A Framework for Identifying the Sources of Indirect Health Effects of COVID-19

Attention to the indirect health effects of COVID-19 is on the rise. Media stories, papers, and research reports are shining a light on the many knock-on health impacts of policies designed to respond to the pandemic. (We’ve been keeping an open inventory of these effects since early April.) In a policy paper released today, we introduce a framework for mapping out these indirect health effects at the country level, and show how it can shape our understanding of how COVID-related policies reverberate across all aspects of health. As we explain here, the framework can help policymakers move to a holistic COVID-19 response that accounts for the impacts of the pandemic and the measures implemented to fight it.

Framework overview

Our framework builds on a literature review of indirect health effects in the context of previous outbreaks and crises (Ebola, SARS, H1N1 outbreaks, and the global financial crisis), as well as the indirect impacts of COVID-19 collected in our inventory. It also draws upon a framework developed by Elston et al. (2017) following the Ebola outbreak, which we expanded to include environmental impacts, temporal considerations and link to the calculation of net health benefits. Because published studies and news reports often cover only a single health issue (e.g., maternal mortality, vaccination, HIV), our framework adds value by looking across the health sector and the various sources of disruptions that can occur during epidemics, so that the wider range of direct and indirect health impacts can inform adoption of appropriate mitigation strategies.

The objectives of the framework are to (1) illustrate the complexity of these “indirect” impacts and (2) provide a simple structure for analysts interested in calculating the overall “net health impact” of the pandemic, accounting for indirect lives lost and saved as a result of the impacts. The framework is organized around four interrelated sets of considerations (economic, environmental, health systems, and social/behavioural), which we discuss below (a comprehensive review of the COVID-19 literature is in our paper). What causes indirect mortality is multifactorial. We also expect the impacts to be overwhelmingly negative, although there could be positive impacts for some conditions and causes of mortality (e.g., outdoor pollution or road traffic injuries). The impacts may also trigger losses (or gains) in health in the short, medium, and long term. For instance, losses due to lack of access to maternal health services may be fairly immediate, whereas losses due to lack of hepatitis B vaccination could take a generation to materialise.

Figure 1. Framework for identifying indirect health impacts of COVID-19

Economic Impact

At the macro level, restrictions on movement, trade, and social distancing can lead to a collapse in economic activity which will affect livelihoods and access to basics (including food) and to education. COVID-19 has already been associated with increased unemployment, loss of income and increased poverty rates, and food insecurity, and has affected school attendance across the world. Extensive research has shown that each of those elements in and of themselves contribute to loss of health. Poverty is a major cause of ill-health because of food insecurity, housing insecurity, and access to hygiene and sanitation (which are expected to play an important role during the COVID-19 outbreak). Poverty will also affect access to healthcare services in many low- and middle-income countries (LMICs).

Environmental impact

Environmental impact will be greater in countries where restrictions on movement and other policies aiming at introducing social distancing are in place. The secondary health impacts of environmental changes are likely to impact both sides of the equation: with reduction in mortality stemming from road traffic and outdoor pollution and increases in mortality from indoor pollution. China, the UK, Turkey, and the US have all reported large reductions in road traffic due to COVID-19 lockdowns. In China, non-life insurers have reported a dramatic drop in claims. It is worth noting that LMICs are home to 93 percent of global road traffic deaths. Zambrano-Monserrate et al. found evidence of large impacts of the lockdown on outdoor pollution in China, Italy, Spain and the US. Chen et al. found that improvements in air quality during the quarantine might have saved 8,911 nitrogen dioxide-related deaths (from chronic pulmonary disease and cardiovascular diseases).

Social/behavioural impact

At the micro level, it is likely that individuals will modify behaviour in response to COVID-19 and response policies. Isolation or increasing economic vulnerability will no doubt increase anxiety and more generally contribute to a rise in mental health needs. In India, a rise in emergency visits for severe alcohol withdrawal was recorded. This could lead to an increase in death by suicide, a leading cause of death in younger populations, as well as child and domestic abuse. A report from UNFPA paints a grim picture on the impact of COVID-19 on gender-based violence, unwanted pregnancies, and child marriages.

Health systems impact

Health system impact can be categorized as funding, supply chain, health workforce, infrastructure, service provision, patient access, and “covidisation.” As we explain in our paper, covidisation refers to the phenomenon of “focusing economic, environmental, health, and social policies and research funding on the impact on COVID-19 (global level), and/or changing social and behavioral constructs in response to experiencing the COVID-19 pandemic” (the term has been sparsely used in research as in here). Those sources of disruptions occur at the macro, meso, and micro levels. At the macro level, policies such as suspension of vaccination campaigns have impacted access by populations. At the meso level, entire facilities (including hospitals) have been repurposed to care for COVID-19 patients. At the micro level, individuals may avoid seeking care because of fear of contracting the virus.

Health impacts are also often thought of in terms of supply of health services. However, we know from other outbreaks that the individual response (changes in demand) can be very strong: in France, emergency visits have dropped 26 percent, including for conditions such as appendicitis or strokes, which are unlikely to have declined during the outbreak. Restrictions on movement (discussed above in the case of Uganda), fear, and stigma can results in patients avoiding visiting facilities, even for life threatening conditions.

In our paper, we develop a more comprehensive sub-framework for health systems impact to support countries in the design of effective mitigation strategies.

A successful COVID policy should not be measured solely by the number of COVID deaths averted: We urgently need to adopt a whole of health perspective

With so many other health and non-health outcomes at stake, estimates of how strategies impact the trajectory of COVID-19 must not be the sole metric informing a “successful” COVID-19 policy response. Different policy responses to COVID-19 will also trigger different levels of disruptions of the economy, social interactions, and the health system, which will lead to different indirect health effects. Contextual factors, including the redesign of health or economic policies, will also be critical to map those indirect health effects.

An appropriate strategy to address COVID-19 requires a holistic approach to health, assessing how the pandemic and various response measures will impact the wider range of health needs across the population, with attention to net health impacts of policy options and explicit consideration of trade-offs across health objectives. We hope that our framework, alongside our net health impacts calculator, will contribute to a broader assessment of the indirect health impacts of COVID-19 and bring those to the fore when assessing the merits of a given policy strategy in the ongoing pandemic response.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.