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Background: Arising from the Ebola virus disease (EVD) outbreak, the 2015- 2021 Investment Plan aimed to improve the health status of the Liberian population through building a resilient health system that contributes to achieving equitable health outcomes. Recognizing the significance of community participation in overcoming the EVD outbreak, strengthening community systems emerged as one of the most important strategies for bridging the gap in accessing primary health care (PHC) services. This study reviewed the community health policy development process in order to draw lessons from the health system strengthening efforts in Liberia post-EVD crisis. Methods: A government-led health system analysis approach was applied to assess, review and revise the community health program in Liberia. The mixed method approach combines the use of an adapted tool to assess bottlenecks and solutions during workshops, a qualitative survey (key informant interviews and focus group discussions) to assess perceptions of challenges and perspectives from different stakeholders, and an inter-agency framework – a benchmarks matrix – to jointly review program implementation gaps using the evidence compiled, and identify priorities to scale up of the community program. Results: Stakeholders identified key health system challenges and proposed policy and programmatic shifts to institutionalize a standardized community health program with fit for purpose and incentivized community health assistants to provide PHC services to the targeted populations. The community health program in Liberia is currently at the phase of implementation and requires strengthened leadership, local capacities, and resources for sustainability. Lessons learned from this review included the importance of: establishing a coordination mechanism and leveraging partnership support; using a systems approach to better inform policy shifts; strengthening community engagement; and conducting evidence-based planning to inform policy-makers. Conclusions: This article contributes toward the existing body of knowledge about policy development processes and reforms on community health in Liberia, and most likely other African settings with weak health systems. Community-based systems will play an even bigger role as we move toward building resilience for future shocks and strengthening PHC, which will require that communities be viewed as actors in the health system rather than just clients of health services.

Background During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. We describe the scope and characteristics of contact tracing in Liberia and assess its performance during the 2014–2015 EVD epidemic. Methodology/Principal findings We performed a retrospective descriptive analysis of data collection forms for contact tracing conducted in six counties during June 2014–July 2015. EVD case counts from situation reports in the same counties were used to assess contact tracing coverage and sensitivity. Contacts who presented with symptoms and/or died, and monitoring was stopped, were classified as “potential cases”. Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Bivariate and multivariate logistic regression models were used to identify characteristics among potential cases. We analyzed 25,830 contact tracing records for contacts who had monitoring initiated or were last exposed between June 4, 2014 and July 13, 2015. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during this period. Eighty-eight percent of contacts completed monitoring, and 334 contacts were identified as potential cases (PPV = 1.4%). Potential cases were more likely to be detected early in the outbreak; hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness compared to contacts who completed monitoring. Conclusions/Significance Contact tracing was a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, these data suggest there were limitations to its performance—particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies., Author summary Contact tracing is comprised of three main steps: identifying, listing, and monitoring persons who have been exposed to infected individuals, with the goal of rapidly diagnosing and treating new cases and preventing further spread of infection. This approach has been used to control transmission of infectious diseases including smallpox, tuberculosis, HIV, and syphilis, and while contact tracing has been used in prior outbreaks of hemorrhagic fever, these outbreaks were small in scale. During the 2014–2015 Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented in all 15 counties on a scale that was unprecedented, particularly within both rural and crowded urban settings. This work provides insight into the magnitude that which contact tracing was implemented, its characteristics, as well as an assessment on its performance. Given that contract tracing is a critical tool for controlling disease spread, these findings aid in informing future planning and decision making for its implementation.

