Building resilient health systems: lessons from international, national and local emergency responses to the Ebola epidemic in Sierra Leone.
Lead Research Organisation:
London School of Hygiene & Tropical Medicine
Department Name: Public Health and Policy
Abstract
The response to the Ebola virus has exposed major weaknesses in the health systems of the affected countries. In part this is because of institutional weaknesses at national and district level but the behaviour of global actors in the response has also attracted criticism. The situation has been particularly acute in Sierra Leone as many progressive reforms such as Free Health Care and other governance initiatives may have been undermined by the epidemic and the nature of the response.
To date, the evidence on the impact of international Ebola-response assistance in Sierra Leone, and the way it has enabled or hampered local responses, is almost non-existent. For example, it is not known how, why and in what ways local health systems were used, or not used; and it is not at all clear whether international assistance has strengthened local health systems, or weakened them by building parallel structures and bypassing local institutions and relationships. The longer term implications of this kind of assistance, especially beyond the immediate crisis, are thus unclear.
Documenting and understanding how and why national and international endeavours to care for the sick and interrupt the transmission of Ebola struggled to produce expected results, is paramount for improving future responses and ensuring health systems are not weakened by future emergencies.
Our study will explore a range of factors including: the extent to which responses were informed by local concerns and perceptions of emergency-response systems; whether external interventions sought to work within or with local systems (and whether this resulted in the building of parallel response structures); whether external interventions ultimately weakened and made the health system less resilient by, for example, taking locally qualified staff away from public sector systems or by diverting resources from other ongoing health requirements (including routine maternal and child health and common preventable diseases).
Specifically, we ask the following research questions:
In what ways has the international Ebola-response affected Sierra Leone's health system and its ability to withstand future shocks?
How can international, national and local emergency response mechanisms be utilised to build a resilient health system in Sierra Leone, and what lessons emerge?
We bring together several different disciplinary and thematic perspectives, including health systems/systems strengthening, policy and implementation science; disaster risk reduction/emergency preparedness; and the anthropology of global health and medical humanitarianism. Explicitly bringing together these often separate bodies of learning will enable us to more fully and effectively answer our principal research questions, identify transferable lessons and contribute to generating substantive health systems research evidence relating to what promotes resilient health systems.
Specific benefits of the project will include:
* Identification of characteristics of resilient health systems that need to underpin health systems strengthening efforts, in Sierra Leone and other similar settings, and how these can be incorporated in national health systems development.
* Identifying the key issues influencing village level responses to Ebola and reflecting on the implications of these issues for understanding and building more resilient health systems.
* Suggestions for revising the existing guidelines for emergency responses, including those of the WHO drawing on the experiences of the recent Ebola epidemic in Sierra Leone.
To date, the evidence on the impact of international Ebola-response assistance in Sierra Leone, and the way it has enabled or hampered local responses, is almost non-existent. For example, it is not known how, why and in what ways local health systems were used, or not used; and it is not at all clear whether international assistance has strengthened local health systems, or weakened them by building parallel structures and bypassing local institutions and relationships. The longer term implications of this kind of assistance, especially beyond the immediate crisis, are thus unclear.
Documenting and understanding how and why national and international endeavours to care for the sick and interrupt the transmission of Ebola struggled to produce expected results, is paramount for improving future responses and ensuring health systems are not weakened by future emergencies.
Our study will explore a range of factors including: the extent to which responses were informed by local concerns and perceptions of emergency-response systems; whether external interventions sought to work within or with local systems (and whether this resulted in the building of parallel response structures); whether external interventions ultimately weakened and made the health system less resilient by, for example, taking locally qualified staff away from public sector systems or by diverting resources from other ongoing health requirements (including routine maternal and child health and common preventable diseases).
Specifically, we ask the following research questions:
In what ways has the international Ebola-response affected Sierra Leone's health system and its ability to withstand future shocks?
How can international, national and local emergency response mechanisms be utilised to build a resilient health system in Sierra Leone, and what lessons emerge?
We bring together several different disciplinary and thematic perspectives, including health systems/systems strengthening, policy and implementation science; disaster risk reduction/emergency preparedness; and the anthropology of global health and medical humanitarianism. Explicitly bringing together these often separate bodies of learning will enable us to more fully and effectively answer our principal research questions, identify transferable lessons and contribute to generating substantive health systems research evidence relating to what promotes resilient health systems.
