Rose Macauley

Availability of essential health services in post-conflict Liberia

OBJECTIVE To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war. METHODS We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness. FINDINGS Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba countys 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively. CONCLUSION Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.

Which Doctor?: Determinants of Utilization of Formal and Informal Health Care in Postconflict Liberia

BackgroundLiberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care. ObjectiveThis study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia. Research Design, Participants, and MeasuresThis was a cross-sectional population-representative survey of 1435 adults living in rural Nimba County, Liberia. Participants were asked about past year visits to traditional and formal health care providers and demographics, health, and trauma indicators. The association between formal and informal visits and potential determinants was estimated in separate models using generalized estimating equations to adjust for village-level clustering. ResultsThe median number of visits in the past year to formal and informal providers was 3 and 10, respectively. Clinic visits increased with younger age and female sex, past trauma exposure, the number of traditional healers, and the presence of a facility dispenser. Frequency of informal visits increased with poor self-reported mental and physical health, the presence of facility fees and decreased with literacy and wealth and satisfaction with the formal health system. ConclusionsRural Liberians use both formal and informal health care extensively and as complements rather than substitutes. The reliance on traditional medicine to address health needs is of concern in a country with a high disease burden. Health system investments that build public confidence in the health system may help shift demand from informal to formal health care.

Building resilient health systems: a proposal for a resilience index

Health system resilience begins with measurement of critical capacities ahead of crisis say Margaret E Kruk and colleagues

Immunization drop-outs and maternal behavior: evaluation of reasons given and strategies for maintaining gains made in the national vaccination campaign in Liberia.

Through annual National Vaccination Weeks, Liberia, one of thirteen African countries participating in the CCCD program, has achieved good rates of initial vaccination coverage against childhood diseases. However, rates of completion have been disappointing. Described is a community-based operations research methodology for a.) identifying reasons for non-completion of the vaccination series according to groups of mothers, front-line health workers and country level administrators, b.) for making recommendations for alternatives in the delivery system, and c.) for critiquing the focus group methodology as a tool for increasing commitment to program goals.

Infection prevention and control of the Ebola outbreak in Liberia, 2014–2015: key challenges and successes

Prior to the 2014–2015 Ebola outbreak, infection prevention and control (IPC) activities in Liberian healthcare facilities were basic. There was no national IPC guidance, nor dedicated staff at any level of government or healthcare facility (HCF) to ensure the implementation of best practices. Efforts to improve IPC early in the outbreak were ad hoc and messaging was inconsistent. In September 2014, at the height of the outbreak, the national IPC Task Force was established with a Ministry of Health (MoH) mandate to coordinate IPC response activities. A steering group of the Task Force, including representatives of the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC), supported MoH leadership in implementing standardized messaging and IPC training for the health workforce. This structure, and the activities implemented under this structure, played a crucial role in the implementation of IPC practices and successful containment of the outbreak. Moving forward, a nationwide culture of IPC needs to be maintained through this governance structure in Liberia’s health system to prevent and respond to future outbreaks.

Beyond the crisis: did the Ebola epidemic improve resilience of Liberia’s health system?

Abstract Resilience was widely identified as a critical attribute for strong health systems following the 2014‐15 West Africa Ebola epidemic. In Liberia, Sierra Leone and Guinea, struggles to control the disease and suspension of the operation of many health services demonstrated that health systems must plan for resilience long before a crisis. However, the operational elements of resilience and ways that a crisis experience can shape resilience are not well described in the literature. To understand how a health system adapts to crisis and how the priorities of different health system actors influence this response we conducted interviews with global, national, and local respondents in Liberia between July and September 2015 (n = 108), several months after the country was first declared Ebola‐free. We found that health system resilience functions prioritized by global and national actors improved to a greater extent than those valued by community leaders and local health actors over the course of the epidemic. Although the Ebola epidemic stimulated some positive adaptations in Liberia’s health system, building a truly resilient health system will require longer‐term investments and sustained attention long beyond the crisis.

Disponibilidad de servicios de salud esenciales en Liberia tras los conflictos

Introduction Large-scale armed conflict has both immediate and long-term effects on population health in low-income countries. (1) In addition to violence-related mortality, disruption in the delivery of basic services, including electricity, water and health care raises death rates among non-combatants during conflict and after it has ended. The collapse of health systems, which suffer from flight of health workers, looting and physical destruction of facilities, exacerbates this indirect mortality. Although humanitarian organizations can alleviate suffering in the short run, repairing the health system is a more daunting task. (2) Liberia emerged from 14 years of civil war in 2003. This conflict resulted in near-total destruction of the countrys infrastructure. Today, six years after the end of the war, the electrical grid still operates solely in the capital city, Monrovia. Few roads have been repaired and schools have only recently reopened. The health system was also destroyed in the war: of the 293 public health facilities operating before the war, 242 were deemed nonfunctional at the end of the war due to destruction and looting. (3) Doctors, nurses and other health workers fled the country, leaving 30 physicians to serve a population of 3 million. (4) Outside Monrovia, where humanitarian agencies provided some services, most of the population has little or no access to health care. The government of Ellen Johnson-Sirleaf, elected in 2005 in the countrys first post-war democratic election, faced a dire health situation. The under-five mortality rate was 110 per 1000 live births and the maternal mortality ratio was 994 deaths per 100 000 live births, with the latter figure representing a 71% increase from the 2000 estimate of 550. (5) Malaria, which is endemic in Liberia, is a major cause of morbidity and an important contributor to under-five mortality. In 2006, one-third of the population had at least one episode of the disease and an estimated 6000 children died from its complications. (6) Mental health problems related to war trauma and exacerbated by dislocation are also a pressing concern. A 2008 survey found that 40% of the population had self-reported symptoms indicative of major depression and 44% probably had post-traumatic stress disorder. (7) The prevalence of human immunodeficiency virus (HIV) infection in Liberia was estimated at 1.5% in 2007, a figure similar to that in the neighbouring countries of Guinea (1.5%) and Ghana (2.2%) but substantially lower than in eastern and southern Africa, where seven countries had an HIV infection prevalence higher than 15%. (5,8) In response to the post-war health challenges, the Ministry of Health and Social Welfare, with assistance from donors and international nongovernmental organizations (NGOs), embarked on rebuilding the health system. The ministrys first aim was to expand the provision of primary health care, particularly in rural areas that were underserved even before the war. The 2007 National Health Plan outlined a basic package of health services: essential health services that would be provided without charge at clinics and hospitals throughout the country, ranging from HIV testing to emergency obstetric care. (9) The preventive and curative interventions in the basic package of health services target the disease burden in the country, particularly infectious disease and the high maternal and child morbidity and mortality (Box 1). (10) The ministry partnered with a large group of international and national NGOs to deliver a basic package of health services. Basic packages of health services implemented with support from international and national NGOs have been used to jump-start the rebuilding of the health system in other post-conflict countries such as Afghanistan and Sierra Leone, where they have been credited with increasing the utilization of health services and reducing mortality and morbidity. (11,12) Box 1. …