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The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review

Monday, 9th of January 2017

The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review

• Haitham ShomanEmail authorView ORCID ID profile,
• Emilie Karafillakis and
• Salman Rawaf

Globalization and Health201713:1

©  The Author(s). 2016

Published: 4 January 2017

 

Excerpts below; full text is at http://download.springer.com/static/pdf/216/art%253A10.1186%252Fs12992-016-0224-2.pdf?originUrl=http%3A%2F%2Fglobalizationandhealth.biomedcentral.com%2Farticle%2F10.1186%2Fs12992-016-0224-2&token2=exp=1483959323~acl=%2Fstatic%2Fpdf%2F216%2Fart%25253A10.1186%25252Fs12992-016-0224-2.pdf*~hmac=940a13101e2ad5da425618ce19a63a9a8b5960aad43122887c39d55b77b0e229

 

Abstract

Background

An Ebola outbreak started in December 2013 in Guinea and spread to Liberia and Sierra Leone in 2014. The health systems in place in the three countries lacked the infrastructure and the preparation to respond to the outbreak quickly and the World Health Organisation (WHO) declared a public health emergency of international concern on August 8 2014.

Objective

The aim of this study was to determine the effects of health systems organisation and performance on the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and lessons learned. The WHO health system building blocks were used to evaluate the performance of the health systems in these countries.

Methods

A systematic review of articles published from inception until July 2015 was conducted following the PRISMA guidelines. Electronic databases including Medline, Embase, Global Health, and the Cochrane library were searched for relevant literature. Grey literature was also searched through Google Scholar and Scopus. Articles were exported and selected based on a set of inclusion and exclusion criteria. Data was then extracted into a spreadsheet and a descriptive analysis was performed. Each study was critically appraised using the Crowe Critical Appraisal Tool. The review was supplemented with expert interviews where participants were identified from reference lists and using the snowball method.

Findings

Thirteen articles were included in the study and six experts from different organisations were interviewed. Findings were analysed based on the WHO health system building blocks. Shortage of health workforce had an important effect on the control of Ebola but also suffered the most from the outbreak. This was followed by information and research, medical products and technologies, health financing and leadership and governance. Poor surveillance and lack of proper communication also contributed to the outbreak. Lack of available funds jeopardised payments and purchase of essential resources and medicines. Leadership and governance had least findings but an overarching consensus that they would have helped prompt response, adequate coordination and management of resources.

Conclusion

Ensuring an adequate and efficient health workforce is of the utmost importance to ensure a strong health system and a quick response to new outbreaks. Adequate service delivery results from a collective success of the other blocks. Health financing and its management is crucial to ensure availability of medical products, fund payments to staff and purchase necessary equipment. However, leadership and governance needs to be rigorously explored on their main defects to control the outbreak.

Background

Ebola Virus Disease (EVD) was first discovered in 1976, near the Ebola river in the Democratic Republic of Congo (formerly known as Zaire) [1]. More than 25 Ebola outbreaks have been recorded since then, but the West African outbreak which started in 2013 recorded the highest number of deaths compared to all previous outbreaks combined [2]. According to Dr. Margaret Chan, World Health Organisation (WHO) Director General at the time of the outbreak, the 2014–2015 Ebola outbreak was the largest and worst of its kind, jeopardising the fragile health systems and economic stabilities of West Africa [3]. Although it started in December 2013 in a small village in Guinea [4], it was not until August 8 2014 that WHO officially announced Ebola as a Public Health Emergency of International Concern (PHEIC) [5]. As of March 27 2016, total cases were highest in Guinea (3811), Liberia (10,675) and Sierra Leone (14,124), making them the three most affected countries of the region [6].

The failure to contain Ebola has been argued to be a violation of the 2005 International Health Regulations (IHR) which urges member states to detect, assess, report and respond promptly to outbreaks and health emergencies [5]. The magnitude of this outbreak and the speed of Ebola transmission presented a significant threat to international security. The United Nations Security Council therefore unanimously passed a resolution to establish the first ever UN Emergency Health Agency, the United Nations Mission for Emergency Ebola Response (UNMEER) [7]. UNMEERs responsibilities were transferred to the WHO after it reached its main objective of strengthening surveillance, supporting health workforce and efficiently mobilising resources [8].

