Bernice Dahn

What is a resilient health system? Lessons from Ebola

The fragility of health systems has never been of greater interest—or importance—than at this moment, in the aftermath of the worst Ebola virus disease epidemic to date. The loss of life, massive social disruption, and collapse of even the most basic health-care services shows what happens when a crisis hits and health systems are not prepared. This did not happen only in west Africa— we saw it in Texas too: the struggle to provide a coherent response and manage public sentiment (which often manifests as fear) in a way that ensures that disease does not spread while also allowing day-to-day life to continue. In other words, we saw an absence of resilience. This Viewpoint puts forth a proposed framework for resilient health systems and the characteristics that defi ne them, informed by insights from other fi elds that have embraced resilience as a practice. Health system resilience can be defi ned as the capacity of health actors, institutions, and populations to prepare for and eff ectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath. Resilient health systems can also deliver everyday benefi ts and positive health outcomes. This double benefi t—improved performance in both bad times and good—is what has been called “the resilience dividend”. Response to a crisis, be it a disease outbreak or other disruption resulting in a surge of demand for health care (eg, a natural disaster or a mass casualty event) needs both a vigorous public health response and a highly proactive and functioning health-care delivery system. These two systems must work in concert during a crisis—and indeed long before crisis strikes. Health-care systems are complex adaptive systems and resilience is an emergent property of the health system as a whole rather than a single dimension. Building resilience is thus context-dependent and iterative, needing advance assessments of system capacities and weaknesses, investments in vulnerable components of the system before a crisis, reinforcements during the emergency, and review of performance after a crisis. Resilience is not a static construct—for example, the rapid pace of recovery from crisis is a cardinal measure of success. The Ebola epidemic has illustrated that several preconditions for resilience were lacking. The fi rst of these preconditions is recognition of the global nature of severe health crises and clarity about the roles of actors at all levels of the global health system. Although national governments are fundamentally responsible for their health systems, they need the capacity to mobilise the full range of local actors and to rapidly draw on external resources if necessary. The need for a global resilience network is both a moral imperative and a recognition of the fact that pathogens do not respect borders. Shocks to the health system of one country can reverberate across regions and the world. Health system resilience is thus a global public good and needs a collective response from the global community. Funding for this response can come from traditional domestic and donor sources or, as recently suggested, a new international health systems fund to which all countries contribute. A second precondition is a legal and policy foundation to guide the response and establish accountability. The implementation of International Health Regulations, which call on countries to build core public health capacities and establish a means of coordinating a response to health emergencies with regional and global partners, is a prerequisite for eff ective emergency response. Additionally, legislation that clarifi es the authority of public health agencies and the roles and responsibilities of private and public health actors is needed as are policies for involving the private and voluntary sector in the response and allowing fl exibility in sharing and reallocating resources across the health system. Third, there is a need for a strong and committed health workforce, characterised by health personnel who show up for work that might be diffi cult and dangerous. Establishing such a workforce begins with training and deployment of a suffi cient number of doctors, nurses, managers, and outreach workers—a colossal task in a country such as Liberia with a population of 3·5 million people and fewer than 100 doctors—but also building and banking a stock of social capital in the health system before crisis strikes. Just as strong social capital in communities promotes individual psychological resilience after mass trauma, social capital in the health system promotes system-wide recovery from crisis. In the health system context, social capital has two dimensions: a sense of worth, community, and responsibility among health actors (clinicians, managers, engineers, outreach workers) and an inclusive and robust community engagement with the health system. Health systems that earn the trust and support of the population and local political leaders by reliably providing high-quality services before crisis have a powerful resilience advantage. Strong management of district level health systems is key to gaining that trust. Diverse fi elds such as ecology, engineering, complex adaptive systems, psychology, and public health have produced resilience frameworks. The Rockefeller Foundation has developed substantial data about resilient Lancet 2015; 385: 1910–12

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

OBJECTIVE To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. DESIGN Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. SETTING Sixteen county hospitals in Liberia. MAIN OUTCOME MEASURES Infrastructure, personnel, procedures performed, and supplies and equipment available. RESULTS Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. CONCLUSIONS The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014

As the disease spread, the scale of the epidemic required a multi-faceted public health response.

Maternity waiting homes and traditional midwives in rural Liberia

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.

