Community engagement for health system resilience: evidence from Liberia's Ebola epidemic.

The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frameworks to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions collected with health system stakeholders in Liberia in the aftermath of the 2014-15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active participants in-as opposed to passive recipients of-health response efforts and that communication platforms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE-all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evidence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises.

Beyond the crisis: did the Ebola epidemic improve resilience of Liberia's health system?

Resilience was widely identified as a critical attribute for strong health systems following the 2014-15 West Africa Ebola epidemic. In Liberia, Sierra Leone and Guinea, struggles to control the disease and suspension of the operation of many health services demonstrated that health systems must plan for resilience long before a crisis. However, the operational elements of resilience and ways that a crisis experience can shape resilience are not well described in the literature. To understand how a health system adapts to crisis and how the priorities of different health system actors influence this response we conducted interviews with global, national, and local respondents in Liberia between July and September 2015 (n = 108), several months after the country was first declared Ebola-free. We found that health system resilience functions prioritized by global and national actors improved to a greater extent than those valued by community leaders and local health actors over the course of the epidemic. Although the Ebola epidemic stimulated some positive adaptations in Liberia's health system, building a truly resilient health system will require longer-term investments and sustained attention long beyond the crisis.

Can the health system deliver? Determinants of rural Liberians' confidence in health care.

BACKGROUND: Following a protracted civil war, Liberia is rebuilding its health system. One of the aims of reconstruction is to expand access to health care to a previously underserved rural population. OBJECTIVE: This study analysed the determinants of Liberians' confidence in their ability to obtain needed care for themselves or their children in case of serious illness. METHODS: A cross-sectional survey of 1435 adults in Nimba County, Liberia was conducted. Logistic regression models were estimated with reported ability to obtain needed health services for serious illness as the dependent variable, and demographics, health need, health system characteristics and informal health care as independent variables. RESULTS: Overall, 50.56% of respondents reported that they could obtain needed services for themselves or their children. Confidence in the ability to obtain care increased with education [odds ratio (OR) 1.62, 95% confidence interval (CI): 1.19-2.21] and poor physical health in the past 30 days (OR 1.38, 95% CI: 1.01-1.88), and decreased with poverty (OR 0.66, 95% CI: 0.47-0.93), exposure to previous trauma (OR 0.50, 95% CI: 0.36-0.71), dissatisfaction with respondent's last formal health visit (OR = 0.70, 95% CI: 0.54-0.91) and high utilization of the informal health sector (OR = 0.84, 95% CI: 0.73-0.96). No correlation was found between health system confidence and being female, being 35 years old or younger, formal health sector use, being within an hour of a clinic and the closest clinic having basic capabilities. CONCLUSIONS: Respondents' experiences with the health care system had a greater correlation with their confidence in obtaining needed health care than proximity or quality of medical equipment in health clinics. Despite pro-poor policies guiding health system reconstruction, poor and less educated individuals have less confidence that the health system can meet their health needs.