Building resilient Health Systems

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

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.

Key project areas

  • Health policy and systems analysis; health systems resilience; health systems strengthening; shocks; outbreak responsiveness; Ebola

Study design

  • Multidisciplinary case studies drawing on health policy and systems analysis and anthropology


  • Sierra Leone


  • Feb 2016-Feb 2019

Principal Investigator(s)

  • Susannah Mayhew
  • CoIs: Johanna Hanefeld; Melissa Parker; Dina Balabanova

Funding source

  • MRC (through HSRI)

Project partners

  • Professor Bashiru, Professor Richards and Ms Esther Mokuwa – Njala University, Sierra Leone

Other LSHTM research staff involved

  • On Advisory group: Peter Piot; Jimmy Whitworth

For more information on this project please contact Susannah Mayhew

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