Evidence on sexual and reproductive health service delivery during and post COVID-19: a multi-country facility assessment

Introduction: The COVID-19 pandemic significantly disrupted global health systems, and sexual and reproductive health (SRH) were among the services often receiving less priority compared to other urgent health needs. Anticipated disruptions included limited access to contraception, abortion care, sexually transmitted infections (STI) prevention, and gender-based violence (GBV) support, particularly in low- and middle-income countries. This study aimed to assess the availability, readiness, and recovery of SRH services during and after the pandemic across nine countries. Methods: This repeated cross-sectional, mixed-methods study was implemented in collaboration with national Ministries of Health across nine countries: Brazil, Burkina Faso, China, England, Ghana, Italy, Kenya, Pakistan, and Thailand. Data were collected from health facilities and SRH clients at two time points: during peak COVID-19 transmission and post-pandemic. Standardized facility assessments and client interviews were analyzed using multilevel logistic regression models. Qualitative data were collected through in-depth interviews and focus group discussions in selected countries to explore service disruptions, health system adaptations, and psychosocial impacts. Thematic analysis identified context-specific challenges and coping strategies. Results: Of 4,346 clients interviewed, 2,292 from seven countries were included in the final analysis. Post-pandemic improvements were modest, with gains in STI testing and GBV response training. Family planning and abortion services showed minimal recovery. Systemic vulnerabilities such as outpatient closures, staff shortages, and supply chain failures contributed to service disruptions. Facilities adopted resilience strategies including telemedicine, task shifting, and triaging. Qualitative findings revealed emotional strain among healthcare providers, stigma, and informal coping mechanisms, underscoring the need for integrated mental health support and flexible service delivery models. Conclusion: The pandemic exposed critical weaknesses in SRH service delivery but also highlighted opportunities for strengthening health system resilience. Integrating qualitative insights enhances understanding of lived experiences and local innovations, essential for building adaptable and accessible SRH systems. Sustained investment in workforce support, supply chains, and context-specific service models is vital for future health emergency preparedness.