Ayanore MA, et al. Towards Resilient Health Systems in Sub-Saharan Africa: A Systematic Review of the English Language Literature on Health Workforce, Surveillance, and Health Governance Issues for Health Systems Strengthening. Annals of Global Health. 2019; 85(1): 113, 1–15. DOI: https://doi.org/10.5334/aogh.2514 REVIEW Towards Resilient Health Systems in Sub-Saharan Africa: A Systematic Review of the English Language Literature on Health Workforce, Surveillance, and Health Governance Issues for Health Systems Strengthening Martin Amogre Ayanore*, Norbert Amuna*, Mark Aviisah*, Adam Awolu*, Daniel Dramani Kipo-Sunyehzi†, Victor Mogre‡, Richard Ofori-Asenso§, Jonathan Mawutor Gmanyami*, Nuworza Kugbey* and Margaret Gyapong‖ Background: Meeting health security capacity in sub-Saharan Africa will require strengthening existing health systems to prevent, detect, and respond to any threats to health. The purpose of this review was to examine the literature on health workforce, surveillance, and health governance issues for health sys- tems strengthening. Methods: We searched PubMed, Science Direct, Cochrane library, CINAHL, Web of Science, EMBASE, EBSCO, Google scholar, and the WHO depository library databases for English-language publications between January 2007 and February 2017. Electronic searches for selected articles were supplemented by manual reference screening. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results: Out of 1,548 citations retrieved from the electronic searches, 31 articles were included in the review. Any country health system that trains a cadre of health professionals on the job, reduces health workforce attrition levels, and builds local capacity for health care workers to apply innovative mHealth technologies improves health sector performance. Building novel surveillance systems can improve clinical care and improve health system preparedness for health threats. Effective governance processes build strong partnerships for health and create accountability mechanisms for responding to health emergencies. Conclusions: Overall, policy shifts in African countries’ health systems that prioritize training a cadre of willing and able workforce, invest in robust and cost-effective surveillance capacity, and create financial accountability and good governance are vital in health strengthening efforts. Introduction by Heymann et al. [4] there is a need to pay attention In the wake of any health threat, the strength of the to health system challenges at all levels of health care health system at the national and international levels delivery in the context of sub-Saharan Africa (SSA). is often tested [1, 2]. The World Health Organization Many debates and disagreements surround the pre- (WHO) defines health system as “all organizations, cise definition of health security despite the universal people and actions whose primary intent is to pro- acceptance of health security as an important public mote, restore, or maintain health [3].” As put forward health issue that requires close attention [5]. Health security at the national and the global level is said to * School of Public Health, University of Health and Allied exist if the following conditions are met: there is pro- Sciences, Ho, GH tection against any health threat, there are new adap- † Legon Centre for International Affairs and Diplomacy, tations and approaches to new health conditions that University of Ghana, Accra, GH may arise, new actors are engaged, including military ‡ Department of Health Professions Education and Innovative establishments, and synergy is drawn between foreign Learning, School of Medicine and Health Sciences, University policy and public health at the national and global lev- for Development Studies, Tamale, GH els [5]. Global public health security aims to minimize § Monash University, Department of Epidemiology and Preventive vulnerability to public health threats across geographic Medicine, Melbourne, AU regions and international boundaries [6]. To attain ‖ Institute of Health Research and Professor, University of Health and Allied Sciences, Ho, GH global health security, attaining individual health secu- Corresponding author: Martin Amogre Ayanore rity at any country level is vital [7]. A country’s health (mayanore@uhas.edu.gh) system that is made resilient through strengthening Art. 113, page 2 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa core building blocks in the health care system can pro- These are the health workforce, health information sys- mote the capacity of global health security [3]. tems, and leadership and governance [3]. The following In SSA, there is renewed interest in strengthening keywords were used in the search: health workforce, national health systems to make them resilient to meet surveillance system, health governance, health system national and global health threats [1, 2, 4]. Health system strengthening, resilient health system, and sub-Saharan strengthening refers to a change in health performance Africa. All possible synonyms were generated for the with the goal of attaining efficiency and effectiveness in main key words and included in the search using Medi- the health system [8]. Kruk et al. defined health system cal Subject Headings (MsSH) in PubMed. The search was resilience as the capacity of health actors, institutions, and conducted in PubMed, Science Direct, Cochrane library, populations to effectively prepare for and respond to the CINAHL, Web of Science, EMBASE, and EBSCO for lit- public health consequence of any health threat, with the erature published between January 2007 and February aim of protecting human life and ensuring good health 2017. Google scholar and the WHO library (WHOLIS) were outcomes during and after crises [1]. In 2014, the Ebola searched for country-level policy documents and proto- outbreak in West Africa was reported as a failure of lead- cols on health system strengthening using the same key ership at many levels [9]. Some identified gaps, such as words above. Figure 1 shows the PRISMA flow diagram the absence of surveillance and health reporting systems of the publications screened prior to the final selection [2, 10], weak health systems not adaptable to changing of reviewed publications. All identified articles were first health conditions [11, 12], and ineffective health systems screened by two authors (MAA, MA) for titles and abstracts, at the primary care level [13, 14]. In addition, the absence and full-text assessment was carried out for eligibility and of vital registration systems [15, 16] and clinic-oriented inclusion. The reference lists of publications were also health system designs which are slow in responding to searched to identify eligible publications for inclusion. new epidemiologic and disease threats [17, 18] were also reported as gaps in the health system in areas where many Inclusion and exclusion criteria died during the Ebola crises. The functionality of health English-language literature that presented findings on systems have improved in some SSA contexts [19–21], health workforce, surveillance, and governance capacities while other settings have witnessed slow health system for strengthening health systems in SSA were included. improvements [22, 23] amidst several health challenges We included health system capacity and gaps identified [21, 24]. Fundamentally, having an adequate health work- during the Ebola crises in West Africa. Although the search force, health surveillance, and health leadership and gov- strategy covered publications across SSA whose popula- ernance are identified as major factors in strengthening tions speak different languages, only English language health systems in SSA [3], in addition to other health sys- publications were included in the review. tem building blocks [25] required to make health systems To avoid data that may not fit our aim, we excluded more resilient now and in the future [26]. publications on disease-specific conditions that have not This systematic review examined the existing English been documented as an epidemic in SSA. Publications on language literature on health workforce, surveillance, and food security and health, climate change, and bioterror- governance capacity for strengthening health systems in ism interlinkages as other broader determinants of health the SSA region. The review addressed the question: how security and a measure of resilience to the health system can health systems in SSA be resilient, with regards to were excluded. Clinical or trial studies on health system the role of the health workforce, surveillance systems, strengthening were excluded. Publications