Specific benefits of the project will include:
* Identification of characteristics of resilient health systems that need to underpin health systems strengthening efforts, in Sierra Leone and other similar settings, and how these can be incorporated in national health systems development.
* Identifying the key issues influencing village level responses to Ebola and reflecting on the implications of these issues for understanding and building more resilient health systems.
* Suggestions for revising the existing guidelines for emergency responses, including those of the WHO drawing on the experiences of the recent Ebola epidemic in Sierra Leone.
Technical Summary
The response to the Ebola epidemic has challenged the dominant paradigm of gradual health systems strengthening, led by national governments and supported by international actors. It poses difficult questions about what kind of responses are helpful in situations when sudden shocks appear to overwhelm already fragile health systems and deplete limited resources. Over the last 12 months, the Ebola epidemic has revealed a lack of resilience in the health systems of affected countries, demonstrating an inability to recover from shocks and mount effective responses.
We ask: In what ways has the international Ebola-response affected Sierra Leone's health system and its ability to withstand future shocks? How can international, national and local emergency response mechanisms be utilised to build a resilient health system in Sierra Leone, and what lessons emerge? Our findings will offer the potential to promote a major shift in the global health systems debate, from one narrowly focused on health system strengthening, to a focus on building health systems that are strong as well as resilient. The study will explore what needs to happen at each systems level, what capacities need to be created at local, district and national level, and what role international actors should play.
To address these questions, we bring together a multidisciplinary team with extensive expertise in a range of highly relevant, but currently largely separate, bodies of scientific scholarship: health systems/health systems strengthening; policy and implementation science; disaster risk reduction/emergency preparedness; and the anthropology of global health and medical humanitarianism. Explicitly bringing together these often separate bodies of learning will enable us to more fully and effectively answer our principal research questions, identify transferable lessons and contribute to generating substantive health systems research evidence relating to what promotes resilient health systems.
We ask: In what ways has the international Ebola-response affected Sierra Leone's health system and its ability to withstand future shocks? How can international, national and local emergency response mechanisms be utilised to build a resilient health system in Sierra Leone, and what lessons emerge? Our findings will offer the potential to promote a major shift in the global health systems debate, from one narrowly focused on health system strengthening, to a focus on building health systems that are strong as well as resilient. The study will explore what needs to happen at each systems level, what capacities need to be created at local, district and national level, and what role international actors should play.
To address these questions, we bring together a multidisciplinary team with extensive expertise in a range of highly relevant, but currently largely separate, bodies of scientific scholarship: health systems/health systems strengthening; policy and implementation science; disaster risk reduction/emergency preparedness; and the anthropology of global health and medical humanitarianism. Explicitly bringing together these often separate bodies of learning will enable us to more fully and effectively answer our principal research questions, identify transferable lessons and contribute to generating substantive health systems research evidence relating to what promotes resilient health systems.
Planned Impact
The project offers potential for achieving significant impact on international debate thus creating momentum for change among institutions seeking to build strong and resilient health systems. Making a difference will involve conducting rigorous research, generating policy-relevant evidence but also engaging with a diverse group of stakeholders on an ongoing basis, and catalysing advocacy efforts. Beneficiaries and potential impacts are described here. Strategies to achieve this are described in our Pathways to Impact document.
Academic beneficiaries are described in a separate section, but include global and national research communities working on health systems.
For this group, our findings will offer the potential to further the understanding of what to look for in research on resilient health systems and what frameworks or theories are useful in linking emergency-response and building resilient health systems - which have currently been largely separate areas of scholarship. Our research also has the potential to showcase the benefits of truly multidisciplinary research, as well as enable lesson learning on how best to make this a reality. These benefits will be achievable relatively early in the project.
A wide range of other beneficiaries will be engaged and reached to facilitate change in policy and practice at different levels of emergency-response and health systems strengthening (described in Pathways to Impact) in the years following the project.
These include:
Decision makers:
Ministry of Health in Sierra Leone and other Ebola-affected countries. We will invite key figures in Sierra Leone to join our local Advisory Committee. Through their active engagement (and pre-existing links with our local partners) our project has the potential to inform future emergency-response strategies and the building of resilient health systems - this may include information for decision making on the coordination and management of foreign aid during emergencies. We would also expect to contribute significantly to improving the effectiveness and sustainability of public health services - the profile of medium to long term health outcomes and the success of responses to any future Ebola epidemic would be the ultimate (long-term) test of this.
District officials, chiefs and other local decision makers will also be included in our Advisory Committee and invited to participate in discussion and dissemination meetings that will be held after our Annual partner meetings in Sierra Leone.
