Building back better: priorities for Ebola-affected countries
Authors: Ranu S Dhillon, Robert Yates
Journal: The Lancet Global Health (2015)

In April, 2015, the World Bank announced US$650 million to help Guinea, Liberia, and Sierra Leone recover from the Ebola epidemic, including building their health systems.1World Bank GroupEbola: World Bank Group provides new financing to help Guinea, Liberia and Sierra Leone recover from Ebola emergency. World Bank, Washington, DC, USAApril 17, 2015http://www.worldbank.org/en/news/press-release/2015/04/17/ebola-world-bank-group-provides-new-financing-to-help-guinea-liberia-sierra-leone-recover-from-ebola-emergencyGoogle Scholar Although there is consensus on the need for more resilient systems with greater surveillance capabilities,2Kieny MP Dovlo D Beyond Ebola: a new agenda for resilient health systems.Lancet. 2015; 385: 91-92Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar there is less clarity on how countries should pragmatically go about this undertaking. In view of the currently severe gaps in health systems whereby almost everything is a need, countries will have to set priorities for initiating this process. The overall goal of these reforms should be to lay the foundation for universal health coverage whereby everybody receives the health services they need without suffering financial hardship. In moving in this direction, immediate objectives will include reducing mortality from diseases that have gone unmitigated during the epidemic, establishing surveillance mechanisms to address future outbreaks, and building trust with communities who, already disaffected from health care before Ebola, have been further alienated by fear during the epidemic. In terms of pragmatic first steps, health system strengthening in the affected countries should address five priorities. The first priority is to look at primary and community-level health systems. In all three countries, many people live remotely and have difficulty accessing any affordable health services, especially at a district hospital level. At the same time, the overwhelming burden of disease consists of basic infections and routine conditions that can be managed at the local level. Health system building should, therefore, provide primary clinics with the staffing and support they need and create cadres of community health workers who could further decentralise services, assist with disease surveillance, and cultivate trust between communities and the health system (work in progress). The creation of a new cadre of community health workers would provide a visible and tangible benefit to communities and also generate rural employment opportunities. The second priority is to make essential medicines and health commodities free to the population. A package of essential drugs and preventive commodities (eg, family planning goods) should be provided at no cost to the public and funded through earmarked government and donor budgets. Improving access to life-saving medicines will go a long way in rapidly reducing the extant disease burden and gaining public confidence in the health system. Third, the catch-up of preventive and promotive health measures should be quick. Key health measures, such as vaccinations, have gone undelivered during the epidemic. These interventions could take an immediate bite out of ongoing morbidity while providing beleaguered communities a tangible sign of confidence. Mass distribution of insecticide-treated antimalarial nets and campaigns to compensate for missed immunisations would be important quick wins.3Johnson-Sirleaf E Berkeley S The next victims of Ebola. Foreign Policy, Washington, DC, USAApril 27, 2015http://foreignpolicy.com/2015/04/27/the-next-victims-of-ebola-measles-polioGoogle Scholar Fourth, surveillance mechanisms should be integrated into general health systems. In some discussions, general health systems and surveillance mechanisms are viewed as divergent priorities with the implication that devoting resources to one precludes support for the other. This view is, however, a false dichotomy and epidemic preparedness systems capable of surveillance and response should be integrated into general horizontal health systems. As seen in this epidemic, initial cases in Guinea and, later, Sierra Leone spread for weeks before it became clear that an epidemic was escalating.4Sack K Fink S Belluck P Nossiter A How Ebola roared back.New York Times (New York). Dec 29, 2015; (Accessed May 1, 2015.).http://www.nytimes.com/2014/12/30/health/how-ebola-roared-back.html?_r=0Google Scholar Stand-alone surveillance will remain inadequate without health systems in which people can access routine care. Household-based surveillance through community health workers and primary clinics, capacity for isolation integrated into the infrastructure of existing hospitals, and expanded networks of referral laboratories are examples of how these priorities could be met synergistically (work in progress). And finally, systems for management and implementation should be strengthened. Resources alone will not be enough to vitalise health systems in the affected countries. As funds increase, greater managerial capacity will be needed to help health ministries and district-level administrators translate these resources into effective implementation. It will therefore be important to embed technical support for national counterparts while transferring skills to strengthen institutional capacity. These five priorities can provide Guinea, Liberia, and Sierra Leone with a practical starting point for the vital task ahead and set them on a path towards stronger health systems and universal health coverage. We declare no competing interests.