related to and governance play in the strengthening of health sys- pharmacovigilance were excluded. Non-English literature tems? This review is based on the premise that adequate was excluded in the review because the research team and skilled health workforce, surveillance systems, and were all English native speakers. governance capacity are vital to attaining resilient health systems [7, 27]. Evidence from this review will add to exit- Screening and extraction ing literature on strengthening health systems in SSA. To minimise bias in our data extraction process, two The review is structured as follows: a detailed methodol- authors (MAA, NA) independently screened the initial ogy outlines the search process, including inclusion and publications for eligibility and inclusion for review. The exclusion criteria, quality appraisals, and data extraction, two authors independently identified six publications followed by synthesis and discussion of studies reviewed. that were difficult to classify into the three areas under the review because they presented cross-cutting issues Methods reflecting in all three areas of interest. Four out of six Study design and framework for review publications were resolved through consensus-based We conducted a systematic literature review following discussions. A third author (VM) assisted in resolving guidelines published by Lancet [28], and the Preferred classification disagreements of two publications among Reporting Items for Systematic reviews and Meta-Analyses MAA and NA. From each eligible publication, the fol- [29] (PRISMA). lowing information was extracted: publication origin and year, sample demographic, study title, design and Search strategy and selection criteria setting, analytical approach, and main findings on health Our search strategy was informed by three out of the six workforce, surveillance, and governance issues for health core elements of the WHO health system building blocks. system strengthening for SSA. Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 3 of 15 Data synthesis English-language publications in SSA countries qualified Narrative synthesis approach was used to summarize the for full review, as presented in Figure 1. Table 1 shows the findings. This procedure was preferred because it applies list of publications and the African regions included in the a textual approach to data synthesis and story-telling [30]. review. A detailed breakdown is provided as a supplemen- Five team members (MA, AA, NK, DDK, and JG) indepen- tary file. Three authors (MA, GJ, VM) screened and classi- dently coded tabulated findings on the three areas of the fied publications into the three areas guided by the WHO review and mapped out common codes, concepts, and framework on health system strengthening that fell within categories. Two other team members (VM, RO) built upon the scope of this review. Three publications were classified five team members’ work by categorizing and synthesiz- under health workforce, 10 publications under surveillance ing salient and emergent codes into final relevant themes. capacity, and 18 publications under governance. Two other team members (MAA, JG) cross validated all synthesized findings and resolved any discrepancies, Health workforce capacity for health system ensuring findings reflected the three areas under review. strengthening Findings on health workforce capacity for health sys- Study quality appraisal tem strengthening are presented in Table 2. Three We appraised the internal validity of individual articles publications were reviewed regarding health workforce. using the Crowe Critical Appraisal Tool (CCAT). This The studies were based in Rwanda, Nigeria, and Bot- technique for checking quality was chosen because of its usefulness for diverse research designs [31]. Applying Table 1: List and origins of publications reviewed. eight domain elements under CCAT, and following the procedure conducted by Crowe et al. [32] we appraised SSA Region Number of and scored each domain element within a range of 0–5. publications The average score for all 31 studies was 4, indicating a East Africa 9 high quality CCAT across all studies. West Africa 10 Results Southern Africa 6 General characteristics of studies Global perspective with 6 A total of 1,548 publications were retrieved across all data- focus on SSA bases. In applying our inclusion and exclusion criterion, 31 Total 31 Figure 1: PRISMA flow diagram showing how publications were screened for eligibility for inclusion. Art. 113, page 4 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Table 2: Health workforce-related publications included in review. Reference Study Title Design/Setting/Data/Analytical Main findings on local health system Publication Approach strategies Ledikwe et al. Establishing a health Mixed method approach with - Prompt on the job training yields 2013 [34], information workforce: qualitative and quantitative data better results and response on health Botswana innovation for low- and was used. Tools included pre information management and needs middle-income countries and post-test, interviews during compared to long term offsite training for stakeholder site visits, a survey health information personnel. focusing on achievements, focus - Planning for attrition through development group discussions, and an attrition of strategies for efficient recruitment and assessment development of training materials that could easily be used to train new staff is important to enhance workforce numbers and improvements for health systems. Otu et al. 2016 Using a mHealth tutorial Quantitative cross-sectional survey - mHealth tutorial applications from this [35], Nigeria application to change in 14 health facilities in Ondo state, study show modest changes in knowledge knowledge and attitude of Nigeria and attitudes of health care workers post frontline health workers project implementation. to Ebola virus disease in - mHealth technologies could be effectively Nigeria: A before-and-after used to disseminate information and train study community health workers working in remote and far to reach country settings. Sayinzoga et al. Drivers of improved Web-based survey among district - Community health workers and health 2016 [33], health sector performance health managers on opinions that insurance come out as factors that are con- Rwanda in Rwanda: A qualitative drive performance in the health sidered to have contributed most to Rwanda’s view from within sector remarkable achievements in the past decade. - Managerial skills and capacities of health staff and the culture of continuous monitoring of key indicators by an active workforce is critical for good progress on health outcomes. swana. The three publications [33–35] focused on health good health returns, as reported in Rwanda [33]. Overall, workforce for health system strengthening in the country the three publications highlighted the need for country context. Four critical issues were drawn from these publi- health systems to address technical and operational con- cations: (1) continual job training for the health workforce cerns in recruitment, training, and retention of a health yields better results compared to long term offsite train- workforce willing and able to support, prevent, detect, ing of a cadre of the health workforce [34], (2) planning and respond to any health threats within the health care for attrition should be anticipated within African health delivery system. systems, with rigorous development of strategies for attri- tion, recruitment, and training [33–35] (3) mHealth tech- Surveillance and health information capacity for nologies can improve community health workers’ (CHW) health systems strengthening health service delivery capacity in low resource settings Table 3 summarizes the findings on surveillance capac- [35], and (4) Improving managerial skills and competen- ity for health system strengthening. In Kenya and Uganda, cies of cadre of workforce to effectively generate and use strong surveillance investments improved the strength of reliable data to inform health system improvement needs the health system [36]. Two publications [37, 38], one on at country level [34]. malaria surveillance in endemic regions in SSA and the A study in Botswana found continual job trainings other on the Guinean Ebola crises, reported the impor- on health information systems (HIS) used for tracking tance of remote sensing and early warning systems for and reporting health indices was effective in improving improving future health emergencies in Africa. The appli- patient care outcomes [34]. The absence of clear admin- cation