Building resilient health systems: lessons from international, national and local emergency responses to the Ebola epidemic in Sierra Leone.

对埃博拉病毒的应对暴露了受影响国家卫生系统的重大弱点。这在一定程度上是由于国家和地区一级的体制弱点，但全球行动者在应对过程中的行为也招致了批评。塞拉利昂的情况尤其严重，因为许多渐进的改革，如免费保健和其他治理举措，可能因疫情和应对措施的性质而受到破坏。迄今为止，关于国际埃博拉应对援助在塞拉利昂产生影响的证据，以及它促进或阻碍当地应对的方式，几乎不存在。例如，不知道如何、为什么以及以何种方式使用或不使用地方卫生系统；而且根本不清楚国际援助是加强了地方卫生系统，还是通过建立平行结构和绕过地方机构和关系削弱了它们。因此，这种援助的长期影响，特别是在当前危机之外的影响，尚不清楚。记录和了解国家和国际为照顾病人和阻断埃博拉传播所作的努力如何以及为何难以产生预期结果，对于改进未来的应对措施和确保卫生系统不会因未来的紧急情况而削弱至关重要。我们的研究将探讨一系列因素，包括：当地对应急响应系统的关注和看法对响应的影响程度；外部干预是否寻求在地方系统内部或与地方系统合作（以及这是否导致建立平行的反应结构）；外部干预措施是否最终削弱并降低了卫生系统的复原力，例如，将当地合格的工作人员从公共部门系统中挖走，或从其他持续的卫生需求（包括常规妇幼保健和常见可预防疾病）中转移资源。具体而言，我们提出以下研究问题：国际埃博拉应对措施在哪些方面影响了塞拉利昂的卫生系统及其抵御未来冲击的能力？如何利用国际、国家和地方应急机制在塞拉利昂建立一个具有复原力的卫生系统？从中可以得到哪些经验教训？我们汇集了几个不同的学科和专题观点，包括卫生系统/系统加强、政策和实施科学；减少灾害风险/应急准备；以及全球健康人类学和医疗人道主义。明确地将这些往往独立的学习机构结合在一起，将使我们能够更充分和有效地回答我们的主要研究问题，确定可转移的经验教训，并有助于产生与促进韧性卫生系统有关的实质性卫生系统研究证据。该项目的具体效益将包括：*确定需要在塞拉利昂和其他类似环境中作为加强卫生系统工作基础的韧性卫生系统的特征，以及如何将这些特征纳入国家卫生系统发展。*确定影响村庄一级应对埃博拉的关键问题，并反思这些问题对理解和建设更具复原力的卫生系统的影响。*建议修订现有应急反应准则，包括世卫组织根据塞拉利昂最近埃博拉疫情的经验提出的准则。

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.