductive and maternal services

The study also assessed reproductive and maternal health services during COVID-19 in Ethio-
pia. However, compared to the total outpatient visits and inpatient admissions, the disruptions
in these services were smaller and rebounded to pre-COVID levels within a short period of
time. For instance, Fig 2 and Table 2 show that institutional deliveries were not affected

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Table 2. Effect of the COVID-19 pandemic on reproductive and maternal health services by region (ITSA—Regression with Newey-West standard errors).
Region Contraceptive users Antenatal care Deliveries Caesarean sections
Level Relative Slope Level Relative Slope Level Relative Slope Level Relative Slope
change level change change (95% level change change level change change level change
(95% CI) change (95% CI) CI) change (95% CI) (95% CI) change (95% CI) (95% CI) change (95% CI)
Addis -5,179 -20% 1,114�� -1,853�� -14% 319 (-38, 9 (-82, 0% -79 (-412, -392 -12% -2 (-149,
Ababa (-8,353, (588, (-3,276, 676) 100) 254) (-929,145) 145)
-2,006) 1,640) -427)
Afar -737 -8% 196�� (99, -439�� -10% 57 (-17, -107 (-262, -8% 29�� (6, 8 (-8, 23) 16% -2�� (-5,
(-1548, 73) 293) (-810, -68) 132) 47) 52) 0)
Amhara -8,665 -3% 3,987 -9,047�� -16% 1,624 -1,732 -5% -95 (-375, -174 (-407, -8% -4 (-44,
(-42,704, (-4293, (-17,856, (-153, (-4,126, 185) 59) 36)
25,374) 12,266) -238) 3,401) 662)
Ben-Gum -846 -9% -64(-299, -324 (-727, -10% -15 (-98, -48 (-208, -3% 8 (-13, 30) 18 (-5, 42) 17% -3 (-7, 1)
(-1,967, 172) 78) 67) 112)
274)
Dire -375 (-803, -10% 116�� (68, -126 (-354, -9% 50�� (18, 32 (-125, 4% 36�� (12, 11 (-25, 47) 7% 7 (-3, 16)
Dawa 52) 163) 102) 81) 188) 60)
Gambella -350 (-798, -24% 119�� (75, -207�� -25% 42�� (20, -5 (-66, -1% 5 (-5, 16) -7 (-17, 4) -25% -1 (-3, 1)
98) 162) (-338, -76) 64) 56)
Harari -628�� -24% 147�� (68, -240�� -27% 55 �� (24, 82 (-95, 10% 2 (-24, 28) 31(-7, 69) 17% -2 (7, 2)
(-1,059, 226) (-453, -27) 85) 259)
-197)
Oromia -26,327 -6% 8,186�� -17,669�� -14% 3,164�� -4,370�� -7% 1,569�� 19 (-186, 1% 49�� (22,
(-58,287, (1,295, (-30,111, (536, (-7,768, (1,118, 224) 76)
5,633) 15,078) -5,227) 5791) -972) 2,021)
SNNP 3,162 1% 298 -4,140 -7% 989�� -1,493 -4% 351�� 24 (-149, 1% -9 (-43,
(-28,183, (-5,439, (-8,405, (119, (-3,529, (136, 566) 197) 25)
34,507) -5439) 124) 1859) 543)
Somali -1,718 -13% -2,187�� -1,141 -7% -257 -172 (-476, -3% 24 (-38, -14 (-49, -10% 4 (-2, 9)
(-7,841, (-3,234, (-2,370, 87) (-475, 133) 87) 20)
4,404) -1,139) -38)

Level change shows the immediate effect of the pandemic in April 2020 and slope change is the monthly change during COVID-19 until the end of 2020. Relative level
change is the immediate level change in April 2020 compared to the average during the pre-COVID period (January 2019 to March 2020). Asterisks �� indicate
statistical significance (p �0.05). SNNP is Southern Nations, Nationalities and People’s region. Ben-Gum is Benishangul-Gumuz region

https://doi.org/10.1371/journal.pgph.0000843.t002

during the first nine months of the pandemic (except in Oromia where there was a brief 7%
decline). In contrast, there was an overall positive trend in facility deliveries in agrarian and
pastoralist areas.
A few regions faced reductions in other reproductive and maternal services. For instance,
the number of contraceptive users significantly declined in Harari at the beginning of the pan-
demic. Similarly, visits for STIs declined in five out of the ten regions but returned to the pre-
COVID levels a few months later (Table B in S1 Appendix). Caesarean sections were only
moderately affected in Afar where they declined by 2.3 caesareans per month (Table 2).

