Abstract
The 2014-16 Ebola Virus Disease outbreak in West Africa was undoubtedly the largest outbreak in the disease’s history, resulting in significant loss of life, and social and economic disruption, particularly in Liberia, Guinea and Sierra Leone. Several interventions were undertaken to control the outbreak, including substantial financial resources from local and international partners, with the engagement of many external agencies and expertise. The assumption is that if all the financial and human resources acquired during and after the outbreak had been optimally aligned, Liberia would be in a good position to respond definitively in a timely manner to a new Ebola virus incursion. This thesis aimed to assess the performance of the current EVD surveillance system in Liberia, focusing on its ability to detect and respond effectively to a potential outbreak of EVD. We employed three public health investigatory approaches to implement a systematic evaluation, involving: a desk review, secondary data analysis, and key informant interviews; a health facility assessment survey; and a standardised patients study (SP). We integrated the WHO and US CDC guidelines for public health surveillance system evaluation to guide the investigation of the four components of the surveillance system (system structure, core and support functions and system quality). In addition, we adopted standardised Integrated Disease Surveillance and Response (IDSR) performance indicators, with some modifications for local implementation and considering a single disease, to measure the system’s performance in each study. Generally, we confirmed the existence of the necessary surveillance competencies and good performance across all four surveillance components at all of the surveillance levels assessed. However, there were inconsistencies between indicators performances relating to case detection at health facilities – healthcare workers showed good knowledge of the case definition for suspected EVD. Still, they could not detect suspected EVD among SPs presenting early symptoms of EVD per the standard case definition. Adherence to Infection Prevention and Control (IPC) standards at health facilities was poor. The major challenges affecting the operations of the EVD surveillance across all levels included limited or no access to resources to support surveillance activities, persistent stock out of EVD sample collection materials and attrition of trained staff, especially at the subnational levels. We uncovered imbalances in the performance of core and support surveillance functions across the different surveillance levels, especially at health facilities. The disparities in performance across levels reduce the possibility of an effective surveillance system and increase the likelihood that the system may fail to meet its objectives. Therefore, Liberia’s EVD surveillance and response system can detect and respond to potential outbreaks, but it may not do so effectively. There are prospects for improvements to strengthen the current system, and we proposed future research projects to inform progress.