Introducing health facility accreditation in Liberia

Abstract In recent years, dozens of countries have introduced accreditation and other quality improvement initiatives. A great deal of information is available regarding best practices in high- and middle-income countries; however, little is available to guide developing nations seeking to introduce an accreditation programme. This paper describes the outputs and lessons learned in the first year of establishing an accreditation programme in Liberia, a developing nation in West Africa that in 2003 emerged from a brutal 14-year civil war. The Liberian experience of developing and implementing a government-sponsored, widespread accreditation programme may provide insight to other low-income and post-conflict countries seeking a way to drive rapid, system-wide reform in the health system, even with limited infrastructure and extremely challenging conditions.

Services for mothers and newborns during the ebola outbreak in liberia: the need for improvement in emergencies.

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.

Interrupting Ebola Transmission in Liberia Through Community-Based Initiatives

On 6 March 2014, Ebola virus disease spread from Guinea to Liberia, sparking an unprecedented outbreak. At the peak of the epidemic in western Africa, Liberia was the most affected country (1). Despite its extraordinary resource constraintsper capita gross domestic product is much lower than that of Guinea or Sierra Leone (2)Liberias steep epidemic trajectory was reversed several weeks before that of those countries. This article details the community-based initiative (CBI) that was instrumental to the shift in transmission dynamics. In the design of public health strategies, organizational and cultural sensitivity, as well as an awareness of infrastructure constraints, are fundamental to promoting adherence to policy recommendations (3, 4). Inadequate consideration of these factors hindered the initial top-down Ebola response in western Africa. Slum and ethnic settlements tend to have cultures characterized by rituals of prevailing tribal groups and a strong sense of connectedness among persons who have lived together for decades. Externally led interventions, such as quarantine and body collection, that did not engage regarded community leaders led to distrust for and underuse of these interventions. In addition, the infrastructural constraints of these impoverished communities, including the lack of running water and overcrowding, made such recommendations as hand washing and isolation of the sick inapplicable (Table). Table. Community Reaction to Misalignment Between Cultural Practice and Public Health Policies In August 2014, unmitigated transmission in West Point, Monrovias largest slum, was recognized as a potentially insurmountable threat to disease containment. Here, we focus on the outbreak in West Point as a case study that can inform the future control of Ebola in the worlds most challenging settings. A Case Study: West Point The first suspected case in West Point was reported to the National Ebola Incident Management System on 6 August 2014. The slum was particularly vulnerable to intense transmission given the cramped conditions of more than 80000 persons living in less than a half square kilometer without municipal water or a sewage system and only 1 physician for the entire community (5). Poverty compounded the distrust of external authorities, including skepticism about whether the Ebola outbreak was real (6). Initially, no Ebola treatment unit facilities were available in West Point to isolate infected patients. A holding center was opened for interim isolation. When it began to receive patients from outside of West Point, unrest erupted over concern that disease was being imported into the community. On 18 August, the center was ransacked and contaminated materials were looted. To prevent the spread of Ebola, the government quarantined the entire slum on 20 August using police and military forces, leading to clashes with the community and the death of a boy shot in his legs. Members of the Ebola Incident Management System with ties to the local community recognized that a less-invasive approach would be needed to achieve acceptance of the interventions. Although West Point residents typically resist government policies, trust for community leaders is unwavering. Harnessing the cooperation of local leaders to build trust between the community and public health authorities was paramount to the successful control of Ebola. On 17 September, a district-wide program was piloted to enhance awareness of and participation in response efforts, with an external team of public health advisors providing guidance (Figure). Coordinators from the Ministry of Health identified districts with active Ebola transmission to engage with the CBI. Community, tribal, and religious leaders, as well as other stakeholders, were invited to an open meeting where they were encouraged to express their thoughts about the Ebola response and propose ways to facilitate public health efforts. The community then organized a team to comprehensively map the area to assess human resource requirements. Figure. Components of the CBI. CBI = community-based initiative. The community leaders who attended the initial meeting recruited community members for a 1-day training session on active surveillance. Each CBI-employed community member was assigned approximately 25 households for daily surveillance. At the training session, county-level CBI coordinators reviewed data collection forms with community members. Supervisors received and were trained to use a mobile telephone preloaded with a user-friendly application for submitting data in real time to inform rapid-response action by case investigation, contact tracing, burial, and ambulance teams. Trained community members collected forms each day that reported on the sick, dead, visitors, and other factors that influenced Ebola transmission in their communities. A hierarchical reporting and coordinating structure was executed, with the community members submitting these forms to their immediate supervisors, who sent aggregate data to the district-level supervisors. The United Nations Development Programme funded CBI training and employed community members and coordinators. Altogether, 6500 persons were employed and equipped for 6 months at a cost of approximately

