Search

The role of pathology in improving cancer in resource‐limited countries is essential, yet many barriers exist. FNA is a rapid, low‐cost and efficient method for diagnosing cancer, planning treatment, and building a cancer registry.

The 5-year Resilient and Responsive Health Systems (RRHS)-Liberia Initiative, funded by PEPFAR via HRSA, launched in 2017 and was designed to support the implementation of Liberia's National Health Workforce Program as a means to improving HIV-related health outcomes. The COVID-19 pandemic, arrived in Liberia just five years after Ebola and during RRHS-Liberia's fourth year, impacted educational programs and threatened the project's continued work. This paper presents the challenges that the COVID-19 pandemic posed to the RRHS partners, as well as adaptations they made to maintain progress towards project goals: 1) contributing to Liberia's 95-95-95 HIV targets via direct service delivery, and 2) building a resilient and responsive health workforce in Liberia via instruction and training. Direct health service impacts included decreased patient volumes and understaffing; adaptations included development of and trainings on safety protocols, provision of telehealth services, and community health worker involvement. Instruction and training impacts included suspension of in-person teaching and learning; adaptations included utilization of multiple online learning and virtual conferencing tools, and increasing clinical didactics in lieu of bedside mentorship. The RRHS team recommends that these adaptations be continued with significant investment in technology, IT support, and training, as well as close coordination among partner institutions. Ultimately, the RRHS Liberia consortium and its partners made significant strides in response to ensuring ongoing education during the pandemic, an experience that will inform continued service delivery, teaching, and learning in Liberia.

Despite major setbacks to its health infrastructure and health workforce capacity, Liberia began its first post-graduate training program for physicians in 2013. Specialty training in Internal Medicine, Pediatrics, General Surgery and Obstetrics and Gynecology were the four inaugural Residency programs that recruited graduates from the country's only medical school, A.M. Dogliotti College of Medicine. The Obstetrics and Gynecology residency program was designed to combat the rising maternal mortality and strengthen health systems to improve maternal care. The program adapted in the face of challenges posed by limited financial support, lack of specialist-faculty and general physician shortages and the Ebola virus outbreak. The manuscript discusses the challenges and successes of the program and demonstrates how the shortage of teaching faculty was addressed by developing a collaboration between local government and educational communities, a United States (US) academic institution and volunteers from the Global Health Service Partnership.

Background The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). Methods Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. Results Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. Conclusions Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Introduction From the outset of the COVID-19 pandemic, guidance from WHO has promoted social distancing, wearing face masks, frequent hand washing, and staying-at-home as measures to prevent the spread of COVID-19. For many across Africa, compliance can be difficult. The aim of this study was to 1) understand the impact of student’s household’s ability to comply with COVID-19 mitigation strategies, 2) identify predictors of mitigation strategy compliance, and 3) describe the impact of COVID-19 on household economics, food-security, and mental well-being. Materials and methods We conducted an email-based survey among current medical and pharmacy students of the University of Liberia College of Health Sciences between July and October 2020. The questionnaire was designed to explore their household’s ability to comply with current mitigation strategies, as well as the pandemic´s impact on the student’s household’s finances and food security. Descriptive statistics were used to delineate demographic characteristics. Logistic regression was used to model factors associated with ability to comply with COVID-19 mitigation strategies, as well as participant’s food security. Results 113 persons responded to the questionnaire. Seventy-six (67∙3%) reported income losses as a result of the pandemic, with 93 (82∙3%) reporting being “somewhat” or “very worried” about their households’ finances. Seventy-seven (68∙1%) participants reported food stocks that were sufficient for one-week or less. Forty (35%) participants reported eating less preferred foods or skipping meals in the past week. Overall, 20 participants (19∙4%) had a positive depression screen. Conclusions Study participants showed mixed results in being able to adhere to national COVID-19 mitigation strategies, with household level stressors experienced around finances and food security. Until Liberia has access to vaccinations for most of its citizens, COVID-19 response measures need to provide social protections that address basic needs (shelter, clothing and food), and which specifically targets food insecurity. Preventative interventions for mental health problems must be incorporated into Liberia’s response to the pandemic.

