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The 2013–2016 epidemic of Ebola virus disease was of unprecedented magnitude, duration and impact. Analysing 1610 Ebola virus genomes, representing over 5% of known cases, we reconstruct the dispersal, proliferation and decline of Ebola virus throughout the region. We test the association of geography, climate and demography with viral movement among administrative regions, inferring a classic ‘gravity’ model, with intense dispersal between larger and closer populations. Despite attenuation of international dispersal after border closures, cross-border transmission had already set the seeds for an international epidemic, rendering these measures ineffective in curbing the epidemic. We address why the epidemic did not spread into neighbouring countries, showing they were susceptible to significant outbreaks but at lower risk of introductions. Finally, we reveal this large epidemic to be a heterogeneous and spatially dissociated collection of transmission clusters of varying size, duration and connectivity. These insights will help inform interventions in future epidemics.

1 47% of the global population has little to no access to diagnostics. 2 Diagnostics are central and fundamental to quality health care. This notion is underrecognised, leading to underfunding and inadequate resources at all levels. 3 The level of primary health care is the diagnostic so-called last mile and particularly affects poor, rural, and marginalised communities globally; appropriate access is essential for equity and social justice. 4 The COVID-19 pandemic has emphasised the crucial role of diagnostics in health care and that without access to diagnostics, delivery of universal health coverage, antimicrobial resistance mitigation, and pandemic preparedness cannot be achieved. 5 Innovations within the past 15 years in many areas (eg, in financing, technology, and workforce) can reduce the diagnostic gap, improve access, and democratise diagnostics to empower patients. 6 As an example of the potential impact, 1•1 million premature deaths in low-income and middle-income countries could be avoided annually by reducing the diagnostic gap for six priority conditions: diabetes, hypertension, HIV, and tuberculosis in the overall population, and hepatitis B virus infection and syphilis for pregnant women. 7 The economic case for such investment is strong. The median benefit-cost exceeds one for five of the six priority conditions in middle-income countries, and exceeds one for four of the six priority conditions in low-income countries, with a range of 1•4:1 to 24:1.Given the depth and breadth of the problems, sustained access to quality, affordable diagnostics will require multi-decade prioritisation, commitment, and investment.Incorporating diagnostics into universal health coverage packages will begin this process.

Objective Maternity waiting homes (MWHs) can reduce maternal morbidity and mortality by increasing access to skilled birth attendants (SBAs). The present analysis was conducted to determine whether MWHs increase the use of SBAs at rural primary health clinics in Liberia; to determine whether traditional midwives (TMs) are able to work with SBAs as a team and to describe the perceptions of TMs as they engage with SBAs; and to determine whether MWHs decrease maternal and child morbidity and mortality. Methods The present analysis was conducted halfway through a large cohort study in which 5 Liberian communities received the intervention (establishment of an MWH) and 5 Liberian communities did not (control group). Focus groups were conducted to examine the views of TMs on their integration into health teams. Results Communities with MWHs experienced a significant increase in team births from baseline to post-intervention (10.8% versus 95.2%, P<0.001), with greater TM engagement. Lower rates of maternal and perinatal death were reported from communities with MWHs. Conclusion The reduction in morbidity and mortality indicates that the establishment of MWHs is an effective strategy to increase the use of SBAs, improve the collaboration between SBAs and TMs, and improve maternal and neonatal health.

A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.

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BackgroundManagement training is fundamental to developing human resources for health. Particularly as Liberia revives its health delivery system, facility and county health team managers are central to progress. Nevertheless, such management skills are rarely prioritized in health training, and sustained capacity building in this area is limited. We describe a health management delivery program in which a north and south institution collaborated to integrate classroom and field-based training in health management and to transfer the capacity for sustained management development in Liberia.MethodsWe developed and implemented a 6-month training program in health management skills (i.e. strategic problem solving, financial management, human resource management and leadership) delivered by Yale University and Mother Patern College from Liberia, with support from the Clinton HIV/AIDS Initiative. Over three 6-month cycles, responsibility for course instruction was transferred from the north institution to the south institution. A self-administered survey was conducted of all participants completing the course to measure changes in self-rated management skills, the degree to which the course was helpful and met its stated objectives, and faculty members' responsiveness to participant needs as the transfer process occurred.ResultsRespondents (n = 93, response rate 95.9%) reported substantial improvement in self-reported management skills, and rated the helpfulness of the course and the degree to which the course met its objectives highly. Levels of improvement and course ratings were similar over the three cohorts as the course was transferred to the south institution. We suggest a framework of five elements for implementing successful management training programs that can be transferred and sustained in resource-limited settings, including: 1) use a short-course format focusing on four key skill areas with practical tools; 2) include didactic training, on-site projects, and on-site mentoring; 3) collaborate with an in-country academic institution, willing and able to scale-up and maintain the training; 4) provide training for the in-country academic faculty; and 5) secure Ministry-level support to ensure participation.ConclusionOur findings demonstrate key elements for scaling up and replicating educational initiatives that address management skills essential for long-term health systems strengthening in resource-poor settings.

Background: The magnitude of the Ebola outbreak in West Africa is unprecedented. Liberia, Guinea, and Sierra Leone are in the bottom ten countries in the Human Development Index, but all had made gains in child survival prior to the outbreak. With closure of healthcare facilities and the loss of health workers secondary to the outbreak, the region risks reversing survival gains achieved in maternal and newborn health. Methods:Anonymized service utilization data were downloaded from the Liberia District Health Information Software (DHIS) 2 for selected maternal health services at PHC facilities in Margibi and Bong Counties from March 2014, when the first case of Ebola was reported in Liberia, through December 2014. Absolute numbers are provided instead of percentage measures because of the lack of a population-based denominator. Results:Overall, the data show a decrease in absolute utilization from the start of the outbreak, followed by a slow recovery after October or November. In Bong County, totals were less than 14% of the peak numbers during the outbreak for number of antenatal visits and pregnant women receiving intermittent preventive treatment for malaria in pregnancy (IPTp). For total deliveries, utilization was less than 33% of the highest month. In Margibi County, during what now appears to be the height of the outbreak, numbers dropped to less than 9% of peak utilization for antenatal care visits and 4% for IPTp. Total health facility deliveries dropped to less than 9% of peak utilization. Conclusion:It is clear that Bong and Margibi Counties in Liberia experienced a large drop in utilization of maternal health care services during what now appears to be the peak of the Ebola outbreak. As the health of women and their babies is being promoted in the post-2015 sustainable development agenda, it is critical that the issue of maternal and newborn survival in humanitarian emergency settings, like the Ebola outbreak, is prioritized. Funding StatementThis work was supported by Save the Children's Saving Newborn Lives program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. BackgroundThe ongoing Ebola outbreak in West Africa is unprecedented in magnitude, and has devastated the countries of Liberia, Sierra Leone and Guinea since early 2014. While Liberia, Guinea, and Sierra Leone are in the bottom ten countries in the Human Development Index, all three had made gains in child survival prior to the outbreak. Liberia in particular had reduced under-five mortality 71% since 1990 and achieved Millennium Development Goal 4, reducing child mortality by two thirds, three years before the end date of 2015. 1 Although under-five mortality rates have fallen, the rate of progress for children in the first month of life -the neonatal period -has been much slower. 1 Sierra Leone and Guinea are currently amongst the top ten countries with the highest neonatal mortality rates (NMR), and for much of the past two decades, Liberia's NMR was ...