LESSONS FROM EBOLA AFFECTED COMMUNITIES: Royal African Society

 
LESSONS FROM EBOLA AFFECTED COMMUNITIES: Royal African Society
LESSONS FROM
EBOLA AFFECTED
COMMUNITIES:
Being prepared for
future health crises
FEBRUARY 2016

This report is written by Polygeia and commissioned by the Africa APPG with fieldwork funding from the Royal African Society. This is not an official publication
of the House of Commons or House of Lords. It has not been approved by either House or its committees. All-Party Parliamentary Groups are informal groups of
Members of both Houses with a common interest in particular issues
LESSONS FROM EBOLA AFFECTED COMMUNITIES: Royal African Society
Cover Photograph:
    Restless Development ©2015

2
LESSONS FROM EBOLA AFFECTED COMMUNITIES: Royal African Society
CONTENTS

ACKNOWLEDGEMENTS						                                                         4
FOREWORD                                                                       9
ACRONYMS AND ABBREVIATIONS                                                    10
EXECUTIVE SUMMARY                                                             11
INTRODUCTION                                                                  13
1 WHAT WEAKNESSES HAS THE EBOLA OUTBREAK EXPOSED?                             14
      1.1    The West African Ebola Outbreak                                  15
		           1.1.1 Lasting Impact on Communities                              18
      1.2    The Response                                                     20
		1.2.1 National Response                                                     21
		1.2.2 International Response		                                              23
		           1.2.3 The UK’s Role in the Ebola Response                        24
      1.3    Underlying Challenges: Health Systems and Infrastructure         27
		           1.3.1 Health Systems in Guinea, Liberia and Sierra Leone         28
		           1.3.2 Rural, Peri-Urban and Urban Challenges                     32
		           1.3.3 Legacies of War and Reconstruction                         33
      1.4    Summary                                                          34

2 HOW IMPORTANT ARE COMMUNITY-LED APPROACHES TO HEALTH?                       35
     2.1   What is a ‘Community-Led’ Approach?                                35
     2.2   The Role of Communities in the Response:
		         Building Trust and Legitimacy                                      38
		         2.2.1 Initial Public Mobilisation Campaigns: Resistance and Fear   38
		         2.2.2 Community Groups: Rising to the Challenge                    39
     2.3   Localised Approaches: Community, Engagement and Consultation       48
     2.4   Avoiding Parallel Systems: Utilising Existing Structures           51
     2.5   Summary                                                            54

3 HOW CAN THE UK AND INTERNATIONAL DONORS BEST SUPPORT
COMMUNITY-LED APPROACHES TO HEALTH SYSTEMS STRENGTHENING?                  55
     3.1    Putting Community at the Centre of Future Health Programmes    55
     3.2    Earlier Community Consultation: Fostering Ownership            57
     3.3    Recognising Communities as Experts in Themselves               58
     3.4    Harnessing Local Resources: Building a Sustainable and Local
		Health Workforce                                                         60
     3.5    Coordination: The Need to Strengthen Multi-Stakeholder
		Partnerships                                                             61
		          3.5.1 Coordinating National Stakeholders                       61
		          3.5.2 Coordinating International Stakeholders                  62
     3.6    Supporting National Governments to Achieve Universal Health
		Care                                                                     64
     3.7    Conclusion                                                     65

4 RECOMMENDATIONS                                                             66
      4.1  Recommendations for UK Government                                  66
      4.2  Recommendations for UK Actors                                      67

REFERENCES                                                                    68

                                                                                   3
LESSONS FROM EBOLA AFFECTED COMMUNITIES: Royal African Society
ACKNOWLEDGEMENTS

    This report was written by Polygeia with    We are especially grateful to Restless
    direction and oversight from the Africa     Development in Sierra Leone and Public
    APPG.                                       Health and Development Initiative (PHDI)
                                                for their support in co-developing and
    Co-editors from Polygeia: Thomas Hird &     conducting the key informant interviews
    Samara Linton                               with community leaders in their
    Researchers: Maisy Grovestock, Shreya       respective countries on behalf of Polygeia
    Nanda, Rhys Wenlock, Waqas Haque &          and the Africa APPG:-
    Ben Walker.
                                                Restless Development in Sierra Leone:
                                                Jamie Bedson,Saiku Bah, Prince Kenneh,
                                                George Tamba Sellu, Susan Manie, Juliana
                                                Sama Fornah, Mohamed A Jalloh and
                                                Alfred T M Nav
    Special thanks to Lord Chidgey (Co-
    Chair) for heading up the inquiry and
    sessions and to Hetty Bailey the APPG
    Coordinator.

