Background
WHO health system building blocks
Methods
Search strategy
Sample | Guinea, Liberia and Sierra Leone |
Phenomenon of Interest | 2014/2015 Ebola outbreak |
Design | Reviews and reports |
Evaluation | Ebola outbreak and health systems organisation and performance |
Research type | Qualitative studies |
Number | Search | Results |
---|---|---|
1 | (ebola or EVD or ebolavirus or EHF).mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] | 4913 |
2 | Hemorrhagic Fever, Ebola/ | 1844 |
3 | 1 or 2 | 4913 |
4 | (Sierra leone or liberia or guinea or west* africa).mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] | 163,908 |
5 | Sierra Leone/ | 853 |
6 | Liberia/ | 750 |
7 | Guinea/ | 549 |
8 | Africa, Western/ | 4467 |
9 | 4 or 5 or 6 or 7 or 8 | 165,741 |
10 | (health* adj3 (workforce or labo?r or personnel or manpower or staff or leadership or govern* or human resource* or financ* or pay* or expenditure or fund* or manag* or admin* or regulat* or technolog* or service* deliver* or information or research* or surveillance)).mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] | 325,886 |
11 | Health Manpower/ | 11,641 |
12 | Health Expenditures/or Financing, Government/or Financial Management/or Healthcare Financing/or Health Services Accessibility/ | 100,798 |
13 | “Delivery of Health Care”/ | 69,493 |
14 | Health Promotion/or Consumer Health Information/or Health Education/or Information Services/ | 120,760 |
15 | Health Services Research/ | 32,015 |
16 | “Equipment and Supplies”/ | 18,766 |
17 | Program Development/or Leadership/or Public Health Administration/or Health Priorities/ | 75,067 |
18 | Public Health Surveillance/or Population Surveillance/ | 49,607 |
19 | (Health* system* or WHO building block* or World health organi?ation building block* or surveillance or medical product* or service delivery).mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] | 204,965 |
20 | 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 | 790,837 |
21 | 3 and 9 and 20 | 147 |
Study selection (inclusion and exclusion criteria)
Inclusion criteria | Exclusion criteria |
---|---|
2014/2015 Ebola outbreak | Ebola outbreaks before 2014 |
Guinea, Liberia, Sierra Leone | Other countries |
Only papers published in English | Any other outbreaks apart from Ebola (like haemorrhagic fevers) |
Reports from Internationally recognised organisations (WHO, CDC, MSF) | Articles on randomised control trials, vaccines, treatments, clinical picture, disease manifestations, ethical considerations |
Review articles | Non English papers |
Articles on the health systems in these three countries | Articles on military and international interventions, modelling and epidemiological analysis |
Opinions, perspectives, editorials and commentaries |
Data extraction and analysis
Study no. | Author | CCAT Score (/40) | Study design and methods (design & research type) | Title | Aims (phenomenon of interest) | Study area and year (sample) | Objective | Health system building block(s) | Key findings (evaluation) |
---|---|---|---|---|---|---|---|---|---|
1 | Alexander et al. | 16 | Review of literature on the challenges and opportunities that led to the Ebola outbreak. | What Factors Might Have Led to the Emergence of Ebola in West Africa? | Review the sociological, ecological and environmental drivers that might have influenced the emergence of Ebola in this region of Africa and its spread throughout the region. The paper also offers recommendations that might support enhanced country level preparedness in Africa. | Guinea, Liberia, Sierra Leone - 2015 |
Impacts the Ebola outbreak brought about on the existing health systems in Guinea,
| Health workforce | * Ebola jeopardised the reputation of staff as they were harshly stigmatized and rejected by their communities and families. This made the community turn against seeking health from fear of contracting Ebola from staff. * By September 2014, in the West African outbreak, 10% of who died were health staff. Lack of health staff in hospitals made other staff work longer and harder leading to exhaustion and increased potential for fatal mistakes. |
2 | Buseh et al. | 22 | Review. Our approach is guided by the use of literature in peer-reviewed journals on disease burden and health system reforms in developing countries, specifically in sub-Saharan West African countries. Periodicals released by international organizations, including the United Nations Development Program, WHO, United States Agency for International Development, and the World Bank, on global health challenges were also relied on to critically examine the health, socio-political, and economic conditions and to identify the priority and policy areas discussed in this article. We extrapolated from these the studies to critically examine the challenges and opportunities that, if understood and addressed, can effectively contribute to halting the spread of Ebola and potential infectious diseases specific to the West African setting. | The Ebola epidemic in West Africa: challenges, opportunities, and policy priority areas | (a) critically examine the socio-political and economic conditions that created the environment for the Ebola epidemic