Health Systems Recovery in Ebola Affected Countries: Concepts & reflections

Health Systems Recovery in Ebola Affected Countries: Concepts & reflections Dr Shams Syed Coordinator UHC & Quality Unit Department of Service Delivery & Safety WHO Headquarters, Geneva International Society for Quality in Health Care (ISQua) Webinar August 24, 2016

Webinar Objectives 1. Identify early recovery strategies applied in the three-affected countries to build back strong health systems; 2. Highlight successful infection, prevention and control strategies applied in the affected countries to improve quality of health services & patient safety; 3. Share lessons learned on the Ebola outbreak for use and application in other health emergency settings.

What happened?

"The 2014 Ebola Virus Disease (EVD, or "Ebola") outbreak continues to evolve in alarming ways, with the severely affected countries, Guinea, Liberia, and Sierra Leone, struggling to control the escalating outbreak against a backdrop of severely compromised health systems, significant deficits in capacity, and rampant fear."

Dr. Francis Kateh from the Liberian Frontline If I were able to plan for this moment 3 years ago I would have 1. Built a strong primary health care system with infection control & patient safety embedded within the system. 2. Established long term trust in health care providers through community engagement (patient-provider partnerships). 3. Ensured a supply chain of essential supplies required for IPC and patient safety. 4. Developed a cadre of IPC & Patient Safety officers for the future. 5. Focused on strong safe service delivery as the basis for "preparedness".

2015 WHO Strategic Response Plan OBJECTIVES 1 2 3 Stop transmission of the Ebola virus in affected countries Prevent new outbreaks of the Ebola virus in new areas and countries Safely reactivate essential health services and increase resilience 4 5 Fast-track Ebola research and development Coordinate national and international Ebola response

Health Sector Recovery Plan: Sierra Leone Key Expected Results Safe and healthy work settings Adequate Human Resources for Health Essential (basic) health and sanitation services are available Communities able to trust the health system and access essential health services Communities able to effectively communicate and effectively send health alerts Improved health system governance processes and standard operating procedures International Health Regulations (IHR) followed Patient & Health Worker Safety Outputs Health Workforce Outputs Essential Health Services Outputs Community Ownership Outputs Surveillance & Information Outputs Sierra Leone Basic Package for Essential Health Services (BPEHS) Fully implemented by 2020 Patient & Health Worker Safety PS and health services & systems development National PS policy Knowledge & learning in PS PS awareness raising Health care-associated infections Health workforce protection Health care waste management Safe surgical care Medication safety PS partnerships PS Funding PS surveillance & research Health Workforce National & 3 regional referral hubs for quality care Establish a medical post-graduate centre Strengthen national & 3 regional training institutions Establish CPD programmes for all health cadres Improving individual, provider and sector performance Strengthening ethics and health regulations Essential Health Services Integrated Management of Childhood Illness Core malaria control interventions, including HIV/AIDS and TB Maternal & Child life-saving interventions Teenage Pregnancy prevention Non-Communicable Diseases Essential Medicines & Supplies including PPEs Improve referral including revitalization of the national ambulance service Diagnostic laboratories & blood transfusion Rehabilitation & facility equipping Health promotion, environmental health & sanitation Community Ownership Revise policy and guidelines on Community leadership Community dialogue Community-based approaches Linkages between facility and community Improve community initiated health alerts Information & Surveillance Disease surveillance & database District health information system (DHIS2) Human Resource information system (HRIS) Logistics Management Information System (LMIS) Burden of disease studies National Health Accounts Enabling Environment: Leadership & Governance, Efficient Health Care Financing Mechanism and Cross-Sectoral Synergies.

