Hi, I'm Deborah McFarland.

I am a professor in the Rollins School of Public Health,

in the Hubert Department of Global Health, here at Emory University.

And I have been involved in health systems and

working in health systems in low and middle income countries for over 30 years.

And particularly have been involved in working in strengthening

health systems in low and middle income countries in sub Saharan Africa.

So the countries in West Africa are the Ebola effected countries are ones that I'm

very familiar with and have lived and worked in so, I hope

that this will be helpful and useful for those of you who are taking this course.

So what we're going to do is talk about

what many people call strengthening health systems but

now is increasingly being referred to as building resilient health systems.

So what I want to do is take you back to some of the key themes and

issues in health systems, so that you understand some of the concepts and

terms, and put it in the context of the Ebola epidemic.

So the question that I want to start with is,

why did it take an Ebola outbreak to realize the importance of health systems?

And you'll see thee importance of health systems in many articles that have

appeared since the beginning of the epidemic.

From the business press, to global health press,

to the technical press, to newspapers, and the popular press.

And I'll say, and usually begin with this kind of comment.

One of the determinants and one of the reasons the Ebola epidemic went so

quickly and was magnified so

quickly was because health systems were weak in Guinea, Liberia and Sierra Leone.

So Paul Farmer has certainly said that, many NGOs

again, the business press, Businessweek, the global excuse me, The World Bank.

And at the end of every article, it will say, well if health systems are weak, and

that was one of the determinants and one of the generators,

one of the motivators for the epidemic, then at the end of every article,

it will say, and oh, yeah, by the way, we need to strengthen health systems.

So what do we mean by strengthen health systems?

That's really what I want to focus on in this session.

So this is a quote and a particularly salient quote,

a particularly pertinent quote I think.

Because the efforts this money is paying for are largely uncoordinated and

directed mostly at specific high-profile diseases.

And those would be diseases like HIV primarily and to a lesser extent malaria.

Since most of the money is going to these specific high profile diseases rather than

public health in general, there is a grave danger that the current

age of generosity could not only fall short of expectations but

actually make things worse on the ground.

Now think about that in the context of the Ebola epidemic.

So this was written in 2007, that's seven years before

the outbreak, before the advent of the Ebola epidemic.

And this very, very, very thoughtful commentator and a very good writer and

journalist an observer of the global health scene says, all of this

money coming into global health is largely uncoordinated and virtually

all directed at very specific high profile diseases, and most of that was HIV.

Not very much of the money was directed toward public health in general.

And her forecast, her prophecy was that there's

a grave danger that all of this money and all of this generosity, which has been

considerable, will not only fall short, but also make things worse on the ground.

Now think about that again in the context of the Ebola epidemic.

That's exactly what happened.

Lots of money came into Guinea, Liberia,

Sierra Leone over the decade from 2000 to 2014.

But almost all of it was very single focused, was directed to s,

to specific diseases and not to health systems in general.

And, we see In the out, aftermath we hope,

aftermath of the Ebola epidemic, that indeed, all of that money

hasn't made much of a dent in the public health system in general.

So again, let me take you back.

In the year 2000, the World Health Organization

wrote a report called Strengthening Health Systems.

Or Health Systems: Improving Performance.

And it ranked health systems around the world in terms of three outcomes.

Health, which makes sense.

We hope that health systems increase individual health as well as

improve community health, so health was one of the outcomes of a health system.

This is what we expect out of a fully functioning health system.

The other is fairness,

in terms of financial contributions and in terms of equity.

And the other was meeting people's expectations,

being responsive to people's expectations.

So that was a very seminal report written in 2000 by the World Health Organization.

And in that report the World Health Organization ranked all of

the countries of the world in terms of their performance of their health system.

And the map shows the,

the rankings of health systems at the point in time of 2000.

So the redder the, the country the poorer the performance.

And you'll see that most of the countries in sub Saharan Africa and

many of the countries in West Africa were ranked

poor in terms of health systems performance.

What country ranked number one?

Well, people were very surprised the country that ranked number

one in health systems performance was France.

The United States didn't do very well.

The United States was ranked 37.

And that caused great angst.

In the United States, but if you look at our three countries that we're looking at

now in the Ebola epidemic Guinea, Liberia, and Sierra Leone.

Guinea was ranked number 161, Liberia number 186,

and Sierra Leone was last at number 191.

It tells us something again about the state of health systems in those countries

in the year 2000.

So we had evidence, certainly at least as early

as 2000 and even before that, that the health systems of Guinea, Liberia, and

Sierra Leone were among the poorest performing health systems in the world.

14 years later, the Ebola epidemic erupted.

Now the community and the global community calls for

health system strengthening in those very same countries.

So here's a question for you to think about.

And we're going to pause the tape to give you time to think.

Suppose you were asked by The minister of health

in one of those three countries to suggest or

to name what you think could be done, and indeed should be done,

to strengthen the health systems in your country.

