Has Ebola delayed progress on access to routine care and financial protection in Sierra Leone? Evidence from a difference-in-differences analysis with propensity score weighting.

INTRODUCTION: Covid-19 has highlighted the need to understand the long-term impact of epidemics on health systems. There is extensive evidence that the Ebola epidemic of 2014-16 dramatically reduced coverage of key reproductive, maternal, newborn, child and adolescent health (RMNCAH) indicators during the period of acute crisis in Sierra Leone. However, less is known about the longer lasting effects, and whether patients continue to be deterred from seeking care either through fear or cost some years after the end of the epidemic METHODS: We analysed nationally representative household surveys from before (2011) and after (2018) the Ebola epidemic to estimate the coverage of 11 indicators of access to RMNCAH, and affordability of care. We used a differences-in-differences analysis, exploiting the variation in epidemic intensity across chiefdoms, to identify the effect of epidemic intensity on access and affordability outcomes, with propensity score weighting to adjust for differences in underlying characteristics between chiefdoms. RESULTS: 13537 households were included across both datasets. Epidemic intensity was associated with a significant stalling in progress (-12.2 percentage points, 95% CI: 23.2 to -1.3, p = 0.029) in the proportion of births attended by a skilled provider. Epidemic intensity did not have a significant impact on any other indicator. CONCLUSION: While there is evidence that chiefdoms which experienced worse Ebola outbreaks had poorer coverage of attendance of skilled providers at birth than would have otherwise been expected, more broadly the intensity of the epidemic did not impact on most indicators. This suggests the measures to restore both staffing and trust were effective in supporting the health system to recover from Ebola.