Reducing under-reporting of stigmatized health events using the List Experiment: results from a randomized, population-based study of abortion in Liberia

65000 (U.S. dollars). Within 24 hours of launching the CBI in West Point, 42 persons with Ebola-like symptoms were identified and transported to Ebola treatment units. Furthermore, the CBI uncovered 34 deaths from suspected Ebola and several secret burials that had not been reported as a result of mistrust of authorities or concern about stigma. The CBI team and local leaders developed a procedure to deliver food and offer social support to make household-based quarantine of contacts feasible. Ultimately, the door-to-door assessments in West Point were accomplished by 152 active case finders, 15 psychosocial support workers, 8 supervisors, and 2 district leaders. After the success in West Point, the Liberian Ministry of Health commissioned a scale-up of the CBI to Ebola hotspots throughout Montserrado County. By 21 September, the CBI was deployed in 6 districts. The implementation of these initiatives substantially improved contact-tracing cooperation and adherence to case isolation. For cases in the districts where the CBI was being implemented, the average number of contacts reported increased from 7.6 to 9.9 and mean time from symptom onset to isolation decreased from 6.5 to 4.7 days. This decrease in duration until isolation is crucial to reduce transmission, because viral load and thus infectiousness of patients with Ebola increase substantially over the course of infection (7). Latest Outbreak In July 2015, a new outbreak emerged in Margibi County, Liberia, where a teenage boy with Ebola was misdiagnosed with malaria. Contact-tracing efforts and the CBI were deployed in parallel to follow known contacts and conduct community-driven surveillance, respectively. A CBI team of 75 community members visited 397 households in the vicinity, identifying 126 contacts who were followed for 21 days. This community mobilization curtailed transmission before any tertiary cases emerged. The success of this effort starkly contrasts with the spiraling epidemic observed a year before, fueled by a similar number of secondary cases before the CBI was initiated. Conclusion By engaging and empowering local communities, the CBI was instrumental to cooperation with contact tracing and accelerating case isolation. This strategy is both feasible and effective in the resource-constrained settings of many western African countries. Leaders of the Liberian CBI are currently advising the Sierra Leone Ministry of Health on the implementation of community-driven efforts to control its outbreak that has yet to be extinguished. More broadly, the momentum of community involvement spurred by the Ebola response provides an opportunity for sustained improvement in the public health infrastructure in Liberia and other western African countries.

Pregnancy outcomes in Liberian women who conceived after recovery from Ebola virus disease

BACKGROUND Direct measurement of sensitive health events is often limited by high levels of under-reporting due to stigma and concerns about privacy. Abortion in particular is notoriously difficult to measure. This study implements a novel method to estimate the cumulative lifetime incidence of induced abortion in Liberia. METHODS In a randomly selected sample of 3219 women ages 15–49 years in June 2013 in Liberia, we implemented the ‘Double List Experiment’. To measure abortion incidence, each woman was read two lists: (A) a list of non-sensitive items and (B) a list of correlated non-sensitive items with abortion added. The sensitive item, abortion, was randomly added to either List A or List B for each respondent. The respondent reported a simple count of the options on each list that she had experienced, without indicating which options. Difference in means calculations between the average counts for each list were then averaged to provide an estimate of the population proportion that has had an abortion. RESULTS The list experiment estimates that 32% [95% confidence interval (CI): 0.29-0.34) of respondents surveyed had ever had an abortion (26% of women in urban areas, and 36% of women in rural areas, P-value for difference < 0.001), with a 95% response rate. CONCLUSIONS The list experiment generated an estimate five times greater than the only previous representative estimate of abortion in Liberia, indicating the potential utility of this method to reduce under-reporting in the measurement of abortion. The method could be widely applied to measure other stigmatized health topics, including sexual behaviours, sexual assault or domestic violence.

A Geospatial Evaluation of Timely Access to Surgical Care in Seven Countries/Evaluation Geospatiale De L'acces En Temps Voulu Aux Soins Chirurgicaux Dans Sept pays/Una Evaluacion Geoespacial del Acceso Oportuno a la Atencion Quirurgica En Siete Paises

BACKGROUND: Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie(R) birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health providers knowledge skills and confidence evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package - involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice - has an effect on the occurrence of haemorrhage-related morbidity and mortality. METHODS/DESIGN: In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded. Intention-to-treat analysis will be used taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health providers skills care and interventions and health system readiness. DISCUSSION: This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201604001582128 . Registered on 12 April 2016.