                                                Public Health and Development Initiative
                                                (PHDI) Liberia: Dr Alaric Topka

    Thank you to RAS for their support of the
    Africa APPG and funding of the report and
    associated field research. Special thanks
    to Richard Dowden, Director at RAS and
    Susana Edjang, a RAS council member for
    their input and guidance. Thank you to
    Gemma Haxby for proof reading.

4
Parliamentarians who contributed to
report drafts or attended thematic
sessions -
• Baroness Armstrong
• Paul Burstow MP
• Lord Cameron
• Lord Chidgey
• Lord Crisp
• Lord Collins
• Mark Durkan MP
• Lord Giddens
• Baroness Hayman
• Meg Hillier MP
• Pauline Latham MP
• Lord Lea
• Jeremy Lefroy MP
• Baroness Kinnock
• Baroness Masham
• Duke of Montrose
• Lord Patel
• Lord Ribeiro
• Earl of Sandwich
• Lord Watson

                                      5
• ReBUILD, COUNTDOWN and REACHOUT
                                                    Consortium
    The Africa APPG expresses their sincere       • Restless Development
    thanks to all those who contributed to        • Save the Children
    this review, without whom this report         • SciDev.Net
    would not have been possible.
                                                  • Professor Joanne Sharp, University of
                                                    Glasgow
    Thank you to all of those that submitted
                                                  • WHO Country Office Liberia & WHO
    written evidence to the inquiry-
                                                    African Programme for Onchocerciasis
    • African Diaspora Healthcare                   Control - Oyene U.E, Prof Amazigo U.V,
      Professionals for Better Health in Africa     Cole I, Zoure H.G.M, Bette A.K,
      initiative & Dr Titi Banjoko                  Dr Afework H.T & Dr Fobi G
    • Amref Health Africa                         • World Vision International UK & Sierra
    • Action Contre la Faim (ACF)                   Leone
    • ActionAid
    • Dan Cohen, Maccabee Seed Company,           Thanks also to Dr Fred Martineau
      Davis CA                                    Coordinator of Ebola Response
    • Doctors of the World (DotW) in              Anthropology Platform and to the
      partnership with Medicos del Mundo          APPG on Global Health who helped
      (MdM)
    • Fambul Tok
    • Prof Mariane Ferme, University of
      California, Berkeley
    • Derek Gatherer PhD CertEd, Lancaster
      University
    • Health Partners International
    • Health Poverty Action
    • Institute of Development Studies in
      particular Professor Melissa Leach &
      Dr Pauline Oosterhoff for their support
    • International Rescue Committee
    • Dr Nathaniel King, The World Bank
      Group
    • Dr. Jill Lewis, Living for Tomorrow
    • Malaria Consortium
    • Marie Stopes International
    • Dr David Nabarro, UN Special Envoy on
      Ebola
    • Njala University, Sierra Leone in
      particular Prof. Paul Richards, Roland
      Suluku & Thomas Songu
    • Dr Melissa Parker, Reader LSHTM & PI
      of the Ebola Response Anthropology
      Platform
    • Pandemic and Epidemic Disease
      department (PED) WHO
    • Peter Penfold, CMG, OBE- former British
      High Commissioner to Sierra Leone