If you were advising the government of these three countries, what are the top

three priorities that you would recommend for health system strengthening?

Before we get to what you would do, let me just go through a bit of a framework for

what we mean by strengthening health systems.

Let me preface this by saying that personally I have seen the health system

in West Africa, and primarily in Liberia, over the last 35 years.

So I was a Peace Corps volunteer in Liberia in the 70s.

I worked with CDC and, on child survival programs in the late 80s and

early 90s, until the civil war broke out.

And then, in the 2000s I was again back in Liberia working as a consultant and

doing some technical assistance with the World Health Organization.

So I've seen Liberia at many different stages of its political history,

civic history and indeed health systems history.

So the notion of strengthening health systems in Liberia and

the other two countries where I've also worked but

not as extensively, is very personal to me and to the Liberian friends that I know.

So what do we mean by this term strengthening health systems?

Well, WHO has this framework, and they have six pillars in the framework.

If you just look at the words, they are words that embody many different concepts.

But think about what is embedded in each one of these, each one of these concepts.

So the, the six pillars are leadership and governance.

Health systems financing.

The availability of medical products, vaccines, technologies, new technologies.

The existence of a good systematic health information system.

A fully trained, good, quality health workforce.

And an efficient and effective way to deliver health services.

So those are the six pillars, or components,

that WHO, that represents, as you know, the governments of the world,

says this is what we mean by strengthening health systems.

Investment in one or all of those six, over time,

will strengthen the health system and lead to the things that we talked about

earlier in the 2000 report, fairness, good health status, responsiveness.

And that's what we're aiming for.

That's what a health system should do.

We shouldn't just pour money into a health system and

expect poor health as an outcome.

We should expect good health for individuals and for communities and for

the country as a whole.

So think about this framework and then go back to the question that I asked you.

If you were charged with advising the minister of health in

any one of these three countries, did you focus in on any one of

those areas that are on the slide, any of the components?

Governance and leadership, health financing, health services delivery,

health information systems, health workforce, and

training of health workforce.

So again, I'm going to ask you to go back and see what you originally wrote

down as what you would have advised the minister of health for

the three critical issues that he or she should address in the aftermath of

the Ebola epidemic, in terms of strengthening health systems,

and see if any of your suggestions fit into one of those six categories.

So now, the, the, much of the literature that you will see now,

just in the last year or so, rather than using the term strengthening

health systems, now goes a bit further and says all right,

what we want is, yes indeed, to strengthen health systems, but

we want at the end of the day resilient health systems.

So you think about resiliency in your own life.

Think about people that you know who are resilient, families that you know that

are resilient, communities that you know that are resilient.

That in the face of what may be extraordinary and complex assaults,

they still manage to absorb the shock of some emergency,

both at a family level, an individual level and at a community level.

Well, that's really what we want in terms of resilient health systems.

It's a health systems that able to absorb the shock of an emergency like Ebola

and, at the same time, to continue to provide regular health services and

leave other sectors of the economy fully functioning.

Now, in Ebola, that didn't happen.

The health system, such as it was, which was very poor to begin with, collapsed.

Health workers were some of the people who were the most at risk, and

their, their, case fatality due to Ebola was very high.

There weren't enough health workers to begin with.

The health facilities were very poor and were not very well supplied and staffed.

The supply chain to get critical supplies, medicines, vaccines, was poor.

Roads were poor.

When I was a Peace Corp volunteer in the very upper on the border of Guinea,

Liberia, and Cote d'Ivoir, the road system actually in the mid-70s wasn't bad.

It was, it was, it was poor and it took us a long time to get from Monrovia,

the capital, to my village up in that area, but there were roads.

But in the aftermath of the civil war in the 90s, virtually

all of those roads disappeared because the bush took over, the bush and the growth,

because this is a very verdant, tropical area with huge rains.

All of the growth began to take over.

People left their villages, and so you would have abandoned villages,

abandoned roads, and really there was just simply no way to get to people.

And many people, as you know, moved into the city,

moved back into Monrovia, so that by the early 2000s,

half of the population of Liberia lived in the city, in Monrovia.

Health services collapsed in the aftermath of the Ebola epidemic, but as I said they

weren't very good to begin with and they were, they, they had lots of challenges.

And other sectors of the economy were indeed booming.

There was an economic boom, principally due to minerals and

mineral resources, investment in those mineral resources.

So there was an economic boom, and I think that you have seen in,

in previous lectures Presentations,

how the economies of these three countries really grew in the decade of the 2000s.

That has come to a screeching halt.

So how do we create a resilient health system in the midst of that,

that doesn't collapse other parts of the health system and

yet, or other parts of the economic and political system that build off of that.

So the Ebola crisis as this article from The Lancet suggests

is revealing itself to be a catalyst, that's good news, for

much needed change in our approach to global health.

Listen to this carefully.

