Impact of the recent Ebola epidemic with pandemic potential on the economies of Guinea, Liberia and Sierra Leone and other West African countries.

West Africa experienced its first Ebola epidemic in 2014. Its magnitude in terms of morbidity and mortality was greater than any other epidemic. It has particularly affected Guinea, Liberia and Sierra Leone. Its impact, beyond the high mortality, is also economic. The Ebola virus disease spread to several other African countries with limited resources, causing a significant financial burden to their health systems but also impacting the entire economy of the countries. The objective of this essay is to reflect on the consequences of the Ebola virus epidemics on West African economies in the short term. Estimates of the economic burden of the epidemic range from $2.8 billion to $32.6 billion in lost gross domestic product. The sectors affected by the economic crisis are the most important of the contaminated countries, namely agriculture, mining and trade. There has been a halt in socio-economic activities in the most affected regions. The decrease in the number of workers affected by the virus, the exodus to the least affected areas, and the repatriation of government employees have contributed to the decrease in the income of individuals and states. The fear of contamination by foreign countries has reduced imports, but also all tourist activities, which in turn have had an impact on the restaurant and hotel sectors. All these financial and food disruptions have exposed the population of these countries to food insecurity. The analysis of the impact of the Ebola virus on West African economies in the short term was as devastating as the health impact. This impact has directly contributed to a decrease in economic growth not only for the affected countries but also for all West African countries that depend on these same resources. A loss of about US$32.6 billion over two years in the West African region has been estimated, which is equivalent to 3.3% of the regional gross domestic product (GDP) in the absence of Ebola in 2014.

Memory reconsolidation impairments in sign-tracking to an audiovisual compound stimulus.

Studies of memory reconsolidation of pavlovian memories have typically employed unimodal conditioned stimuli, despite the use of multimodal compound stimuli in other settings. Here we studied sign-tracking behaviour to a compound audiovisual stimulus. First, we observed not unexpectedly that sign-tracking was poorer to the audiovisual compound than to unimodal visual stimuli. Then, we showed that, depending on the parameters of compound stimulus re-exposure at memory reactivation, systemic MK-801 treatment either impaired extinction to improve sign-tracking at test, or disrupted reconsolidation to impair test behaviour. When memory reactivation consisted of re-exposure to only the auditory component of the compound stimulus, we observed sign-tracking impairments following MK-801 treatment, but only under certain test conditions. This was in contrast to the consistent impairment following reactivation with the full audiovisual compound. Moreover, the parameters of auditory stimulus presentation to enable MK-801-induced impairment at test varied depending on whether the stimulus was presented within or outside the training context. These findings suggest that behaviour under the control of appetitive pavlovian compound stimuli can be modulated by targeting both extinction and reconsolidation, and that it is not necessary to re-expose to the full compound stimulus in order to achieve a degree of modulation of behaviour.

Quality improvement of health systems in an epidemic context: A framework based on lessons from the Ebola virus disease outbreak in West Africa.

Quality improvement (QI) in health generally focuses on the provision of health services with the aim of improving service delivery. Yet QI can be applied not only to health services but also to health systems overall. This is of growing relevance considering that due to deficiencies in health systems, the main countries affected by Ebola virus disease (EVD) outbreak in West Africa (2014-2016) were insufficiently prepared for the epidemic, and according to the WHO, epidemics are increasingly becoming a threat to global health. Our objective is to analyze QI constraints in health systems during that EVD epidemic and to propose a practical framework for QI in health systems for epidemics in developing countries. We applied a framework analysis using experiences shared at the "Second International Quality Forum" organized by the University of Heidelberg and partners in July 2015 and information gathered from a systematic literature review. Empirical results revealed multiple deficiencies in the health systems. We systemized these shortfalls as well as the QI measures taken as a response during the epidemic. On the basis of these findings, we identified six specific "priority intervention areas," which ultimately resulted in the synthesis of a practical QI framework. We deem that this framework that integrates the priority intervention areas with the WHO building blocks is suitable to improve, monitor, and evaluate health system performance in epidemic contexts in developing countries.

On the Resistance to Relapse to Cocaine-Seeking Following Impairment of Instrumental Cocaine Memory Reconsolidation.

Reconsolidation normally functions to update and maintain memories in the long-term. However, this process can be disrupted pharmacologically to weaken memories. Exploiting such experimental amnesia to disrupt the maladaptive reward memories underpinning addiction may provide a novel therapeutic avenue to prevent relapse. Here, we tested whether targeted disruption of the reconsolidation of instrumental (operant) lever pressing for cocaine resulted in protection against different forms of relapse in a rat self-administration model. We first confirmed that systemic injection of the non-competitive N-methyl-D-aspartate receptor (NMDAR) antagonist MK-801 did impair reconsolidation to reduce spontaneous instrumental drug-seeking memory at test. This deficit was not rescued by pharmacological induction of stress with the anxiogenic α2-noradrenergic receptor antagonist yohimbine. In contrast, cocaine-seeking was restored to control levels following priming with cocaine itself, or presentation of a cocaine-associated cue. These results suggest that while stress-induced relapse can be reduced by disruption of instrumental memory reconsolidation, the apparent sparing of the pavlovian cue-drug memory permitted other routes to relapse. Therefore, future reconsolidation-based therapeutic strategies for addictive drug-seeking may need to target both instrumental and pavlovian memories.

A scoping analysis of the aspects of primary healthcare physician job satisfaction: facets relevant to the Indonesian system.

