Introduction
The recent outbreak of Ebola virus disease (EVD) has been unprecedented in magnitude, duration and geographic spread. As of 5 August 2015, it has caused over 27 862 cases and 11 281 deaths in Guinea, Liberia and Sierra Leone.1 Roughly 40% of all cases and deaths were recorded in Liberia.
While the direct effects of the outbreak on EVD mortality have been estimated in official figures, little is known about the outbreak's indirect effects on non-EVD health outcomes or health-seeking behaviour. Although previous research suggests the indirect effects of EVD are likely substantial,2 these studies have predominantly relied on extrapolation from pre-existing data on health-seeking behaviour to estimate potential health impacts. Many of these predictions are quite dire, but their severity depends on the validity of the underlying assumptions about reduced health service utilisation. Moreover, few of these studies allow for behavioural change during the outbreak, which can also influence patterns of demand of health services.
The outbreak had a devastating effect on affected countries. During its peak, most employers, government institutions, non-governmental organisations (NGOs) and international corporations ceased operations, causing widespread unemployment and increased food insecurity.3 Incidents of civil unrest flared throughout the region, and states of emergency further limited economic activity. In Liberia, the government declared a state of emergency that was in effect from early August through mid-November, closed schools, imposed a curfew and limited public gatherings. Household quarantines were common, and citizens were encouraged to stay home and prevent the entry of strangers into their community.
Theoretically, the outbreak may have indirectly affected non-EVD health outcomes through several channels, the most obvious of which is the massive disruption to health systems in affected countries (we refer to this set of factors as ‘supply-side’ factors). By the end of March 2015, roughly 3–4% of the health workforce in select health professional categories had become infected, and at least two-thirds of those had died.4 As much as 8% of Liberia's stock of doctors, nurses and midwives may have been lost to the disease.5 The outbreak disrupted the delivery of non-EVD health services, including routine immunisation,6 maternal and child health programmes,7 ,8 malaria control9 and HIV treatment services.10 As a result, it has been estimated that maternal mortality may have doubled, and child mortality rates may have risen by 20% in Liberia.5 During the peak of the outbreak, many health facilities were closed due to the lack of staff, many of whom stayed home due to fear of contracting the disease.11 However, some of the health system changes may have had positive effects: efforts to promote handwashing and a reduction in contact between individuals may have contributed to a lower incidence of diarrheal or other infectious diseases.
Beyond its effect on health systems, Ebola may have affected demand-side factors that influence health-seeking behaviour. The crisis brought risk and uncertainty to affected communities, particularly during the peak of the epidemic.12 Rumours that Ebola was a government conspiracy were common in all three of the highly affected countries.13 As a result, sick people may have stayed home because they lacked trust in public services or feared contracting the virus. Indeed, trust has been associated with usage of health services in Liberia and other contexts.14 Direct exposure to the outbreak—such as knowing Ebola victims, witnessing dead bodies or other traumatic experiences—may have further increased fear and distrust.
The response of governments, NGOs and communities may also have affected demand for health services. In the case of Liberia, the Ministry of Health and Social Welfare and international NGOs (INGOs) conducted community outreach to build trust and increase compliance with prevention policies.11 These efforts commonly involved door-to-door canvassing by government-sponsored or NGO-sponsored workers to educate residents about proper preventative techniques and inform residents about the response efforts by government and NGOs. These activities could have increased demand for health services if they served to dispel rumours, build trust in authority or reduce fear.15
Understanding the outbreak's non-EVD health impacts—and the pathways by which they occur—is essential for rebuilding the health system in Ebola-affected countries and for improving the response to future health crises.16 Using panel household survey data collected in the late-crisis and postcrisis periods in Monrovia, Liberia, this paper documents trends in the prevalence of reported illness and subsequent health-seeking behaviour. It also documents the determinants of health service utilisation during the late-crisis and postcrisis periods.