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

权力下放如何加强突发公共卫生事件的应对能力？

• 批准号: 2594491
• 金额: --
• 依托单位: University of Birmingham
• 依托单位国家: 英国
• 项目类别: Studentship
• 财政年份: 2021
• 资助国家: 英国
• 起止时间: 2021 至 无数据
• 项目状态: 未结题
• 来源: https://gtr.ukri.org/projects?ref=studentship-2594491
• 关键词: How; decentralisation; strengthen; responses; public

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.

基于“由于缺乏对当地文化和环境的了解，中央集权系统无法协调大规模活动”的论点，自 20 世纪 70 年代以来，权力下放一直是发展中国家卫生服务发展和改革的核心。人们不太了解的是，权力下放对一个国家有效应对突发公共卫生事件的能力或对卫生系统复原力这一重要相关概念的影响——在危机前、危机期间和危机后维持核心卫生系统功能的同时，做好准备和有效应对危机的能力。这在目前流行病持续流行的情况下尤其重要，在这种情况下，对最有效的应对措施几乎没有达成共识。该项目通过分析利比里亚、几内亚和塞拉利昂的权力下放改革及其在应对 2014-16 埃博拉疫情中的作用，探讨权力下放、卫生系统复原力和有效的公共卫生应急响应之间的联系，从而解决这一差距。在高度贫困或不稳定的国家，卫生系统的复原力尤其重要，这些国家的人们极易受到与健康不良（包括重大流行病）相关的冲击。由于流行病和灾害频繁且广泛发生，这一点在非洲尤其重要。利比里亚、几内亚和塞拉利昂提供了一个理想的案例，因为它们最近在应对埃博拉病毒方面有着共同的经验，其中的一个核心教训是需要制定以社区为中心的综合战略和分散的规划，以促进灵活性和适应当地情况。由于这些国家的社会和经济结构相似，但政治记录却截然不同，因此对比较分析有着明显的诉求；它们在权力下放方面存在很大差异，但由于位于同一地区，因此具有相对恒定的混杂因素。该项目的研究目标是确定卫生系统权力下放是否可以更有效地应对突发公共卫生事件。为此，它提出了以下研究问题：什么是对突发公共卫生事件的有效应对？卫生系统的复原力在实现这一目标方面发挥什么作用？权力下放如何帮助建立一个有复原力的卫生系统？权力下放的哪个方面最有可能塑造对公共卫生紧急情况的复原力和有效反应？该项目采用混合方法。定量研究方法使用结构方程模型 (SEM) 和有向无环图 (DAG) 来比较世卫组织的六个卫生系统组成部分如何影响应急响应，研究了利比里亚、几内亚和塞拉利昂的权力下放、卫生系统复原力和公共卫生应急响应之间的关系。 SEM 允许在潜在变量之间绘制路径，而 DAG 用于表示连接暴露、结果和混杂因素的因果网络的结构。自变量——权力下放——是通过财政和政治权力下放的不同变量的指数来衡量的。因变量包括公共卫生紧急响应指标，例如埃博拉病例、死亡、检测和治疗设施数量。定性方法用于了解利比里亚权力下放的政治经济。作为埃博拉死亡人数最多的国家，也是最后一个被宣布为无埃博拉病毒的国家，利比里亚的案例提供了一个机会来分析采取更有效应对措施的障碍以及推动这些障碍的因素。主要数据将通过采访政府官员、发展伙伴和权力下放的医疗保健提供者来收集，重点关注国家宏观层面和区域部门层面权力下放改革的背景、关键参与者和动机。