6
in circulating the Africa APPG’s call for       the World Health Organisation African
evidence.                                       region;
Thank you to those that contributed to        • Dr. Adrian Thomas - Vice President of
the five thematic panels on the subject or      Global Market Access & Head of Global
gave oral evidence -                            Public Health, Janssen Pharmaceutical
• Dr Uche Amazig - former head of the           Companies of Johnson & Johnson
  African Partnership for Onchoceriasis       • H.E. Edward Mohamed Turay - High
  Control                                       Commissioner for Sierra Leone
• Dr Egeruan Babatunde Imoukhuede             • Peter West - British High Commissioner
  - Clinical Project Manager and                to Sierra
  Vaccinologist, The Jenner Institute
• Dr Titilola Banjoko – Royal Africa
  Society
• Dr Michael Edelstein - Centre on Global
  Health Security, Chatham House
• Nic Hailey, Former Director Africa at the
  FCO
• Prof Catherine Hoppers - University of
  South Africa
• Dr. Arif Husain - Chief Economist, World
  Food Programme
• Dr. Adesina Iluyemi PhD - Executive
  Board Member, NEPAD Council
• Dr. Monty Jones - Special Advisor to the
  President of Sierra Leone
• Tulip Mazumdar - Global Health
  Correspondent, BBC News
• Solomon Mugera - Editor, BBC Africa
• Dr David Nabarro - UN Special Envoy on
  Ebola
• Baroness Northover - Former
  Parliamentary Under Secretary of State
  for DFID
• Dr Francis Omaswa - Executive Director
  of the African Centre for Global Health
  and Social Transformation and former
  Director General of Health services in
  Uganda;
• Dr. Robtel Neajai Pailey - Liberian
  academic, activist, and author based at
  SOAS, University of London
• Larissa Pelham - Emergency Food
  Security & Vulnerable Livelihoods
  Adviser, Oxfam
• Mr Jon Pender - Vice President,
  Government Affairs, GlaxoSmithKline
• Dr. Paul Richards - Njala University,
  Sierra Leone
• Dr Luis Sambo - Executive Director of

                                                                                         7
8
FOREWARD

      The Ebola crisis in West Africa
      demonstrated clearly how vulnerable
      the region was to rampant disease.
      Robust health systems, available at the
      point of need, were simply not there.
      There was little ability among the
      populations to pay. In the circumstances
      the responses from community health
      workers, local health systems and the
      people themselves were, in many cases,
      remarkable and totally selfless.

      The Republic of Guinea, Sierra Leone
      and Liberia share not only common
      borders, but deep cultural, language and
      ethnic affinities. The borders themselves
      barely exist for the local populations
      that straddle them. In the mountainous
      rainforest regions of the interior, there
      are minimal transport networks and
      non-existent utilities such as mains water,
      sanitation and electricity. Communities in
      remote villages are virtually inaccessible.

      Congratulations are due to Polygeia in
      drawing together written and verbal
      evidence on the responses to the Ebola
      health crisis from well over 200 sources.
      Their extensive analysis of the community
      engagement in the response to Ebola
      alongside national, international, and
      health aid agencies intervention in this
      report provides important guidance for
      the future.

      Lord Chidgey,
      Co-Chair Africa All-Party Parliamentary Group

                                                      9
ACRONYMS AND ABBREVIATIONS

     APPG        All-Party Parliamentary Group
     ACAPS       Assessment Capacities Project
     AFRO        (World Health Organization) African Region Office
     ASEOWA      African Union Support to Ebola Outbreak in West Africa
     AMREF       African Medical and Research Foundation
     AU          African Union
     CDC         Centers for Disease Control and Prevention
     CEBS        Community Evidence-Based Surveillance
     CHW         Community Health Worker
     CLEA        Community-Led Ebola Action
     CWC         Community Watch Committee
     DERC        District Emergency Response Centre (Sierra Leone)
     DFID        Department for International Development
     DHMT        District Health Management Team (Sierra Leone)
     EBOLA/EVD   Ebola Virus Disease
     ETU         Ebola Treatment Unit
     FGM         Female Genital Mutilation
     FHCI        Free Healthcare Initiative
     HIV/AIDS    Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
     HSS         Health Systems Strengthening
     IDC         International Development Committee
     IDS         Institute of Development Studies
     IFRC        International Federation of Red Cross
     IHR         International Health Recommendations
     IOM         Institutional Organisation for Migration
     IRC         International Rescue Committee
     LSHTM       London School of Hygiene and Tropical Medicine
     MNCH        Maternal Neonatal and Child Health
     MOH         Ministry of Health
     MoHS-HED    MOH Health Education Department (Sierra Leone)
     MSF         Médecines Sans Frontières
     NGO         Non-Governmental Organisation
     NHS         National Health Service
     OECD        Organisation for Economic Co-Operation and Development
     PHU         Public Health Unit
     PPE         Personal Protective Equipment
     PRA         Participatory Rural Appraisal
     SAGE        Scientific Advisory Group in Emergencies
     SMAC        Social Mobilisation Action Consortium
     UK          United Kingdom
     UN          United Nations
     UNFP        United Nations Population Fund
     UNICEF      United Nations Children’s Fund
     UNMEER      UN Mission for Ebola Emergency Response
     US          United States of America
     USAID       United States Agency for International Development
     WHO         World Health Organization