Child healthcare services

The study also looked at visits for child diarrhea, malnutrition, and pneumonia. Fig 3 and
regression analyses (Table 3) show that these services were affected in several regions. In par-
ticular, the number of children under 5 years who were treated for pneumonia declined sub-
stantially in all regions. For instance, in Addis Ababa, the relative level reduction in
pneumonia visits compared to the pre-COVID average was 110% (Table 3). The slope change
for pneumonia and diarrhea was generally positive except in Benishangul-Gumuz and the
Ethiopian Somali regions where these services continued to decline.

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 Table 3. Effect of the COVID-19 pandemic on child health services and vaccinations by region (ITSA—Regression with Newey-West standard errors).

Region Diarrhea Malnutrition Pneumonia Pentavalent Measles Fully vaccinated by 1

Level Relative Slope Level Relative Slope Level Relative Slope Level Relative Slope Level Relative Slope Level Relative Slope
change level change change level change change level change change level change change level change change level change
(95% CI) change (95% (95% CI) change (95% CI) (95% CI) change (95% (95% CI) change (95% (95% CI) change (95% CI) (95% CI) change (95% CI)
CI) CI) CI)
Addis -715� � -38% 132� � -32,736� � -62% 2,466� � -3,881� � -110% 45 -1,084 -10% 66 -614 -6% 124 -594 -6% 77
Ababa (-1,290, (38, (-39,228, (1,464, (-5,464, (-123, (-2,644, (-177, (-3,791, (-230, (-2,620, (-235,
-139) 226) -26,244) 3,468) -2,297) 213) 475) 308) 2,564) 478) 1,431) 388)
Afar 57 (-78, 7% 11 (-25, -2,418 -22% 364 -814� � -42% 5 (-64, -389� � -12% -2 (-50, -239 -8% -59� � 68 (-163, 3% 1 (-35,
PLOS GLOBAL PUBLIC HEALTH

192) 46) (-10,150, (-10,000, (-1,350, 75) (-673, 46) (-580, (-110, 300) 36)
5,314) 1,728) -277) -104) 102) -8)
Amhara -1,034� � -17% 170� � -119,584 -12% 35,340� � -21,051� � -64% 792 -1,117 -2% 120 -59 0% 10 239 0% 112
(-1,984, (51, (-262,268, (11,176, (-28,732, (-129, (-7,045, (-835, (-9,033, (-1,406, (-7,967, (-1,178,
-84) 290) 23,100) 59,505) -13,370) 1,713) 4,811) 1,075) 8,915) 1,427) 8,446) 1,402)
Ben Gum -156 -22% -36� � 9759 17% -2,802 -1,543 � � -58% -91 122 5% -65 112 5% -40 73 (-377, 3% -48
(-371, (-71, -1) (-34,948, (-10,373, (-2,461, (-193, (-304, (-148, (-436, (-125, 523) (-116,
60) 54,466) 4,770) -626) 12) 548) 19) 660) 45) 21)
Dire -124� � -52% 14� � (3, -1,766� � -43% 552� � -145� � -52% 12 (-8, -305� � -30% 38� � -166� � -18% 5 (-18, -147� � -17% -1 (-21,
Dawa (-214, 24) (-3,082, (193, 910) (-220, -70) 32) (-413, (22, 53) (-306, 27) (-241, 20)
-34) -450) -198) -26) -54)
Gambella -55� � -38% 9� � (1, -4,033 -49% -393 -482� � -77% 27 (-32, -97 (-219, -10% 37� � 70 (-105, 9% 36� � (2, 64 (-76, 10% 5 (-22,
(-107, -2) 16) (-16,901, (-1,746, (-780, 87) 23) (13, 62) 246) 69) 204) 31)
8,835) 959) -184)
Harari -6 (-68, -4% 7 (-9, -6,836� � -81% 1,633� � -212� � -82% 40� � -121 -18% 31� � -106 -16% 43� � -139 -24% 40� �
55) 22) (-10,507, (844, (-362, -61) (13, 66) (-252, 10) (12, 49) (-289, 78) (14, 72) (-300, 21) (15, 64)
-3,165) 2,422)
Oromia -2,971� � -13% 401 -265,179 -10% 64,892� � -35,571� � -44% 1,634 -6,647 -6% 1,782� � -4,265 -4% 1,483 -3,253 -4% 1,577

PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000843 September 12, 2022

(-5,879, (-157, (-552,967, (24,851, (-51,885, (-65, (-15,805, (439, (-18,045, (-565, (-14,191, (-229,
-63) 959) 22,609) 104,933) -19,256) 3,333) 2,511) 3,125) 9,516) 3,530) 7,687) 3,384)
SNNP -1,620� � -24% 67 (-51, -57,424� � -5% 26,439� � -15,440� � -44% 806� � 149 0% 170 1,396 3% 163 803 2% 210
(-2,324, 186) (-107,298, (16,684, (-22,725, (31, (-4,751, (-611, (-4,420, (-770, (-4,310, (-615,
-916) -7,550) 36,193) -8,155) 1,580) 5,050) 950) 7,211) 1,096) 5,916) 1,037)
Somali -769 -15% -281� � -3,540 -11% 953 (-186, -1,501� � -19% -282� � -787 -5% -420� � -557 -4% -450� � -935� � -9% -216� �
(-2,294, (-526, (-9,344, 2,092) (-2,443, (-436, (-1,834, (-569, (-1,526, (-601, (-1,625, (-325,
758) -37) 2,263) -559) -128) 260) -272) 412) -300) -246) -108)

Level change shows the immediate effect of the pandemic in April 2020 and slope change is the monthly change during COVID-19 until the end of 2020. Relative level change is the immediate level
change in April 2020 compared to the average during the pre-COVID period (January 2019 to March 2020). Asterisks �� indicate statistical significance (p �0.05). SNNP is Southern Nations,
Nationalities and People’s region. Ben-Gum is Benishangul-Gumuz region

https://doi.org/10.1371/journal.pgph.0000843.t003

9 / 16
Health service utilization in Ethiopia during the COVID-19
PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Child vaccinations
The study also investigated the effect of the pandemic on various child vaccines and on the
number of children fully vaccinated by one year of age. Unlike curative services for sick chil-
dren, child vaccinations were less affected by the pandemic (Fig 3, Table 3, and Tables A-C in
S1 Appendix). Afar, Dire Dawa and Harari had declines in several vaccines. There was also a
negative trend in all vaccines in Somali. The number of children fully vaccinated by age 1
declined substantially in Dire Dawa and Somali (Table 3).

Other services
The study also examined the provision of antiretrovirals (ART) and the number of road traffic
injuries treated in health facilities. The pandemic did not lead to a significant reduction in the
number of adults and children receiving ART except in Gambella where ART declined by 16%
in April 2020 (Table C in S1 Appendix). On the other hand, there were immediate and signifi-
cant reductions in the number of people treated for road traffic accidents in half of Ethiopian
regions. Relative level reductions ranged from 18% in Oromia to 92% in Harari (Table C in S1
Appendix).
Results from analyses using prais-winsten regressions and those that accounted for season-
ality were consistent with results from the main analysis.

