Introducing COUNTDOWN’s newest partner: UL-PIRE

At the end of 2015, DFID approved the continued inclusion of Liberia within the COUNTDOWN consortium following successful control of the Ebola epidemic. The COUNTDOWN ‘family’ were elated with this confirmation from DFID, emphasising team Liberia’s integral importance within the COUNTDOWN consortium. Given the critical focus on implementation research for COUNTDOWN and the Liberian Ministry of Health (MoH), as plans for the inception year got underway in Liberia, it was clear to the MoH that they needed to engage with a national research partner.

The MoH underwent a transparent and systematic approach to selecting a research partner that would be able to support implementation research for COUNTDOWN in Liberia. Initially, the MoH identified the core competencies that the research partner must have. These were: strengths in COUNTDOWNs core research areas (social science, health economics and evidence synthesis); good financial management capacity; and infrastructure able to support additional staff. Once core competencies had been identified, the MoH identified five possible research partners. Based on their alignment to the above criteria, these five partners were reduced to three by a team at the MoH. Members of the MoH then made site visits to each of the three remaining research partners to understand more about their work and explore synergies with the COUNTDOWN programme. Following these site visits, with the support of the LSTM programme management team, the MoH identified the most suitable implementation research partner for COUNTDOWN Liberia.

Following this detailed selection process, COUNTDOWN are delighted to introduce the University of Liberia-Pacific Institute for Research and Evaluation (UL-PIRE) as our newest implementation research partner. Fred Sosu, Research Coordinator from UL-PIRE was able to attend our recent partners annual review meeting and it was a great pleasure for all involved in the consortium to understand more about UL-PIREs work and explore in detail their involvement in the partnership. UL-PIRE has a wealth of experience in the delivery of health systems research projects as well as those that span other disciplines such as agriculture, water, sanitation and education.  Project evaluation, survey development and administration are core competence strength. With a strong focus on ethics and community engagement they provide unique and innovative perspectives from the Liberian context.

As the inception year continues within Liberia, the Liberian MoH and all other COUNTDOWN partners are very much looking forward to a long and fruitful partnership with UL-PIRE.

‘No more room for excuses’: Building the health system in Sierra Leone after Ebola

By Laura Dean (and Haja Wurie)

In preparation for our stakeholder meeting in Liberia detailed in our previous blog I spent some time interviewing Haja Wurie. Haja is based at the College of Medicine and Allied Health Sciences in Sierra Leone and works as part of the ReBUILD Consortium focusing on health systems research in post-conflict countries. Interviewing Haja, allowed time for reflection on the impact Ebola has had in Sierra Leone and enabled us to begin to strategize how best to move forward to build back more ‘responsive and resilient’ health systems. The interview will be used at our stakeholder meeting in Liberia to spark debate and encourage cross-country lesson learning.

The impact of Ebola in Sierra Leone

Haja believes that Ebola has exposed weaknesses across all pillars of the health system from service delivery to human resources for health and beyond. Haja describes the health workforce as ‘victims’ both during the conflict in Sierra Leone and during the Ebola crisis. During conflict health workers were targets of kidnap, and during Ebola they have become targets of a virus which they were ill-equipped to avoid due to lack of training and resources, at the onset of the outbreak. Ebola has impacted on health programmes through a decrease in service use because of mistrust and fear between service users and providers. Where vertical programmes, such as the Neglected Tropical Disease programme, had begun to establish themselves, Ebola has resulted in them taking ‘three steps back’. Haja believes there is ‘no more time for excuses’ and we need to address the systemic problems that allowed such a crisis to develop. There is a need for the health system to be prepared as future outbreaks of Ebola are likely once one has already occurred.

Building back better: What’s next for Sierra Leone’s health system?

Haja believes that we have to look toward strengthening all six pillars of the health system simultaneously to be able to build back better. It is too simplistic to argue for better training of staff or more available equipment without looking at all underlying factors that caused weaknesses in the system. For example, instigating infection prevention and control training is unlikely to be effective when most health workers are in facilities where there is no running water or electricity. Just as it is unproductive to have numerous donors and NGOs operating in an uncoordinated manner. So we need to think about how we strengthen systems in a holistic and unified way at a pace where no building blocks are left behind. This can be a hard thing to swallow as an academic with your own personal research interests in a specific disease area, or as the implementer of a vertical programme only concerned with a particular disease. The reality however is that unless we all start to think about the health system as a whole we are unlikely to be able to respond in a resilient manner to crisis.

What does building back better really look like?

