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Following the 2014 Ebola outbreak, signs of recovery for Liberian healthcare system

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Following Losses During the 2014 Ebola Outbreak, Signs of Recovery for Liberian Healthcare System

image: The Ebola virus disease (EVD) outbreak in 2014-2015 disrupted the provision of healthcare in Sierra Leone, Guinea, and Liberia. view more 

Credit: US Army Corps of Engineers, Savannah District

The effects of the Ebola virus disease (EVD) outbreak in 2014-2015 were felt not only directly, in the 28,616 cases of EVD and 11,310 deaths, but also indirectly, through the disruption in the provision of healthcare in Sierra Leone, Guinea, and Liberia -- the countries most severely impacted by the outbreak. In a research article published this week in PLOS Medicine, Bradley H. Wagenaar, of the Department of Global Health, University of Washington, and colleagues quantify the health system output losses in Liberia during and in the immediate aftermath of the EVD outbreak, and the recovery of the health systems in the two years following.

Wagenaar and colleagues used routine health information system (RHIS) data from 379 public-sector health facilities across Liberia, from January 2010 through December 2016, to conduct a time series analysis of changes in 10 essential primary healthcare service indicators (clinic visits; bacille Calmette-Guérin (BCG) vaccinations; measles vaccinations; first pentavalent vaccinations; first antenatal care (ANC) visits; institutional births; postnatal care (PNC) visits within 6 weeks of birth; artemisinin-based combination therapy (ACT) treatments for malaria; acute respiratory infections (ARIs) treated; medroxyprogesterone acetate doses). They found that 4 months into the outbreak (September 2014), healthcare service outputs dropped between 67.3% (measles vaccinations; 95% CI: ?77.9%, ?56.8%, p < 0.001) and 35.2% (first ANC visits; 95% CI: ?45.8%, ?24.7%, p < 0.001) compared to the month preceding the outbreak (May 2014). Encouragingly, health system outputs began rebounding after a nadir in August 2014, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. However, health system outputs are time limited, and the disruption resulted in a loss of an estimated 776,110 clinic visits, 24,449 BCG vaccinations, 9,129 measles vaccinations, 12,941 first pentavalent vaccinations, 5,122 institutional births, 17,191 PNC visits within 6 weeks of birth, 101,857 ACT treatments, and 45,024 treatments of ARIs. The effects of some of these losses (e.g. vaccine-preventable diseases due to missing vaccinations) may persist for years to come.

The authors note several limitations to this study, including unknown impact of the EVD epidemic on quality of record keeping, unknown changes in quality of care, exclusion of Montserrado County, and exclusion of HIV and tuberculosis data. Still, the authors note that this analysis provides important lessons on preparing for and recovering from large scale outbreaks and other interruptions to health systems. They conclude: "Sustained investments in public-sector health system strengthening are needed across EVD-affected countries to close gaps in primary care that occurred during the EVD outbreak, and to build resilient primary healthcare systems capable of mitigating collateral effects of the next emerging epidemic."


Research Article


This study was supported by Partners in Health, Liberia and the Liberian Ministry of Health. No specific funding was received for this study. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

The authors have declared that no competing interests exist.


Wagenaar BH, Augusto O, Beste J, Toomay SJ, Wickett E, Dunbar N, et al. (2018) The 2014-2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010-2016. PLoS Med 15(2): e1002508.

Author Affiliations:

Department of Global Health, University of Washington, Seattle, Washington, United States of America
Partners in Health, Monrovia, Liberia
Health Alliance International, Seattle, Washington, United States of America
Universidade Eduardo Mondlane, Maputo, Mozambique
Brigham and Women's Hospital, Boston, Massachusetts, United States of America
Harvard Medical School, Boston, Massachusetts, United States of America
Ministry of Health, Monrovia, Liberia


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