Discussion
In this study, we used DHIS2 data from all of Ethiopia (with the exception of the Tigray
region) to assess the effect of the pandemic on health care utilization across sub-national
regions. Prior analyses found only small reductions in health service use at the national level in
Ethiopia. In this paper, we found substantial heterogeneity in the impact of the pandemic on
health services across regions. The three urban regions in Ethiopia (Addis Ababa, Dire Dawa
and Harari) were the most affected. For example, the immediate decline in outpatient visits
ranged from 52% to 58% in urban areas while declines ranged from 10% to 27% in agrarian
regions. Across the study regions, it seems that the pandemic immediately disrupted utilization
of services in urban and agrarian regions. On the other hand, the effect of the pandemic per-
sisted overtime during the COVID period in some pastoralist regions (Afar, Benishangul-
Gumuz, Gambella and Somali) which had statistically significant negative trends in several ser-
vices. Our analysis reflects the importance of studying subnational differences in the impact of
the pandemic on health services.
Variations in the spread of COVID and in the preventive measures taken across regions
could explain the regional heterogeneities in service disruptions. For instance, by August 16,
2020, about 62% of national COVID cases were reported in Addis Ababa city. On the other
hand, the share of confirmed cases in pastoralist regions including Afar, Gambella and
Benishangul Gumz was less than 5% (Table A in S1 Appendix) [20]. Accordingly, COVID-19
preventive measures such as social distancing and restriction on movements were mainly
enforced in urban areas. In addition, there was a limited awareness of the coronavirus and lim-
ited adoption of preventive measures in rural and remote areas of Ethiopia [21, 22]. Therefore,
those who lived far away from urban areas seem to have continued their normal activities and
to have visited health facilities without being concerned about the risk of contracting COVID.
In addition, unlike in urban areas, the presence of community-based health services in rural
Ethiopia could also contribute to maintaining service use during the pandemic. For instance,
in different agrarian regions, health extension workers and volunteers conduct home visits to
promote routine health services, check on pregnant women and provide immunization ser-
vices [20, 23].

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Important declines in service use in urban areas could also be partly attributed to economic
factors. The pandemic led to worst disruptions in income-generating activities in urban areas.
Agricultural activities were less affected during COVID-19. The pandemic mostly affected the
service, manufacturing and construction sectors. Many people in urban areas lost their jobs,
and their incomes were considerably reduced. It is estimated that the pandemic led to a 14%
job loss in the service sector alone and to a 3.5 percentage-point increase in the poverty head-
count ratio at the national level. Consequently, consumption expenditures including health
spending among households (especially those in informal urban sectors) were severely dis-
rupted [24–26]. The increase in the cost of public transports (due to the mandated reduction
in passenger volumes) also played a role in reducing health care use in urban areas by increas-
ing direct non-medical costs [27, 28]. Furthermore, although government health expenditure
as a share of total expenditures reached 10% for the first time in 2020, most of these resources
were directed to the COVID-19 response. A reduction in the availability of health services that
were offered free of charge in public facilities has been reported [29].
We also found that different services were differently affected. Outpatient visits, emergency
attendance and inpatient admissions were disrupted in almost all regions of the country. Visits
for STIs also declined substantially in half the regions. Curative services for sick children (ORS
for diarrhea, child pneumonia visits and malnutrition visits) also declined substantially. In the
case of diarrhea and pneumonia, declines may partially be explained by reduced disease inci-
dence from social distancing, mask wearing and better handwashing.
The magnitude of disruptions in maternal health services and child vaccination were rela-
tively lower and there were fewer regions reporting significant declines in these services. For
instance, only two out of the ten study regions had significant declines in postnatal care visits.
Facility delivery and caesarian sections were not disrupted (except in Oromia were facility
deliveries declined by 7%). It is well known that facility delivery and caesarian sections are key
services to reduce maternal complications and deaths and maintaining these services is crucial
[30]. Similarly, child vaccinations were generally maintained except in Dire Dawa and Harari
regions.
The relatively limited effects of COVID-19 on maternal health and child vaccinations ser-
vices, could be due to previous health programs and better awareness of the importance of
MCH services. Since 2003, the country has implemented the health extension program and
health development army which focused on health education, outreach, and improving
demand for maternal and child health services. These programs contributed to reductions in
maternal and child mortality rates by increasing healthcare seeking behavior for maternal and
child services especially in rural Ethiopia [31, 32]. After the incidence of COVID in Ethiopia,
governmental and non-governmental organizations also disseminated information using mass
media to promote the use of maternal and child health services by following the COVID-19
preventive measures [33].
The pandemic did not seem to affect the number of patients who were on ART in any of
the study regions. However, there had been significant reduction in the volume of visits for
road traffic injuries especially in urban and agrarian areas. Following the spread of the
COVID-19 diseases, the government of Ethiopia announced travel restrictions especially in
urban areas. This led to considerable reduction in daily vehicle movements and thereby the
incidence of traffic injuries [34].
In addition to the immediate effect of COVID at the beginning of April 2020, the study also
assessed the trends in services until the end of 2020.The change in slopes were positive for vari-
ous indicators including outpatient, emergency attendance and inpatient admission. This
implies a trend toward recovery in health services and that the disruptions caused by COVID-
19 and lock down measures were not severe and long lasting. This is consistent with results