Background: In low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their own FHR and alert a midwife of changes detected.Methods: 474 women admitted in labour without obstetric complications were approached. 461 consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately one minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded.Results: 461 out of 474 women gave consent, of whom 425 (92%) completed the monitoring themselves. 387 of 400 women who gave comments, reported positive and 13 negative experiences. 28 participants reported FHR changes, confirmed in 26 cases with meconium stained liquor in 17. Fetal death was identified on admission during training in one mother. 13 neonates required resuscitation, with 12 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl’s ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants. Conclusions: Women in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

Introduction The 2014-2016 Ebola virus disease (EVD) outbreak in Liberia highlighted the importance of robust preparedness measures for a well-coordinated response; the initially delayed response contributed to the steep incidence of cases, infections among health care workers, and a collapse of the health care system. To strengthen local capacity and combat disease transmission, various healthcare worker (HCW) trainings, including the Ebola treatment unit (ETU) training, safe & quality services (SQS) training and rapid response team (RRT), were developed and implemented between 2014 and 2017. Methods Data from the ETU, SQS and RRT trainings were analyzed to determine knowledge and confidence gained. Results The ETU, SQS and RRT training were completed by a total of 21,248 participants. There were improvements in knowledge and confidence, an associated reduction in HCWs infection and reduced response time to subsequent public health events. Conclusion No infections were reported by healthcare workers in Liberia since the completion of these training programs. HCW training programmes initiated during and post disease outbreak can boost public trust in the health system while providing an entry point for establishing an Epidemic Preparedness and Response (EPR) framework in resource-limited settings.

Introduction Lessons learned from the Ebola virus disease (EVD) outbreak enabled Liberia to develop a health plan for strengthening public health capacity against potential public health threats. risk communication is one of the core pillars that provide life-saving information and knowledge for the public to take preventive and proactive actions against public health threats. These were applied in response to the post-ebola meningococcal septicemia and meningitis outbreaks in Sinoe and Grand Kru counties. This paper documents risk communication experiences in these post-ebola outbreaks in Liberia. Methods Risk Communication and health promotion strategies were deployed in developing response plans and promptly disseminating key messages to affected communities to mitigate the risks. Other strategies included engagement of community leaders, partnership with the media and dissemination of messages through the community radios, active monitoring community risk perceptions and compliance, rumor management, mobile stage and interpersonal communication (IPC) during the Meningococcal disease outbreaks in Sinoe and Grand Kru counties. Results In Sinoe, about 36,891 households or families in 10 health districts were reached through IPC and dialogue. Circulating rumors such as "Ebola" was the cause of deaths was timely and promptly mitigated. There was increased trust and adherence to health advice including prompt reporting of sick people to the nearest health facility in the two counties. Conclusion Risk communication and health promotion encouraged community support and involvement in any response to public threats and events. No doubt, risk communication and health promotion play an important role in preparedness and response to public health emergencies.

In Liberia, 75% of those who died from 2014 Ebola epidemic were women and the effects of this gruelling epidemic were more severely felt by pregnant women. This immediately raised fears about the long-term impacts of the epidemic on maternal and child health. As part of a larger study, this paper uses Andersen's behavioural model of health care utilization and Goffman's stigma theory to explain the timing and utilization of maternal health services before the outbreak of the Ebola epidemic as a background to the potential long-term effects on maternal health. We conducted survival and multiple regression analysis using the 2007 (N = 3524) and 2013 (N = 5127) Liberia's Demographic and Health Survey (LDHS) data. Our sample consisted of women of reproductive age (15-49 years) that had given birth in the last five years preceding the survey year. The findings show that from 2007 to 2013, there was an overall improvement in the timing of first antenatal care (ANC) visits (TR = 0.92, p

Introduction Measles is an acute viral disease that remains endemic in much of sub-Sahara Africa, including Liberia. The 2014 Ebola epidemic disrupted an already fragile health system contributing to low uptake of immunization services, population immunity remained low thus facilitating recurrent outbreaks of measles in Liberia. We describe lessons learnt from detecting and responding to recurrent outbreaks of measles two years post the 2014 Ebola epidemic in Liberia. Methods We conducted a descriptive study using the findings from Integrated Diseases Surveillance and Response (IDSR) 15 counties, National Public Health Institute of Liberia (NPHIL), National Public Health Reference Laboratory (NPHRL) and District Health Information Software (DIHS2) data conducted from October to December, 2017. We perused the outbreaks line lists and other key documents submitted by the counties to the national level from January 2016 to December 2017. Results From January 2016 to December 2017, 2,954 suspected cases of measles were reported through IDSR. Four hundred sixty-seven (467) were laboratory confirmed (IgM-positive), 776 epidemiologically linked, 574 clinically confirmed, and 1,137 discarded (IgM-negative). Nine deaths out of 1817 cases were reported, a case fatality rate of 0.5%; 49% were children below the age of 5 years. Twenty-two percent (405/1817) of the confirmed cases were vaccinated while the vaccination status of 55% (994/1817) was unknown. Conclusion Revitalization of IDSR contributed to increased detection and reporting of suspected cases of measles thus facilitating early identification and response to outbreaks. Priority needs to be given to increasing the uptake of routine immunization services, introducing a second dose of measles vaccine in the routine immunization program and conducting a high-quality supplementary measles immunization campaign for age group 1 to 10 years to provide protection for a huge cohort of susceptible.