International donors, NGOs and development agencies: our results will have the potential to inform and influence the actions of international health actors involved in emergency assistance enabling them to implement more nuanced responses that strengthen rather than destabilise system building efforts already in place and promote resilience drawing on a wide range of resources including existing community capacity. A critical goal of emergency-response to such disasters is to avoid setting back a country's post-emergency health systems development by years. The timeframe for benefits to be achieved ranges from near to long term.
As with local decision makers, international stakeholders will be invited to discussion and dissemination meetings to be held in Sierra Leone throughout the project (see the timeline in the Case for Support for details). We will also consider inviting representatives (e.g. from MSF and/or SCF; DFID) to sit on our Advisory Committee.
Academic beneficiaries are described in a separate section, but include global and national research communities working on health systems.
For this group, our findings will offer the potential to further the understanding of what to look for in research on resilient health systems and what frameworks or theories are useful in linking emergency-response and building resilient health systems - which have currently been largely separate areas of scholarship. Our research also has the potential to showcase the benefits of truly multidisciplinary research, as well as enable lesson learning on how best to make this a reality. These benefits will be achievable relatively early in the project.
A wide range of other beneficiaries will be engaged and reached to facilitate change in policy and practice at different levels of emergency-response and health systems strengthening (described in Pathways to Impact) in the years following the project.
These include:
Decision makers:
Ministry of Health in Sierra Leone and other Ebola-affected countries. We will invite key figures in Sierra Leone to join our local Advisory Committee. Through their active engagement (and pre-existing links with our local partners) our project has the potential to inform future emergency-response strategies and the building of resilient health systems - this may include information for decision making on the coordination and management of foreign aid during emergencies. We would also expect to contribute significantly to improving the effectiveness and sustainability of public health services - the profile of medium to long term health outcomes and the success of responses to any future Ebola epidemic would be the ultimate (long-term) test of this.
District officials, chiefs and other local decision makers will also be included in our Advisory Committee and invited to participate in discussion and dissemination meetings that will be held after our Annual partner meetings in Sierra Leone.
International donors, NGOs and development agencies: our results will have the potential to inform and influence the actions of international health actors involved in emergency assistance enabling them to implement more nuanced responses that strengthen rather than destabilise system building efforts already in place and promote resilience drawing on a wide range of resources including existing community capacity. A critical goal of emergency-response to such disasters is to avoid setting back a country's post-emergency health systems development by years. The timeframe for benefits to be achieved ranges from near to long term.
As with local decision makers, international stakeholders will be invited to discussion and dissemination meetings to be held in Sierra Leone throughout the project (see the timeline in the Case for Support for details). We will also consider inviting representatives (e.g. from MSF and/or SCF; DFID) to sit on our Advisory Committee.
Publications
Chersich M
(2020)
COVID-19 in Africa: care and protection for frontline healthcare workers
in Globalization and Health
Hanefeld J
(2018)
Towards an understanding of resilience: responding to health systems shocks.
in Health policy and planning
Richards P
(2020)
Ebola and COVID-19 in Sierra Leone: comparative lessons of epidemics for society
in Journal of Global History
Ebola Gbalo Research Group
(2019)
Responding to the Ebola virus disease outbreak in DR Congo: when will we learn from Sierra Leone?
in Lancet (London, England)
Parker M
(2019)
Ebola and Public Authority: Saving Loved Ones in Sierra Leone.
in Medical anthropology
Mokuwa EY
(2020)
Rural populations exposed to Ebola Virus Disease respond positively to localised case handling: Evidence from Sierra Leone.
in PLoS neglected tropical diseases
Richards P
(2020)
Re-analysing Ebola spread in Sierra Leone: The importance of local social dynamics.
in PloS one
Kamara FM
(2020)
How villagers in central Sierra Leone understand infection risks under threat of Covid-19.
in PloS one
Richards P
(2019)
Trust, and distrust, of Ebola Treatment Centers: A case-study from Sierra Leone.
in PloS one
Mayhew SH
(2021)
Responding to the 2018-2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches.