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

from a previous study conducted in selected Ethiopian districts on essential health and nutri-
tion services. By the end of 2020, the study showed that utilization of services had started to
recover to pre-pandemic level [10]. A periodic facility assessment conducted by UNICEF
(2020) also reported that the trends in service utilization had recovered after an initial decrease
in Oromia, Amhara, SNNP and Somalia regions [35].
The recovery of services during the second half of 2020 can be attributed to different rea-
sons. In June 2020, the Federal Ministry of Health (FMoH) developed strategies to maintain
essential health services and dissimilated guidance on service adaptation during COVID to the
regions [36, 37]. In addition, since the number of COVID-19 cases and deaths were lower than
initial expectations, public trust in receiving safe services from health facilities was improved.
Hence, health facility visits increased overtime [38]. A number of health facilities also resumed
various health services that had been suspended. Moreover, public hospitals introduced tele-
medicine in mid-2020. In collaboration with FMoH, health promotion campaigns were carried
out by non-governmental organizations like UNICEF to maintain maternal and child health
service use during the pandemic [39].
Nonetheless, the pandemic affected various services and these effects were largest in April-
June 2020.This implies that the Ethiopian health system has a limited capacity to face shocks
and was not prepared to maintain essential health services during a crisis [4]. The pandemic
affected utilization of essential services directly and indirectly in various ways. First, COVID
patients were given priority by central and local governments since coronavirus was consid-
ered to be a highly contagious disease which could lead to a high death rate. In response, there
were closure of health facilities, reduction in services, and many health workers were rede-
ployed to COVID-19 treatment centers [10, 40]. Second, there was fear of exposure to corona-
virus while receiving care and many decided to forgo or delay care even when needed [41].
Third, as part of the state of emergency measures, the government also restricted movements
of people for five months. This could have affected household income and financial capacity to
afford healthcare. In addition, access to transport to travel to health facilities were also limited.
In addition, several public hospitals in urban areas were converted in COVID treatment cen-
ters and stopped providing other health services. Other hospitals also reduced their level of
inpatient admissions and cut the length of hospital stays to prevent COVID infections. This
could have also reduced access to essential services in urban areas compared to pastoralist
areas. On the contrary, the impact of COVID on utilization of services could be more persis-
tent in pastoralist regions where access to medical services is extremely limited [42] Therefore,
once COVID spreads in pastoralist areas, it would be difficult to provide treatment for both
COVID patients and to those who need other types of services.
Similar to this evidence, a multi-country study based on data collected in Burkina Faso,
Ethiopia, and Nigeria reported maternal health services were interrupted during the pandemic
[4]. However, the percentage of reductions for these services were slightly less as compared to
the reduction of other services including HIV treatments and surgical services. An assessment
conducted in 11 Sub-Saharan African countries also indicated that the COVID-19 pandemic
impaired utilization of services for 18% of the study respondents mainly due to travel restric-
tions, health facility closures, and fear of contracting the virus [43]. Another study stated that
reduction in maternal health service use were less generalized even if significant declines in
facility deliveries, antenatal care and postnatal care were observed in some Sub-Saharan Afri-
can countries. In April 2020, there were about 18% reduction in antenatal care visit in Nigeria
and a 17% decline in postnatal care use in Mali [2]. A study conducted in urban Ethiopia
found a significant reduction in child vaccination services in urban area especially in Addis
Ababa and Harari [30]. However, these reductions occurred only for a few months after the
pandemic was declared.

