Essays on Disease Outbreaks and Health System Resilience in Sub-Saharan Africa

Abstract

In the past decade, there has been an increasing interest in the concept of health system resilience, defined as the ability of a health system to prepare for, manage (absorb, adapt, and transform), and learn from shocks. Motivated in part by the 2014-16 Ebola outbreak in West Africa and more recently motivated by the COVID-19 pandemic, this research agenda seeks to understand how health systems prepare for and absorb major shocks to their routine functioning capacity. However, many basic questions still remain about how to define health system resilience, and even more fundamentally, it is not always clear what is at stake for health systems when preparing for future events. This dissertation aims to add to the evidence base for understanding the resilience capacity of health systems by investigating the absorptive capacity of Guinea, Liberia, and Sierra Leone in response to the Ebola outbreak and estimating the recovery period after the outbreak. Additionally, this dissertation provides evidence of community-level health technology adoption behaviors that can guide health interventions to prepare for and manage shocks at the local level. The first study uses annual national childhood immunization rate estimates to quantify the causal impact of the 2014-16 Ebola outbreak on childhood immunization rates as well as the time required for health systems to return to pre-outbreak trends. The second study uses annual national maternal mortality rate estimates to quantify the causal impact of the Ebola outbreak on maternal mortality rates as well as the time required for health systems to return to pre-outbreak trends. The second study additionally uses nationally representative individual-level survey data to explore mechanisms for the elevated levels of maternal mortality seen during the outbreak. The third study uses randomized controlled trial (RCT) data from rural Kenya to identify the causal impact of the health technology adoption behaviors of neighbors on a household’s decision to adopt new technology. The first two studies add to the evidence base on the impacts of major health system shocks on key health system indicators, while the third study provides evidence for health technology adoption behaviors that can inform contextually aware health interventions at the local level, an important aspect of building health system resilience prior to and during shocks. All three studies add to a growing evidence base required to build effective and resilient health systems.