10
EXECUTIVE SUMMARY

By January 20th 2016, an Ebola epidemic       groups in the community including
in West Africa had killed 11,316 people.      women, young people and community
It had begun over two years before in         leaders and highlights the crucial role
Guinea and exposed under-resourced            they played in creating successful
and over-burdened health systems in           strategies to control Ebola. To ensure
the affected countries. The international     the voices of affected communities
response was weak. However the UK             were represented in the report, 23 key
played a key role by providing Sierra         informants were interviewed. In Sierra
Leone with £427m worth of medical,            Leone these were conducted by Restless
technical and logistical support              Development, and in Liberia by Public
largely through the Department for            Health & Development Initiative (PHDI).
International Development. These
funds were given to the Sierra Leone          This report finds that response efforts
government, front-line NGOs and other         were most effective when communities
vital actors and used to support a range      demanded assistance at the local level.
of research.                                  It therefore advocates that although
                                              a top down approach (nationally and
At Westminster between October 2014           internationally) may always be necessary
and May 2015 the Africa All Party             in a health crisis such as an Ebola
Parliamentary Group organised a series        outbreak, it is only effective when the
of panel discussions on the international     affected communities trust that response.
response to Ebola. Panellists who             The report acknowledges that the
had worked in the Ebola-affected              need to react rapidly in a health crisis
communities stressed repeatedly that          makes it almost impossible to consult
the response was being hindered               communities immediately. However the
by fear and a lack of trust between           key lesson in ensuring preparedness for
national actors, international actors and     future health crises is that health systems
affected communities. Consequently            should be developed horizontally, local
the APPG, together with Polygeia,             ownership should be prioritised and
launched an enquiry into attempts to          investment made at community level.
engage the affected communities in            Such approaches foster trust and create
the response (1). This report reviews the     demand for health services. Communities
evidence submitted by key informants          should be consulted about their needs
through interviews and a literature           and local facilities and systems developed
review. It reflects the lessons learned       to provide permanent services which
from the Ebola outbreak and explores          local people trust and access and which
the importance of trust between               can respond effectively during a crisis.
governments, health workers and
communities and the importance of local       The chief finding of the report is that
ownership of health systems.                  efforts to curb the outbreak of Ebola in
                                              West Africa were most effective when
A diverse range of actors were involved       local leaders of affected communities
in the response in West Africa. They often    led the demand for assistance from
had different priorities and strategies       their governments and the international
and not every strategy was successful. In     actors, and played an essential leadership
the early stages mistrust of and resistance   role in the management of that
to responders was indicative of a lack        assistance.
of community engagement. This report
analyses the engagement by different

                                                                                            11
The chief recommendation of this report
     is that the UK government and non-
     governmental organisations should give
     higher priority to community ownership
     of health. This would strengthen local
     health systems and enable them to
     respond more effectively to a crisis.
     The conclusions of this report will help
     guide a UK response to future epidemics
     and, in the long term, help reconstruct
     and strengthen health systems in poor
     countries.

     A summary of this report and its
     recommendations was included as
     written evidence to the House of
     Commons International Development
     Committee; Ebola: Responses to a public
     health emergency (2).

