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

基于中央系统由于缺乏对当地文化和环境的了解而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，即在危机前、危机中和危机后为危机做好准备并有效应对危机，同时维持核心卫生系统功能的能力。这在当前大流行病持续蔓延的环境下尤其重要，在这种情况下，对最有效的应对措施几乎没有达成共识。本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- 2016年埃博拉疫情中的作用，探索权力下放、卫生系统复原力和有效的突发公共卫生事件应对之间的联系，解决了这一差距。在高度贫困或不稳定的国家，卫生系统的复原力尤其重要，因为这些国家的人民极易受到与健康不良有关的冲击，包括重大流行病。这在非洲尤其重要，因为流行病和灾害经常和广泛发生。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方面有共同的经验，其中的一个主要教训是需要一项以社区为中心的综合战略，以及分散规划，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，但政治记录截然不同，因此对比较分析具有明显的吸引力；它们在去中心化方面存在很大差异，但由于处于同一地区，它们具有相对恒定的混杂因素。本项目的研究目标是确定卫生系统权力下放是否能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？卫生系统复原力在实现这一目标方面的作用是什么？权力下放如何帮助建立一个有弹性的卫生系统？权力下放的哪个方面最有可能形成应对突发公共卫生事件的韧性和有效对策？这个项目使用混合方法。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构建模块如何影响应急响应，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——分权——是由财政和政治分权的不同变量组成的指数来衡量的。因变量包括应对突发公共卫生事件的指标，如埃博拉病例、死亡、检测和治疗设施数量。定性方法被用来了解利比里亚权力下放的政治经济学。利比里亚是埃博拉死亡人数最多的国家，也是最后一个宣布摆脱埃博拉的国家，因此，利比里亚的案例提供了一个机会，可以分析提供更有效应对的障碍以及造成这些障碍的原因。将通过与政府官员、发展伙伴和分散的医疗保健提供者的访谈收集主要数据，重点关注国家宏观层面和区域部门层面分散改革的背景、关键行为者和动机。

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.