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Our study showed the effect of the COVID-19 pandemic on utilization of healthcare across
Ethiopian regions using data from the DHIS2 for a period of two years and robust statistical
methods. However, our study has the following limitations. First, the Ethiopian health infor-
mation system continues to face challenges with data completeness, consistency and timeli-
ness. Data quality may also vary across regions. For example, some have found higher odds of
misreporting in Somali and Afar [44, 45]. Moreover, there is a risk that the pandemic affected
the ability of facilities to report service utilization especially in those regions most heavily
affected by the pandemic. We attempted to reduce estimation bias attributed to data quality
problems by conducting two-step cleaning procedures in order to include only facilities with
stable reporting over time and exclude outliers. This could affect generalizability by excluding
the hardest hit facilities. However, we ensured that the data cleaning excluded less than 5% of
service volumes provided over two years on average. Second, due to the conflict in Tigray, the
results are not generalizable to that region. Third, the routine data systems generally did not
include telemedicine consultations that were introduced to provide follow up services during
the pandemic. Finally, due to aggregate reporting of service visits at regional levels, it is not
possible to quantify the extent to which people switched from the public to the private sector
during the pandemic.

Conclusion
Within a month of the first confirmed COVID case, nearly all Sub-Saharan countries enforced
swift and strict lock down measures at both national and regional levels. Such measures have
contributed to contain the spread of COVID across the region [46, 47]. However, these restric-
tions brought unintended consequences by reducing the utilization of essential services [2, 3].
The evidence from our sub-national analysis in Ethiopia implies that health shocks especially
affected those regions where there was community transmission. Reduction in health care uti-
lization in Ethiopia could have prolonged and devastating effects. Therefore, it is necessary to
design appropriate policies and strategies to strengthen the capacity of health systems to main-
tain essential health services during future pandemics or health shocks.

Supporting information
S1 Appendix. Table A. Sample size and confirmed COVID-19 cases per region. Table B.
Effect of COVID on maternal and child health services across regions (ITSA—Regression with
Newey-West standard errors). Table C. Effect of COVID on various services across regions
(ITSA—Regression with Newey-West standard errors). Table D. List of healthcare use indica-
tors included in the analysis and their definitions.
(DOCX)
S1 Fig. Utilization of other health services in 2020 compared to 2019 by region type.
(TIF)

Acknowledgments
The authors are grateful to the Ethiopian Federal Ministry of Health for providing access to
service utilization data from the Ethiopian District Health Information System 2 for the period
from January 2019 to December 2020. The authors also thank all members of the ICODA
REHCORD project (assessing the resilience of health systems during COVID using routine
data) and members of the QuEST network that supported the overall project.

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PLOS GLOBAL PUBLIC HEALTH Health service utilization in Ethiopia during the COVID-19

Author Contributions
Conceptualization: Anagaw Derseh Mebratie, Adiam Nega.
Data curation: Anna Gage, Munir Kassa Eshetu, Catherine Arsenault.
Formal analysis: Anagaw Derseh Mebratie, Catherine Arsenault.
Funding acquisition: Catherine Arsenault.
Investigation: Adiam Nega, Damen Haile Mariam.
Methodology: Anagaw Derseh Mebratie, Anna Gage, Catherine Arsenault.
Project administration: Adiam Nega, Damen Haile Mariam.
Supervision: Anna Gage, Catherine Arsenault.
Validation: Catherine Arsenault.
Visualization: Anagaw Derseh Mebratie.
Writing – original draft: Anagaw Derseh Mebratie, Adiam Nega.
Writing – review & editing: Anagaw Derseh Mebratie, Anna Gage, Damen Haile Mariam,
Munir Kassa Eshetu, Catherine Arsenault.

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