to occur, (b) identify challenges to and opportunities for the prevention and control of Ebola and future outbreaks, (c) Discuss policy recommendations and priority areas for addressing the Ebola epidemic and future outbreaks in West Africa. | Guinea, Liberia, Sierra Leone - 2015 |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Medical products and technology/service delivery | * Due to lack of proper transportation and ambulances, access to supportive medical needs and primary care services was compromised. * There was a severe lack of medical equipment (PPE) and supplies. Equipment were used more than once and this led to more infection transmission between health personnel and increase in comorbidities. * There is also a shortage in technologies used for diagnosis and disease management. * There is also poor road networks, lack of electricity, no medical records and poor information and technologies for rapid access to medical services. |
Information and research | * Disease surveillance is very limited in West Africa and health centres face logistical issues on a regular basis. * African traditional healer are the first point of access for health services in rural areas. This happened due to the lack of adequate treatments for patients. (Clash of Ethno-medicine with Biomedicine)
| ||||||||
Health workforce | * The three countries are emerging from civil wars and this deprived them from properly trained and competent enough healthcare workers. Prior to Ebola, democracy was still taking place and the countries’ health staff were trying to serve the population’s health needs in-spite the slow economic growth and development of these countries. | ||||||||
Health financing | Severe shortage of funds for the purchase of supplies and the investment in the infrastructure. | ||||||||
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone
| Health workforce | * Staff that were experienced in prevention and treatment of infectious diseases were the frontline victims in this outbreak while they were trying to treat the cases. This caused a deprivation in health workforce in the already weak health system. * Ebola took the motivation of nurses to work and the lives of prominent doctors and nurses depriving the countries from the experienced and dedicated medical teams. | |||||||
3 | Gostin et al. | 16 | A review and analysis on the health system problems in West Africa. The papers offers recommendation for policy reforms | A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex | Suggest leadership innovative reforms to transform the worldwide health system into a purposeful organised one. | Guinea, Liberia, Sierra Leone - 2015 |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Health workforce | There was a huge gap in the health workforce involved in the outbreak control and human resources response required and international action. Apart from international support, there was still shortages in health workforce supply at the Ebola treatment centres despite the Ebola cases rising in December in Sierra Leone. The UN estimated that more than 1000 international staff are still needed. |
4 | Trad et al. | 10 | Review of pervious literature on technological approaches to link patients with health care facility. The paper proposes an SMS approach to link patients with health facilities. | Guiding Ebola patients to suitable health facilities: an SMS-based approach | SMS based approach to help map closest health facilities for Ebola patients | Guinea, Liberia, Sierra Leone - 2015 |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Medical products and technologies | * Patients had the problem of finding the closest health facilities with adequate supplies and resources. They were also confused to whom to report the cases. |
Report number | Author | Title | Objective | Building block | Relevant data extracted and results |
---|---|---|---|---|---|
1 | WHO | How Liberia reached zero cases of EVD | Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Leadership and governance | Leadership and coordination of the country president, health officials and the government was adequate. Presidential advisory committee on EVD was established and introduction of an incident management system helped ensure that resources and capacities were placed when needed. Health officials realised the importance of community engagement and responded accordingly. |
Health financing | This added more supplies, human resources, more treatment beds, increased laboratory capacity, more contact tracing and ensured safe burial teams were deployed. Funding helped installation of transparent walls around treatment centres allowing families and friends to watch what was happening, thus increasing trust. Funding helped increase transportation to treatment facilities. Most of this was international funding. | ||||
2 | WHO | Ebola virus disease (EVD) in West Africa: an extraordinary epidemic | Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak | Information and research | Limited EVD detection and diagnostics facilities was a reason for the silent progress of Ebola in West Africa. |
Medical products and technologies | Health centres lack resources to implement basic infection prevention measures. | ||||