Introduction Although Liberia adapted the integrated diseases surveillance and response (IDSR) in 2004 as a platform for implementation of International Health Regulation (IHR (2005)), IDSR was not actively implemented until 2015. Some innovations and best practices were observed during the implementation of IDSR in Liberia after Ebola virus disease outbreak. This paper describes the different approaches used for implementation of IDSR in Liberia from 2015 to 2017. Methods We conducted a cross-sectional study using the findings from IDSR supervisions conducted from September to November 2017 and perused the outbreaks linelists submitted by the counties to the national level from January to December 2017 and key documents available at the national level. Results In 2017, the country piloted the use of mobile phones application to store and send data from the health facilities to the national level. In addition, an electronic platform for acute flaccid paralysis (AFP) surveillance called Auto-Visual AFP Detection and Reporting (AVADAR) was piloted in Montserrado County during the first semester of 2017. The timeliness and completeness of reports submitted from the counties to national level were above the target of 80% stable despite the challenges like insufficient resources, including skilled staff. Conclusion IDSR is being actively implemented in Liberia since 2015. Although the country is facing the same challenges as other countries during the early stages of implementation of IDSR, the several innovations were implemented in a short time. The surveillance system reveled to be resilient, despite the challenges.

Introduction in spite of the efforts and resources committed by the division of infectious disease and epidemiology (DIDE) of the national public health institute of Liberia (NPHIL)/Ministry of health to strengthening integrated disease surveillance and response (IDSR) across the country, quality data management system remains a challenge to the Liberia NPHIL/MoH (Ministry of health), with incomplete and inconsistent data constantly being reported at different levels of the surveillance system. As part of the monitoring and evaluation strategy for IDSR continuous improvement, data quality assessment (DQA) of the IDSR system to identify successes and gaps in the disease surveillance information system (DSIS) with the aim of ensuring data accuracy, reliability and credibility of generated data at all levels of the health system; and to inform an operational plan to address data quality needs for IDSR activities is required. Methods multi-stage cluster sampling that included stage 1: simple random sample (SRS) of five counties, stage 2: simple random sample of two districts and stage 3: simple random sample of three health facilities was employed during the study pilot assessment done in Montserrado County with Liberia institute of bio medical research (LIBR) inclusive. A total of thirty (30) facilities was targeted, twenty nine (29) of the facilities were successfully audited: one hospital, two health centers, twenty clinics and respondents included: health facility surveillance focal persons (HFSFP), zonal surveillance officers (ZSOs), district surveillance officers (DSOs) and County surveillance officers (CSOs). Results the assessment revealed that data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the subnational level. The findings indicated the following: 23% (7/29) of health facilities having dedicated phone for reporting, 20% (6/29) reported no cell phone network, 17% (5/29) reported daily access to internet, 56.6% (17/29) reported a consistent supply of electricity, and no facility reported access to functional laptop. It was also established that 40% of health facilities have experienced a stock out of laboratory specimens packaging supplies in the past year. About half of the surveyed health facilities delivered specimens through riders and were assisted by the DSOs. There was a large variety in the reported packaging process, with many staff unable to give clear processes. The findings during the exercise also indicated that 91% of health facility staff were mentored on data quality check and data management including the importance of the timeliness and completeness of reporting through supportive supervision and mentorship; 65% of the health facility assessed received supervision on IDSR core performance indicator; and 58% of the health facility officer in charge gave feedback to the community level. Conclusion public health is a data-intensive field which needs high-quality data and authoritative information to support public health assessment, decision-making and to assure the health of communities. Data quality assessment is important for public health. In this review completeness, accuracy, and timeliness were the three most-assessed attributes. Quantitative data quality assessment primarily used descriptive surveys and data audits, while qualitative data quality assessment methods include primarily interviews, questionnaires administration, documentation reviews and field observations. We found that data-use and data-process have not been given adequate attention, although they were equally important factors which determine the quality of data. Other limitations of the previous studies were inconsistency in the definition of the attributes of data quality, failure to address data users' concerns and a lack of triangulation of mixed methods for data quality assessment. The reliability and validity of the data quality assessment were rarely reported. These gaps suggest that in the future, data quality assessment for public health needs to consider equally the three dimensions of data quality, data use and data process. Measuring the perceptions of end users or consumers towards data quality will enrich our understanding of data quality issues. Data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the sub national level.