12
INTRODUCTION

The Africa All-Party Parliamentary          with community leaders in rural and
Group commissioned researchers from         urban areas to gain insights into the
Polygeia, a student-run global health       response of their communities in the
think tank, to explore the experiences of   Ebola response.
communities affected by the 2014 - 2015
Ebola crisis in Sierra Leone, Liberia and   The role of communities in the response
Guinea. The researchers also examined       to a health crisis such as Ebola is complex
the role of affected communities in the     and multifaceted. This report uses a
response to the outbreak and learned        broad definition of community to include
lessons for community engagement            any group of people who are linked by
in health crises and more broadly the       social ties and common perspectives, and
implications for strengthening health       engage in joint actions. Communities
systems in West Africa.                     vary hugely within and between these
                                            countries so it is difficult to generalise
Chapter One explores the response and       their response to the crisis. However, this
the effectiveness of national health        report aims to draw out central themes
systems of countries affected by the        and lessons from the Ebola outbreak,
Ebola outbreak in the context of their      which could improve community
socio-political and historical factors.     engagement and effectiveness in
                                            response to a health crisis in the short
Chapter Two examines evidence of            term and in the longer term contribute
community mobilisation and community-       to a stronger health system.
led interventions in the Ebola crisis and
evaluates their importance.

Chapter Three focuses on how the UK
can influence, strengthen and improve
the response of communities and
national health systems to health crises.

The report includes evidence from 31
written submissions in response to a call
for evidence; the findings of 5 meetings
held by the Africa APPG to discuss the
Ebola response including the role of
the media, pharmaceutical companies
and community actors, the impacts on
economies, food security, women and
community resilience; and a review of
the literature on Ebola outbreaks. 19
parliamentarians were involved in the
process. To ensure the voices of affected
communities were represented, the
Africa APPG and Polygeia worked with
Restless Development, a youth-led
development agency, in Sierra Leone and
Public Health & Development Initiative
Liberia (PHDI) in Liberia. Researchers
conducted 23 key informant interviews

                                                                                          13
1 WHAT WEAKNESSES HAS THE
       EBOLA OUTBREAK EXPOSED

      The Ebola Virus Disease (Ebola) was first     “Clinicians in equatorial Africa have
      identified in the Democratic Republic         good reasons to suspect Ebola when a
      of Congo (then Zaire) and South Sudan         “mysterious” disease occurs, and this
      (then Sudan) in 1976 and named after          favours early detection. Laboratory
      the Ebola River in northern Congo. It is      capacity is in place. Staff know where
      believed to be zoonotic which means           to send patient samples for rapid and
                                                    reliable diagnosis. Health systems are
      it normally exists in animals but can
                                                    familiar with Ebola and much better
      be transmitted to people. Once in the
                                                    prepared. For example, hospitals in
      body, rapid viral replication affecting       Kinshasa, the capital of the Democratic
      immune cells and blood vessels triggers       Republic of Congo, have isolation wards,
      systemic inflammation and a drop in           and staff are trained in procedures
      blood pressure. This can lead to death        for infection prevention and control.
      from shock and multiple organ failure         Governments know the importance of
      (3). Ebola is also passed between people      treating a confirmed Ebola case as a
      through direct contact with the blood or      national emergency.”
      other bodily fluids or the secretions of an
      infected person. On average, it takes 8       West African countries, having never
      to 10 days for symptoms to appear and is      experienced an Ebola outbreak, were
      often confused with cholera and malaria,      poorly prepared for this disease at
      making early diagnosis difficult (4,5).       every level, leading to the initial rapid
      Treatment consists of intensive care, oral    and undetected spread in what was to
      rehydration salts and intravenous fluids.     become the largest and deadliest Ebola
      At present, candidate vaccines are in         outbreak in history.
      clinical trials with planned submission for
      licensure by the end of 2017 (6).

