Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone.

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers.

BACKGROUND: Despite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers' inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership. METHODS: We conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2. RESULTS: Study participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation. CONCLUSION: Health care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success.

Litigating for Native American health: the liability of alcoholic beverage makers and distributors.

Native American populations have long experienced excess morbidity and mortality attributable to alcohol. Historically, alcohol was introduced to the Native American population by European settlers, and was used to help those settlers get land and goods from the Indian population. In modern times, alcohol beverage makers and distributors continue to supply and market their products to Native American populations in amounts and manners that contribute to continuing health and safety problems. When some other products have been over-supplied or over-promoted to the detriment of the public's health, litigation has been brought against the makers or dealers of those products, sometimes using the legal theory of public nuisance. This article explores the potential for litigation brought by Native Americans against alcoholic beverage makers and distributors.

Priority-setting ethics in public health.

Unlike the well-developed system of ethical priority-setting that physicians and bioethicists have developed in the field of organ transplantation, public health lacks a standardized and publicly recognized system for making ethical resource allocation decisions. Such a system would be useful for the purpose of countering prejudice-based arguments that tend to hinder the progress of public health programs aimed at marginalized groups. By examining organ transplantation priority-setting criteria as they relate to public health issues, this article seeks to stimulate debate about the varieties of criteria that should and should not be used in public health decision-making.