of appropriate and sustainable case monitoring sys- istrative roles and command structures can lead to high tems acts as a means of both providing reliable informa- health workforce attrition rates, particularly in health tion and building data for the health systems, as evident emergencies. Clearer roles, responsibilities, job security, during the Ebola crises in Guinea [38]. and appropriate career trajectories for both old and new Weak epidemiologic data gathering and application was cadres of health professionals can reduce attrition rates in reported in three publications [39–41] as a threat to com- the health sector. One study [35] reported on-the-job train- bating future health threats at country levels. Investments ings for CHWs can improve health worker responsiveness in novel surveillance systems, such as the cloud-based to dealing with emergency health threats in Botswana. electronic medical systems, was reported in Kenya [42] Additionally, effective monitoring of health worker sup- to have improved clinical outcomes among HIV patients. port roles in the health service delivery system can bring Three publications in Uganda, South Africa, and Ethiopia Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 5 of 15 Table 3: Surveillance and data management-related publications reviewed. Reference Study Title Design/Setting/data/Analytical Main findings on local health system Publication Approach strategies Martha Gyansa- Antibiotic resistance Comment on antibiotic use and its - Low capacity of linking laboratory diagnostic Lutterodt 2013 in Ghana growing resistance in Ghana tests to selection of medicines for treatments [39], Ghana exist. - Uncontrolled antibiotic use for agriculture and veterinary purposes is growing and likely to increase drug use resistance. - An improved surveillance on drug supply and use and regulatory mechanisms for improving antibiotic use will go a long way to improve most health systems in Africa. Justine Davis Sustainable clinical Comment on laboratory capacities - Targeting and training a cadre of et al. 2017 [40], laboratory capacity across Africa multi-skilled health professionals to work in Africa for health in Africa laboratories that can deal with broad range of health conditions (communicable and non-communicable) are crucial for promoting individualized health security needs. Lancet Editorial Global health security: Editorial comment with focus in - There is need to actively promote and support 2017 [41], Africa How can laboratories Africa laboratories to be reliable both in diagnostic help? and treatments. Providing laboratory leadership seminars and training programmes is important to improve and guarantee this objective. Jones et al. 2008 District-based malaria Development and testing of a - The system transfer of responsibility to district [36], Kenya and epidemic early warn- district-based malaria surveillance level manpower resulted in perceptions of em- Uganda ing systems in East system in four pilot districts of powerment among district-based health staff. Africa: Perceptions Kenya and Uganda. Health staff - Improved support together with transfer of of acceptability and interviews conducted among responsibility helped to sustain motivation usefulness among key 52 health staff at districts and and improved surveillance on malaria staff at health facility, Ministries of Health in Kenya and tracking and control. district and central Uganda - Increased logistical support is vital in levels the midst of increased participation and involvement to sustain surveillance gains. Cox et al. 2007 Early warning systems Review of evidence in Africa - The development of appropriate and [37], Africa for malaria in Africa: sustainable case monitoring systems can From blueprint to act both as means to providing reliable practice information and building data for the health systems vital in poor settings with poor data or non-existent malaria data systems. Peckham et al. Satellite and the new Data synthesis of available evi- - Remote sensing could be applied to 2017 [38], West war on Infection: dence of study aim track disease and monitor isolated rural Africa Tracking Ebola in communities, providing mapping data that West Africa supports on-the-ground logistics and contract tracing as evidenced during the Ebola crises. Haskew et al. Implementation of a Project evaluation of an electronic - Cloud based electronic medical system pro- 2015 [42], Kenya Cloud-Based Electronic medical record systems for HIV vides for real-time access to anonymised data Medical Record to cases in rural Kenya beyond the level of the clinic to inform timely Reduce Gaps in the decision making on HIV interventions. HIV Treatment Con- - The system proved to be cost effective, scalable tinuum in Rural Kenya compared to other local context models. Kiberu et al. Strengthening Training facilitation for cadre of - Training resulted in timeliness and complete- 2014 [43], district-based health health professional on the use of ness in health reporting of routine outpatient, Uganda. reporting through the the district health management inpatient, and health service usage data from district health man- information software system ver- district to the national. agement information sion 2 (DHIS2) across 112 districts. - Onsite support and training for data software system: The managers and professional in addition to Ugandan experience removing logistical constraints improves data management efficiency at district level. (Contd.) Art. 113, page 6 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Reference Study Title Design/Setting/data/Analytical Main findings on local health system Publication Approach strategies Mate et al. 2009 Challenges for A survey conducted between - System improvements must improve front [44], South Routine Health January-December 2007 on line health staff skills/knowledge on routine Africa System Data Manage- completeness and accuracy of HIV quality data, adopt use of simplified data ment in a Large Public data for decision making in South tools, maintain minimum set of indicators Programme to Prevent Africa and registers. Mother-to-Child HIV Transmission in South Africa Wong et al. Developing patient Pre-post intervention study in - The evidence showed merging of patient regis- 2009 [45], registration large referral hospital trations and medical records into one process, Ethiopia and medical records designing master patient index and improved management filing procedures together with adequate system in Ethiopia training of human resources are vital to guarantee improved patient care services. [43–45] reported that innovative data management sys- Topp and colleagues in Zambia [51] reported the need tems used at the lower level of the health system struc- for health systems to create administrative answerability ture can improve primary health care outcomes. Novel mechanisms to monitor and deliver health services, par- data managing processes, such as merging patient regis- ticularly during emergencies. Delivering health services in trations and medical records into a unified process, assists a holistic and integrated manner can help avoid resource in providing a timely response for patient care outcomes fragmentation and improve efficiency in health care in Ethiopia [45]. delivery [48, 51, 52]. Furthermore, public-private partner- Reliable data generation and use can support monitor- ships (PPP) are required to address unmet health service ing and controlling growing disease resistance for oppor- demands in Africa [48, 53]. Policies that address broader tunistic infections such as HIV and tuberculosis [46]. determinants of health, such as poverty, inequality, and Incompleteness and poor data accuracy poses a challenge violence, are vital to enable health systems to function for improving HIV patient outcomes, as reported in South effectively [54]. Africa [47]. In Ethiopia, a study reported prompt, efficient, Identifying and prioritizing cost-effective interventions and timely medical record documentation was vital to during emergencies can control infection and re-infection improving population health outcomes [45]. Onsite sup- rates during disease outbreaks [53]. At the apex of global port and training for data managers and professionals can health governance, strong partnership with the WHO and improve data management efficiency [43]. Additionally, national and global actors is required to avoid late respon- electronic record management systems can aid in gener- siveness, such as during the Ebola crises [55]. Timely and ating alerts and reports on health service outcomes [37, prompt global response at national