Health Systems Reconstruction Among Remote Populations: Trends From Rural Liberia Prior to the Ebola Epidemic

Abstract

Background: The weak health network in post-war Liberia is likely a primary contributor to the unprecedented 2014 Ebola outbreak in West Africa. This paper seeks to assess gaps in the health system prior to the epidemic by evaluating changes in access to maternal and child health services in a remote region compared to rural averages from 2007-2013. Methods: We conducted a two-staged cluster survey in 2012 in the remote district of Konobo, Liberia. Our primary outcomes of interest were access to prenatal, peri-natal and postnatal care, and access to sick child services. We compared results from our survey to the rural sub-samples from the Demographic and Health Survey (DHS) in 2007 and 2013 to assess for differential service utilization in remote regions. Results: Although most child and maternal health indicators improved in the DHS rural sub-sample from 2007 to 2013, this progress was not reflected in the remote Konobo population. Fewer women received 4+ antenatal care visits (OR 0.28, P< 0.001) and any postnatal care (OR 0.25, P<0.001) in Konobo as compared to the 2013 DHS. Similarly, fewer children received professional care for common childhood illnesses, including acute respiratory infection (9% vs 52%, P<0.001) and diarrhea (11% vs. 46%, P< 0.001). Conclusions: Even before the Ebola epidemic, residents in remote areas of Liberia had severely limited access to basic services. Most indicators remain below 2013 levels, despite the overall progress seen elsewhere in rural Liberia from 2007-2013. As attention turns to rebuilding the healthcare infrastructure in Liberia, a specific focus on remote areas will be crucial.