Introduction Early detection of disease outbreaks is paramount to averting associated morbidity and mortality. In January 2018, nine cases including four deaths associated with meningococcal disease were reported in three communities of Foya district, Lofa County, Liberia. Due to the porous borders between Lofa County and communities in neighboring Sierra Leone and Guinea, the possibility of epidemic spread of meningococcal disease could not be underestimated. Methods The county incidence management system (IMS) was activated that coordinated the response activities. Daily meetings were conducted to review response activities progress and challenges. The district rapid response team (DRRT) was the frontline responders. The case based investigation form; case line list and contacts list were used for data collection. A data base was established and analysed daily for action. Tablets Ciprofloxacin were given for chemoprophylaxis. Results Sixty-seven percent (67%) of the cases were males and also 67% of the affected age range was 3 to 14 years and attending primary school. The attack rate was 7/1,000 population and case fatality rate was 44.4 % with majority of the deaths occurring within 24-48 hours of symptoms onset. Three of the cases tested positive for Neisseria Meningitidis sero-type W while six cases were Epi-linked. None of the cases had recent meningococcal vaccination and no health-worker infections were registered. Conclusion This cluster of cases of meningococcal disease during the meningitis season in a country that is not traditionally part of the meningitis belt emphasized the need for strengthening surveillance, preparedness and response capacity to meningitis.

Introduction Liberia remains at high risk of poliovirus outbreaks due to importation. The country maintained certification level acute flaccid paralysis (AFP) surveillance indicators each year until 2014 due to Ebola outbreak. During this time, there was a significant drop in non-polio AFP rate to (1.2/100,000 population under 15 years) in 2015 from 2.9/100, 000 population in 2013, due to a variety of reasons including suspension on shipment of acute flaccid paralysis stool specimen to the polio regional lab in Abidjan, refocusing of surveillance officers attention solely on Ebola virus disease (EVD) surveillance, inactivation of national polio expert committee (NPEC) and National Certification Committee (NCC). The Ministry of Health (MOH) supported by partners worked to restore AFP surveillance post EVD outbreak and ensure that Liberia maintains its polio free certification. Methods We conducted a desk review to summarize key activities conducted to restore acute flaccid paralysis (AFP) surveillance based on World Health Organization (WHO) AFP surveillance guidelines for Africa region. We also reviewed AFP surveillance indicators and introduction of new technologies. Data sources were from program reports, scientific and gray literature, AFP database, auto visual AFP detection and reporting (AVADAR) and ONA Servers. Data analysis was done using Microsoft excel and access spread sheets, ONA software and Geographic Information System (Arc GIS). Results AFP surveillance indicators improved with a rebound of non-polio AFP rate (NPAFP) rate from 1.2/100, 000 population under 15 years in 2015 to 4.3 in 2017. The stool adequacy rate at the national level also improved from 79% in 2016 to 82% in 2017, meeting the global target. The percentage of counties meeting the two critical AFP surveillance indicators NPAFP rate and stool adequacy improved from 47% in 2016 to 67% in 2017.The Last polio case reported in Liberia was in late 2010. Conclusion There was significant improvement in the key AFP surveillance indicators such as NPAFP rate and stool adequacy with a 3.5 fold increase in NPAFP from 2014 to 2017. By 2017, the stool adequacy rate was up to target levels compared to 2016, which was below target level of 80%. The number of counties meeting target for the two critical AFP surveillance indicators also increased by 20% points between 2016 and 2017. Similarly there was approximately two-fold increase in the oral polio vaccines (OPV) coverage for the reported AFP cases between 2015 and 2017. Strategies employed to address gaps in AFP surveillance included enhanced active case search for AFP, re-instatement of laboratory testing, supportive supervision in addition to facilitating enhanced community engagement in surveillance activities. New technologies such as AVADAR Pilot, electronic integrated supportive supervision (ISS) and electronic surveillance (eSurv) tools were introduced to improve real time AFP case reporting. However, there remain residual gaps in AFP surveillance in the country especially at the sub-national level. Similarly, the newly introduced technologies will require continued funding and capacity building for MOH staff to ensure sustainability of the initiatives.