in Risk management and healthcare policy
| Title | Ebola's First Responders: stories of resilience from the pandemic frontline |
| Description | This 15m video tells the stories, in their own words, of Ebola affected communities and frontline district health staff who were first responders to the Ebola pandemic in Sierra Leone. Partners Njala University (Sierra Leone) and LSHTM conducted interviews with respondents in two early affected districts in Sierra Leone (MRC funded Ebola Gbalo project). The video (MRF funded Rethinking Humanitarian Approaches project) details their examples of how they built community resilience and responded to the Ebola pandemic and the challenges they faced. Their stories highlight the critical importance of learning from and working with first-responders to a humanitarian crisis. |
| Type Of Art | Film/Video/Animation |
| Year Produced | 2022 |
| Impact | We showed this as the expert workshop of humanitarian responders (see separate entry under "engagement") and we use this in teaching (health systems, crisis response, pandemics) at the London School of Hygiene and Tropical Medicine. So far it has been seen by around 150 people who have been impressed and moved by it, promoting debate and questions about our research, how best to respond in humanitarian crisis settings and what can be learned from frontline experiences. |
| URL | https://vimeo.com/808240308 |
| Description | The multidisciplinary Ebola Gbalo (Ebola Troubles) study, reconstructed the history of the epidemic in Sierra Leone and the work of responders in Bo and Moyamba districts in the country who worked successfully to control the outbreak before the arrival of national and international responders. Our findings underline the importance of learning from local front-line responders and working closely with and through communities (involving chiefs, herbalists, youth leaders, traditional health attendants, community health workers, teachers, and others) to promote locally acceptable treatment and burial practices, including offering as-safe-as-possible options for home care where access to care centres is impossible. Four key lessons can be learned: 1) Establish trust with local communities: In Sierra Leone, we found that community-level distrust was related to the nature of the response and the distance to the locus of operational decision making. Burial teams and contact tracing worked best when the recruits were local. Panic and confusion were alleviated when home carers were given clear instructions about how to care for their loved ones safely while waiting for help to arrive. Treatment centres began to be trusted, and used, when they were placed close to communities (community care centres) rather than far away in isolation. Our findings suggest that in Bo and Moyamba districts the response succeeded when community and district leaders were fully engaged. The actors differed in each district; international responders need to work with district and traditional authorities, as well as health workers embedded in communities, to discover other local leaders and figures of influence, including women's groups, secret societies and religious groups, traditional healers, citizen welfare groups, and youth organisations. 2) Learn from local front-line health staff and others attempting to care for the sick:Local learning during the Ebola virus disease outbreak in Sierra Leone was rapid among health workers and villagers alike. In the absence of a functioning, well-resourced health system, people drew on their own empirical observations about how Ebola virus was transmitted, as well as any previous experiences of responding to cholera and smallpox. Front-line health workers responding to the first cases passed on critical information to colleagues in neighbouring districts (e.g. on symptoms in Sierra Leon being different from elsewhere) allowing other staff to be prepared. Had there been a different mindset in action then guidelines and information on local symptoms, dignified burials, home care, and acceptable siting of treatment centres would probably have been corrected and agreed much earlier. 3) Home care for the management of a person with Ebola virus disease is controversial. For many, the risks of infection are too high, especially where supplies and support for families are inconsistent. However, in some circumstances, home care is unavoidable. The Ebola Gbalo study showed that families often had to wait long periods for help during the Sierra Leone epidemic, and beds in Ebola treatment centres were not always available. In these circumstances, families refused to abandon their loved ones but coped as best they could, often with only their own resources. Given the inadequate infrastructure and reach of the official response, there is always the issue of how care is to be given while waiting for help and in settings where no help is likely to arrive. In Sierra Leone, international non-governmental organisations and donors, as well as the government, persistently overruled the suggestion to provide information and resources to enable people to care for loved ones within their homes. Consistent guidelines on homecare, like those eventually developed in Sierra Leone the US Centers for Disease Control and Prevention can be very effective, as can dissemination of accurate information about responses via radio. Disseminating gloves, boots, and possibly even chlorine, as local need arises, to support home care is also a critical consideration. 4) The armed forces had a major part in enforcing quarantine in Sierra Leone. They provided 24-h armed guard for 21 days in houses where a person had become infected with Ebola virus. The reactions to military intervention were mixed across our fieldwork area, with some study participants saying it was necessary to enforce compliance, and others finding enforced quarantine counterproductive. There were multiple examples of bylaws and quarantine being broken, suggesting that it might be better to engage with populations in such a way that they take responsibility for their own quarantine, rather than relying on external military forces. External actors could support such an approach through provision of food and medical supplies for a range of ailments. |