The unprecedented spread of Ebola in the region has been explained in many ways and has been linked to factors such as human mobility between the affected countries, behavioural and cultural practices like traditional burials or bush meat consumption, as well as inefficient health systems [9]. Guinea, Liberia, and Sierra Leone have suffered from devastating civil wars, which have had a profound impact on the countries health system infrastructure [7]. According to the WHO Health report, they have the lowest human development indexes and among the weakest health system infrastructures in the world [10, 11].

In Guinea, health workforce density (physicians, nurses, midwives, dentists, pharmacists, and psychiatrists) is less than 1.5 per 10,000 population [12], with a total of three hospital beds per 10,000 population [13]. The per capita government expenditure on health is 9 US$ per year [14]. Sierra Leone has a health workforce density of 2.2 per 10,000 population [14] and approximately four hospital beds per 10,000 population [15]. Their per capita government expenditure on health is 12 US$ [14]. In Liberia, the density of the health workforce is less than 3.7 per 10,000 population [14], with around eight hospital beds per 10,000 population [13] and a per capita government expenditure on health of 13 US$ [14]. The public health system infrastructure of the three countries lacked the primary essential elements required to control an outbreak [16], including a strong healthcare workforce [17, 18]. However, the Ebola outbreak also had a significant impact on the already weak health systems and contributed to the decline in the availability of human and physical resources for health.

The aim of this study was to assess existing evidence on the links between the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and the organisation and performance of the countries health systems by undertaking a systematic literature review completed by structured expert interviews. Two objectives were developed to achieve this aim: 1) identify effects of the health systems in Guinea, Liberia and Sierra Leone on the management of the Ebola outbreak, and 2) explore the impacts of the Ebola outbreak on the existing health systems in the three countries.

WHO health system building blocks

The WHO states that “a well-functioning health system working in harmony is built on having trained and motivated health workers, a well maintained infrastructure, and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies” [19]. These elements have been referred to as the WHO Health System Building Blocks, a framework which will be used in this study to explore the health systems of Guinea, Liberia and Sierra Leone [19, 20, 21]. They were selected as a set of internationally agreed health priorities set to create a common understanding of what a health system is and how can it be strengthened [22]. A health system involves all organisations, people and actions whose ultimate priority is to promote, restore or maintain health [22, 23]. The six building blocks are 1) health workforce, 2) health financing, 3) information and research, 4) medical products and technologies, 5) leadership and governance, and 6) service delivery [19, 20, 21].

Health workforce include service providers such as physicians, nurses, pharmacists and dentists, health management and support workers [21]. At least 23 physicians, nurses and midwives per 10,000 population are needed for well-functioning primary health care interventions [21]. Their availability should be adequately distributed to offer the best outcomes to the entire population [19, 20, 21]. Health workforce should be well qualified, capable, responsive and efficient [19, 20, 21].

Strong health systems are adequately financed to provide people with the services they need while ensuring they do not suffer from the financial hardships of the inability to pay for their care [19, 20, 21]. Health financing is indispensable to maintain and improve human welfare by ensuring workforce employment, availability of medicines and offering promotion and prevention public health programs [21].

A well-functioning information and research system ensures the effective and timely collection, analysis, distribution, and communication of information [19, 20, 21]. Reliable information is needed for policy development, implementation, governance and regulation, training and health education and for the support of the other five building blocks [21]. Information and research is also important for monitoring and evaluation of diseases and programmes and for early warning of health emergencies [21].

Medical products (including essential medicines), vaccines and technologies should be available and accessible to the population [19, 20, 21]. They should also be of high quality and efficacy, and scientifically proven to be safe and cost effective [19, 20, 21]. Essential medicines are those that satisfy the populations priority needs [21].

A well led and governed health system is one that has vital policy frameworks in place, together with proper stewardship, established partnerships, a respect of regulations, and provision of incentives [19, 20, 21]. Leadership and governance are closely linked to accountability [21].