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

- Prompt on the job training yields better results and response on health information management and needs compared to long term offsite training for health information personnel.

- Planning for attrition through development of strategies for efficient recruitment and development of training materials that could easily be used to train new staff is important to enhance workforce numbers and improvements for health systems.

- mHealth tutorial applications from this study show modest changes in knowledge and attitudes of health care workers post project implementation.

- mHealth technologies could be effectively used to disseminate information and train community health workers working in remote and far to reach country settings.

- Community health workers and health insurance come out as factors that are considered to have contributed most to Rwanda’s 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.

- Low capacity of linking laboratory diagnostic tests to selection of medicines for treatments 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.

- Targeting and training a cadre of multi-skilled health professionals to work in laboratories that can deal with broad range of health conditions (communicable and non-communicable) are crucial for promoting individualized health security needs.

- There is need to actively promote and support laboratories to be reliable both in diagnostic and treatments. Providing laboratory leadership seminars and training programmes is important to improve and guarantee this objective.

- The system transfer of responsibility to district level manpower resulted in perceptions of empowerment among district-based health staff.

- Improved support together with transfer of responsibility helped to sustain motivation and improved surveillance on malaria tracking and control.

- Increased logistical support is vital in the midst of increased participation and involvement to sustain surveillance gains.

- The development of appropriate and sustainable case monitoring systems can act both as means to providing reliable information and building data for the health systems vital in poor settings with poor data or non-existent malaria data systems.

- Remote sensing could be applied to track disease and monitor isolated rural communities, providing mapping data that supports on-the-ground logistics and contract tracing as evidenced during the Ebola crises.

- Cloud based electronic medical system provides for real-time access to anonymised data beyond the level of the clinic to inform timely decision making on HIV interventions.

- The system proved to be cost effective, scalable compared to other local context models.

- Training resulted in timeliness and completeness in health reporting of routine outpatient, inpatient, and health service usage data from district to the national.

- Onsite support and training for data managers and professional in addition to removing logistical constraints improves data management efficiency at district level.

- System improvements must improve front line health staff skills/knowledge on routine quality data, adopt use of simplified data tools, maintain minimum set of indicators and registers.

- The evidence showed merging of patient registrations and medical records into one process, designing master patient index and improved filing procedures together with adequate training of human resources are vital to guarantee improved patient care services.

- Health systems must pay attention to individual health security needs. Resource availability and allocation is both a 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.

- Mentorship and enhanced supervision (MESH) of health staff improves quality care at health facilities.

- The use of community health household registers to track activities and improve reporting at facility levels improves health system outcomes.

- The use of electronic record management systems for generating alerts and reporting improves quality of care at facility centres.

- In health systems with multiple district level partners, building communication and support channels across all levels of the health system with partners is vital to success.

- 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.

- Investments for the development of suitable and effective vaccines is key for preparedness in any health emergencies.

- Patient safety issues are important to the efficacy of preventing potential accidents during disease outbreaks in Africa.

- Holistic country and continental assessment of health system gaps along 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.

- Effective health systems are those in use every day and capable of scaling up in emergencies.

- Despite nascent capacity in Nigeria, a well-coordinated surveillance and laboratories emergency operations by trained health staff enabled the control of Ebola.

- Country and global political and economic determinants to health can be tackled 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.

- High-quality monitoring and evaluation, including disease

- surveillance and immunization coverage monitoring, resource, performance, and management accountability.

- Viewing health service delivery in a holistic and integrated manner rather than as independent, disparate programmes is recognized as necessary 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.

- Promoting family-centered approaches in emergencies could help control infection and re-infection rates during disease 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.

- An empowered WHO at the apex, with well-coordinated funding and actions among many parties, is important to improve health emergences and vulnerabilities, particularly in poor resourced settings.

- Community health workers knowledge of cultural and social complexities at community centres enhances patients trust and confidence in the health system during emergencies.

- In critical emergencies, adequate training and guidelines with supportive supervision to community health workers help deliver lifesaving services to patients.

- Criterion-based audit is scalable in poor resource settings where referral care is vital for obstetric care.

- Local health actors support, and strong involvement is vital for, sustaining health system gains at long term.

- Resource-intensive investments in HIV services contributes to improving administrative answerability and improving capacities to deliver and monitor service delivery.

- Community dialoguing, patient score cards are local level approaches used to improve micro-level (people-centeredness) for services delivery.

- Programmes with direct impact on the social determinants of health and development (stigma, subordination of women, poverty and inequality, violence, and 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, unemployment, and inequities are essential for health systems strengthening.

- The Ebola outbreak must trigger substantial investments and adequate reforms in the worst-affected countries health systems. National governments, assisted by external partners, need to develop 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.

- Summary points: Strong and effective health systems at country levels are the foundations to ensuring global health security. Appropriately applying standardized measures and indicators to appraise health systems within the global context will support in planning and health prioritization in national health system needs.

- Summary points: There is need for pragmatic synergy among various technical working relationships in WHO. In developing strategies for country health systems, synergy strategies should be pursued in care provision, monitoring of indicators and outcomes, health financing and improving quality of care for patients and the health workforce.