How can decentralisation strengthen the responses to public health emergencies? Evidence for West Africa

Based on the argument that centralised systems are unable to coordinate large-scale activities due to lack of knowledge about local culture and circumstances, decentralisation has been central to health services development and reform in developing countries since the 1970s. What is less well understood is the impact decentralisation has on a country's ability to effectively respond to public health emergencies or on the important related concept of health system resilience - the capacity to prepare for and effectively respond to crises while maintaining core health system functions pre-, during, and post-crisis. This is particularly relevant in the current climate of an ongoing pandemic in which there is little consensus on the most effective response.
This project addresses this gap by exploring the links between decentralisation, health system resilience, and effective public health emergency responses through an analysis of decentralisation reforms in Liberia, Guinea, and Sierra Leone and their role in the responses to the 2014-16 Ebola outbreak.
Health system resilience is especially important in countries with high levels of poverty or instability where people are highly vulnerable to shocks associated with ill health, including major epidemics. This is particularly relevant in Africa due to the frequent and widespread occurrence of epidemics and disasters. Liberia, Guinea, and Sierra Leone provide an ideal case due to their recent shared experienced of responding to Ebola, where a central lesson was the need for a comprehensive strategy with communities at the centre and decentralized programming to facilitate flexibility and adaptation to the local context. Due to their similar social and economic structures but sharply dissimilar political records, these countries have an obvious appeal for comparative analysis; they have substantial variation in terms of decentralisation but share relatively constant confounders due to being in the same region.
The research objective of this project is to determine whether health system decentralisation leads to more effective responses to public health emergencies. To this end, it asks the following research questions:
What constitutes an effective response to public health emergencies?
What is the role of health system resilience in achieving this?
How does decentralisation help to build a resilient health system?
Which aspect of decentralisation is most likely to shape resilience and effective responses to public health emergencies?
This project uses a mixed methods approach. Quantitative research methods examine the relationship between decentralisation, health system resilience, and public health emergency responses in Liberia, Guinea, and Sierra Leone, using structural equation modelling (SEM) and directed acyclic graphs (DAGs) to compare how the WHO's six health system building blocks impact emergency responses. SEM allows for paths to be drawn between latent variables while DAGs are used to represent the structure of the causal networks linking exposure, outcome, and confounders. The independent variable - decentralisation - is measured by an index of different variables of fiscal and political decentralisation. Dependent variables comprise metrics for public health emergency responses such as Ebola cases, deaths, testing, and number of treatment facilities.
Qualitative methods are used to gain understanding of the political economy of decentralisation in Liberia. As the country with the highest number of Ebola deaths and as the last country to be declared Ebola-free, the Liberian case presents an opportunity to analyse the barriers to delivering a more effective response and what drives these. Primary data will be collected through interviews with government officials, development partners, and decentralised healthcare providers focusing on the context, key actors, and motivations for decentralisation reform at the national macro-level and regional sector-level.