Summary Background Outbreak response efforts for the 2014–15 Ebola virus disease epidemic in west Africa brought widespread transmission to an end. However, subsequent clusters of infection have occurred in the region. An Ebola virus disease cluster in Liberia in November, 2015, that was identified after a 15-year-old boy tested positive for Ebola virus infection in Monrovia, raised the possibility of transmission from a persistently infected individual. Methods Case investigations were done to ascertain previous contact with cases of Ebola virus disease or infection with Ebola virus. Molecular investigations on blood samples explored a potential linkage between Ebola virus isolated from cases in this November, 2015, cluster and epidemiologically linked cases from the 2014–15 west African outbreak, according to the national case database. Findings The cluster investigated was the family of the index case (mother, father, three siblings). Ebola virus genomes assembled from two cases in the November, 2015, cluster, and an epidemiologically linked Ebola virus disease case in July, 2014, were phylogenetically related within the LB5 sublineage that circulated in Liberia starting around August, 2014. Partial genomes from two additional individuals, one from each cluster, were also consistent with placement in the LB5 sublineage. Sequencing data indicate infection with a lineage of the virus from a former transmission chain in the country. Based on serology and epidemiological and genomic data, the most plausible scenario is that a female case in the November, 2015, cluster survived Ebola virus disease in 2014, had viral persistence or recurrent disease, and transmitted the virus to three family members a year later. Interpretation Investigation of the source of infection for the November, 2015, cluster provides evidence of Ebola virus persistence and highlights the risk for outbreaks after interruption of active transmission. These findings underscore the need for focused prevention efforts among survivors and sustained capacity to rapidly detect and respond to new Ebola virus disease cases to prevent recurrence of a widespread outbreak. Funding US Centers for Disease Control and Prevention, Defense Threat Reduction Agency, and WHO.

The fragility of health systems has never been of greater interest—or importance—than at this moment, in the aftermath of the worst Ebola virus disease epidemic to date. The loss of life, massive social disruption, and collapse of even the most basic health-care services shows what happens when a crisis hits and health systems are not prepared. This did not happen only in west Africa— we saw it in Texas too: the struggle to provide a coherent response and manage public sentiment (which often manifests as fear) in a way that ensures that disease does not spread while also allowing day-to-day life to continue. In other words, we saw an absence of resilience. This Viewpoint puts forth a proposed framework for resilient health systems and the characteristics that defi ne them, informed by insights from other fi elds that have embraced resilience as a practice. Health system resilience can be defi ned as the capacity of health actors, institutions, and populations to prepare for and eff ectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath. Resilient health systems can also deliver everyday benefi ts and positive health outcomes. This double benefi t—improved performance in both bad times and good—is what has been called “the resilience dividend”. Response to a crisis, be it a disease outbreak or other disruption resulting in a surge of demand for health care (eg, a natural disaster or a mass casualty event) needs both a vigorous public health response and a highly proactive and functioning health-care delivery system. These two systems must work in concert during a crisis—and indeed long before crisis strikes. Health-care systems are complex adaptive systems and resilience is an emergent property of the health system as a whole rather than a single dimension. Building resilience is thus context-dependent and iterative, needing advance assessments of system capacities and weaknesses, investments in vulnerable components of the system before a crisis, reinforcements during the emergency, and review of performance after a crisis. Resilience is not a static construct—for example, the rapid pace of recovery from crisis is a cardinal measure of success. The Ebola epidemic has illustrated that several preconditions for resilience were lacking. The fi rst of these preconditions is recognition of the global nature of severe health crises and clarity about the roles of actors at all levels of the global health system. Although national governments are fundamentally responsible for their health systems, they need the capacity to mobilise the full range of local actors and to rapidly draw on external resources if necessary. The need for a global resilience network is both a moral imperative and a recognition of the fact that pathogens do not respect borders. Shocks to the health system of one country can reverberate across regions and the world. Health system resilience is thus a global public good and needs a collective response from the global community. Funding for this response can come from traditional domestic and donor sources or, as recently suggested, a new international health systems fund to which all countries contribute. A second precondition is a legal and policy foundation to guide the response and establish accountability. The implementation of International Health Regulations, which call on countries to build core public health capacities and establish a means of coordinating a response to health emergencies with regional and global partners, is a prerequisite for eff ective emergency response. Additionally, legislation that clarifi es the authority of public health agencies and the roles and responsibilities of private and public health actors is needed as are policies for involving the private and voluntary sector in the response and allowing fl exibility in sharing and reallocating resources across the health system. Third, there is a need for a strong and committed health workforce, characterised by health personnel who show up for work that might be diffi cult and dangerous. Establishing such a workforce begins with training and deployment of a suffi cient number of doctors, nurses, managers, and outreach workers—a colossal task in a country such as Liberia with a population of 3·5 million people and fewer than 100 doctors—but also building and banking a stock of social capital in the health system before crisis strikes. Just as strong social capital in communities promotes individual psychological resilience after mass trauma, social capital in the health system promotes system-wide recovery from crisis. In the health system context, social capital has two dimensions: a sense of worth, community, and responsibility among health actors (clinicians, managers, engineers, outreach workers) and an inclusive and robust community engagement with the health system. Health systems that earn the trust and support of the population and local political leaders by reliably providing high-quality services before crisis have a powerful resilience advantage. Strong management of district level health systems is key to gaining that trust. Diverse fi elds such as ecology, engineering, complex adaptive systems, psychology, and public health have produced resilience frameworks. The Rockefeller Foundation has developed substantial data about resilient Lancet 2015; 385: 1910–12

