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This Viewpoint puts forth a proposed framework for resilient health systems and the characteristics that define them, informed by insights from other fields that have embraced resilience as a practice.

During recent disease outbreaks, quantitative research has been used to investigate intervention scenarios while accounting for local epidemiological, social, and clinical context. Despite the value of such work, few documented research efforts have been observed to originate from low-income countries. This study aimed to assess barriers that may be limiting the awareness and conduct of quantitative research among Liberian public health graduate students. A semi-structured questionnaire was administered September-November 2021 to Master's in Public Health (MPH) students in Liberia. Potential barriers around technology access, understanding of quantitative science, and availability of mentorship were interrogated. Associations between barriers and self-reported likelihood of conducting quantitative research within six months of the investigation period were evaluated using ordinal logistic regression. Among 120 participating MPH students, 86% reported owning a personal computer, but 18.4% and 39.4% had machines with malfunctioning hardware and/or with battery power lasting ≤2 hours, respectively. On average, students reported having poor internet network 3.4 days weekly. 47% reported never using any computer software for analysis, and 46% reported no specific knowledge on statistical analysis. Students indicated spending a median 30 minutes per week reading scientific articles. Moreover, 50% had no access to quantitative research mentors. Despite barriers, 59% indicated they were very likely to undertake quantitative research in the next 6 months; only 7% indicated they were not at all likely. Computer ownership was found to be statistically significantly associated with higher likelihood of conducting quantitative research in the multivariable analysis (aOR: 4.90,95% CI: 1.54-16.3). The high likelihood of conducting quantitative research among MPH students contrasts with limitations around computing capacity, awareness of research tools/methods, and access to mentorship. To promote rigorous analytical research in Liberia, there is a need for systematic measures to enhance capacity for diverse quantitative methods through efforts sensitive to the local research environment.

From the outset of the COVID-19 pandemic, guidance from WHO has promoted social distancing, wearing face masks, frequent hand washing, and staying-at-home as measures to prevent the spread of COVID-19. For many across Africa, compliance can be difficult. The aim of this study was to 1) understand the impact of student's household's ability to comply with COVID-19 mitigation strategies, 2) identify predictors of mitigation strategy compliance, and 3) describe the impact of COVID-19 on household economics, food-security, and mental well-being. We conducted an email-based survey among current medical and pharmacy students of the University of Liberia College of Health Sciences between July and October 2020. The questionnaire was designed to explore their household's ability to comply with current mitigation strategies, as well as the pandemic´s impact on the student's household's finances and food security. Descriptive statistics were used to delineate demographic characteristics. Logistic regression was used to model factors associated with ability to comply with COVID-19 mitigation strategies, as well as participant's food security. 113 persons responded to the questionnaire. Seventy-six (67∙3%) reported income losses as a result of the pandemic, with 93 (82∙3%) reporting being \"somewhat\" or \"very worried\" about their households' finances. Seventy-seven (68∙1%) participants reported food stocks that were sufficient for one-week or less. Forty (35%) participants reported eating less preferred foods or skipping meals in the past week. Overall, 20 participants (19∙4%) had a positive depression screen. Study participants showed mixed results in being able to adhere to national COVID-19 mitigation strategies, with household level stressors experienced around finances and food security. Until Liberia has access to vaccinations for most of its citizens, COVID-19 response measures need to provide social protections that address basic needs (shelter, clothing and food), and which specifically targets food insecurity. Preventative interventions for mental health problems must be incorporated into Liberia's response to the pandemic.