and international lev- 43] and strengthen health system preparedness to han- els by multiple actors is important in pointing the way to dle health threats [45, 47]. In addition, the application of meeting national and global health systems goals. problem solving and quality improvement techniques can improve population health outcomes [43, 45, 47]. Discussion This review covered only eligible English-language litera- Governance capacity for health systems strengthening ture that examined health workforce, surveillance, and One publication in the West Africa region [4], shown governance capacities for strengthening health systems in Table 4, reported health resource availability and in SSA. This section discusses country findings in SSA and allocation is both a technical and political problem. compares them to those in other countries outside the Health systems with effective communication and support scope of this review that share similar country level char- channels can support building leadership capacities in acteristics. the management of health services [48]. Also, the devel- opment of a national-level transformative initiative for Health workforce capacity for strengthening health health risk mitigation is vital for health system improve- systems ments [49]. Three publications [3, 10, 25] reported the Low technical and operational human resource capacity for need for building strong partnerships and improving health is not a new phenomenon and has been reported in stewardship and management of resources to deliver other SSA studies as vital for strengthening health systems good health outcomes at a population level. Criterion- [13, 56]. Continual on-the-job training for health profes- based audits as a public sector performance management sionals is a better option compared with long term offsite tool can improve health deliverables, as evident in Malawi training of the health workforce, particularly during emer- [50]. A study in Zambia reported community dialoguing gencies. Our results suggest the need for a cadre of health and the application of provider and patient score cards professionals who are adequately trained in the concepts were cost-effective approaches for accountability in the of monitoring and evaluation, in addition to clinical skills, health sector [51]. to strengthen country level health systems. Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 7 of 15 Table 4: Health Governance-related publications included in review. Reference Study Title Design/Setting/Data/Analytical Main findings on local health system Publication Approach strategies Heymann et al. Global Health security: Historical and secondary review of - Health systems must pay attention to 2016 [4], Lancet, Wider lessons from the Ebola events in West Africa during individual health security needs. Resource West Africa West African Ebola Virus and post Ebola availability and allocation is both a disease epidemic technical and political problem for most African countries. - Adequate funding for research and development and access to safe vaccines are among pivotal vehicles to driving an effective health system. - Poor political commitments at governments level is worrying and not in the best interest of a growing African population. Drobac et al. Comprehensive and Impact evaluation using - Mentorship and enhanced supervision 2013 [76], integrated district health population level outcome data (MESH) of health staff improves quality Rwanda systems strengthening: from demographic health surveys care at health facilities. The Rwanda population (DHS) in Rwanda (protocol) - The use of community health household Health Implementation registers to track activities and improve and Training (PHIT) reporting at facility levels improves health Partnership system outcomes. - The use of electronic record management systems for generating alerts and report- ing improves quality of care at facility centres. Sherr et al. Strengthening integrated Evaluation design technique - In health systems with multiple district 2013 [48], primary health care in employing a quasi-experimental level partners, building communication Mozambique Sofala, Mozambique controlled time-series design and support channels across all levels of to assess impact of partnership the health system with partners is vital to strategy on under-5 mortality rates success. in study setting - Applying practical skills-based training approaches in management serves as useful and feasible technique to build leadership capacity across multiple districts/regions in a country. Cho et al. 2014 Out of Africa, Into Global Editorial comment - Investments for the development of [85], Global Health Security Agenda suitable and effective vaccines is key for Editorial preparedness in any health emergencies. - Patient safety issues are important to the efficacy of preventing potential accidents during disease outbreaks in Africa. Cho et al. 2015 Two Epidemics and Editorial comment - Holistic country and continental [86], Global Global Health Security assessment of health system gaps along Editorial Agenda multiple areas is needed to improve long term health security needs. - Ebola and MERS showed health is directly related to national security issues, emphasizing commitment at all levels for ensuring early detection, prevention, and rapid response to biological threats to human health. GHSA Task Global Health Security: Retrospective assessment of Ebola - Effective health systems are those in use Force Team The Lessons from the and MERS every day and capable of scaling up in 2015 [87], West African Ebola Virus emergencies. Brief Report Disease Epidemic and - Despite nascent capacity in Nigeria, MERS outbreak in the a well-coordinated surveillance and Republic of Korea laboratories emergency operations by trained health staff enabled the control of Ebola. (Contd.) Art. 113, page 8 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Reference Study Title Design/Setting/Data/Analytical Main findings on local health system Publication Approach strategies Patel et al. 2015 Health security and Correspondence on global health - Country and global political and economic [49], West Africa political and economic security and its needs determinants to health can be tackled determinants of Ebola multi-sectoral and may not involve only one government(s) level intervention. - National level consensus on transformative initiatives with potential to mitigate risk are necessary to curtail any future health emergencies. Wang et al. 2013 New vaccine introduc- Mixed approaches that includes a - High-quality monitoring and evaluation, [52], Global tions: Assessing the review of published and grey litera- including disease Review impact and the oppor- ture, in-depth case studies in three - surveillance and immunization coverage tunities for immuniza- countries, interviews with monitoring, resource, performance, and tion and health systems key informants from countries and management accountability. strengthening WHO Regional Offices, and a multi- - Viewing health service delivery in variable analysis examining impact a holistic and integrated manner of NVI on coverage for rather than as independent, disparate 3rd dose of diphtheria–tetanus– programmes is recognized as necessary pertussis vaccine (DTP3). in order to achieve efficiencies and avoid fragmentation. - A strong, country-led, evidence-based decision-making, - planning, and prioritization process that is accountable and - coordinated with other components of the health system. Buseh et al. The Ebola Epidemic in Literature review of peer-reviewed - Promoting family-centered approaches in 2015 [53], West West Africa: Challenges, journals on disease burden and emergencies could help control infection Africa opportunities and policy health reforms in developing coun- and re-infection rates during disease priority areas tries with focus on West Africa outbreaks such as Ebola in West Africa. - Public-private partnerships to deliver reliable and efficient basic health services, in addition to the development of affordable vaccines and drugs. - Identifying and strengthening formal and informal African institutions will improve the resilience of countries to respond in health emergencies. Gostin et al. A retrospective and pro- A synthesis of public policy issues - An empowered WHO at the apex, with 2015 [88], Lan- spective analysis of the in post-Ebola outbreak in West well-coordinated funding and actions cet West Africa West African Ebola virus Africa among many parties, is important disease epidemic: Robust to improve health emergences and national health systems vulnerabilities, particularly in poor at the foundation and resourced settings. an empowered WHO at the apex Siekmans Community-based health A descriptive observational study - Community health workers knowledge et al. 2017 [89], care is an essential design using mixed methods to of cultural and social complexities at Liberia component of a resilient collect data among community community centres enhances patients trust health system: Evidence health workers. and confidence in the health system during from Ebola outbreak in emergencies. Liberia - In critical emergencies, adequate training and guidelines with supportive supervision to community health workers help deliver lifesaving services to patients. Kongnyuy Criteria-based audit to A criteria-based audit by conduct- - Criterion-based audit is scalable in poor et al. 2008 [50], improve a district referral ing a retrospective review of 60 resource settings where referral care is vital Malawi system in Malawi: A Pilot obstetric emergencies from 12 for obstetric care. study health centres - Local health actors support, and strong involvement is vital for, sustaining health system gains at long term. (Contd.) Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 9 of 15 Reference Study Title Design/Setting/Data/Analytical Main findings on local health system Publication Approach strategies Topp et al. 2015 The impact of human Guided by the Mechanisms of - Resource-intensive investments in [51], Zambia immunodeficiency virus Effect framework and Brinkerhoff’s HIV services contributes to improving (HIV) work on accountability. In-depth administrative answerability and improving service scale-up on multi-case study with case data capacities to deliver and monitor service mechanisms of account- interviews collected among provid- delivery. ability ers. Direct observation and key - Community dialoguing, patient score cards in Zambian primary informant interviews were also are local level approaches used to improve health centres: A case- used micro-level (people-centeredness) for based services delivery. health systems analysis Coovadia The health and health Historical review of South African - Programmes with direct impact on the et al. 2009 [54], system of South Africa: Health Care Systems social determinants of health and develop- South Africa Historical roots of ment (stigma, subordination of women, current public health poverty and inequality, violence, and challenges traditional practices) have positive effects on health systems functioning. - Macroeconomic policies that promote growth alone are insufficient for health systems effectiveness. An economic architecture that allows the development of programmes that reduce poverty, unem- ployment, and inequities are essential for health systems strengthening. Kieny et al. 2014 Health-system resilience: Perspectives on the health systems - The Ebola outbreak must trigger [10], Western Reflections on the Ebola in affected West African countries substantial investments and adequate Africa crisis in western Africa reforms in the worst-affected countries health systems. National governments, assisted by external partners, need to devel- op and implement strategies to make their health systems stronger and more resilient. - In the short-term, nongovernmental organizations, civil society, and international organizations will have to bolster the national health systems, both to mitigate the direct consequences of the outbreak and to ensure that all essential health services are being delivered. WHO 2010 [25] Monitoring the building A published book on the essential - Summary points: Strong and effective blocks of health systems: building blocks in health systems health systems at country levels are the A handbook of indicators strengthening foundations to ensuring global health and their measurement security. Appropriately applying standard- strategies ized measures and indicators to appraise health systems within the global context will support in planning and health prior- itization in national health system needs. WHO 2007 [3] Everybody’s business: A published book on making - Summary points: There is need for Strengthening health health systems strengthening a pragmatic synergy among various technical systems to improve priority for all citizens, academ- working relationships in WHO. In develop- health outcomes: WHOs ics, WHO staff, governments, and ing strategies for country health systems, framework for action donors. synergy strategies should be pursued in care provision, monitoring of indicators and outcomes, health financing and im- proving quality of care for patients and the health workforce. A well-trained monitoring and evaluation workforce is also analyse, and interpret data for quality reporting on health critical for providing a culture of continuous assessment of indices [34, 57–60]. This review has identified the need for key health indicators at points of service delivery [33]. Health health systems to generate reliable and timely data on health information officers’ ability to acquire and apply knowledge workforce gaps useful in making timely decisions regarding on cost-effective monitoring and evaluation methodologies human resource capacities requirements to address unmet can enhance frontline health workers’ abilities to collect, health service demands in SSA. Art. 113, page 10 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa The review found mHealth technologies to be effective support the design and preparation of health emergency in some low-resource settings for disseminating informa- preparedness plans. Evidence from the WHO corroborates tion and meeting training capacity of community health this and emphasizes the need for integrated surveillance workers through (1) improving knowledge and attitudes systems in SSA during health emergencies, as evidenced on clinical care and (2) enabling the delivery of essential during the Ebola crises [78]. medicines and information to distant population groups, especially during emergencies. Growing evidence corrob- Governance capacity for health system strengthening orates mHealth’s role for strengthening health systems in Two health governance shifts were reported as vital to Africa [61–64]. The WHO indicates that low knowledge strengthen health systems in Africa: the political and and information on mHealth applications is a challenge technical commitments to strengthen health capacities. A in Africa, hence the need for investments to assess its use key political decision in strengthening health systems is and scale-up [65]. financial commitment at the national level. Despite the Fundamentally, no single strategy can address all the Abuja declaration on health financing requirements for health workforce challenges Africa faces today; a mix of African governments, many health systems operate with strategies and interventions are required. Task shifting, minimal support from their governments [79]. To deliver performance-based payments, and results-based financ- real-time health responses to health threats, country level ing as strategies for improving skilled health professional commitments across SSA that will mobilize and allocate numbers have been sparsely piloted in Rwanda, the resources appropriately to strengthen existing weak Democratic Republic of Congo, South Africa, and Kenya health systems are vital. Governments in SSA need to cre- [66–70]. Different models for attracting, recruiting, train- ate health systems that are inclusive and provide account- ing, and retaining a critical health workforce must be ability at all levels of the health structure. To enhance experimented at country levels. weak accountability systems, administrative answerabil- ity mechanisms must be effectively developed. Effective Surveillance and health information needs for accountability systems can help deliver positive health strengthening health systems system outcomes [11, 12]. This review highlighted the need for investments that will Strengthening health partnerships at country level and build robust epidemiologic systems to anticipate future across SSA has the potential to address technical and logis- threats in the health system [46, 71]. The findings from tical capacity regarding the delivery of health services. this review point to the need to initiate or strengthen PPP Review findings point to the fact local partnership build- arrangements that can support building country level ing improves PPP initiatives to support health systems capacities and laboratory infrastructure to improve dis- so they function effectively. Strong health partnerships ease surveillance, diagnosis, and treatments. assist to