Text below taken from “Patterns of demand for non-Ebola health services during and after the Ebola outbreak: panel survey evidence from Monrovia, Liberia,” Ben Morse, Karen A Grépin, Robert A Blair, Lily Tsai, BMJ Global Health . Full article can be read online here.


Introduction. The recent Ebola virus disease (EVD) outbreak was unprecedented in magnitude, duration and geographic scope. Hitherto there have been no population-based estimates of its impact on non-EVD health outcomes and health-seeking behaviour.

Methods. We use data from a population-based panel survey conducted in the late-crisis period and two postcrisis periods to track trends in (1) the prevalence of adult and child illness, (2) subsequent usage of health services and (3) the determinants thereof.

Results. The prevalence of child and adult illness remained relatively steady across all periods. Usage of health services for children and adults increased by 77% and 104%, respectively, between the late-crisis period and the postcrisis periods. In the late-crisis period, (1) socioeconomic factors weakly predict usage, (2) distrust in government strongly predicts usage, (3) direct exposure to the EVD outbreak, as measured by witnessing dead bodies or knowing Ebola victims, negatively predicts trust and usage and (4) exposure to government-organised community outreach predicts higher trust and usage. These patterns do not obtain in the post-crisis period.

Interpretation. Supply-side and socioeconomic factors are insufficient to account for lower health-seeking behaviour during the crisis. Rather, it appears that distrust and negative EVD-related experiences reduced demand during the outbreak. The absence of these patterns outside the crisis period suggests that the rebound after the crisis reflects recovery of demand. Policymakers should anticipate the importance of demand-side factors, including fear and trust, on usage of health services during health crises.

Key questions

What is already known about this subject?
Model-based studies on the impact of the Ebola outbreak on health outcomes in heavily affected countries have predicted large increases in non-Ebola morbidity due to declines in the use of preventative and curative services. However, these studies rely on modeling assumptions and/or extrapolation from pre-crisis data rather than population-based estimates of health service utilisation during the crisis.

What are the new findings?
We use panel data from a household survey conducted in the late-crisis (December 2014) and two postcrisis periods (March 2015 and June 2015) to estimate the prevalence of health service utilisation for adult and child illness in Monrovia, Liberia. We document a 77% increase in health service utilisation for child illness and a 104% increase for adult illness between December 2014 and March 2015. These increases persist through June 2015. We find that distrust in government, knowing victims or witnessing dead bodies negatively predict health service usage, while experience with government-organised community outreach positively predicts usage during the crisis.

In Monrovia, health service utilisation rebounded rapidly after the end of the crisis. The recovery cannot be explained by supply-side or socioeconomic factors. Rather, distrust in government and negative experiences during the outbreak appear to be a major reason why people did not use health services during the outbreak. After the crisis, utilisation quickly recovered.

Recommendations for policy and practice
Policymakers should anticipate the influence of demand-side factors, including trust and negative EVD-related experiences, on usage of health services during health crises. Building trust through community outreach may be an effective intervention to increase the resilience of health systems during epidemics.