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

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          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.


          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.


          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.


          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.


          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.

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          Most cited references 39

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          Everybody business-strengthening health systems to improve health outcomes: WHO’s framework for action

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            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.

            The Ebola virus disease outbreak in west Africa is pivotal for the worldwide health system. Just as the depth of the crisis ultimately spurred an unprecedented response, the failures of leadership suggest the need for innovative reforms. Such reforms would transform the existing worldwide health system architecture into a purposeful, organised system with an empowered, highly capable WHO at its apex and enduring, equitable national health systems at its foundation. It would be designed not only to provide security against epidemic threats, but also to meet everyday health needs, thus realising the right to health. This retrospective and prospective analysis offers a template for these reforms, responding to the profound harms posed by fragile national health systems, delays in the international response, deficient resource mobilisation, ill defined responsibilities, and insufficient coordination. The scope of the reforms should address failures in the Ebola response, and entrenched weaknesses that enabled the epidemic to reach its heights.
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              A review of critical appraisal tools show they lack rigor: Alternative tool structure is proposed.

              To evaluate critical appraisal tools (CATs) that have been through a peer-reviewed development process with the aim of analyzing well-designed, documented, and researched CATs that could be used to develop a comprehensive CAT. A critical review of the development of CATs was undertaken. Of the 44 CATs reviewed, 25 (57%) were applicable to more than one research design, 11 (25%) to true experimental studies, and the remaining 8 (18%) to individual research designs. Comprehensive explanation of how a CAT was developed and guidelines to use the CAT were available in five (11%) instances. There was no validation process reported in 11 CATs (25%) and 33 CATs (77%) had not been reliability tested. The questions and statements that made up each CAT were coded into 8 categories and 22 items such that each item was distinct from every other. CATs are being developed while ignoring basic research techniques, the evidence available for design, and comprehensive validation and reliability testing. The basic structure for a comprehensive CAT is suggested that requires further study to verify its overall usefulness. Meanwhile, users of CATs should be careful about which CAT they use and how they use it. Copyright © 2011 Elsevier Inc. All rights reserved.

                Author and article information

                0044 777 87 233 87 , Haitham.sh89@gmail.com
                Global Health
                Global Health
                Globalization and Health
                BioMed Central (London )
                4 January 2017
                4 January 2017
                : 13
                [1 ]WHO Collaborating Centre for Public Health Education and Training, Faculty of Medicine, Imperial College London, Charing Cross Campus, Reynolds building, third floor, St Dunstans Road, W6 8RP London, UK
                [2 ]Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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