Following the devastation caused by the 2014 Ebola outbreak in Liberia there remains much to be done for the health system to fully recover and become resilient against any future public health threat. Liberia is a post-conflict setting having experienced prolonged years of civil conflict that weakened the health system. With the decline in the incidence of new Ebola cases in late 2014 and the progressive draw down of the emergency and humanitarian response resources from early 2015, the government of Liberia moved to set the scene for the health system’s recovery and resilience through the development of a comprehensive seven-year Investment Plan for building a resilient health system (2015-2021). The Plan aims to ensure universal health coverage, guarantee health security and improve health outcomes for the population of Liberia, while complementing the National Health Policy and Plan (2011-2021). The plan requires the investment of 1.7 billion US dollars over a period of seven years and realignments that the Government of Liberia alone does not currently have the capacity to undertake without long term external support. This paper describes the experience of Liberia in the development of the Investment Plan for building a resilient health system following the 2014-15 Ebola crisis, the approaches, process and realignments that were undertaken, lessons learned, and the way forward. It aims to provide lessons for countries recovering from crises, on how to manage their system recovery efforts.

There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement.A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits.The total catchment area of the 11 hospitals surveyed was 2,313,429--equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease.A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.

BACKGROUND: Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie(R) birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health providers knowledge skills and confidence evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package - involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice - has an effect on the occurrence of haemorrhage-related morbidity and mortality. METHODS/DESIGN: In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded. Intention-to-treat analysis will be used taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health providers skills care and interventions and health system readiness. DISCUSSION: This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201604001582128 . Registered on 12 April 2016.

SummaryThe 2013-2016 epidemic of Ebola virus disease in West Africa was of unprecedented magnitude, duration and impact. Extensive collaborative sequencing projects have produced a large collection of over 1600 Ebola virus genomes, representing over 5% of known cases, unmatched for any single human epidemic. In this comprehensive analysis of this entire dataset, we reconstruct in detail the history of migration, proliferation and decline of Ebola virus throughout the region. We test the association of geography, climate, administrative boundaries, demography and culture with viral movement among 56 administrative regions. Our results show that during the outbreak viral lineages moved according to a classic ‘gravity’ model, with more intense migration between larger and more proximate population centers. Notably, we find that despite a strong attenuation of international dispersal after border closures, localized cross-border transmission beforehand had already set the seeds for an international epidemic, rendering these measures relatively ineffective in curbing the epidemic. We use this empirical evidence to address why the epidemic did not spread into neighboring countries, showing that although these regions were susceptible to developing significant outbreaks, they were also at lower risk of viral introductions. Finally, viral genome sequence data uniquely reveals this large epidemic to be a heterogeneous and spatially dissociated collection of transmission clusters of varying size, duration and connectivity. These insights will help inform approaches to intervention in such epidemics in the future.