Background The aim of this study is to estimate the immediate and lasting effects of the 2014–2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data. Methods and findings We analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: −77.9%, −56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: −69.0%, −53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: −45.8%, −24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: −47.6%, −29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of −776,110 clinic visits (95% CI: −1,480,896, −101,357, p = 0.030); −24,449 bacille Calmette–Guérin vaccinations (95% CI: −45,947, −2,020, p = 0.032); −9,129 measles vaccinations (95% CI: −12,312, −5,659, p < 0.001); −17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: −28,344, −5,775, p = 0.002); and −101,857 ACT malaria treatments (95% CI: −205,839, −2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of −12,941 first pentavalent vaccinations (95% CI: −20,309, −5,527, p = 0.002); −5,122 institutional births (95% CI: −8,767, −1,234, p = 0.003); and −45,024 acute respiratory infections treated (95% CI: −66,185, −24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate doses and first ANC visits did not show statistically significant net losses. ACT treatment for malaria was the only indicator with an estimated net increase in system outputs through December 2016, showing an excess of +78,583 outputs (95% CI: −309,417, +450,661, p = 0.634) compared to pre-EVD forecasted trends, although this increase was not statistically significant. However, comparing December 2013 to December 2017, ACT malaria cases have increased 49.2% (95% CI: 33.9%, 64.5%, p < 0.001). Compared to pre-EVD forecasted trends, there remains a statistically significant loss of −15,144 PNC visits within 6 weeks (95% CI: −29,453, −787, p = 0.040) through December 2016. Conclusions The Liberian public-sector primary healthcare system has made strides towards recovery from the 2014–2015 EVD outbreak. All primary healthcare indicators tracked have recovered to pre-EVD levels as of November 2016. Yet, for most indicators, it took more than 1 year to recover to pre-EVD levels. During this time, large losses of essential primary healthcare services occurred compared to what would have been expected had the EVD outbreak not occurred. The disruption of malaria case management during the EVD outbreak may have resulted in increased malaria cases. Large and sustained investments in public-sector primary care health system strengthening are urgently needed for EVD-affected countries., Bradley Wagenaar and colleagues use health facility data to analyze losses to essential primary healthcare service outputs during and immediately after the EVD outbreak, and their recovery in the years after., Author summary Why was this study done? Almost 2 years after the final case of Ebola virus disease (EVD) was discharged in Liberia, it is essential to understand the lingering effects of the EVD outbreak on the public-sector primary healthcare system. Existing studies of the effects of the EVD outbreak on population health and health system functioning have relied on small survey samples, mathematical modeling approaches, and data collected at single points in time before, during, or immediately after the epidemic rather than using health system output data to understand long-term system trends. We aimed to improve on these limitations and extend existing analyses to cover a census of health facilities in Liberia (excluding Montserrado County) from January 2010 to December 2016. What did the authors do and find? We used health facility data across a census of facilities and over an 84-month period to analyze changes in essential primary healthcare service indicators during and after the EVD outbreak. We found that it took only 4 months (June–September 2014) to lose between 35% and 67% of essential primary care health system outputs across Liberian clinics, and that, as of November 2016 (19 months post-EVD), all health system indicators had recovered to their pre-EVD levels. Given that health system outputs are time-limited, the loss of an estimated 776,110 clinic visits, 24,449 bacille Calmette–Guérin vaccinations, 9,129 measles vaccinations, 12,941 first pentavalent vaccinations, 5,122 institutional births, 17,191 postnatal care visits within 6 weeks of birth, 101,857 artemisinin-based combination therapy treatments for malaria, and 45,024 treatments of acute respiratory infections due to the EVD outbreak will continue to severely affect population health. We estimate that the number of malaria cases treated has increased by 49% from December 2013 to December 2016—a finding potentially due to increases in the transmission of the disease following large-scale treatment interruptions during the EVD outbreak. What do these findings mean? These findings add to the body of literature suggesting that the 2014–2015 EVD outbreak across West Africa had devastating effects on the delivery of all types of public-sector primary healthcare services. For most primary healthcare indicators, it took more than 1 year post-EVD to recover to pre-EVD levels, with net losses persisting as of December 2016. Malaria cases may have increased since the EVD outbreak in Liberia, as predicted from previous modelling efforts across EVD-affected countries; the extent to which a similar trend for malaria has been recorded in Sierra Leone or Guinea is not clear. Public-sector primary healthcare system strengthening is urgently needed across West Africa, with specific focus targeted to general outpatient care, childhood vaccination, maternal health, and malaria prevention/treatment.