The Indirect Health Effects of COVID-19: Long-term Costs for Health Systems

As countries around the world begin to ease or entirely lift their lockdowns, reports of the indirect effects the coronavirus pandemic on health systems continue to emerge. Our previous blogs on the indirect health effects of COVID-19 show the pandemic has created additional barriers for patients accessing essential care through restrictions on movement, lack of service provision, stigma, impoverishment from loss of livelihoods, and avoidance of care due to concerns over contracting the virus. In this blog, we highlight reports of substantial long-term impacts of the COVID-19 response on health systems, ranging from government reductions in health spending to sharp decreases in utilisation of health services across health areas.

As readers of earlier posts in this series know, we have built an open-access inventory of accounts of indirect health effects of COVID-19 to support researchers working to quantify these impacts and devise pragmatic approaches to minimising them. We are posting regular snapshots such as this one to broadcast some of the reports captured in our inventory. Rather than a comprehensive overview, we aim to give a horizontal view of the indirect impact of COVID-19 around the world, showing the complex and fast-changing nature of the pandemic.

Health areas

Non-communicable diseases

  • Hospital admissions for strokes have decreased drastically; a study in Southern Europe shows a 25 percent reduction in admitted cases, and Brazil reports a 36.4 percent decline in admissions. Both studies point to patients avoiding care, but a paper on stroke treatment during the pandemic in Italy, France, and Germany reports another possible cause: reduced social contact with relatives, neighbours, and friends may result in symptoms like dysarthria, aphasia, neglect, or mild paresis being under-recognised.

Communicable diseases

  • McQuaid and co-authors explore the potential impact of COVID-19-related physical distancing on transmission of tuberculosis in South Africa, India, and China. The modelled results suggest that in some scenarios where health services will be less affected, TB transmission will be reduced during a lockdown period due to reduced social contacts. Despite this, the model shows that the disruptions in services are likely to outweigh the benefits from reduced transmission, leading to an increase in TB deaths overall.


  • In the New York Times, Dr. Anita Shet reports that data from the Centers for Disease Control and Prevention’s Vaccine Safety Datalink in the United States show an almost 50 percent drop in children being vaccinated for measles during the first quarter of 2020, compared with the same period in 2019. The drop is attributed to the suspension of vaccination campaigns and country lockdowns. 
  • A rapid analysis by ThinkWell calculates the increased operational costs for immunisation campaigns during the pandemic to show that with all WHO-suggested protective measures and operational changes combined, the operational cost of a campaign could increase by 49 percent in the low-intensity and up to 154 percent in the high-intensity scenario. The low-intensity scenario is described as a situation without widespread transmission of COVID-19, with simple handwashing stations but where vaccinators do not use PPE. The high-intensity scenario includes full PPE equipment for vaccinators, including masks, goggles, and gloves, and advanced handwashing stations.

Maternal and reproductive health

  • In India, Vora and colleagues report injectable contraception doses given have decreased by 36 percent and IUD insertion has dropped by 21 percent. Distribution of the combined oral pill and condoms has dropped by 15 percent and 23 percent respectively. The number of abortions performed fell by 28 percent. Indian NGO FRHS India reports that a likely scenario is that 25.63 million couples in India are unable to access contraceptives, resulting in an additional 2.38 million unintended pregnancies, 679,864 live births, 1.45 million abortions (including 834,042 unsafe abortions), and 1,743 maternal deaths.


Health spending reductions

  • Akinwotu reports in the Guardian that the Nigerian government has announced its intention to cut healthcare spending by 40 percent despite coronavirus cases in the country continuing to climb. The impact of the pandemic on the economy, as well as dwindling oil sales and the crash in global oil prices, are understood to be the reason for the cuts.

In good news...

  • In Singapore, an unintended consequence of the pandemic response has been a drop in influenza. Whilst influenza activity in Europe and the US have remained high, influenza activity in tropical Singapore took an unprecedented steep decline likely due to the public health response to the COVID-19 pandemic; the suspension of mass gatherings, social distancing, and staying at home when unwell.

  • Zambrano-Monserrate and colleagues report a significant association between pandemic response measures and improvement in air quality, clean beaches, and environmental noise reduction in China, the US, Italy, and Spain. However, they also found negative secondary aspects, such as a reduction in recycling and an increase in waste during the pandemic.

  • Chen and co-authors show that the interventions to contain the COVID-19 outbreak in China led to air quality improvements that have avoided 8,911 pollution-related deaths, mainly due to pollution-associated cardiovascular diseases, with the number of deaths due to coronavirus at 4633 as of 4 May, 2020.
  • Our team published this week a new CGD policy paper “Beyond COVID-19: A Whole of Health Look at Impacts During the Pandemic Response,” the outcome of an extensive review and data collection work carried out over the last few months. In this paper, we set out a whole of health approach to the COVID response and discuss what is known about the indirect health impacts of COVID-19 using a framework of four interrelated sets of impacts: economic, environmental, health systems, and social/behavioural. Read the policy paper here.

Stay tuned for more on the indirect health effects of COVID-19, and please do get in touch by email (, Twitter, or in the comments section of this post if you have resources or news that you would like to see included in our inventory. Our thanks to those of you who have already contributed—please continue to share!


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.

Image credit for social media/web: Ricci Coughlan/Department for International Development