LIBERIA Investment Plan for Building a Resilient Health System

Key Concepts & Definitions

Differentiating our phases Getting to zero Early Recovery Recovery Functional health system Start Dec 2015 Dec 2016 Dec 2017 Dec 2020 9 months 18 months 21 months 4 years From National HS Recovery Plan, Sierra Leone GETTING BACK ON AGENDA FOR PROSPERITY To build functional and resilient national and sub-national health systems that deliver safe, efficient and high quality health care services that are accessible, equitable and affordable for all Sierra Leoneans

Definitions: Early recovery a multisectoral process of recovery that begins in a humanitarian setting. It is guided by development principles that seek to build on humanitarian programs and to catalyze sustainable development opportunities. It aims to generate self-sustaining, nationally owned, resilient processes for post crisis recovery. It encompasses the restoration of basic services, livelihoods, shelter, governance, security and rule of law, environment and social dimensions, including the reintegration of displaced populations. (IASC Cluster Working Group, 2007) WHO Ebola early recovery priorities Source: WHO

Definitions: Preparedness and Resilience Preparedness The knowledge and capacities developed by governments, professional response and recovery organizations, communities and individuals to effectively anticipate, respond to, and recover from, the impacts of likely, imminent or current hazard events or conditions (UNISDR) Resilience the ability of a system exposed to a shock to resist, absorb, accommodate and recover from the effects of the shock in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions (WHO HSS Glossary)

Definitions: Universal Health Coverage All people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services do not expose the user to financial hardship

Shocks, Recovery & Resilience Poor quality Inequity Fragmented Lack of resource Service Delivery S H O C K Progress Progress Resilience Progress Quality Health for all Integrated Resourceful IPC & Patient Safety Health workforce Recovery Surveillance Essential services

Seven Reflections

Point 1: Link Global Drive with Local Action

Point 2: Streamline Technical Resources 20+ WHO technical programs/units Integrated library of tools & resources in a single source. Purpose: support countries in the reactivation of health services which may have suffered as a result of the emergency. Used in Ebola affected countries through WHO Country Offices but now released for all countries. http://who.int/csr/resources/publications /ebola/recovery-toolkit/en/

Point 3: Focus on critical structures for quality stay concrete! WASH is critical for achieving public health goals Reduces infections, increases community trust in services, and saves money Access to WASH is poor, and significantly impacted Ebola response Efforts to improve: - WHO/Unicef action plan - Liberia national standards and training

Point 4: Drive integration between health security and health systems See: http://www.who.int/csr/disease/ebola/healthsystems-recovery/health-security/en/

Point 5: Strengthen community engagement for quality in the context of UHC Community engagement key to quality and resilience More than just social mobilization and information dissemination Should be systemic in - clinical setting - institutional/policy settings - community settings Effective engagement for quality requires: - capacity of staff to engage - linkage of micro & macro systems - recognition of link between health system resilience and community resilience

Point 6: Catalyze National Quality Efforts through recovery & resilience planning Policies & strategies for quality must be embedded systematically into health services Post-shock opportunity to advocate for reform Need policies & strategies to maintain quality during & after emergencies Engage stakeholders and frontline perspectives in policy-making Leadership and governance are key

Point 7: Emphasize District Management for quality in the context of UHC Vital for improving health outcomes and Ebola response benefited from decentralization. Role of district health management teams (DHMT): - identify and appropriately allocate resources - local coordination to improve health status MOH Referral/ Teaching Hosp Provicial Hospital IHR (2005) compliance regulations requires strong integrated health systems able to prevent, detect and respond to health threats at the district level. However DHMTs need to be adequately resourced, planned and monitored to be effective.link with health financing. District Hospital Health Centers Communities/ Clinics Figure 1: Composition of a national health system

25 New Vision on Achieving UHC: A Framework for Sustainable Security Supported by Health Systems Strengthening

in Liberia, a country that never before had an incidence of Ebola, we were utterly ill-equipped and unprepared. What is so tragic is that, until this outbreak, Liberia had made significant progress in building up its public health systems countries like Liberia need long-term investment to build up our health systems to prevent outbreaks of this scale from ever happening again. We owe it to the thousands of citizens and health workers who have so far lost their lives to be prepared President Ellen Johnson Sirleaf Washington Post, 19 October 2014