Background It is widely recognized that use of research evidence to guide health policy and practice could lead to adoption of life-saving interventions and more effective resource allocation. However, the skills around research utilization are often assumed and rarely taught, particularly in low- and middle-income country contexts. Here we present a set of competency areas and learning objectives developed for institutionalization of research utilization across health professions schools in Liberia. Ahead of implementation and to gauge their perceived value and utility, a participatory formative evaluation was undertaken. Methods Focus group discussions were held to gain feedback on a set of research utilization learning objectives and the proposed implementation approach. Focus group participants were drawn from faculty and students at the University of Liberia College of Health Sciences (ULCHS), which houses the country’s only medical and pharmacy schools, along with schools of public health and nursing and midwifery. ULCHS serves an essential role in the health workforce pipeline. Results Findings from the focus group discussions identified a limited understanding of research utilization at the ULCHS but a demand for stronger understanding of research methodology and evidence. Participants identified clear examples of how the skills represented in the learning objectives could help specifically their personal careers as well as more broadly the health sector of Liberia. Potential challenges were noted around the incorporation of research utilization learning objectives into existing courses and tended to be logistical (for example, poor internet connectivity and low digital literacy) or around lack of foundational understanding and skills (for example, lack of experience with literature searches and reviews). However, the approach was generally perceived as contextually aware since it would not add new courses, which come with credit fees and extra time commitment, and would focus on practical skills-building rather than theoretical content. Conclusions Integrating research utilization learning objectives into existing curricula in health professions schools is expected to enhance uptake and application of research evidence in the Liberian health sector, as students emerge from the workforce pipeline to fill positions in clinical and policy settings. The success of the approach will warrant ongoing evaluation, along with mentorship of faculty, to increasingly incorporate skills and content of local relevance into courses.

Background Contributing to the high hospital-based maternal, neonatal, and child mortalities in low resource countries and conflict zones is a shortage of health workers, especially physicians. Training programs, conducted over 12 years, have enhanced the skills of midwives, and nurses, to provide high quality, hospital-based, care to pregnant women, newborn infants, children, and adolescents. Methods A task-shifting partnership between the Ministry of Health, World Health Organisation, United Nations Population Fund, United Nations Children’s Emergency Fund and the charity Maternal and Childhealth Advocacy International was established in 2012. Rural county health teams selected 37 midwives, 20 nurses, 1 nurse/midwife and 2 physician assistants, for advanced training. They were appointed following a written examination and interview. Obstetric clinician trainees underwent a 3-year programme, which included operative procedures. The training programs for neonatal and paediatric clinician trainees were 2 years and 2.3 years, respectively. Training consisted of apprenticeship-based training and distance learning. It was delivered by Liberian and international specialists. Trainee competence was established by continuous clinical assessment, oral, and written clinical examinations. The programme also upgraded hospital buildings and provided essential equipment and drugs. Results 59 trainees completed training, 2 failed and 57 qualified in final examinations. 27 are working as obstetric clinicians, 15 are working as neonatal clinicians, and 11 are working as paediatric clinicians. Therefore, 53 are working in 18 hospitals and 4 Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facilities. Obstetric clinicians manage major obstetric emergencies. They perform abdominal surgery, including the management of ruptured ectopic pregnancy and basic and complicated caesarean sections. Neonatal clinicians resuscitate and care for sick and premature babies to WHO Special Care Level 2. Paediatric clinicians manage the main paediatric emergencies that contribute to high mortality. Before the arrival of the international trainer, paediatric mortality in the training hospital was 9.5% and was 4.1% in the final year of training. Conclusions This task shifting programme in Liberia has shown that midwives and nurses can be trained to provide safe and effective hospital care for pregnant women, newborn infants and children. This approach is one solution to the health workforce problem in low resource and conflict settings.

IntroductionGlobal health collaborations between individuals from high-resource and low-resource settings are complex and often built on hierarchical structures and power differentials that are difficult to change. There have been many calls and frameworks developed to facilitate more equity within these collaborations, yet little is known about the lived experiences of global health donors and recipients working within such collaborations and how those experiences can facilitate more equitable collaboration. Liberia, a postconflict, post-Ebola country, provides an ideal setting to study lived experiences of global health collaborations.MethodsOur qualitative analysis used key informant interviews representing the perspectives of those working on behalf of the Liberian government, Liberian academics, foreign donors and non-governmental organisations and implementing partners. Thematic analysis guided this analysis to explore topics such as financial control, accountability and decision making.ResultsThe first phase of the analysis mapped the existing patterns of priority setting. Priority-setting power was most strongly held by those with financial control (donors), and implementation plans tended to be built on metrics that aim to meet donor expectations. The second phase of the analysis explored the interplay between underlying factors that we identified in our data associated with driving collaborative inequity: history of prior of engagement, level of transparency and patterns of accountability.ConclusionsOur findings highlight that global health collaborations in Liberia are structured to hinder equitable partnerships. The power structure tied to financial ownership offers little space for recipients to have an equitable role in collaborations, which maintains dependence on external aid and ensures that weak systems remain weak. While our study is limited to Liberia, we anticipate that these dynamics are common elsewhere and reinforce the importance of intentional efforts to ensure equitable decision making and power structures in similar settings worldwide.

