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Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.

IntroductionType 2 diabetes Miletus (T2DM) is becoming one of the leading causes of morbidity and mortality worldwide, including among Africans. Knowledge of the association between risk factors and both diabetes and pre-diabetes, and whether these differ by age and sex, are important for designing targeted interventions. However, little is known about these associations for African populations.MethodsThe study used data from WHO STEPS surveys, comprising 15,520 participants (6,774 men and 8,746 women) aged 25-64 years. Chi-square and T-test were used to compare differences in the prevalence of risk factors for both sexes. Multinomial logistic regression was conducted to ascertain the relative risks (RR) and 95% confidence intervals (CI) for both T2DM and IFG relating to each risk factors, including obesity (defined by BMI, waist circumference (WC), waist to hip ratio (WHR), and waist to height ratio (WHtR)), high blood pressure (HBP), fruit and vegetable consumption, physical inactivity, alcohol consumption and smoking. Models for each risk factor were fitted with interactions for age and sex.ResultsFactors associated with T2DM and IFG were age, BMI, waist circumference(WC), waist to hip ratio(WHR), waist to height ratio(WHtR), hypertension, physical inactivity, smoking, alcohol, fruit, and vegetable consumption]. Significant interaction with age was observed for the association between hypertension and T2DM(p = 0.05); WHtR and T2DM (p = 0.007) and WHR with IFG (p= 0.006).ConclusionThe study found that for most risk factors examined, associations with both IFG and T2DM did not vary by age and sex. Policies for the prevention may consider the impact of risk factors equally among adults of any age or sex in West Africa.

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.

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March–July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

Background: The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population health. We describe one of the most critical of these secondary consequences, the decrease in the utilization of health services and the resulting consequences for mortality. In low- and middle-income countries, these disruptions can halt progress towards reducing maternal and child mortality. Methods: Data on service utilization from January 2018 to June 2021 is extracted from health management information systems of 18 low- and lower-middle-income countries. Interrupted time series design is used to estimate percent change in the volumes of essential health services delivered during the pandemic compared to projected volumes based on pre-pandemic trends. The Lives Saved Tool mathematical model is used to estimate the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions are also correlated to the COVID-19 burden, time since the start of the pandemic, and relative severity of mobility restrictions. Findings: We estimate that decreases in essential health service utilization between March 2020 and June 2021 led to 113,873 additional deaths in the 18 countries, representing 3.8% and 1.4% increases in child and maternal mortality, respectively. This corresponds to an average of 2.6 indirect deaths per COVID-19 death officially reported in the same period. This excess mortality results from the decline in utilization of the RMNCH services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, resulting in 27.5% of the excess death, occurred during the second quarter of 2020, regardless of whether countries experienced the highest rate of COVID-19-related deaths during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. Interpretation: Large declines in health care utilization during the COVID-19 pandemic amplify the pandemic's harmful impacts on health outcomes. As efforts and resource allocation towards prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low and middle-income countries. Funding: The Global Financing Facility for Women, Children, and Adolescents. Declaration of Interests: We declare no competing interests.

Background: The COVID-19 pandemic and its secondary effects pose a major global threat to the continuity of essential health services. Disruptions in essential services can lead to increases in morbidity and mortality and a protracted public health crisis. We quantify the disruption of the COVID-19 crisis on essential health services, focusing on maternal and child health, in eight sub-Saharan countries. Methods: Service volumes are extracted from administrative systems for the months between January 2018 and July 2020 in eight sub-Saharan countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone, and Somalia. We examine monthly data for 59,546 facilities covering eight selected services. We employ a regression model using data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for secular trends, seasonality, and facility characteristics. Estimates of disruption are derived by comparing these predictions to the observed service utilization level during the pandemic period. Findings: All countries experienced service disruptions for at least one month, but the magnitude, and duration of the disruptions vary. Although decreases in service volume were most common in April and May, there were still significant disruptions as of July. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5,445,068 OPD consultations and 277,018 third doses of pentavalent vaccine during the five months in these eight countries. Decreases in maternal health service utilization are less generalized. Significant declines in institutional deliveries, antenatal care, and postnatal care were detected in four, six, and five countries, respectively. Of the eight countries, the strongest and most persistent disruptions were detected in Liberia, Mali, Nigeria, and Sierra Leone. More limited disruptions were found in Cameroon, the Democratic Republic of Congo, Malawi, and Somalia. Interpretation: Results show that the COVID-19 pandemic caused substantial interruptions in the delivery of essential health services, albeit with significant cross-country variation. While this analysis cannot speak to the causes behind the declines in service utilization, they may be driven by changes in care-seeking behavior due to fear of infection, reallocation of resources, lockdown policies, and income shocks. The design of interventions to mitigate these disruptions requires detailed local knowledge and additional data on the behaviors of health providers and households during the pandemic. Timely monitoring of service volumes through administrative data should be an integral component of a responsive pandemic strategy. Funding Statement: The Global Financing Facility for Women, Children, and Adolescents. Declaration of Interests: No conflicts of interest.

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.

In late November, 2014, Liberia’s Ministry of Health and World Health Organization (WHO) Liberia did a rapid qualitative assessment (supported by the World Bank) of the perceptions of selected communities in Monrovia on an incentive scheme that intends to increase the reporting of EVD cases. Participants from various groups living in Monrovia were invited to participate in focus-group discussions: contact tracers, active case finders, community leaders, young people, and women. Participants argued that the following pressing problems have to be solved in order to curb the disease: 1) Provide food for families in quarantine. Although there are steps in place to provide all contacts with food while under follow-up, a substantial number of families who are quarantined do not receive food or they receive it late. It forces families to break the quarantine to buy food. (2) Enable reliable communication between Ebola treatment units and the families of the sick. Families are often not informed to which unit their loved ones are taken or what the condition of their relative is. People see the treatment units as “black holes” where loved ones disappear. (3) Restore and improve basic health services. Very few clinics and hospitals are operational; pregnant women especially are often rejected when they attend for delivery. (4) Provide psychosocial support to families of EVD patients. Supporting families who have lost loved ones should be an essential part of care in any Ebola response. (5) Include Ebola survivors in the teams of active case finders and contact tracers. The investigation revealed some important information from the demand side on how to make sure active case finding and community based EVD interventions work.