Health workforce | Limited health workforce was noticed and this added a burden on health centres leading them to more infection transmission and slow response. | ||||
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Health workforce | The epidemic was characterised by the high numbers of health care personnel infected by the disease. In the 3 countries, more than 800 contracted the disease and more than 500 died. | |||
3 | WHO | Report of the Ebola interim assessment panel | Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak | Information and research | The panel found that there was no data collection, aggregation, analysis or shared in a timely manner and sometimes not at all. There was also lack of proper surveillance. |
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Health workforce | There was a noticed short deployment of personnel. This added to the outbreak chaos where there as a constant, rapid turnover of staff and some didn’t have the required capacities. There was a shortage in the coherent human resources management process as some were confused of their exact job description and to whom to report. | |||
4 | CDC | A plan for the community event-based surveillance to reduce Ebola transmission – Sierra Leone, 2014–2015 | Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Information and research | Community Event – Based Surveillance (CEBS) system was developed to help strengthen the country’s Ebola surveillance and response capabilities. It is developed to supplement case finding and contact tracing, the core of Ebola surveillance in the West African response. CEBS started in a few low and medium transmission districts and will be deployed to other parts of Sierra Leone. |
5 | CDC | Use of a nationwide call centre for Ebola response and monitoring during a 3 day house to house campaign – Sierra Leone, September 2014 | Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Information and research | A national Ebola toll free call centre was established in Sierra Leone by the Emergency Operations Centre. This helped to report cases and deaths to public health officials and offers health education messages to the public. This also helps supporting surveillance and alerting any emergencies. Public health officials, then respond promptly delegating tasks to the concerned personnel and start contact tracing and follow up (such as safe transportation of Ebola patients to treatment units or safe burials) |
6 | CDC | Rapid assessment of Ebola infection prevention and control needs--six districts, Sierra Leone, October 2014 | Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak | Medical products and technology. | * There was insufficient PPE supplies, running water, incinerators, chlorine and blood collection supplies all over the three countries. * Due to delays in patient transport and bed availability, home care took place and carers were not trained on ow to deal with cases properly. * There were delays in transporting patients and specimens due to limited availability of ambulances and fuel. The vehicles were not even properly decontaminated. This risks the lives of the teams and the suspected patients. The time between confirming results was long and this jeopardised the process of separation of patients suspected from confirmed in holding centres. |
Health workforce | * Health systems in the three countries lack adequate number of trained and competent staff in IPC. There was also lack of payments in addition to this shortage that lead more staff to leave and this was compounded by the staff fatigue from the burden of having more patients. IPC training wasn’t properly given to staff, ambulance teams and cleaners where as some burial teams and laboratory technicians had some trainings. This made them unable to safely screen or isolate suspected Ebola cases before transport health centres for treatment. | ||||
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Information and research | IPC training protocols and programs were developed by the MoH in Sierra Leone. There was also monitoring and evaluation programs for the IPC implementation and quality assurance using IPC metrics. The National Ebola IPC ensures that gaps are identified and responses offered promptly. | |||
7 | CDC | Assessment of Ebola virus disease, health care infrastructure, and preparedness – four counties, South-eastern Liberia, August 2014 | Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak | Medical products and technologies. | * There was shortage in gloves, hand washing stations, water jugs (in case there was no water stations), PPE (and staff were not trained in using it), soap, bleach, alcohol hand gel and there was no adequate water nor electricity. Bamboo washing stations were created to compensate for this shortage. There was no waste disposal nor isolation facilities. * There was no proper connections in place as internet, phone signals or even radio. * Transportation was also a major challenged for patients and specimens transport. |
Information and research | No surveillance nor training on case investigation, case management, contact tracing, or safe burial practices had been was offered in counties and hospitals. | ||||
