Charting health system reconstruction in post-war Liberia: a comparison of rural vs. remote healthcare utilization.

BACKGROUND: Despite a growing global emphasis on universal healthcare, access to basic primary care for remote populations in post-conflict countries remains a challenge. To better understand health sector recovery in post-conflict Liberia, this paper seeks to evaluate changes in utilization of health services among rural populations across a 5-year time span. METHODS: We assessed trends in healthcare utilization among the national rural population using the Liberian Demographic and Health Survey (DHS) from 2007 and 2013. We compared these results to results obtained from a two-staged cluster survey in 2012 in the district of Konobo, Liberia, to assess for differential health utilization in an isolated, remote region. Our primary outcomes of interest were maternal and child health service care seeking and utilization. RESULTS: Most child and maternal health indicators improved in the DHS rural sub-sample from 2007 to 2013. However, this progress was not reflected in the remote Konobo population. A lower proportion of women received 4+ antenatal care visits (AOR 0.28, P < 0.001) or any postnatal care (AOR 0.25, P <0.001) in Konobo as compared to the 2013 DHS. Similarly, a lower proportion of children received professional care for common childhood illnesses, including acute respiratory infection (9 % vs. 52 %, P < 0.001) or diarrhea (11 % vs. 46 %, P < 0.001). CONCLUSIONS: Our data suggest that, despite the demonstrable success of post-war rehabilitation in rural regions, particularly remote populations in Liberia remain at disproportionate risk for limited access to basic health services. As a renewed effort is placed on health systems reconstruction in the wake of the Ebola-epidemic, a specific focus on solutions to reach isolated populations will be necessary in order to ensure extension of coverage to remote regions such as Konobo.

Using two-component systems and other bacterial regulatory factors for the fabrication of synthetic genetic devices.

Synthetic biology is an emerging field in which the procedures and methods of engineering are extended living organisms, with the long-term goal of producing novel cell types that aid human society. For example, engineered cell types may sense a particular environment and express gene products that serve as an indicator of that environment or affect a change in that environment. While we are still some way from producing cells with significant practical applications, the immediate goals of synthetic biology are to develop a quantitative understanding of genetic circuitry and its interactions with the environment and to develop modular genetic circuitry derived from standard, interoperable parts that can be introduced into cells and result in some desired input/output function. Using an engineering approach, the input/output function of each modular element is characterized independently, providing a toolkit of elements that can be linked in different ways to provide various circuit topologies. The principle of modularity, yet largely unproven for biological systems, suggests that modules will function appropriately based on their design characteristics when combined into larger synthetic genetic devices. This modularity concept is similar to that used to develop large computer programs, where independent software modules can be independently developed and later combined into the final program. This chapter begins by pointing out the potential usefulness of two-component signal transduction systems for synthetic biology applications and describes our use of the Escherichia coli NRI/NRII (NtrC/NtrB) two-component system for the construction of a synthetic genetic oscillator and toggle switch for E. coli. Procedures for conducting measurements of oscillatory behavior and toggle switch behavior of these synthetic genetic devices are described. It then presents a brief overview of device fabrication strategy and tactics and presents a useful vector system for the construction of synthetic genetic modules and positioning these modules onto the bacterial chromosome in defined locations.

Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey.

BACKGROUND: This study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Better understanding the relationship between distance from health facilities and rural health care utilization is important for post-Ebola health systems reconstruction and for general rural health system planning in sub-Saharan Africa. METHODS: Cluster-sample survey data collected in 2012 in a very rural southeastern Liberian population were analyzed to determine associations between quartiles of GPS-measured distance from the nearest health facility and the odds of maternal (ANC, facility-based delivery, and PNC) and child (deworming and care seeking for ARI, diarrhea, and fever) service use. We estimated associations by fitting simple and multiple logistic regression models, with standard errors adjusted for clustered data. FINDINGS: Living in the farthest quartile was associated with lower odds of attending 1-or-more ANC checkup (AOR = 0.04, P < 0.001), 4-or-more ANC checkups (AOR = 0.13, P < 0.001), delivering in a facility (AOR = 0.41, P = 0.006), and postnatal care from a health care worker (AOR = 0.44, P = 0.009). Children living in all other quartiles had lower odds of seeking facility-based fever care (AOR for fourth quartile = 0.06, P < 0.001) than those in the nearest quartile. Children in the fourth quartile were less likely to receive deworming treatment (AOR = 0.16, P < 0.001) and less likely (but with only marginal statistical significance) to seek ARI care from a formal HCW (AOR = 0.05, P = 0.05). Parents in distant quartiles more often sought ARI and diarrhea care from informal providers. CONCLUSIONS: Within a rural Liberian population, distance is associated with reduced health care uptake. As Liberia rebuilds its health system after Ebola, overcoming geographic disparities, including through further dissemination of providers and greater use of community health workers should be prioritized.