address technical and logistics supply needs and Health systems that invest in developing surveillance to provide mentorship for country level health system systems for data gathering, monitoring, and feedback improvements, as reported in a Rwandan publication [76]. can improve disease tracking and control in SSA [72, 73]. Furthermore, health partnerships along multiple district Studies from developing countries also support the posi- levels can help provide effective health leadership, com- tive effects of satellite imaging for health service delivery munication, and support channels across many health [74, 75]. Furthermore, linking facility level health data to sectors [80, 81]. broader determinants of health at the population level Health leadership and governance policies that address can support tracking any potential health threats before broad social determinants needs can yield better health they become epidemics [76]. outcomes. Financial investments that address broader In SSA, the adoption and use of electronic medical tech- determinants of health is a good investment to guarantee niques can provide timely detection and response to any global health security [82]. The evidence reviewed from health threats to the health system. Our review found that the South African health systems after the Apartheid show novel electronic and data processing techniques helped to strengthening social determinants on HIV stigma, subor- improve HIV treatment outcomes in Kenya [42], as well dination of women, poverty, inequality, reducing violence, to improve disease infection control and prevention at and traditional practices can improve health care system the health facility level. This evidence is corroborated by a capacities and improve quality of life [54]. An inclusive study in Guinea, Liberia, and Sierra Leone [77]. Their use approach should be taken among governments, civil soci- and advancement to improve data accuracy, as the case ety, and local level actors to advance partnership to drive reviewed from South Africa, is also important for most the delivery of health services. African health systems. While a substantial amount of financial commitment Novel surveillance systems can help solve health prob- at country and global levels are vital to deliver large scale lems by introducing data quality improvement techniques changes to population health systems, other cost-effec- at health facility levels to improve patient health out- tive strategies exist that can equally deliver timely and comes. The evidence from the review points to the need responsive health care outcomes for populations. This for health managers to invest in designing and monitoring review found community dialoguing and the applica- health performance using cost-effective surveillance sys- tion of patient score cards were cost-effective strategies tems. Novel surveillance systems can facilitate a country’s that can improve health service delivery at the micro- quick response during a disease emergency, as well as level. Applying cost-effective health approaches can help Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 11 of 15 overcome health system constraints [83] and help deliver References appropriate health solutions [84] for country health 1. Kruk ME, Myers M, Varpilah ST, et al. What is system improvements. a resilient health system? Lessons from Ebola. The review has limitations. Although we searched several Lancet. 2015; 385: 1910–1912. DOI: https://doi. databases, there is the potential that we might have missed org/10.1016/S0140-6736(15)60755-3 other relevant publications. We acknowledge that our 2. Kieny MP and Dovlo D. Beyond Ebola: A new exclusion of other periodicals, protocols, and publications agenda for resilient health systems. Lancet. 2015; from health development partners may have limited our 385: 91–92. DOI: https://doi.org/10.1016/ scope of evidence. Our inclusion criteria for only publica- S0140-6736(14)62479-X tions in English from SSA might limit generalisability of 3. World Health Organization (WHO). Everybody’s our findings across French and Portuguese-speaking coun- business: Strengthening health systems to improve tries. Also, we did not find and include any policy docu- health outcomes-WHO’s framework for action. ment at country levels on health security. We acknowledge 2007. Geneva: WHO. this limitation on country level evidence on what strate- 4. Heymann DL, Chen L, Takemi K, et al. Global gies exist on improving their health systems. We found health security: The wider lessons from the West most evidence on country examples in West Africa stem- African Ebola virus disease epidemic. Lancet. 2016; ming from the Ebola crises. None was examined in North 385: 1884–1901. DOI: https://doi.org/10.1016/ Africa. Other cases of country evidence presented came S0140-6736(15)60858-3 from East and South African countries. Despite these coun- 5. Aldis W. Health security as a public health con- try or regional coverages, our findings remain relevant and cept: A critical analysis. Health Policy and Planning. applicable across other countries in SSA that share similar 2008; 23: 369–375. DOI: https://doi.org/10.1093/ health care system capacity needs or barriers. heapol/czn030 6. World Health Organization (WHO). World Conclusion Health Report 2017: Safer future: Global public This review re-emphasizes the role of an effective cadre health security in the 21st century. 2007. Geneva: of health care workers, good investments in surveillance World Health Organization. for decision making, and strong governance in health 7. The Lancet. No health workforce, no global health as critical for the success of any country health system. secu rity. Lancet (London, England). 2016; 387: 2063. A health system that trains a cadre of health profession- DOI: https://doi.org/10.1016/S0140-6736(16)305 als on the job, reduces health workforce attrition levels, 98-0 and builds local capacity for health care workers to apply 8. Chee G, Pielemeier N, Lion A, et al. Why differen- innovative mHealth technologies in delivering services tiating between health system support and health can improve health worker motivation and support for system strengthening is needed. International the health sector. Building novel surveillance systems can Journal of Health Planning and Management. 2013; improve clinical care and health system preparedness for 28: 85–94. 07/09. DOI: https://doi.org/10.1002/ health threats. A strong health leadership and partner- hpm.2122 ship can help deliver financial and logistical capacity for 9. Fidler D. Epic Failure of Ebola and Global Health the effective delivery of essential health services. A mix of Security. Brown Journal of World Affairs. 2015; XXI: strategies in addition to the main areas covered under this 179–197. review, as advocated by the WHO, is needed for strength- 10. Kieny MP, Evans DB, Schmets G, et al. Health- ening health system capacities [25]. Overall, policy shifts system resilience: Reflections on the Ebola crisis in in African countries’ health systems that prioritize training Western Africa. Bull World Health Organ. 2014; 92. a cadre of health care workers willing and able to provide DOI: https://doi.org/10.2471/BLT.14.149278 timely responses to any disease or health threat, investing 11. Brinkerhoff DW. Accountability and health in building a robust and cost-effective surveillance capac- systems: Toward conceptual clarity and policy ity, and creating financial accountability in health financ- relevance. Health Policy and Planning. 2004; 19: ing and governance can assist in strengthening country 371–379. DOI: https://doi.org/10.1093/heapol/ level health capacities to deliver better health outcomes. czh052 12. Frenk J. The global health system: Strengthen- Competing Interests ing national health systems as the next step for The authors have no competing interests to declare. global progress. PLoS Med. 2010; 7: e1000089. DOI: https://doi.org/10.1371/journal.pmed.1000089 Author Contribution 13. Travis P, Bennett S, Haines A, et al. Overcom- MAA conceived the study with NA and MA. MAA, NA, MA, ing health-systems constraints to achieve the AA, DDK VM, and JG supported in data extraction and Millennium Development Goals. Lancet. 2005; selection of eligible papers for review. MAA drafted the 364: 900–906. DOI: https://doi.org/10.1016/ initial manuscript. ROA, NK, and MG read and provided S0140-6736(04)16987-0 technical inputs on the contents. MAA and JG undertook 14. Coovadia H, Jewkes R, Barron P, et al. The health a second revision of the manuscript. All authors read and and health system of South Africa: Historical approved the manuscript for submission. roots of current public health challenges. Art. 113, page 12 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Lancet. 