Effects of COVID-19 on paediatric cardiac centres in low-income and middle-income countries: a mixed-methods study


Campbell Dopke, Prevention and Community Health, George Washington University School of Public Health and Health Services, Washington, District of Columbia, USA.
Jean Connor, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.
Bistra Zheleva, Children's HeartLink, Minneapolis, Minnesota, USA.
Kimberlee Gauvreau, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.
Bojana Bakalcheva, Department of Cardiology, National Heart Hospital, Sofia, Bulgaria.
Najeebullah Bina, Department of Cardiology, French Medical Institute for Children (FMIC), Kabul, Afghanistan.
Gonzalo Calvimontes, Department of Cardiology, Unidad de Cirugia Cardiovascular de Guatemala, Guatemala City, Guatemala.
Ivana Cerovic, Department of Cardiology, Mother and Child Health Institute of Serbia, Belgrade, Serbia.
Naizihijwa Majani, Department of Paediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar Es Salaam, Tanzania, United Republic of.
Michael Oketcho, Department of Paediatric Cardiac Surgery, Uganda Heart Institute, Kampala, Uganda.
Dimitar Pechilkov, Department of Paediatric Cardiology, National Heart Hospital, Sofia, Bulgaria.
Fenny Shidhika, Department of Paediatric Cardiology, Windhoek Central Hospital, Windhoek, Namibia.
Tengiz Shiryaev, Congenital Cardiac Surgery Department, JoAnn McGowan Paediatric Cardiac Surgery Center, Tbilisi, Georgia.
Kathy Jenkins, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA kathy.jenkins@childrens.harvard.edu.

Document Type

Journal Article

Publication Date



BMJ open








COVID-19; Congenital heart disease; HEALTH SERVICES ADMINISTRATION & MANAGEMENT; Paediatric cardiology; Public health


OBJECTIVES: The aim of this study was to understand the effects of the COVID-19 pandemic on paediatric cardiac services in critical access centres in low-income and middle-income countries. DESIGN: A mixed-methods approach was used. SETTING: Critical access sites that participate in the International Quality Improvement Collaborative (IQIC) for congenital heart disease (CHD) were identified. PARTICIPANTS: Eight IQIC sites in low-income and middle-income countries agreed to participate. OUTCOME MEASURES: Differences in volume and casemix before and during the pandemic were identified, and semistructured interviews were conducted with programme representatives and analysed by two individuals using NVivo software. The qualitative component of this study contributed to a better understanding of the centres' experiences and to identify themes that were common across centres. RESULTS: In aggregate, among the seven critical access sites that reported data in both 2019 and 2020, there was a 20% reduction in case volume, though the reduction varied among programmes. Qualitative analysis identified a universal impact for all programmes related to Access to Care/Clinical Services, Financial Stability and Professional/Personal Issues for healthcare providers. CONCLUSIONS: Our study identified and quantified a significant impact of the COVID-19 pandemic on critical access to CHD surgery in low-income and middle-income countries, as well as a significant adverse impact on both the skilled workforce needed to treat CHD and on the institutions in which care is delivered. These findings suggest that the COVID-19 pandemic has been a major threat to access to care for children with CHD in resource-constrained environments and that this effect may be long-lasting beyond the global emergency. Efforts are needed to preserve vulnerable CHD programmes even during unprecedented pandemic situations.


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