The 5-year Resilient and Responsive Health Systems (RRHS)-Liberia Initiative, funded by PEPFAR via HRSA, launched in 2017 and was designed to support the implementation of Liberia’s National Health Workforce Program as a means to improving HIV-related health outcomes. The COVID-19 pandemic, arrived in Liberia just five years after Ebola and during RRHS-Liberia’s fourth year, impacted educational programs and threatened the project’s continued work. This paper presents the challenges that the COVID-19 pandemic posed to the RRHS partners, as well as adaptations they made to maintain progress towards project goals: 1) contributing to Liberia’s 95-95-95 HIV targets via direct service delivery, and 2) building a resilient and responsive health workforce in Liberia via instruction and training. Direct health service impacts included decreased patient volumes and understaffing; adaptations included development of and trainings on safety protocols, provision of telehealth services, and community health worker involvement. Instruction and training impacts included suspension of in-person teaching and learning; adaptations included utilization of multiple online learning and virtual conferencing tools, and increasing clinical didactics in lieu of bedside mentorship. The RRHS team recommends that these adaptations be continued with significant investment in technology, IT support, and training, as well as close coordination among partner institutions. Ultimately, the RRHS Liberia consortium and its partners made significant strides in response to ensuring ongoing education during the pandemic, an experience that will inform continued service delivery, teaching, and learning in Liberia.

Following civil war and the Ebola epidemic, Liberia’s health workforce was devastated, essential health services and primary care were disrupted, and health outcomes for maternal and child mortality were amongst the worst in the world. To reverse these trends, the government of Liberia developed the Health Workforce Program (HWP) Strategy 2015–2021. With the goal of building a resilient and responsive health system to ensure access to essential services and the ability to respond to future crises, this strategy aimed to add 6,000 new professionals to the workforce. In the context of the COVID-19 pandemic, we share lessons learned from the program’s development and first years of implementation.

Following the Ebola crisis in Liberia in 2014-15, the Liberian Ministry of Health developed a strategy to build a fit-for-purpose health workforce, focusing on both health care providers and health managers. To help fulfill national capacity-building goals for health management, a team of faculty, staff, and practitioners from the Yale School of Medicine, the University of Liberia, the National Public Health Institute of Liberia, and the Ministry of Health collaboratively developed and launched the health management program in Liberia in July 2017. The team worked to build specific management and leadership competencies for healthcare workers serving in management and leadership roles in Liberia's health sector using two concurrent strategies-1) implementation of a hospital-based partnership-mentorship model in the two largest hospitals in the capital city of Monrovia, and 2) establishment of an executive education-style advanced Certificate in Health Systems Leadership and Management at the University of Liberia. Here we describe the health management program in Liberia, its focus, and its evolution from program launch in 2017 to the present, as well as ongoing efforts to transition program activities to local partner ownership by the end of 2021.

The 2014-2016 Ebola virus disease (EVD) outbreak in Liberia highlighted the importance of robust preparedness measures for a well-coordinated response; the initially delayed response contributed to the steep incidence of cases, infections among health care workers, and a collapse of the health care system. To strengthen local capacity and combat disease transmission, various healthcare worker (HCW) trainings, including the Ebola treatment unit (ETU) training, safe & quality services (SQS) training and rapid response team (RRT), were developed and implemented between 2014 and 2017. Data from the ETU, SQS and RRT trainings were analyzed to determine knowledge and confidence gained. The ETU, SQS and RRT training were completed by a total of 21,248 participants. There were improvements in knowledge and confidence, an associated reduction in HCWs infection and reduced response time to subsequent public health events. No infections were reported by healthcare workers in Liberia since the completion of these training programs. HCW training programmes initiated during and post disease outbreak can boost public trust in the health system while providing an entry point for establishing an Epidemic Preparedness and Response (EPR) framework in resource-limited settings.