BACKGROUND: Although there is extensive literature on the different aspects of physician job satisfaction worldwide, existing questionnaires used to measure job satisfaction in developed countries (e.g., the Job Satisfaction Scale) do not capture the aspects specific to Indonesian primary healthcare physicians. This is especially true considering the 2014 healthcare system reform, which led to the implementation of a national social health insurance scheme in Indonesia that has significantly changed the working conditions of physicians. Therefore, the current study aimed to identify aspects of primary care physician job satisfaction featured in published literature and determine those most suitable for measuring physician job satisfaction in light of Indonesia's recent reforms. METHODS: A scoping literature review of full-text articles published in English between 2006 and 2015 was conducted using the PubMed, Psycinfo, and Web of Science databases. All aspects of primary care physician job satisfaction included in these studies were identified and classified. We then selected aspects mentioned in more than 5% of the reviewed papers and identified those most relevant to the post-reform Indonesian context. RESULTS: A total of 440 articles were reviewed, from which 23 aspects of physicians' job satisfaction were extracted. Sixteen aspects were deemed relevant to the current Indonesian system: physical working conditions, overall job satisfaction, patient care/treatment, referral systems, relationships with colleagues, financial aspects, workload, time of work, recognition for good work, autonomy, opportunity to use abilities, relationships with patients, their families, and community, primary healthcare facilities' organization and management style, medical education, healthcare systems, and communication with health insurers. CONCLUSION: Considering the recent reforms of the Indonesian healthcare system, existing tools for measuring job satisfaction among physicians must be revised. Future research should focus on the development and validation of new measures of physician job satisfaction based on the aspects identified in this study.

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach.

BACKGROUND: Performance-based financing (PBF) is often proposed as a way to improve health system performance. In Benin, PBF was launched in 2012 through a World Bank-supported project. The Belgian Development Agency (BTC) followed suit through a health system strengthening (HSS) project. This paper analyses and draws lessons from the experience of BTC-supported PBF alternative approach - especially with regards to institutional aspects, the role of demand-side actors, ownership, and cost-effectiveness - and explores the mechanisms at stake so as to better understand how the "PBF package" functions and produces effects. METHODS: An exploratory, theory-driven evaluation approach was adopted. Causal mechanisms through which PBF is hypothesised to impact on results were singled out and explored. This paper stems from the co-authors' capitalisation of experiences; mixed methods were used to collect, triangulate and analyse information. Results are structured along Witter et al framework. RESULTS: Influence of context is strong over PBF in Benin; the policy is donor-driven. BTC did not adopt the World Bank's mainstream PBF model, but developed an alternative approach in line with its HSS support programme, which is grounded on existing domestic institutions. The main features of this approach are described (decentralised governance, peer review verification, counter-verification entrusted to health service users' platforms), as well as its adaptive process. PBF has contributed to strengthen various aspects of the health system and led to modest progress in utilisation of health services, but noticeable improvements in healthcare quality. Three mechanisms explaining observed outcomes within the context are described: comprehensive HSS at district level; acting on health workers' motivation through a complex package of incentives; and increased accountability by reinforcing dialogue with demand-side actors. Cost-effectiveness and sustainability issues are also discussed. CONCLUSION: BTC's alternative PBF approach is both promising in terms of effects, ownership and sustainability, and less resource consuming. This experience testifies that PBF is not a uniform or rigid model, and opens the policy ground for recipient governments to put their own emphasis and priorities and design ad hoc models adapted to their context specificities. However, integrating PBF within the normal functioning of local health systems, in line with other reforms, is a big challenge.

Perceptions of the usefulness of external support to immunization coverage in Guinea-Bissau: a Delphi analysis of the GAVI-Alliance cash-based support.

INTRODUCTION: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau. METHODS: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting. RESULTS: Consensus attributed about 25% of the failure to perform better to implementation problems; and about 10% to governance and also 10% to scarce resources. The qualitative analysis validates the importance of implementation issues and upgraded the relevance of the human resources crisis as an important drawback. The recommendations were balanced in their upstream-downstream focus but were blind to health information issues and logistical difficulties. CONCLUSIONS: It is commendable that such a fragile state, with all sorts of barriers, manages to sustain a slow steady growth of its vaccination coverage. Not reaching the targets set reflects the inappropriateness of those targets rather than a lack of commitment of the health workforce. In the unstable context of countries such as Guinea-Bissau, the predictability of the funds from global health initiatives like the GAVI-Alliance seem to make all the difference in achieving small consistent health gains even in the presence of other major bottlenecks.

Perceptions of the usefulness of external support to immunization coverage in Guinea-Bissau: a Delphi analysis of the GAVI-Alliance cash-based support

INTRODUCTION: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau. METHODS: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting. RESULTS: Consensus attributed about 25% of the failure to perform better to implementation problems; and about 10% to governance and also 10% to scarce resources. The qualitative analysis validates the importance of implementation issues and upgraded the relevance of the human resources crisis as an important drawback. The recommendations were balanced in their upstream-downstream focus but were blind to health information issues and logistical difficulties. CONCLUSIONS: It is commendable that such a fragile state, with all sorts of barriers, manages to sustain a slow steady growth of its vaccination coverage. Not reaching the targets set reflects the inappropriateness of those targets rather than a lack of commitment of the health workforce. In the unstable context of countries such as Guinea-Bissau, the predictability of the funds from global health initiatives like the GAVI-Alliance seem to make all the difference in achieving small consistent health gains even in the presence of other major bottlenecks.