| Exploitation Route | Mayhew and Mokuwa from this project shared an expert panel at the Graduate Institute in Geneva together with Michael Ryan (Executive Director, Health Emergencies Programme, World Health Organization) and Emanuele Capobianco (Director, Health & Care, International Federation of Red Cross and Red Crescent Societies) on May 13th 2019 to share key lessons from our research. Prof Peter Piot (Executive Director of the London School of Hygiene & Tropical Medicine), an adviser to this research, also supported the findings and reflected the importance of community engagement (one of our key findings) in remarks on Radio 4's Today programme and in his advice to WHO. Results were also shared with the Chief Scientific Adviser in DfID, Prof Charlotte Watts, who told us they would be useful in her internal negotiations. Our results were used in the response to the Ebola outbreak in Eastern Congo after being translated into French (by a team at Berkeley, California, with our permission) (see narrative impact). We have also drawn on them in current discussions on the Covid19 response, in particular findings around quarantine and community responses, including a BMJ Opinion piece and written evidence to a parliamentary inquiry on the NHS response to Covid. Two of our local partners have successfully completed and submitted their PhD theses to Njala University - their analysis focused on aspects of our research (and formal publications are now in progress). This has significantly built their research capacities and finalising their PhDs means they are eligible for senior university positions (Vandi has already been appointed a Head of Department and Babawo is a senior lecturer and advisor on the Sierra Leone government's SAGE-equivalent body). |
| Sectors | Healthcare,Government, Democracy and Justice,Security and Diplomacy |
| URL | https://responding-to-ebola.org/ |
| Description | Our project staff have been involved not only in the Sierra Leone outbreak response, but also that in DRC at both UK government and Congolese government and sub-district levels. We believe our findings reported in The Lancet, The Guardian and through personal communications with Prof Peter Piot (Exec Dir LSHTM and key player in the UK's Ebola Response), Prof Charlotte Watts (DFID Chief Scientific Adviser) and Daniel Bausch (Director, UK Rapid Support Team) have had some impact. The three named individuals all welcomed our findings. We have seen an increase in public statements acknowledging that community-engagement has been poorly done in the past and must be done better in future. Reports from the ground in DRC suggest that over the course of that epidemic, as this point was pushed (not only by us, also notably by MSF) that the approached started to change. Specifically, our research has been extremely relevant to those working on the DRC outbreak. A team from Berkley California requested permission from us to translate our key findings into French for use during the Congo outbreak. All French translations can be found on our project website. Daniel Cohen, the external advisor to the Congolese President's Ebola adviser told us that "the great change in approach to Ebola in Eastern DRC which took a while, reflected this work". Our papers are used for anthropology and wider social science teaching at Harvard University and within LSHTM. We are beginning to be seen as key authorities in this field. We were commissioned to write a paper reviewing literature and reflecting on the challenges for humanitarian response, drawing on the experience of DRCongo (paper to be published later in 2021 by the Journal of Risk Management and Healthcare Policy). The Managing Editor at the International African Institute, SOAS, which produces the African Arguments book series and blogs, Stephanie Kitchen, told us that the piece our authors wrote on the Africa Arguments blog site ("What Might Africa Teach the World? Covid-19 and Ebola Virus Disease Compared") was "the most read on our site in 2020 with over 40k views. More qualitatively, this and other publication expanded readership overall for our coverage of the epidemic and other African topics to its 'biggest' ever according to the main editor on the site. So impacts not just for epidemic understanding/coverage, but understanding of Africa at large. A big outcome for research from a 'small' country." In November 2021 we were awarded a MRF Changing Policy and Practice Award to package our findings for policy and practitioner audiences and hold a dedicated dissemination event (hybrid in-person/virtual) for humanitarian response agencies, West Africa regional policy makers and Western donors supporting emergency response. This was held at the Noguchi Memorial Research Institute, University of Ghana in October 2022. We produced a Policy Brief and co-created (at the workshop) a Guidance Document for Community Engagement in Humanitarian Crises. We have since engaged with 56 named humanitarian responders, from a range of backgrounds (government and ministry, international humanitarian agencies, intergovernmental organisations including WHO, international and national NGOs, academics). Follow up with these participants is ongoing and expected to lead to some level of direct policy and programme impact within international and national emergency response agencies and enable them to better facilitate rapid engagement with front-line responders. |