To assess the consistent availability of basic surgical resources at selected facilities in seven countries.In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh.Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.Évaluer la disponibilité constante des ressources chirurgicales de base dans certains établissements de sept pays.En 2010–2014, nous avons utilisé un outil d'analyse de situation pour recueillir des données dans des hôpitaux régionaux et de district au Bangladesh (Seuls 41 (34,2%) des 120 hôpitaux analysés remplissaient les critères définissant une offre constante de services chirurgicaux de base. La population totale desservie par les hôpitaux analysés dans chaque pays allait de 3,3 millions de personnes au Liberia à 151,3 millions de personnes au Bangladesh. Cependant, la population totale desservie par les hôpitaux analysés dans chaque pays et qui remplissaient les critères définissant une offre constante de services chirurgicaux de base était nettement inférieure, allant de 1,3 millions de personnes au Liberia à 79,2 millions de personnes au Bangladesh.De nombreux établissements analysés n'avaient pas les infrastructures élémentaires nécessaires pour offrir de façon constante des soins chirurgicaux de base.Evaluar la disponibilidad coherente de recursos quirúrgicos básicos en centros seleccionados de siete países.En 2010–2014, se utilizó una herramienta de análisis situacional para recopilar datos en hospitales de distrito y regionales de Bangladesh (Únicamente 41 (34,2%) de los 120 hospitales del estudio cumplieron con los requisitos de suministro constante de servicios quirúrgicos básicos. Los beneficiarios combinados de los hospitales del estudio en cada país de estudio oscilaron entre 3,3 millones de personas en Liberia y 151,3 millones de personas en Bangladesh. Sin embargo, los beneficiarios combinados de los hospitales del estudio en cada país de estudio que cumplieron los criterios de suministro constante de servicios quirúrgicos básicos fueron mucho menores y oscilaron entre 1,3 millones en Liberia y 79,2 millones en Bangladesh.Muchos de los centros del estudio carecían de la infraestructura básica necesaria para suministrar atención quirúrgica básica de forma coherente.الغرض تقييم التوافر المستمر للموارد الجراحية الأساسية في المرافق المحددة في سبع دول. الطريقة في الفترة الممتدة ما بين عاميّ 2010 وحتى 2014، استخدمنا أداة تحليل ظرفية لجمع البيانات في المستشفيات الواقعة في الأحياء والمناطق في بنغلاديش (عدد旨在评估七个国家选定机构持续提供基本外科资源的能力。.在 2010 年到 2014 年期间,我们使用情景分析工具收集了埃塞俄比亚 (在调查的 120 家医院中,仅 41 (34.2%) 家医院满足标准,能够提供持续的基本外科服务。每个调查国家对象医院的综合服务范围人口在 330 万(利比里亚)和 15,130 万(孟加拉国)之间变动。但是,符合提供持续基本外科服务的调查国家对象医院的综合服务范围人口显著更小,在 130 万(利比里亚)和 7,920 万(孟加拉国)之间变动。.许多研究医疗机构在持续提供基本外科护理必要的基本设施方面存在不足。.Оценить постоянную доступность основных хирургических ресурсов в отдельных медицинских учреждениях в семи странах.В 2010–2014 годах мы использовали инструмент ситуационного анализа для сбора данных в районных и областных больницах в Бангладеш (Только 41 (34,2%) из 120 больниц, участвовавших в исследовании, отвечала критериям предоставления постоянных базовых хирургических услуг. Совокупные популяции, обслуживаемые исследуемыми больницами в каждой исследуемой стране, варьировались между 3,3 млн человек в Либерии и 151,3 млн человек в Бангладеш. Тем не менее совокупные популяции, обслуживаемые исследуемыми больницами в каждой исследуемой стране, которые соответствовали критериям предоставления постоянных базовых хирургических услуг, были существенно меньше и варьировались между 1,3 млн человек в Либерии и 79,2 млн человек в Бангладеш.Многие из исследуемых медицинских учреждений испытывали недостаток в базовой инфраструктуре, необходимой для обеспечения базовой хирургической помощи на постоянной основе.

In recent years, dozens of countries have introduced accreditation and other quality improvement initiatives. A great deal of information is available regarding best practices in high- and middle-income countries; however, little is available to guide developing nations seeking to introduce an accreditation programme. This paper describes the outputs and lessons learned in the first year of establishing an accreditation programme in Liberia, a developing nation in West Africa that in 2003 emerged from a brutal 14-year civil war. The Liberian experience of developing and implementing a government-sponsored, widespread accreditation programme may provide insight to other low-income and post-conflict countries seeking a way to drive rapid, system-wide reform in the health system, even with limited infrastructure and extremely challenging conditions.

BackgroundDirect measurement of sensitive health events is often limited by high levels of under-reporting due to stigma and concerns about privacy. Abortion in particular is notoriously difficult to measure. This study implements a novel method to estimate the cumulative lifetime incidence of induced abortion in Liberia.MethodsIn a randomly selected sample of 3219 women ages 15–49 years in June 2013 in Liberia, we implemented the ‘Double List Experiment’. To measure abortion incidence, each woman was read two lists: (A) a list of non-sensitive items and (B) a list of correlated non-sensitive items with abortion added. The sensitive item, abortion, was randomly added to either List A or List B for each respondent. The respondent reported a simple count of the options on each list that she had experienced, without indicating which options. Difference in means calculations between the average counts for each list were then averaged to provide an estimate of the population proportion that has had an abortion.ResultsThe list experiment estimates that 32% [95% confidence interval (CI): 0.29-0.34) of respondents surveyed had ever had an abortion (26% of women in urban areas, and 36% of women in rural areas, P-value for difference < 0.001), with a 95% response rate.ConclusionsThe list experiment generated an estimate five times greater than the only previous representative estimate of abortion in Liberia, indicating the potential utility of this method to reduce under-reporting in the measurement of abortion. The method could be widely applied to measure other stigmatized health topics, including sexual behaviours, sexual assault or domestic violence.

