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      Liberia health system's journey to long-term recovery and resilience post-Ebola: a case study of an exemplary multi-year collaboration


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          This article is part of the Research Topic ‘ Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'

          Liberia is one of the three countries worst hit by the 2014–2016 West Africa Ebola Virus disease (EVD) outbreak, during which it recorded over 10,000 cases, including health workers. Estimates suggest that the non-EVD morbidity and mortality resulting from the collapse of the health system exceeded the direct impact of EVD. Lessons from the outbreak were clear, not only for Liberia but also for the regional and global communities: that building health system resilience through an integrated approach is an investment in population health and wellbeing, as well as economic security and national development. It is therefore no surprise that Liberia made recovery and resilience a national priority from the time the outbreak waned in 2015. The recovery agenda provided the platform for stakeholders to work toward the restoration of the pre-outbreak baseline of health system functions while aiming to build a higher level of resilience, informed by lessons from the Ebola crises. Based on the co-authors' experiences of on-the-ground country-support work, this study sought to provide an overview of the Liberia Health Service Resilience project (2018–2023) funded by KOICA, and propose a set of recommendations for national authorities and donors, derived from the authors' perceptions of best practices and key challenges associated with the project. We used both quantitative and qualitative approaches to generate the data represented in this study by reviewing published and unpublished technical and operational documents, and datasets derived through situational and needs assessments and routine monitoring and evaluation activities. This project has contributed to the implementation of the Liberia Investment Plan for Building a Resilient Health System and the successful response to the COVID-19 outbreak in Liberia. Although limited in scope, the Health Service Resilience project has demonstrated that health system resilience could be operationalized by applying a catchment and integrated approach and encouraging multi-sectoral collaboration, partnership, local ownership, and promoting the Primary Health Care approach. Principles applied in this pilot could guide the operationalization of health system resilience efforts in other resource-limited settings similar to Liberia and beyond.

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          Most cited references15

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          What is a resilient health system? Lessons from Ebola.

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            Effects of the West Africa Ebola Virus Disease on Health-Care Utilization – A Systematic Review

            Significant efforts were invested in halting the recent Ebola virus disease outbreak in West Africa. Now, studies are emerging on the magnitude of the indirect health effects of the outbreak in the affected countries, and the aim of this study is to systematically assess the results of these publications. The methodology for this review adhered to the Prisma guidelines for systematic reviews. A total of 3354 articles were identified for screening, and while 117 articles were read in full, 22 studies were included in the final review. Utilization of maternal health services decreased during the outbreak. The number of cesarean sections and facility-based deliveries declined and followed a similar pattern in Guinea, Liberia, and Sierra Leone. A change in the utilization of antenatal and postnatal care and family planning services was also seen, as well as a drop in utilization of children’s health services, especially in terms of vaccination coverage. In addition, the uptake of HIV/AIDS and malaria services, general hospital admissions, and major surgeries decreased as well. Interestingly, it was the uptake of health service provision by the population that decreased, rather than the volume of health service provision. Estimates from the various studies suggest that non-Ebola morbidity and mortality have increased after the onset of the outbreak in Sierra Leone, Guinea, and Liberia. Reproductive, maternal, and child health services were especially affected, and the decrease in facility deliveries, cesarean sections, and volume of antenatal and postnatal care visits might have significant adverse effects on maternal and newborn health. The impact of Ebola stretches far beyond Ebola cases and deaths. This review indicates that indirect health service effects are substantial and both short and long term, and highlights the importance of support to maintain routine health service delivery and the maintenance of vaccination programs as well as preventative and curative malaria programs, both in general but especially in times of a disaster.
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              Toward a theory-led meta-framework for implementing health system resilience analysis studies: a systematic review and critical interpretive synthesis

              Introduction The variety of frameworks and models to describe resilience in the health system has led researchers and policymakers to confusion and the inability to its operationalization. Therefore, the purpose of this study was to create a meta-framework using the Critical Interpretive Synthesis method. Method For this purpose, studies that provide theories, models, or frameworks for organizational or health system resilience in humanitarian or organizational crises were systematically reviewed. The search strategy was conducted in PubMed, Web of Science, Embase, and Scopus databases. MMAT quality appraisal tool was applied. Data were analysed using MAXQDA 10 and the Meta-ethnography method. Results After screening based on eligibility criteria, 43 studies were reviewed. Data analysis led to the identification of five main themes which constitute different framework dimensions. Health system resilience phases, attributes, tools, and strategies besides health system building blocks and goals are various dimensions that provide a systematic framework for health system resilience analysis. Discussion This study provides a systemic, comprehensive framework for health system resilience analysis. This meta-framework makes it possible to detect the completeness of resilience phases. It examines the system’s resilience by its achievements in intermediate objectives (resilience system attributes) and health system goals. Finally, it provides policy solutions to achieve health system resilience using tools in the form of absorptive, adaptive, and transformative strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12496-3.

                Author and article information

                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                19 June 2023
                19 June 2023
                : 11
                : 1137865
                [1] 1Health Systems Strengthening, World Health Organization - Country Office for Liberia, Monrovia , Montserrado, Liberia
                [2] 2World Health Organization , Geneva, Switzerland
                [3] 3Ministry of Health Liberia , Monrovia, Liberia
                [4] 4World Health Organization - Country Office for Liberia, Monrovia , Montserrado, Liberia
                [5] 5National Public Health Institute of Liberia, Monrovia , Montserrado, Liberia
                Author notes

                Edited by: Aladeen Alloubani, King Hussein Cancer Center, Jordan

                Reviewed by: Janneth Mghamba, Commonwealth Secretariat, United Kingdom; Karen Sliter, International Atomic Energy Agency, Austria

                *Correspondence: Louis Ako-Egbe louisakoegbe02@ 123456gmail.com
                Copyright © 2023 Ako-Egbe, Seifeldin, Saikat, Wesseh, Bolongei, Ngormbu, George, Ocan and Peter Lasuba.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                : 04 February 2023
                : 22 May 2023
                Page count
                Figures: 6, Tables: 6, Equations: 0, References: 32, Pages: 18, Words: 12500
                Public Health
                Policy and Practice Reviews
                Custom metadata
                Public Health Policy

                health systems,resilience,integration,catchment approach,emergency preparedness and response,healthcare quality,recovery,covid-19


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