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Health workforce | Nurses abandoned facilities, staff left Liberia and in some cases, staff were not paid for three months. | |||
8 | CDC | Developing an incident management system to support Ebola response - Liberia, July-August 2014 | Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone | Leadership and governance | Incident Management System was introduced by the MoH and Social Welfare in the early months of the outbreak. |
9 | CDC | Challenges in responding to the Ebola epidemic - four rural counties, Liberia, August-November 2014 | Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak | Medical products and technologies | * There was a lack in proper communication due to shortage in proper telephone coverage and leaders were not able to notify specified health staff on suspected cases, arrange clinical checks or notify each other on any specimen results on time. * Transportation was also a problem as specimens were not transferred on time to laboratories. |
Health workforce | * Health staff in the four counties reported lacking necessary training in case investigation, contact tracing, infection control (including safe burial practices), and health education * Only Grant Bassa had an ambulance team trained in loading and transport of patients and trained staff in case investigation and contact tracing. * There was only one laboratory technician trained in collecting and handling specimens safely in Grand Cape Mount and Grand Bassa. * Sinoe had not technicians at all. * All counties were short on drugs at clinics and PPE and staff were not trained in using it properly. |
Expert interviews
Results
Database name | Studies found |
---|---|
MEDLINE | 147 |
EMBASE | 284 |
Global Health | 137 |
Scopus | 375 |
Cochrane | 1 |
Google Scholar | 24 |
Total | 968 |
External report | 1 |
Total | 969 |
After removing duplicates | 433 |
Study | 1. Preliminaries | 2. Introduction | 3. Design | 4. Sampling | 5. Data collection | 6. Ethical matters | 7. Results | 8. Discussion | 9. Total score (/40) | Percent |
---|---|---|---|---|---|---|---|---|---|---|
Title - Abstract - Text | Background - Objective | Research design - Exposure - Outcome - Bias | Size - Protocol - Method | Method - Protocol | Participant ethics - Researcher ethics | Analysis, integration - Essential analysis - Outcome | Interpretation - Generalisation - Concluding remarks | |||
1. Aexander et al. | 4 | 4 | 2 | 1 | 1 | 0 | 2 | 2 | 16 | 40 |
2. Buseh et al. | 4 | 5 | 2 | 0 | 1 | 0 | 5 | 5 | 22 | 55 |
3. Gostin et al. | 4 | 4 | 3 | 2 | 1 | 0 | 1 | 1 | 16 | 40 |
4. Trad et al. | 3 | 4 | 2 | 0 | 0 | 0 | 0 | 1 | 10 | 25 |
Name | Date + duration | Affiliation | Communication + Location | Objective | Health System building blocks mentioned | Opinion |
---|---|---|---|---|---|---|
1. Gillian McKay | 04/08/2015 25 mins 48 s | GOAL International – Behaviour change advisor | Face to face – LSHTM |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Health financing | For the most part, the lack of investment in training of healthcare workers, in infrastructure, supply chain management (drugs, PPE, water and electricity), working with the community to increasing their valuing in the health care system is the biggest problem. In SL for example they have the least amount of government funding. Lack of supply chain and training in IPC and general epidemic management would be the most important things. |
Health workforce | They were not well trained and so they were not able to deal with Ebola and lots of them died. | |||||
Information and research | When Ebola came, it wasn’t recognised early and this lead to lots of casualties. This also fits into information and research where it was important to recognise the virus early and allow for contact tracing. | |||||
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone
| Health workforce | Health workforce! A big problem is the number of healthcare workers who die in Ebola compared to other viral haemorrhagic. | ||||
Service delivery | The shut of schools has led to an increase in teenage pregnancy which added burden to the health systems of the countries. People still do not trust the health systems of these countries. The number of women giving birth decreased in hospitals, increasing maternal mortality. Immunization rates are down and there is potential for other epidemics as a result. HCW decreases as they don’t feel safe to do so. | |||||
2. Jimmy Whitworth | 30/07/2015 24 mins 23 s | London School of Hygiene and Tropical Medicine - Professor | Face to face – LSHTM |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| The six blocks (GENERAL) | Simply insufficient money that goes into health systems and that means that they don’t have the staff, finances needed to provide services needed, medical products are only available intermittently, technologies only found in that capital cities, the leadership and governance isn’t very strong. Mostly service delivery isn’t that great. Perhaps in SL it might be better than the others. So it has not been a priority for others. |
