Date Published: February 20, 2018
Publisher: Public Library of Science
Author(s): Bradley H. Wagenaar, Orvalho Augusto, Jason Beste, Stephen J. Toomay, Eugene Wickett, Nelson Dunbar, Luke Bawo, Chea Sanford Wesseh, Margaret E. Kruk
Abstract: BackgroundThe 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 findingsWe 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.ConclusionsThe 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.
Partial Text: The 2014–2015 Ebola virus disease (EVD) outbreak across West Africa represented an international tragedy, directly leading to 28,616 cases of EVD and 11,310 deaths in total, and 10,675 confirmed, probable, and suspected cases in Liberia, resulting in 4,809 deaths . Due to already weakened health systems, the EVD outbreak led to incredible disruption in the continued provision of life-saving public-sector primary healthcare across Sierra Leone, Guinea, and Liberia—the 3 countries most severely impacted by the epidemic . Analyses using routine health information system (RHIS) data originating from Guinea and Sierra Leone have recently chronicled the effect of the EVD epidemic on the delivery of public-sector care for maternal, child, and reproductive health services, showing dramatic decreases during the Ebola outbreak (on the order of 50% declines) and sustained low levels not suggesting recovery [3–5]. Previous descriptive studies using RHIS data from Liberia have shown decreases in maternal and child health (MCH) indicators [6,7], malaria treatment , HIV testing , and tuberculosis diagnoses  during the EVD outbreak. Others have estimated that EVD-related disruptions in treating malaria alone will contribute to significantly more excess deaths than direct EVD-related mortality . Mathematical modeling of malaria in Liberia has estimated that the disruption of treatment due to EVD will result in 520,000 untreated malaria cases, 57,200 new malaria cases that would not have occurred otherwise, and a 62% increase in malaria-attributable mortality . Other modeling approaches have suggested that EVD-related deaths may significantly decrease life expectancy across Sierra Leone, Liberia, and Guinea —not to mention collateral morbidity and mortality due to the disruption of these countries’ health systems. The majority of existing studies on the effects of the EVD outbreak on the delivery of primary healthcare have used survey sampling data or mathematical modeling methods [14–30].
Across the 379 clinics and the 31,836 clinic-months in the analyses, the mean clinic-level catchment population was 6,912 (range: 214–67,381), serving an estimated total population of approximately 2.6 million (Table 1). Across the 14 counties included in the analyses, there were a total of 2,320 EVD cases, ranging from 2 cases in Grand Gedeh and River Cess to 746 cases in Lofa. Data from previous community surveys suggest that all counties except Sinoe and Grand Kru have more than 90% of women attending at least 1 ANC visit, although on average across all counties, only 52.7% of women deliver in a health facility (range: 34.6%–75.6%). The average BCG coverage across counties is 89.5%, with measles coverage lower, at 70.6%. Malaria prevalence in children is high, at 34.4%.
To our knowledge, this study is the first analytical assessment of public-sector primary healthcare delivery before, during, and after the 2014–2015 EVD outbreak. This study uses data from 7 years of service delivery in Liberia (excluding Montserrado County) to accurately estimate trends before, during, and after the outbreak, as well as forecast system losses attributable to the EVD outbreak. We observed large and significant changes in the delivery of public-sector primary healthcare across Liberia during and after the EVD outbreak. It took only 4 months to lose between 35% and 67% of essential primary care health system outputs across Liberian clinics after the beginning of the EVD outbreak (with the time period of the outbreak defined as June 2014–April 2015). The Liberian health system showed early resilience during the EVD outbreak, with all primary healthcare indicators showing increases from October to December 2014. Unlike findings from recent studies in Guinea , our analyses show that, through December 2016, primary healthcare delivery across Liberia has shown significant evidence of recovery from the EVD outbreak. However, due to the large magnitude of health system output losses during the EVD outbreak, there remain estimated net losses of tens of thousands of key childhood vaccinations and essential MCH consultations and hundreds of thousands of clinic visits.