Bulletin of the World Health Organization
Volume 92, Number 12, December 2014, 849-924
http://www.who.int/bulletin/volumes/92/12/en/

Health-system resilience: reflections on the Ebola crisis in western Africa
Marie-Paule Kieny a, David B Evans a, Gerard Schmets a & Sowmya Kadandale a
a. World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
Bulletin of the World Health Organization 2014;92:850. doi: http://dx.doi.org/10.2471/BLT.14.149278
Disease outbreaks and catastrophes can affect countries at any time, causing substantial human suffering and deaths and economic losses. If health systems are ill-equipped to deal with such situations, the affected populations can be very vulnerable.1

The current Ebola virus disease outbreak in western Africa highlights how an epidemic can proliferate rapidly and pose huge problems in the absence of a strong health system capable of a rapid and integrated response. The outbreak began in Guinea in December 2013 but soon spread into neighbouring Liberia and Sierra Leone.2 In early August 2014, Ebola was declared an international public health emergency.2

At the time the outbreak began, the capacity of the health systems in Guinea, Liberia and Sierra Leone was limited. Several health-system functions that are generally considered essential were not performing well and this hampered the development of a suitable and timely response to the outbreak. There were inadequate numbers of qualified health workers.3 Infrastructure, logistics, health information, surveillance, governance and drug supply systems were weak. The organization and management of health services was sub-optimal. Government health expenditure was low whereas private expenditure – mostly in the form of direct out-of-pocket payments for health services – was relatively high.4

The last decade has seen increased external health-related aid to Guinea, Liberia and Sierra Leone. However, in the context of Millennium Development Goals 4, 5 and 6, most of this aid has been allocated to combat human immunodeficiency virus infection, malaria and tuberculosis, with much of the residual going to maternal and child health services. Therefore, relatively little external aid was left to support overall development of health systems.5 This lack of balanced investment in the health systems contributes to the challenges of controlling the current Ebola outbreak. Weak health systems cannot be resilient.6–8 A strong health system decreases a country’s vulnerability to health risks and ensures a high level of preparedness to mitigate the impact of any crises.

Frequently, the response by governments and external partners to a health crisis posed by a communicable disease, such as Ebola, is to focus solely on reducing transmission and the effect of the disease. However, such a response is insufficient. Febrile individuals need to be screened for Ebola – even if most of them have fevers caused by other infections – and those found to be negative for Ebola still need to be treated rather than simply turned away. Even in the worst-affected areas, women still need antenatal services, safe delivery and postnatal care. Many people will travel to seek care for unrelated conditions in areas that they perceive to be Ebola-free, putting enormous strain on the health system in so-called “non-Ebola” areas. Routine services need to be assured while dealing with the direct effects of an epidemic. Otherwise, more people may die – of unrelated causes – from a general breakdown of health services than as a direct result of the epidemic.

If this Ebola outbreak does not trigger substantial investments in health systems and adequate reforms in the worst-affected countries, pre-existing deficiencies in health systems will be exacerbated. The national governments, assisted by external partners, need to develop and implement strategies to make their health systems stronger and more resilient. Only then can they meet the essential health needs of their populations and develop strong disaster preparedness to address future emergencies. In the short-term, nongovernmental organizations, civil society and international organizations will have to bolster the national health systems, both to mitigate the direct consequences of the outbreak and to ensure that all essential health services are being delivered. However, this assistance should be carefully coordinated under the leadership of the national governments and follow development effectiveness principles. We expect health systems in the worst-affected areas to be left in a very weak state once the outbreak has ended. Hopefully, after the epidemic has ended, economic growth and government health spending will eventually rebound, with increased domestic investments in health systems. For the foreseeable future however, the negative economic impact on the affected countries9 means that substantial external financing will be needed to build stronger national and subnational health systems.
References

Systematic Review
Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review
Ana LP Mateus, Harmony E Otete, Charles R Beck, Gayle P Dolan & Jonathan S Nguyen-Van-Tam
Abstract
Objective
To assess the effectiveness of internal and international travel restrictions in the rapid containment of influenza.
Methods
We conducted a systematic review according to the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-care databases and grey literature were searched and screened for records published before May 2014. Data extraction and assessments of risk of bias were undertaken by two researchers independently. Results were synthesized in a narrative form.
Findings
The overall risk of bias in the 23 included studies was low to moderate. Internal travel restrictions and international border restrictions delayed the spread of influenza epidemics by one week and two months, respectively. International travel restrictions delayed the spread and peak of epidemics by periods varying between a few days and four months. Travel restrictions reduced the incidence of new cases by less than 3%. Impact was reduced when restrictions were implemented more than six weeks after the notification of epidemics or when the level of transmissibility was high. Travel restrictions would have minimal impact in urban centres with dense populations and travel networks. We found no evidence that travel restrictions would contain influenza within a defined geographical area.
Conclusion
Extensive travel restrictions may delay the dissemination of influenza but cannot prevent it. The evidence does not support travel restrictions as an isolated intervention for the rapid containment of influenza. Travel restrictions would make an extremely limited contribution to any policy for rapid containment of influenza at source during the first emergence of a pandemic virus.

Post-licensure deployment of oral cholera vaccines: a systematic review
Stephen Martin, Anna Lena Lopez, Anna Bellos, Jacqueline Deen, Mohammad Ali, Kathryn Alberti, Dang Duc Anh, Alejandro Costa, Rebecca F Grais, Dominique Legros, Francisco J Luquero, Megan B Ghai, William Perea & David A Sack
Abstract
Objective
To describe and analyse the characteristics of oral cholera vaccination campaigns; including location, target population, logistics, vaccine coverage and delivery costs.
Methods
We searched PubMed, the World Health Organization (WHO) website and the Cochrane database with no date or language restrictions. We contacted public health personnel, experts in the field and in ministries of health and did targeted web searches.
Findings
A total of 33 documents were included in the analysis. One country, Viet Nam, incorporates oral cholera vaccination into its public health programme and has administered approximately 10.9 million vaccine doses between 1997 and 2012. In addition, over 3 million doses of the two WHO pre-qualified oral cholera vaccines have been administered in more than 16 campaigns around the world between 1997 and 2014. These campaigns have either been pre-emptive or reactive and have taken place under diverse conditions, such as in refugee camps or natural disasters. Estimated two-dose coverage ranged from 46 to 88% of the target population. Approximate delivery cost per fully immunized person ranged from 0.11–3.99 United States dollars.
Conclusion
Experience with oral cholera vaccination campaigns continues to increase. Public health officials may draw on this experience and conduct oral cholera vaccination campaigns more frequently.

PERSPECTIVES
Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda
Lynn P Freedman, Kate Ramsey, Timothy Abuya, Ben Bellows, Charity Ndwiga, Charlotte E Warren, Stephanie Kujawski, Wema Moyo, Margaret E Kruk & Godfrey Mbaruku
doi: 10.2471/BLT.14.137869

Dilemmas of evaluation: health research capacity initiatives
Donald C Cole, Garry Aslanyan, Alison Dunn, Alan Boyd & Imelda Bates
doi: 10.2471/BLT.14.141259