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone
| Service delivery | All general services were not offered adequately as vaccinations, mother and child services. The number of people who died from Malaria are at least as many as those who died from Ebola. Babies who died from diarrhoea were high in numbers as well as from pneumonia. We started seeing epidemics of Measles as these countries were not able to avoid and deal with continuing vaccination programmes | ||||
3. Christina Atchison | 07/08/2015 27 mins 54 s | NHS England, Imperial College London, Department of Primary Care and Public Health - Clinical Lecturer in Public Health Medicine | Face to face – Imperial College London, Charing Cross Hospital, Department of Primary Care and Public Health |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Leadership and governance | Leadership and governance closely linked to planning and financing. Leadership is the overarching. Lack of leadership at the national government level and the organisational leadership in the governmental level and ministries of health |
4. Erin Polich | 12/08/2015 45 mins 40 s | GOAL International – Emergency and transition coordinator | Skype – London to Freetown, Sierra Leone |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Leadership and Governance | Ebola wasn’t mentioned publicly by the president until July of last year and there was a great amount of distrust in SL and they were very fearful of this disease that it was lethal. They were not even sure of it existed and if it did, it wasn’t brought up by the government. There was a lack of understanding by the government and on how communities operate. One of the reasons the outbreak has become so bad and so widespread is that there has been not enough emphasis on the understanding of the distrust of the communities in the health systems and their own governments as well |
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone
| Service delivery | People were afraid to go the health facilities because people were afraid of being infected if the doctors and nurses are infected and they can’t help themselves. People didn’t want to be transferred to wards as they knew that people walk in as Ebola negative and they walk out being positive. There weren’t enough beds and people were sharing beds and there was lots of contact with vomits, diarrhoea and so on | ||||
Health workforce | These countries are already low in human resources and we have lost hundreds of HCW that we can’t afford to lose. These people have put their heart and soul in defending the lives of other people more than you can imagine. People lost their lives because they were able to be there to care for the Ebola patients. We have lost a huge resource there that would take years and years to build back. One of the really sad things, in SL some of the prominent doctors like Dr. Khan are heroes before Ebola came and were looked up at. | |||||
Health financing | Incredible influx of donor funding in rate that SL has not seen in years which is now available to try to strengthen the government facilities. We see projects that started as IPC projects in hospitals and were now expanded to wider Ebola responses and beyond to build facilities for longer term | |||||
Medical products and technologies | There is now a national IPC unit that exists in the MOH in SL that didn’t exist before to make sure that this doesn’t happen again in the future. There is also the disaster preparedness unit that will be established. If this is funded and coordinated properly, this would be a great resource and we could see a really good thing happening for future outbreaks. | |||||
5. David Heymann | 24/08/2015 6 mins 22 s | London School of Hygiene and Tropical Medicine/Public Health England/Chatham House - Professor | Phone call – London to Geneva |
Effects the health systems in Guinea, Liberia and Sierra Leone had on the management of the Ebola outbreak
| Health workforce | These countries are recovering from war and many healthcare workers left these countries leaving the workforce in shortage. |
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone
| Service delivery | The outbreak has affected the countries negatively by shutting down health facilities in some areas and people without signs and symptoms of Ebola had difficulties to get care; some died from other diseases as diarrhoea or malaria, and in some areas of these countries immunisation programmes broke down and there were outbreaks of measles. | ||||
6. Chris Lewis | 28/08/2015 20 mins 36 s | Department for International Development – Health advisor | Phone call – London to London |
Impacts the Ebola outbreak brought about on the existing health systems in Guinea, Liberia and Sierra Leone
| Health Workforce | Ebola is a crisis that primarily affects healthcare workers and therefore there is a particularly negative impact with the number of healthcare workers that died, those who were sick as well as the psychological impact on healthcare workers. |
Service delivery | There is also the secondary impact on other diseases. It was incredibly difficult to have effective interventions for other health problems when Ebola has affected health facilities |