Learn More Here: http://www.who.int/servicedeliverysafety/areas/qhc/en/

Health System Recovery: Lessons from the 2014 Ebola Outbreak in West Africa Infection, prevention & control perspective B. Allegranzi, IPC Global Unit SDS, HIS, WHO HQ 24 August 2016

Key lessons learned for infection prevention and control (IPC) from the Ebola outbreak 1. Absence of IPC/WASH basic measures and infrastructures both in the community and in healthcare settings led to the unprecedented situation of this outbreak 29

54 countries (LMIC) 66,101 facilities http://www.who.int/water_sanitation_health/publications/wash-health-care-fac 30

Water, sanitation, and hygiene Lack of access to water, sanitation, and poor hygiene practices were problems pre-ebola, exacerbated the outbreak, and remain problems to be resolved post-ebola Country N healthcare facilities (HCFs) Water coverage in HCFs Sanitation coverage in HCFs Guinea 1401 13% Soap for HW availability Liberia 328 50% 91% 54% Sierra Leone 1264 62% 78% 95%

Assessment of IPC needs in 6 districts in Sierra Leone (Oct 2014) 32 Pathmanathan I et al. MMWR 2014; 63:1172-4

EVD in healthcare workers HCWs were 21 to 32 times more likely to be infected by EVD than the general population Total N EVD in HCWs (3 countries): 815 (3.9% of conf. & probable cases), with 65.5% CFR (418/635) WHO Interim Report, May 2015, http://www.who.int/csr/resources/publications/ebola/health-worker-infections/en/

Key lessons learned for infection prevention and control (IPC) from the Ebola outbreak 1. Absence of IPC basic measures and infrastructures both in the community and in healthcare settings led to the unprecedented situation of this outbreak 2. Importance of partners coordination and of consistency and standardization of technical approaches and SOPs 34

36 Key Measures for Prevention and Control of Ebola Virus Disease

Inappropriate IPC practices!

40 Key Measures for Prevention and Control of Ebola Virus Disease Courtesy, Shaheen Mehtar

New WHO Guidelines on Personal Protective Equipment (PPE) What are the benefits and harms of double gloves, full face protection, head cover, impermeable coveralls, particulate respirators, and rubber boots as PPE when compared with alternative less robust PPE for HCWs caring for patients with filovirus disease? Guideline development process Development of key research questions Systematic literature reviews Literature review and an online survey on values and preferences of health workers Evidence-to-recommendations exercise using the GRADE framework Expert consultation WHO Guideline Review Committee Issued on 31 October 2014 http://who.int/csr/resources/publications/ ebola/infection-prevention/en/

Protection depends on: adequate and regular supplies adequate staff training appropriate donning and removal proper hand hygiene appropriate human behavior close supervision and support 43 Key Measures for Prevention and Control of Ebola Virus Disease

Other key elements for IPC 1. Standard precautions for all patients at all times 2. Patient triage and isolation 3. Hand hygiene 4. Environmental cleaning and disinfection 5. Cleaning and disinfection of patient care equipment 6. Waste disposal 7. Injection safety and prevention of sharps injuries 8. Laboratory safety 9. Safe post-mortem examination 10. Safe management of dead bodies 11. Management of exposure risk and accidents

45 Community engagement in Ebola IPC

Health Response & Early Recovery from Ebola Crisis 6 months 2015 5-10 years Response `Getting to Zero` Early Recovery Priorities Development `Health Systems Development` Trust Prepar edness Essential services Delivery capacity Access 47 Lessons Learnt

National Level: Appointment of National IPC Coordinator Appointment of hospital IPC focal persons Ring IPC Coordination with NERC National SOPs Facility Level: IPC Focal Persons in district hospitals Massive Hospital and PHU Training Efforts ETU Assessments Hospital and PHU Assessments Screening and Isolation Improvements Ring IPC 48 Sierra Leone IPC: Response Activities