Rebuilding trust between the health system and the communities which it is designed to serve is a critical first step in moving forward from Ebola. Haja believes that health education and health promotion are a crucial and that close-to-community providers play an essential role in their delivery. The Ebola crisis meant that there were travel restrictions within affected countries, as a result close-to-community providers had to be selected from within communities to ensure that health services did not cease altogether. Haja believes that it is these very close-to-community providers that present an opportunity for rebuilding trust. As ‘sons of soil’, they are trusted by their communities and the messages they share are respected. Driven by willingness and pride, often supported by minimal incentives (~three dollars every three months for community health workers), it is critical that community health workers are well supported by the health system they are serving.

Vertical disease programmes, such as those for the control of neglected tropical disease are essential health services. However strengthening them in isolation from the rest of the system is unlikely to contribute to a stronger health system. Through the delivery of essential health services vertical health programmes present a potential platform to strengthen another elements of health care. These health programmes should therefore look at ways to support and strengthen human resources for health through the cadre of community health workers and integrate this within their programmes. Vertical programmes could then promote co-ordination between strengthening building blocks and avoid contributing to fragmentation.

Internationally there is the scope for learning between all Ebola affected countries, specifically, Liberia, Guinea and Sierra Leone. Haja believes in the recent crisis, opportunities were missed to learn from systems in place in Uganda and this should not continue in rebuilding the health system. Countries have the opportunity to share their post-crisis action plans and ideas regarding their implementation. National ownership of health system strengthening is critical however, and it is essential that countries are given the opportunity to work together to harness donors to provide strategic support that is in line with nationally identified action plans building on countries strengths and developing their weaknesses.

Finally, Haja believes that health systems research is critical, but it has to be context relevant and led from within. There needs to be national ownership of research that incorporates community (service users and service providers) voices. Health systems research needs to be co-ordinated and directed in collaboration between policy makers, academics and health staff to ensure successful policy generation and implementation.  It should not only focus on issues directly related to Ebola but explore issues across all sectors and all levels of the health system.

As I embark on a new area of research in an Ebola affected country, I will continue to ask myself; how can our research contribute to a stronger health system so that we build back better?

Watch the video of Laura and Haja in action.

The Ebola outbreak and the wider health system: understanding impact and the way forward in Liberia

By Laura Dean, Anthony Bettee, Kate Hawkins, Sally Theobald and Karsor Kollie

During the recent Ebola outbreak Liberia lost over 185 of its professional health workforce. Trust between health workers and communities broke down and resources were diverted from routine health system activities to control the outbreak. This resulted in the near collapse of the health system as well as changes in the disease landscape and increased vulnerabilities related to the social determinants of health for many people.  As the health system is rebuilt, it is critical that the full impact of the outbreak at all levels of the health system is understood from the perspective of different stakeholders, in order to put forward strategies to strengthen the resilience of the health system.

Small grant

In collaboration with the Ministry of Health in Liberia, COUNTDOWN colleagues were recently awarded a small grant for research engagement from the Thematic Working Group on Health Systems Research in Fragile and Conflict Affected States. We will use this to convene two stakeholder meetings, one at the national and one at the county level that explore the impact of the Ebola outbreak on the health system with a specific focus on  the Neglected Tropical Disease (NTD) control programme. We aim to highlight the opinions of people whose voices are often not heard at such meetings, for example community members and frontline health staff. We hope these meetings will provide a unique opportunity to gain deeper understanding of the impact of health system collapse on vertical programmes and explore how these programmes can help support the wider system.

The Neglected Tropical Disease Programme in Liberia

The NTD control programme in Liberia is an integrated programme established in 2012 that engages with the health system from central Ministry of Health to the community level. During the Ebola outbreak the NTD programme ceased activity in order to support Ebola control, however it is now slowly beginning to resume activity. However before it starts up fully there is a need to understand in more detail the challenges faced in NTD control both prior to and since the Ebola outbreak. The stakeholder meetings allow reflections on the operations of the NTD control programme prior to the Ebola outbreak, as well as assessing how the Ebola outbreak may allow for a revitalisation of the programme to achieve a scaled-up, equitable response to NTDs in Liberia.

Follow up

As a result of the meeting we hope to develop a research agenda for health systems with specific focus on NTD control in Liberia that we can begin to address within COUNTDOWN. The engagement of international stakeholders from other Ebola affected countries such as Sierra Leone aims to increase the transferability of this research agenda and its findings, as well encouraging south-south collaboration and lesson learning as health systems are rebuilt. Watch this space for more information and outputs from COUNTDOWN’s first stakeholder meeting in Liberia!

Image: Courtesy of UNMIL/Emmanuel Tobey