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The term resilience has dominated the discourse among health systems researchers since 2014 and the onset of the Ebola outbreak in West Africa. There is wide consensus that the global community has to help build more resilient health systems. But do we really know what resilience means, and do we all have the same vision of resilience? The present paper presents a new conceptual framework on governance of resilience based on systems thinking and complexity theories. In this paper, we see resilience of a health system as its capacity to absorb, adapt and transform when exposed to a shock such as a pandemic, natural disaster or armed conflict and still retain the same control over its structure and functions.

Sierra Leone was highly impacted by the 2014–2016 West Africa Ebola out-break, with 3,955 recorded deaths. Already stressed maternal health services were deeply affected by the outbreak due to fears of viral transmission, reallocation of maternity staff, and broader policies to stop transmission including travel restrictions. This research sought to explore women’s perspectives on delaying pregnancy during the Ebola outbreak using family planning methods. Qualitative data collection took place in Kambia District in 2018 and included 35 women participants, with women who were either family planning users or nonusers at the time of the outbreak. Women reported a variety of reasons for choosing to take or not to take family planning during the outbreak, which we categorized as proximal (directly related to the outbreak) or distal (not directly outbreak related). Proximal reasons to take family planning included to avoid interacting with health care spaces where Ebola could be transmitted, to avoid the economic burden of additional children in a time when economic activities were curtailed and to return to school when education resumed postoutbreak. Distal reasoning included gender roles affecting women’s decision making to seek family planning, concerns related to the physiological side effects of family planning, and the economic burden of paying for family planning. Women’s perspectives for choosing to take or not take family planning during the Sierra Leone Ebola crisis had not been explored prior to this paper. Using the lens of family planning to consider how women choose to access health care in an outbreak gives us a unique perspective into how all health care interactions are impacted by a generalized outbreak of Ebola, and how outbreak responses struggle to ensure such services remain a priority.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project.

Although the number of direct Ebola-related deaths from the 2013 to 2016 West African Ebola outbreak has been quantified, the number of indirect deaths, resulting from decreased utilization of routine health services, remains unknown. Such information is a key ingredient of health system resilience, essential for adequate allocation of resources to both ‘crisis response activities’ and ‘core functions’. Taking stock of indirect deaths may also help the concept of health system resilience achieve political traction over the traditional approach of disease-specific surveillance. This study responds to these imperatives by quantifying the extent of the drop in utilization of essential reproductive, maternal and neonatal health services in Sierra Leone during the Ebola outbreak by using interrupted time-series regression to analyse Health Management Information System (HMIS) data. Using the Lives Saved Tool, we then model the implication of this decrease in utilization in terms of excess maternal and neonatal deaths, as well as stillbirths. We find that antenatal care coverage suffered from the largest decrease in coverage as a result of the Ebola epidemic, with an estimated 22 percentage point (p.p.) decrease in population coverage compared with the most conservative counterfactual scenario. Use of family planning, facility delivery and post-natal care services also decreased but to a lesser extent (-6, -8 and -13 p.p. respectively). This decrease in utilization of life-saving health services translates to 3600 additional maternal, neonatal and stillbirth deaths in the year 2014–15 under the most conservative scenario. In other words, we estimate that the indirect mortality effects of a crisis in the context of a health system lacking resilience may be as important as the direct mortality effects of the crisis itself.

In Sierra Leone, for example, at least 2400 pregnant women were at risk of dying each year before the outbreak of Ebola. 3 In addition, women are more vulnerable to the consequences of Ebola infection-two different studies suggest that pregnant women have a higher risk of mortality than non-pregnant women and that their newborn babies have a lower chance of survival. 4 The social vulnerability of women increases their susceptibility to morbidity and mortality related to Ebola because of their role as prime care giver to those who are sick. 5 In addition, reports in the media suggest that pregnant women are being triaged out of care owing to the perceived risk of potential transmission of the Ebola virus during childbirth. 6 Substantial long term investment is needed to rebuild all aspects of the health systems in these affected countries and stronger evidence based voice must be given to citizens to hold their elected governments to account on their health related commitments.

Needs assessment by Options UK in Camden, London, to examine maternity service provision in the light of recommendations in Maternity Matters (2007) and identify unmet needs of vulnerable pregnant women and those at higher risk of poor outcomes. Findings concerning choice, access, continuity of care and safety issues are presented. 4 references