Sierra Leone: 13211 HCWs trained on IPC (Sept 2014 Dec 2015)

50 National Recovery Plans

National Structure of IPC Chief Medical Officer Chief Nursing Officer Directorate of Primary Health Care National IPC Co-ordinator Directorate of Hospitals and Laboratory Services DHMT: DMO District Health Sister District IPC Focal Person District IPC Supervisor Hospital Medical Superintendent Matron IPC Focal Person Chiefdom IPC Focal Person (PHUs) Chiefdom IPC Focal Person (PHUs) 2015

Capacity building activities (1) National IPC Policy IPC technical guidelines IPC Pocket book Table top training manual for PHUs IPC standard assessment tool IPC Training Manual for traditional healers Standardised IPC Training manual 2015

Capacity building activities (2) TOT on the Standardised IPC Training manual Middle-Level Managers trained IPC management structures established in all districts National IPC Advisory Committee established and functional MOHS and partners review meeting to share successes, identify gaps and way forward 2015

Capacity building activities (3) Supportive supervision and mentorship Private and faith based Hospitals included in the National IPC Programme Functional Hospital Safety Committees Awareness of IPC among HCWs and the Community 2015

IPC implementation approach - Liberia Keep Safe Keep Serving (KSKS) training: 40 master trainers, 2258 HCWs Safe & Quality Services (SQS) training: 13000 HCWs 55 Cooper et al. BMC Med 2016; 14:2

Inter-country collaborations: identification of 28 common IPC/WASH indicators DOMAIN: Organization and management (Administrative) Sub-domain: human resources, governance & technical guidelines Priority indicator(s) No. % Basis/Data source Criteria Score 1a. Number and % of HCFs with a Data source: Existing IPC All indicators achieve dedicated IPC focal person in place HCF audits; a score >85% 1b. Number and % of HCFs with a Basis: IPC Core At least 1 indicator dedicated WASH focal person in Components 2008 (under achieves a score of place revision) 70% but 85% Essential environmental All indicators achieve health standards in health a score <70% care DOMAIN: Training Priority indicator(s) No. % Basis/Data source Criteria Score 4. Proportion of existing health care personnel trained on IPC/WASH within the previous year Data source: WCO IPC/MoH Team training database Basis: IPC Core Components 2008 (under revision) Indicator achieves a score >85% Indicator achieves a score of 70% but 85% Indicator achieves a score <70% 14 IPC and WASH priority indicators: Organization & management Training Infrastructure Practices Supplies Patient placement Occupational health & safety 57

58 Remaining Challenges Dependence from external support Temporary and inadequate infrastructures (screening, triaging and isolation structures, WASH) Weak coordination of supply chain system from National to District Stores to end users HCWs complacency on IPC after Ebola outbreak Varying levels of engagement and/or support of senior administration Funding gaps/inadequate budget allocation Limited structures in place to provide supervision and monitoring of IPC practice Serious difficulties to achieve real behavioural change at the point of care Need for guidance on prioritization

IPC Lessons Learned: Conclusions (1) IPC measures and infrastructure/supplies implementation were paramount for successful outbreak containment, including health care workers protection Including social mobilization and taking culture into account in IPC messages was crucial Guidance on standards and coordination of key players were essential to achieve fast and impactful results Progressive leadership and ownership of key interventions by the government were key for successful implementation Despite very serious initial gaps, all three countries achieved exceptional improvements and high level of awareness of the importance of IPC/WASH 59

IPC Lessons Learned: Conclusions (2) Countries are seriously committed to build resilient IPC programmes and a deeply rooted IPC integrated framework aimed at preparedness and safe service delivery Countries continue to have important needs for support in IPC mentorship, coordination and technical guidance The priority is now to create local expertise and countrybased approaches, systems and leadership on IPC/WASH Facilitated by WHO, the three countries understood the value of sharing progress and challenges and of developing common approaches and monitoring indicators 60

THANK YOU!!! WHO Infection Prevention and Control Global Unit