The lesson painfully learned shows that we do not need another

vertical program for a specific health condition or challenge.

Now think back to that quote that I gave you earlier from 2007.

Where Laurie Garrett who read that article says, if we're not careful,

all of the money that has gone into global health over the years,

directed toward high profile diseases, is going to come to naught.

It may, in fact be negative for the health system.

Particularly, if there is no investment in public health.

Now, seven years later, in the aftermath of the epidemic, The Lancet says,

the lesson, painfully learned, shows that we don't need another vertical program.

My plea is that Ebola,

that in the, the aftermath and we hope the end of Ebola

will in fact leave the global community, ministries of health, communities and

others to in fact, invest in public health and health systems in general.

And not go back to the vertical approach that has been

the cornerstone of global health for the last several decades.

If we don't do that we're, we're going to end up seven years from now.

Ten years from now.

15 years from now with exactly the same quote that I'm giving you now.

We forgot, we forgot to invest in public health.

We forgot to invest in health systems.

We went down the vertical approach.

If we continue to do that, I promise you, that ten years from now we'll be back,

and these countries will be back in exactly the same position.

One of the most important prerequisites of a resilient health system is trust.

One of the things that broke down

totally during the Ebola epidemic is trust in the health system.

How do, how do communities, how does the country,

how does the social and civic society rebuild that trust?

The hollowing out of the public sector, including the health system,

followed by the Ebola epidemic, has left people without any trust.

In the political system, the economic system and indeed in health systems.

So, how do we build that trust?

Building that community trust, engagement and

ownership is key to building resilient health systems.

Another challenge for you to think about is with all of these global actors and

all of these global health initiatives and all of the dominant power players

from the outside coming in to Guinea, Liberia, Sierra Leone.

Our communities, our local people going to

have any say at all in how the health system is strengthened,

rebuilt, and indeed heads toward resiliency.

Without them, without their trust, without their engagement,

and without their ownership it won't happen.

The challenge for the global community is to give it time and

that's something that the global health community, the global health

agenda just really doesn't deal with very well giving things time.

We want to have short term fixes.

Short term and immediate responses.

And indeed, there are short term and

immediate responses that need to happen in all three countries in the health systems.

But there also has to be, at base, at the foundation.

There has to be this long term rebuilding of trust.

Think about it, in all 3 of these countries.

Primarily, Sierra Leone and Liberia, there is a legacy of mistrust, not just

because of Ebola, because of the military invasions, because of the civil wars.

People have, and

now they're saying in some ways a militarized response to the epidemic.

In the wake of their fear, and loathing really of, war.

The fact that communities suffered dramatically during the war,

people were displaced.

Again, there, there is no trust in the political system,

in the economic system and the health system.

And when the health system seems to be militarized, in order to

respond to this immediate threat, one wonders what

people have in the back of their minds, and how people respond in terms of trust.

As I said, will the community, will the global health community, global health

actors, like the World Bank, like the Center for Disease Control, like USAID,

like all of these other major global health players, give the space time and

involvement needed for communities and local people to engage.

To rebuild resilient health systems.

That's my question for you, and

I wonder if in, as you think about resilient health systems,

what kinds of things you put in your first response to the minister saying,

these are the three things that I think you need to do.

And whether now as you think about it,

you might change your mind about what the three top priorities are.

One of the key sectors that has as it's cornerstone

is trust is the faith-based sector.

Can the faith-based sector live up to the promise of rebuilding trust and

engaging communities in building resilient health systems?

My last slide and a quote that's from 17, and,

from the mid 1700s and for some of you, you will recognize the name, Adam Smith.

He was the Father of Economics, but he was also a moral philosopher.

And I like this quote and I think that it says very much where we are in the global

community today when we think about rebuilding and

creating resilient health systems with communities and

with those people who are the most affected, affected.

So what Adam Smith said and the language is a little convoluted because it is

actually from the 1700s but we'll read it carefully.

What improves the circumstances of the greater part,

that is the circumstances of the the greater population can

never be regarded as an inconveniency to the whole.

No society, and this is the important one, no society can surely be flourishing and

happy of which the far greater part of the members are poor and miserable.

That's what we want to avoid, that's what we want

to build in terms of health systems.

Making and

ensuring that, at least on the health side, people are not poor and miserable.

Because as Adam Smith said, no society can flourish, no society can be happy.

If the biggest portion of the members of that society are poor and miserable.

So I leave you to think about that in your role now as a, an adviser

to the Minister of Health in Guinea, in Liberia or Sierra Leone.

What would you do?

What are your priorities to strengthen health systems and to build resilient

health systems that respond to the poor so that they in fact be,

are not poor and miserable 15 years from now, 20 years from now.

And that will lead, yet another quote in the global health literature that says,

oh my goodness, we forgot.

We needed to invest in health systems and we needed to invest in people

Building Resilient Health Systems

Ebola Virus Disease: An Evolving Epidemic

Meet the Instructors