374: 817–834. DOI: https://doi.org/10.1016/ 27. Baker MG and Fidler DP. Global public health sur- S0140-6736(09)60951-X veillance under new international health regula- 15. AbouZahr C and Boerma T. Health information tions. Emerging Infectious Diseases. 2006; 12: 1058. syst ems: The foundations of public health. Bul- DOI: https://doi.org/10.3201/eid1207.051497 letin of the World Health Organization. 2005; 83: 28. Systematic reviews and meta-analyses in Lancet: for- 578–583. matting guidelines. 16. Mahapatra P, Shibuya K, Lopez AD, et al. Civil 29. Moher D, Liberati A, Tetzlaff J, et al. Pre- registration systems and vital statistics: Successes ferred reporting items for systematic reviews and missed opportunities. Lancet. 2007; 370: and meta-analyses: The PRISMA statement. 1653–1663. DOI: https://doi.org/10.1016/ Ann Intern Med. 2009; 151. DOI: https://doi. S0140-6736(07)61308-7 org/10.7326/0003-4819-151-4-200908180-00135 17. World Health Organization (WHO). Addressing 30. Popay J, Roberts H, Sowden A, et al. Guidance the Challenges of Women’s Health in Africa. 2012. on the conduct of narrative synthesis in system- Brazzaville: WHO Regional Office for Africa. atic reviews. A product from the ESRC methods pro- 18. Ten Hoope-Bender P, de Bernis L, Campbell gramme Version. 2006; 1: b92. J, et al. Improvement of maternal and new- 31. Crowe M, Sheppard L and Campbell A. Reliability born health through midwifery. Lancet. 2014; analysis for a proposed critical appraisal tool 384: 1226–1235. DOI: https://doi.org/10.1016/ demonstrated value for diverse research designs. S0140-6736(14)60930-2 Journal of Clinical Epidemiology. 2012; 65: 375–383. 19. Lomazzi M, Borisch B and Laaser U. The Millen- DOI: https://doi.org/10.1016/j.jclinepi.2011.08.006 nium Development Goals: Experiences, achieve- 32. Crowe M. Crowe critical appraisal tool (CCAT) user ments and what’s next. Millennium Development guide. Scotland, UK: Conchra House; 2013. Goals; sustainable development; equity; education; 33. Sayinzoga F and Bijlmakers L. Drivers of improved accountability; governments; post-2015 agenda health sector performance in Rwanda: A qualitative 2014-01-03. 2014; 7. DOI: https://doi.org/10.3402/ view from within. BMC Health Services Research. gha.v7.23695 2016; 16: 123. DOI: https://doi.org/10.1186/ 20. Accorsi S, Bilal NK, Farese P, et al. Countdown to s12913-016-1351-4 2015: Comparing progress towards the achievement 34. Ledikwe JH, Reason LL, Burnett SM, et al. Estab- of the health Millennium Development Goals in lishing a health information workforce: Innova- Ethiopia and other sub-Saharan African countries. tion for low- and middle-income countries. Human Transactions of The Royal Society of Tropical Medicine Resources for Health. 2013; 11: 35. DOI: https://doi. and Hygiene. 2010; 104: 336–342. DOI: https://doi. org/10.1186/1478-4491-11-35 org/10.1016/j.trstmh.2009.12.009 35. Otu A, Ebenso B, Okuzu O, et al. Using a mHealth 21. Requejo JH, Bryce J, Barros AJD, et al. Count- tutorial application to change knowledge and atti- down to 2015 and beyond: Fulfilling the health tude of frontline health workers to Ebola virus agenda for women and children. Lancet. 2015; disease in Nigeria: A before-and-after study. Human 385: 466–476. DOI: https://doi.org/10.1016/ Resources for Health. 2016; 14: 5. DOI: https://doi. S0140-6736(14)60925-9 org/10.1186/s12960-016-0100-4 22. Braa J, Hanseth O, et al. Developing Health 36. Jones C, Abeku TA, Rapuoda B, et al. District- Informa tion Systems in Developing Countries: The based malaria epidemic early warning systems in Flexible Standards Strategy. MIS Quarterly. 2007; 31: East Africa: Perceptions of acceptability and use- 381–402. DOI: https://doi.org/10.2307/25148796 fulness among key staff at health facility, district 23. Jamison DT, Breman JG, Measham AR, et al. and central levels. Social Science & Medicine. 2008; Disease Control Priorities in Developing Countries 67: 292–300. DOI: https://doi.org/10.1016/j. (Second Edition); 2006. socscimed.2008.03.001 24. Fehling M, Nelson BD and Venkatapuram S. 37. Cox J and Abeku TA. Early warning systems for Limitations of the Millennium Development Goals: malaria in Africa: From blueprint to practice. Trends A literature review. Global Public Health. 2013; 8: in Parasitology. 2007; 23: 243–246. DOI: https:// 1109–1122. DOI: https://doi.org/10.1080/1744169 doi.org/10.1016/j.pt.2007.03.008 2.2013.845676 38. Peckham R and Sinha R. Satellites and the New 25. World Health Organization (WHO). Monitoring War on Infection: Tracking Ebola in West Africa. the building blocks of health systems: A handbook Geoforum. 2017; 80: 24–38. DOI: https://doi. of indicators and their measurement strategies. org/10.1016/j.geoforum.2017.01.001 Geneva, Switzerland: WHO Library Cataloguing-in- 39. Newman MJ, Frimpong E, Donkor ES, et al. Publication Data; 2010: 110. Resistance to antimicrobial drugs in Ghana. Infect 26. Nsubuga P, Nwanyanwu O, Nkengasong JN, Drug Resist. 2011; 4: 215–220. DOI: https://doi. et al. Strengthening public health surveillance org/10.2147/IDR.S21769 and response using the health systems strength- 40. Davies J, Abimiku Al, Alobo M, et al. Sustainable ening agenda in developing countries. BMC clinical laboratory capacity for health in Africa. Public Health. 2010; 10: S5. DOI: https://doi. Lancet Global Health. 2017; 5: e248–e249. DOI: org/10.1186/1471-2458-10-S1-S5 https://doi.org/10.1016/S2214-109X(17)30024-4 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 13 of 15 41. Global health security: How can laboratories help? 2015; 63: 30–40. DOI: https://doi.org/10.1016/j. Lancet Global Health. 2017; 5: e115. DOI: https:// outlook.2014.12.013 doi.org/10.1016/S2214-109X(17)30009-8 54. Coovadia H, Jewkes R, Barron P, et al. The health 42. Haskew J, Rø G, Turner K, et al. Implementation and health system of South Africa: Historical roots of a cloud-based electronic medical record to reduce of current public health challenges. Lancet. 2009; gaps in the HIV treatment continuum in rural 374: 817–834. DOI: https://doi.org/10.1016/ Kenya. PloS One. 2015; 10: e0135361. DOI: https:// S0140-6736(09)60951-X doi.org/10.1371/journal.pone.0135361 55. Gostin LOF and Friedman EA. A retrospective 43. Kiberu VM, Matovu JK, Makumbi F, et al. Strength- and prospective analysis of the West African Ebola ening district-based health reporting through the virus disease epidemic: Robust national health sys- district health management information software tems at the foundation and an empowered WHO system: The Ugandan experience. BMC Medical at the apex. Lancet. 2015; 385. DOI: https://doi. Informatics and Decision Making. 2014; 14: 40. DOI: org/10.1016/S0140-6736(15)60644-4 https://doi.org/10.1186/1472-6947-14-40 56. World Health Organization (WHO). Ebola situa- 44. Mate KS, Bennett B, Mphatswe W, et al. Chal- tion report. 2016. World Health Organization. lenges for routine health system data management 57. Mutale W, Chintu N, Amoroso C, et al. Improv- in a large public programme to prevent mother-to- ing health information systems for deci- child HIV transmission in South Africa. PloS One. sion making across five sub-Saharan African 2009; 4: e5483. DOI: https://doi.org/10.1371/jour- countries: Imple mentation strategies from nal.pone.0005483 the African Health Initiative. BMC Health Ser- 45. Wong R and Bradley EH. Developing patient regis- vices Research. 2013; 13: S9. DOI: https://doi. tration and medical records management system in org/10.1186/1472-6963-13-S2-S9 Ethiopia. International Journal for Quality in Health 58. Chaulagai CN, Moyo CM, Koot J, et al. Design Care. 2009: mzp026. DOI: https://doi.org/10.1093/ and implementation of a health management intqhc/mzp026 information system in Malawi: Issues, innovations 46. Global health security: How can laboratories help? and results. Health Policy and Planning. 2005; 20: Lancet Global Health. 2017; 5: e115. DOI: https:// 375–384. DOI: https://doi.org/10.1093/heapol/ doi.org/10.1016/S2214-109X(17)30009-8 czi044 47. Mate KS, Bennett B, Mphatswe W, et al. Chal- 59. Chan M, Kazatchkine M, Lob-Levyt J, et al. Meet- lenges for routine health system data management ing the demand for results and accountability: a in a large public programme to prevent mother-to- call for action on health data from eight global child HIV transmission in South Africa. PLoS One. health agencies. PLoS Med. 2010; 7: e1000223. DOI: 2009; 4. DOI: https://doi.org/10.1371/journal. https://doi.org/10.1371/journal.pmed.1000223 pone.0005483 60. Pappaioanou M, Malison M, Wilkins K, et al. 48. Sherr K, Cuembelo F, Michel C, et al. Strengthen- Strengthening capacity in developing countries for ing integrated primary health care in Sofala, Mozam- evidence-based public health: The data for decision- bique. BMC Health Services Research. 