| First Year Of Impact | 2019 |
| Sector | Communities and Social Services/Policy,Healthcare,Other |
| Impact Types | Societal,Policy & public services |
| Description | A multi-disciplinary course on "Engaging and supporting local responders to build resilient pandemic-response: Lessons from Sierra Leone" |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Influenced training of practitioners or researchers |
| URL | https://www.lshtm.ac.uk/study/courses/short-courses/pandemics |
| Description | Advice to British Govt on DRC Congo Ebola outbreak |
| Geographic Reach | Africa |
| Policy Influence Type | Participation in a guidance/advisory committee |
| Description | CATALYSING LOCAL LEADERSHIP TO SUSTAINABLY RESPOND TO SHOCKS |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to new or improved professional practice |
| Description | Embedding findings on governance, anti-corruption & resilience in the Health Systems module, MSc programme at the LSHTM |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Influenced training of practitioners or researchers |
| URL | https://healthsystems.lshtm.ac.uk/teaching/health-systems-module/ |
| Description | Guidance Document on Community Engagement in Humanitarian Crises |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to new or improved professional practice |
| Description | Training in Health Policy and Systems Research |
| Geographic Reach | Africa |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Description | Written Evidence to House of Commons Health and Social Care Select Committee inquiry on "Delivering core NHS and care services during the Pandemic and Beyond". |
| Geographic Reach | National |
| Policy Influence Type | Contribution to a national consultation/review |
| URL | https://committees.parliament.uk/writtenevidence/4546/html/ |
| Description | Written Evidence to House of Lords International Relations and Defence Committee Inquiry on Peace and Development in Africa. |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to a national consultation/review |
| URL | https://committees.parliament.uk/writtenevidence/5172/html/ |
| Description | Written Evidence to International Development Committee Inquiry on Humanitarian Crisis Monitoring |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to a national consultation/review |
| URL | https://committees.parliament.uk/writtenevidence/4732/html/ |
| Description | COHRIE-0000000214 |
| Amount | $4,500,000 (CAD) |
| Funding ID | COHRIE-0000000214 |
| Organisation | International Development Research Centre |
| Sector | Public |
| Country | Canada |
| Start | 01/2022 |
| End | 12/2024 |
| Description | Medical Research Foundation Changing Policy and Practice Award |
| Amount | £29,978 (GBP) |
| Funding ID | MRF-145-0012-DG-MAYH-C0919 |
| Organisation | Medical Research Council (MRC) |
| Department | Medical Research Foundation |
| Sector | Charity/Non Profit |
| Country | United Kingdom |
| Start | 02/2022 |
| End | 01/2023 |
| Description | NIHR Global Health Research Group: Building Partnerships for Resilience (PARES) |
| Amount | £2,540,362 (GBP) |
| Funding ID | NIHR133333 |
| Organisation | National Institute for Health Research |
| Sector | Public |
| Country | United Kingdom |
| Start | 09/2021 |
| End | 08/2025 |
| Title | Multi-disciplinary framework for research on resilient health systems |
| Description | We have developed a multi-disciplinary framework for guiding research on health systems resilience. The framework draws on health systems frameworks (building blocks), ecological and socio-economic theories of resilience and adaptation, organisational management theories and anthropological theories. The resulting framework captures both structural dimensions (infrastructure, level of operations) and human elements (influences of actors at different levels within the system). It is expected to contribute to robust theoretical developments of the health policy and systems research field as well as become a good-practice example of how multiple disciplines can combine their epistemological expertise to become more than the sum of their parts. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Provided To Others? | No |
| Impact | We have not yet submitted the paper of the framework, but expect to disseminate it to other research groups and wider audiences, with resulting impact, once it has been published and presented at conferences. |
| Title | Video-voice diaries for policy analysis |
| Description | Background___The use of audio and video-voice diaries to collect data on daily routines of study participants is extensive in sociology and anthropology but relatively new to health systems research. These are thought to have significant advantages: a) participant-led and therefore authentic in reflecting unique individual experiences; b) capturing experiences in real time, thereby minimizing recall bias; and c) reflexive, stimulating the maturation of respondents' ideas over time, and d) motivating for respondents-in particular video, which is seen as more interactive. Outcome___The outcome sought it to capture community volunteers's perspectives of reality compared to the formal policies and understand better their own needs, and those of their community using Videovoice diaries. The community volunteers (Health Development Army) are expected to facilitate accessible and responsive primary health care in Ethiopia. Development and outputs___Footage is obtained over 3-4 months, from 30 Health Development Army cell leaders (each covering five families) in 3 woredas (districts) with diverse health system performance and population contexts. Following community engagement and training, participants receive an encrypted phone with recording capability. They are supported by experienced researchers through regular communication and visits, to