Background: The magnitude of the Ebola outbreak in West Africa is unprecedented. Liberia, Guinea, and Sierra Leone are in the bottom ten countries in the Human Development Index, but all had made gains in child survival prior to the outbreak. With closure of healthcare facilities and the loss of health workers secondary to the outbreak, the region risks reversing survival gains achieved in maternal and newborn health. Methods: Anonymized service utilization data were downloaded from the Liberia District Health Information Software (DHIS) 2 for selected maternal health services at PHC facilities in Margibi and Bong Counties from March 2014, when the first case of Ebola was reported in Liberia, through December 2014. Absolute numbers are provided instead of percentage measures because of the lack of a population-based denominator. Results: Overall, the data show a decrease in absolute utilization from the start of the outbreak, followed by a slow recovery after October or November. In Bong County, totals were less than 14% of the peak numbers during the outbreak for number of antenatal visits and pregnant women receiving intermittent preventive treatment for malaria in pregnancy (IPTp). For total deliveries, utilization was less than 33% of the highest month. In Margibi County, during what now appears to be the height of the outbreak, numbers dropped to less than 9% of peak utilization for antenatal care visits and 4% for IPTp. Total health facility deliveries dropped to less than 9% of peak utilization. Conclusion: It is clear that Bong and Margibi Counties in Liberia experienced a large drop in utilization of maternal health care services during what now appears to be the peak of the Ebola outbreak. As the health of women and their babies is being promoted in the post-2015 sustainable development agenda, it is critical that the issue of maternal and newborn survival in humanitarian emergency settings, like the Ebola outbreak, is prioritized.

The voices of the countries most affected by Ebola have not been at the forefront of the numerous global commissions convened to review the crisis. The history of the HIV pandemic suggests that nuances of managing such a response need to come from those who managed the response and were most affected by it. One review suggests that the global response to Ebola remains inadequate. This Correspondence is a regional perspective from west Africa, the community most affected by the Ebola epidemic and by infectious-disease outbreaks in general. Systematic inclusion of the perspective of the most affected people in these epidemics will contribute to the overall success of health-related security efforts worldwide.

Objective To establish representative local-area baseline estimates of maternal and neonatal mortality using a novel adjusted sisterhood method. Methods The status of maternal and neonatal health in Bomi County, Liberia, was investigated in June 2013 using a population-based survey (n = 1985). The standard direct sisterhood method was modified to account for place and time of maternal death to enable calculation of subnational estimates. Results The modified method of measuring maternal mortality successfully enabled the calculation of area-specific estimates. Of 71 reported deaths of sisters, 18 (25.4%) were due to pregnancy-related causes and had occurred in the past 3 years in Bomi County. The estimated maternal mortality ratio was 890 maternal deaths for every 100 000 live births (95% CI, 497–1301]. The neonatal mortality rate was estimated to be 47 deaths for every 1000 live births (95% CI, 42–52). In total, 322 (16.9%) of 1900 women with accurate age data reported having had a stillbirth. Conclusion The modified direct sisterhood method may be useful to other countries seeking a more regionally nuanced understanding of areas in which neonatal and maternal mortality levels still need to be reduced to meet Millennium Development Goals.

Maternity waiting homes (MWHs) can reduce maternal morbidity and mortality by increasing access to skilled birth attendants (SBAs). The present analysis was conducted to determine whether MWHs increase the use of SBAs at rural primary health clinics in Liberia; to determine whether traditional midwives (TMs) are able to work with SBAs as a team and to describe the perceptions of TMs as they engage with SBAs; and to determine whether MWHs decrease maternal and child morbidity and mortality.The present analysis was conducted halfway through a large cohort study in which 5 Liberian communities received the intervention (establishment of an MWH) and 5 Liberian communities did not (control group). Focus groups were conducted to examine the views of TMs on their integration into health teams.Communities with MWHs experienced a significant increase in team births from baseline to post-intervention (10.8% versus 95.2%, P0.001), with greater TM engagement. Lower rates of maternal and perinatal death were reported from communities with MWHs.The reduction in morbidity and mortality indicates that the establishment of MWHs is an effective strategy to increase the use of SBAs, improve the collaboration between SBAs and TMs, and improve maternal and neonatal health.

Objective To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. Design Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. Setting Sixteen county hospitals in Liberia. Main Outcome Measures Infrastructure, personnel, procedures performed, and supplies and equipment available. Results Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. Conclusions The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Background Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases. Methods We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia. Results Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system. Conclusions The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.