2013; 13. DOI: making project. Social Science & Medicine. 2003; https://doi.org/10.1186/1472-6963-13-S2-S4 57: 1925–1937. DOI: https://doi.org/10.1016/ 49. Patel MS and Phillips CB. Health security and polit- S0277-9536(03)00058-3 ical and economic determinants of Ebola. Lancet. 61. Horvath T, Azman H, Kennedy GE, et al. Mobile 2015; 386: 737–738. DOI: https://doi.org/10.1016/ phone text messaging for promoting adherence to S0140-6736(15)61533-1 antiretroviral therapy in patients with HIV infection. 50. Kongnyuy EJ, Mlava G and van den Broek N. Cochrane Database Syst Rev. 2012; 3. DOI: https:// Criteria-based audit to improve a district refer- doi.org/10.1002/14651858.CD009756 ral system in Malawi: A pilot study. BMC Health 62. Chin CD, Cheung YK, Laksanasopin T, et al. Services Research. 2008; 8: 190. DOI: https://doi. Mobile device for disease diagnosis and data tracking org/10.1186/1472-6963-8-190 in resource-limited settings. Clin Chem. 2013; 59. 51. Topp SM, Black J, Morrow M, et al. The impact of DOI: https://doi.org/10.1373/clinchem.2012.199 human immunodeficiency virus (HIV) service scale- 596 up on mechanisms of accountability in Zambian 63. Blaya JA, Fraser HS and Holt B. E-health technolo- primary health centres: A case-based health systems gies show promise in developing countries. Health analysis. BMC Health Services Research. 2015; 15: 67. Affairs (Project Hope). 2010; 29. DOI: https://doi. DOI: https://doi.org/10.1186/s12913-015-0703-9 org/10.1377/hlthaff.2009.0894 52. Wang SA, Hyde TB, Mounier-Jack S, et al. New 64. Black AD, Car J, Pagliari C, et al. The impact of vaccine introductions: Assessing the impact and the eHealth on the quality and safety of health care: opportunities for immunization and health systems A systematic overview. PLoS Med. 2011; 8. DOI: strengthening. Vaccine. 2013; 31: B122–B128. DOI: https://doi.org/10.1371/journal.pmed.1000387 https://doi.org/10.1016/j.vaccine.2012.10.116 65. World Health Organization (WHO). mHealth 53. Buseh AG, Stevens PE, Bromberg M, et al. The New horizons for health through mobile Ebola epidemic in West Africa: Challenges, oppor- technologies. 2011. Geneva, Switzerland: World tunities, and policy priority areas. Nursing Outlook. Health Organization. Art. 113, page 14 of 15 Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa 66. Soeters R, Habineza C and Peerenboom PB. Per- 77. Shoman H, Karafillakis E and Rawaf S. The formance-based financing and changing the district link between the West African Ebola outbreak health system: Experience from Rwanda. Bulletin of and health systems in Guinea, Liberia and Sierra the World Health Organization. 2006; 84: 884–889. Leone: A sys tematic review. Globalization and 67. Bonfrer I, Soeters R, Van de Poel E, et al. Introduc- Health. 2017; 13: 1. DOI: https://doi.org/10.1186/ tion of performance-based financing in Burundi was s12992-016-0224-2 associated with improvements in care and quality. 78. World Health Organization (WHO). Statement Health Affairs. 2014; 33: 2179–2187. DOI: https:// on the 1st meeting of the IHR Emergency Com- doi.org/10.1377/hlthaff.2014.0081 mittee on the 2014 Ebola outbreak in West Africa. 68. Soeters R, Peerenboom PB, Mushagalusa P, et al. Media Centre. Geneva, Switzerland; 2014. Performance-based financing experiment improved 79. Govender V, McIntyre D and Loewenson R. Pro- health care in the Democratic Republic of Congo. gress towards the Abuja target for government Health Affairs. 2011; 30: 1518–1527. DOI: https:// spending on health care in East and Southern Africa. doi.org/10.1377/hlthaff.2009.0019 Cape Town, SA: EQUINET; 2008. 69. Petersen I, Lund C, Bhana A, et al. A task shifting 80. De Savigny D and Adam T. Systems thinking for approach to primary mental health care for adults health systems strengthening. World Health Organi- in South Africa: Human resource requirements and zation; 2009. costs for rural settings. Health Policy and Planning. 81. Cassels A. Health sector reform: Key issues in 2012; 27: 42–51. DOI: https://doi.org/10.1093/ less developed countries. Journal of International heapol/czr012 Development. 1995; 7: 329–347. DOI: https://doi. 70. Selke HM, Kimaiyo S, Sidle JE, et al. Task-shifting org/10.1002/jid.3380070303 of antiretroviral delivery from health care workers 82. World Health Organization (WHO). Closing the to persons living with HIV/AIDS: Clinical outcomes gap: Policy into practice on social determinants of of a community-based program in Kenya. JAIDS health. Discussion paper; 2011. Journal of Acquired Immune Deficiency Syndromes. 83. Travis P, Bennett S, Haines A, et al. Overcom- 2010; 55: 483–490. DOI: https://doi.org/10.1097/ ing health-systems constraints to achieve the QAI.0b013e3181eb5edb Millennium Development Goals. Lancet. 2004; 71. Ofori-Asenso R, Brhlikova P and Pollock AM. Pre- 364: 900–906. DOI: https://doi.org/10.1016/ scribing indicators at primary health care centers S0140-6736(04)16987-0 within the WHO African region: A sys tematic analysis 84. Russell LB, Gold MR, Siegel JE, et al. The role of (1995–2015). BMC Public Health. 2016; 16: 724. cost-effectiveness analysis in health and medicine. DOI: https://doi.org/10.1186/s12889-016-3428-8 JAMA. 1996; 276: 1172–1177. DOI: https://doi. 72. Uchtmann N, Herrmann JA, Hahn EC, et al. Bar- org/10.1001/jama.1996.03540140060028 riers to, efforts in, and optimization of integrated 85. Cho H-W and Chu C. Out of Africa, Into Global one health surveillance: A review and synthesis. Health Security Agenda. Osong Public Health and Ecohealth. 2015; 12: 368–384. DOI: https://doi. Research Perspectives. 2014; 5: 313. DOI: https://doi. org/10.1007/s10393-015-1022-7 org/10.1016/j.phrp.2014.11.004 73. Hunter SS. Orphans as a window on the AIDS 86. Cho H-W and Chu C. Two Epidemics and Global epidemic in sub-Saharan Africa: Initial results and Health Security Agenda. Osong Public Health and implications of a study in Uganda. Social Science Research Perspectives. 2015; 6: S1. DOI: https://doi. & Medicine. 1990; 31: 681–690. DOI: https://doi. org/10.1016/j.phrp.2015.12.008 org/10.1016/0277-9536(90)90250-V 87. Team GPTF. Global Health Security: The Lessons 74. Engel-Cox JA, Holloman CH, Coutant BW, et al. from the West African Ebola Virus Disease Epi- Qualitative and quantitative evaluation of MODIS demic and MERS Outbreak in the Republic of Korea. satellite sensor data for regional and urban scale Osong Public Health and Research Perspectives. air quality. Atmospheric Environment. 2004; 38: 2015; 6: S25–S27. DOI: https://doi.org/10.1016/j. 2495–2509. DOI: https://doi.org/10.1016/j. phrp.2015.12.006 atmosenv.2004.01.039 88. Gostin LO and Friedman EA. A retrospective and 75. Thomson M, Connor S, Milligan P, et al. Mapping prospective analysis of the West African Ebola virus malaria risk in Africa: What can satellite data con- disease epidemic: Robust national health systems tribute? Parasitology Today. 1997; 13: 313–318. DOI: at the foundation and an empowered WHO at the https://doi.org/10.1016/S0169-4758(97)01097-1 apex. Lancet. 2015; 385: 1902–1909. DOI: https:// 76. Drobac PC, Basinga P, Condo J, et al. Compre- doi.org/10.1016/S0140-6736(15)60644-4 hensive and integrated district health systems 89. Siekmans K, Sohani S, Boima T, et al. Community- strengthening: The Rwanda Population Health based health care is an essential component of a Implementation and Training (PHIT) Partnership. resilient health system: Evidence from Ebola out- BMC Health Services Research. 2013; 13: S5. DOI: break in Liberia. BMC Public Health. 2017; 17: 84. https://doi.org/10.1186/1472-6963-13-S2-S5 DOI: https://doi.org/10.1186/s12889-016-4012-y Ayanore et al: Towards Resilient Health Systems in Sub-Saharan Africa Art. 113, page 15 of 15 How to cite this article: Ayanore MA, Amuna N, Aviisah M, Awolu A, Kipo-Sunyehzi DD, Mogre V, Ofori-Asenso R, Gmanyami JM, Kugbey N and Gyapong M. Towards Resilient Health Systems in Sub-Saharan Africa: A Systematic Review of the English Language Literature on Health Workforce, Surveillance, and Health Governance Issues for Health Systems Strengthening. Annals of Global Health. 2019; 85(1): 113, 1–15. DOI: https://doi.org/10.5334/aogh.2514 Published: 16 August 2019 Copyright: © 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. Annals of Global Health is a peer-reviewed open access journal published by Ubiquity Press. OPEN ACCESS