establish trust and monitor preferences (e.g. for audio), ensure data validity and reduce social desirability of responses and other biases. We developed a checklist for researchers to support and elicit information from the respondents. We have developed a protocol for a co-production workshop with participants and researchers aims to support interpretation. Participants view their diaries, interpret and prioritise reoccurring themes, identify 'blind spots'. They are interviewed about their experience of participating in the study. The videos and qualitative data are being analysed and compared using Atlas ti. The work will conclude with a development of a methodological guidance and narrative review exploring the potential added value of the Videovoice diaries and the ways to maximise its benefits: ability to capture individual perspectives, better recall, emergence of new ideas or follow-up of previously discussed issues, respondent motivation, and complementarity with other methods. Strategies to reduce social desirability are identified, especially where there are concerns about anonymity and data confidentiality and clashing social norms and expectations. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2016 |
| Provided To Others? | Yes |
| Impact | The outputs of the project include expanding the evidence base about the use of audio-visual and diary methods in health systems research. The tools and resulting studies have been widely disseminated and discussed through presentations at major conferences (4th Global Symposium on Health System Research in Vancouver, 4th African Health Economics and Policy Association conference in Rabat and the 3rd UCL Qualitative Health Research Symposium 2017: Engagement, Co-production, and Collaborative Meaning-Making: Collaboration in Qualitative Health Research). The ideas behind the methods, and the methodological guidance on data analysis including co-production have underpinned a newly funded 4-year project (Creating building blocks for better treatment & control of NCD in poor & vulnerable households in Malaysia & Philippines, Wellcome Trust/Newton Fund). We will also seek to develop a narrative review reflecting on the use of audio-visual methods in health systems research. Tools, methodological guidance notes and other supportive documentation will be provided to interested researchers as well as opportunity to enter conversations with the Ethiopian and UK teams that led the work. |
| Title | National Archive of Sierra Leone Ebola Data |
| Description | This grant contributed to the development of the National Archive for Ebola-related data in Sierra Leone, held at Njala University. We did this through our support for Njala University (some of their overheads were used for this and our researchers supported the establishment in various ways) and through data collection for this project that gathered material which we handed over to the Archive. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2018 |
| Provided To Others? | Yes |
| Impact | The database is not yet fully accessible, but a Board has been established (in 2018) to hear requests for access to data. The database itself still requires some further cleaning to be fully publicly accessible (this is being undertaken by Wageningen University in The Netherlands). |
| Description | Writing workshop funded by CPAID |
| Organisation | London School of Economics and Political Science (University of London) |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | This project brought our three research assistants from Sierra Leone for a two-week workshop on data analysis. We have also provided the LSE team access to data and research sites alongside our researchers - we have started to uncover data that are relevant to public authority (there is some overlap) and have facilitated LSE access to relevant respondents and sites from our own research. |
| Collaborator Contribution | LSE is paying for our three SL research assistants to stay an extra week to attend a writing workshop funded under their Public Authority grant - this allowed our researchers to take the data from our project and discuss further how to use that in paper-writing as a first step to the project outputs. |
| Impact | Too early - the analysis workshop is in progress this week and the writing workshop is next week. It is multidisciplinary: health systems and policy researchers and anthropologists. |
| Start Year | 2018 |
| Description | Conference presentation at 10th European Congress on Tropical Medicine and International Health |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Conference presentation on "Complex adaptive health system governance: Sierra Leone case study of epidemic response" to a mixed audience of international academics, students, policy, donor and NGO reps. c.150 people attended. The presentation sparked a good level of questions and discussion and afterwards several people came up to ask for further details. |
| Year(s) Of Engagement Activity | 2017 |
| Description | Ebola Gbalo website |
| Form Of Engagement Activity | Engagement focused website, blog or social media channel |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Public/other audiences |
| Results and Impact | The Ebola Gbalo project website seeks to engage all interested parties (listed above) with our research findings. We have deposited all open access peer-reviewed publications arising from our project, including their French translations (given their relevance for the Ebola response in DRC). We also include newspaper items arising from our research, presentations from conferences and expert meetings and a blog. |
| Year(s) Of Engagement Activity | 2018,2019,2020,2021 |
| URL | https://responding-to-ebola.org/ |
| Description | Expert Policy Panel at Graduate Institute, Geneva |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Policymakers/politicians |
