Strengthening health systems – lessons learned from the Ebola response by David Peters

In this presentation David Peters, from Johns Hopkins Bloomberg School of Public Health, discusses how lesson learning from responses to the recent ebola outbreak in West Africa can strengthen health systems. His presentation focuses on strengthening national health systems, rather than at the international level.

The outbreak has caused over 10,000 deaths. In addition, the epidemic has caused fear and mistrust to develop within the population. For health systems that were already weak to begin with, the ebola outbreak has put even more pressure on the fragile system. This led to worsening of health conditions and further weakening of health infrastructure. The health work force was also damaged with workers dying or being demotivated. Health facilities were closed, resulting in a downward spiral, all caused by the outbreak.

David describes some lessons that should have been learned before the epidemic started. Many of the lessons from smallpox control are relevant to the ebola context. For example, the international response should focus on supporting national leadership to carry out their plans. Working with local communities to ensure isolation of cases is critical. Communication needs to be rapid and systematic, with data analysed and shared as and when possible.

Lessons could also have been learned from the Democratic Republic of Congo, where 6 previous ebola epidemics had been experienced. The lessons include control of the outbreak depending on a rapid response, community engagement and implementing an integrated community based containment and care strategy. Communities must own the fight against ebola, with survivors being integrated back to society as soon as possible. Quality of care and safe dignified burial of people who have died will also be important.

David goes on to describe some of the lessons that should have been learned during the current epidemic. In the early stages of the outbreak there was lots of denial experienced, with some cases of people hiding patients.

A correspondence from the WHO Ebola Response Team published in the New England Journal of Medicine provides some lessons on the West African Ebola Epidemic after one year. The uneven success of ebola control measures to date, in the face of shifting geographic patterns of transmission, illustrates the continuing threat posed by the Ebola virus 1 year after the start of the epidemic. The authors argue that despite the worst fears of persistent exponential growth beyond September 2014 not being realised, Ebola still presents a huge challenge in West Africa.

An article on controlling ebola that was published in the Lancet argues that ebola treatment centres are key to the response. It describes how an initially perceived self-limited outbreak of Ebola virus disease in a forested area of Guinea became an unprecedented epidemic of international concern that continues to spread unabated in parts of West Africa. The authors conclude that a lack of public health infrastructure together with delays in virus detection and implementation of control interventions have contributed to the widespread transmission of Ebola virus disease in a region inexperienced with this disease.

In terms of what we still need to learn, David gives details on clinical and basic sciences research agenda. He also discusses the health system research agenda. This includes learning how to prevent, rapidly identify and respond to public health emergencies. A better understanding of behavioural factors, contacts, risk factors and surveillance activities is needed. All of this will help us to develop better models of epidemic transmission and effects on health systems.

A briefing paper published by IDS that focused on strengthening health systems for resilience describes how the ebola outbreak illustrates how the lack of an effective health system can affect the ability of individuals, communities and societies to thrive and develop. Several factors associated with high poverty levels, fragile state systems and neglect of public health made those in the Ebola-affected countries particularly vulnerable to health shocks. They have high levels of exposure to many infectious diseases associated with inadequate disposal of human wastes, poor nutrition, crowded housing and uncontrolled breeding grounds for the insect vectors of malaria and other diseases.

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