| Results and Impact | This expert policy panel took place as part of the Graduate Institute's Policy Series. Entitled "What can we learn? Ebola then and now." Prof Susannah Mayhew and Ms Esther Mokuwa, from Ebola Gbalo project team, spoke on the panel together with Michael Ryan (Executive Director, Health Emergencies Programme, World Health Organization) and Emanuele Capobianco (Director, Health & Care, International Federation of Red Cross and Red Crescent Societies). It was attended by c.100 people in person and many more online/subsequently listening to/watching the podcast. Many questions were asked. Subsequent post-panel debate led to a Guardian article (see separate entry) which was cited in the Guardian's oped. |
| Year(s) Of Engagement Activity | 2019 |
| URL | https://graduateinstitute.ch/sites/default/files/2019-06/May%2013%20Bio%20of%20Speakers.pdf |
| Description | Health systems & Policy training for university staff |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Professional Practitioners |
| Results and Impact | At the request of a local university affiliated to our partner university, Njala, we conducted a one-day training session on health systems and policy research tools and methods. The training was very well attended with around 150 staff and some postgrad students. |
| Year(s) Of Engagement Activity | 2019 |
| Description | How to (or not) respond to health system shocks. 4th Global Symposium on Health Systems Research, Vancouver, 14-18 Nov.2016 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | This was an interactive satellite session at the 4th Global Symposium on Health Systems Research, Vancouver, 14-18 Nov.2016 - the major forum for health systems research. The session generated substantive discussion and led to ideas for further research. The full details of the session are: How to (or not) respond to health system shocks - lessons from Ebola, climate change, migration and the financial crisis. Speakers: Johanna Hanefeld, Susannah Mayhew, Karl Blanchet, Dina Balabanova. 4th Global Symposium on Health Systems Research, Vancouver, 14-18 Nov.2016. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Humanitarian Responders workshop |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Policymakers/politicians |
| Results and Impact | In October 2022, the Rethinking Humanitarian Approaches research team convened a workshop of humanitarian response experts in a hybrid workshop at the Noguchi Memorial Research Institute, University of Ghana, followed by a final virtual meeting. Attendees (n=32) included Sierra Leonean and Liberian government representatives, national and international humanitarian NGOs and donor agencies, policy and public health experts and academics. Together these stakeholders heard directly from first-responders in Sierra Leone's outbreak, reflected on the Ebola Gbalo research findings (MRC award) and discussed how community engagement (CE) strategies can be improved and practically implemented by actors though CE strategies. Although debate focused primarily on experiences from the West African and DRC Ebola outbreaks, they also drew on the collective experience of participants and the agreed priorities for action are applicable to other crisis settings. |
| Year(s) Of Engagement Activity | 2022 |
| URL | http://lshtm.ac.uk/rethinkinghumanitarianreponse |
| Description | Presentation on organised panel at 5th Health Systems Global conference |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Presentation on a competitively selected panel at the 5th Health Systems Global (HSG) conference: Critical junctures: reflections on cross-disciplinary and cross-sector approaches to development challenges. HSG is the leading international conference for health systems and policy work which provides a venue for disseminating preliminary results to key audiences of academics, policy makers, donors, third sector agencies and others. |
| Year(s) Of Engagement Activity | 2018 |
| Description | Stakeholder Workshop to discuss findings |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Study participants or study members |
| Results and Impact | All study stakeholders including those interviewed and key decision influencers were invited to two workshops (one regional, one national) to hear and discuss the study findings. c.100 stakeholders attended across the workshops, including section and paramount chiefs, medical practitioners and managers, academic staff and post-graduate students, UN and donor representatives, NGO representatives, Government representatives from several sectors. Good questions were asked and good discussions had which will now feed into the final publications of results. |
| Year(s) Of Engagement Activity | 2019 |
| Description | Stakeholder engagement meetings |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Professional Practitioners |
| Results and Impact | Meetings with key stakeholders at study sites to sensitise them to the project, get their support and initial views on the research. they will later be invited to larger stakeholder meetings. |
| Year(s) Of Engagement Activity | 2017 |
| Description | TV and radio interviews in Sierra Leone |
| Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Public/other audiences |
| Results and Impact | National TV, newspaper and radio journalists were invited to attend the training workshop run as part of the capacity building of this project at the invitation of Njala University. The interviews described the project to the general public, including policy makers, health professionals and patients, and highlighted the partnership between LSHTM and Njala University. The interviews were only aired in Feb/March so it is too early to have feedback on any impact. |
| Year(s) Of Engagement Activity | 2017 |