      In the 40 years since its discovery there
      have been 26 Ebola outbreaks in 12
      countries. The case fatality rate for each
      outbreak ranges between 25% and 90%
      with approximately 2361 cases and 1548
      deaths prior to the 2014 - 2015 West
      African Ebola outbreak (5). Countries
      in equatorial Africa have experienced
      the most Ebola outbreaks: seven in
      the Democratic Republic of Congo
      and five in Uganda. In contrast to the
      recent West Africa Ebola outbreak, all
      previous outbreaks were controlled in
      periods ranging from three weeks to
      three months. This is partly attributable
      to the preparedness of health systems.
      According to the World Health
      Organisation (7):

14
1.1 THE WEST AFRICAN EBOLA OUTBREAK
   In December 2013, an 18-month-old boy        the UK, Spain and US were diagnosed as
   in Melindou, a village in Guinea, became     infected (11–13). The US-based Center
   the first case in the West Africa Ebola      for Disease Control warned of up to 1.4
   outbreak. There is evidence that he may      million cases in West Africa by January
   have been infected by contact with bats      2015 (13). Local and international press
   (8). Family members quickly developed        began to speculate on the potential
   similar symptoms, as did funeral             catastrophic consequences. This spurred
   attendees and several traditional healers    the international response to further
   and hospital staff who had treated them      action, but it also created an image of
   in nearby Gueckedou. Over the following      Africa that created panic and fear.
   three months transmission chains carried
   the virus cycle of exposure, cases, deaths   Transmission peaked during October
   and funerals to several cities, including    2014 with approximately 900 new
   the capital, Conakry, and many more          infections per week (see figure 1 and box
   villages and rural districts (9).            1). The plateauing and eventual decline
                                                of the incidence of the virus coincided
   Initial investigations by the Meliandou      with a surge in local and international
   health centre, and later by staff from       responses. Although direct correlation
   Médecins Sans Frontières (MSF),              between specific responses (medical,
   suspected cholera which is endemic           social or political) and the reduction in
   in the region, but without conclusive        cases is yet to be made.
   evidence. In March 2014, a larger
   investigation began which included           At present – 2nd February 2016 –
   the Ministry of Health, World Health         The West African Ebola outbreak
   Organisation (WHO), WHO Regional             was declared to have ended on 14th
   Office for Africa (AFRO) and Médecins        January, however there has already
   Sans Frontières (MSF) staff and the Ebola    been re-emergence in Sierra Leone
   virus was identified as the causative        (14). There have been, in total, 28,638
   agent. In June, MSF warned that Ebola        confirmed probable and suspected cases
   was “out of control” and called for the      worldwide and 11,316 deaths. All but
   “massive deployment of resources” as         36 cases and 15 deaths have occurred in
   the disease continued to penetrate local     Guinea, Liberia and Sierra Leone. The
   communities in south-eastern Guinea          geographical distribution of these cases is
   and began to spread in neighbouring          shown in Figure 2 (15).
   Sierra Leone and Liberia. On August 8th,
   as the disease was entering its deadliest
   phase, the WHO declared a Public Health
   Emergency of International Concern
   (PHEIC). During the following months,
   Ebola intensified in both rural and urban
   areas, with cases reported in Nigeria, a
   country of almost 200 million people,
   and Senegal.

   In autumn 2014, two leading doctors,
   Dr Samuel Brisbane of Liberia and Dr
   Sheikh Umar Khan of Sierra-Leone,
   succumbed to the disease (10), and
   several healthcare workers returning to

                                                                                              15
Figure 1 &
     Box 1: Stages
     of the West
     African Ebola
     crisis (1-4) by
     the number
     of confirmed
     new Ebola
     cases by
     week.
     (adapted from
     presentation
     by Dr Nabarro,
     UN Special
     Envoy for
     Ebola (16)
     & European
     Centre for
     Disease
     Prevention
     and Control
     report (17))
                       Stage 1                                  Stage 3
                       • An unidentified disease spreading      • Number of infections per week
                           through Guinea, Sierra Leone             plateaus and falls
                           and Liberia. Lassa fever, Ebola or   • Continued support from the
                           Cholera?                                 international community, with the
                       • MSF and national governments               focus moving away from care of
                           responded the earliest, with             the infected to contact tracing
                           little initial buy-in from the       • Community engagement is
                           international community                  instrumental in this stage
                       • Growing fear in communities
                           fuelled by misinformation and lack   Stage 4
                           of understanding of preventative     • Decrease in infections, outbreak
                           measures                                 declared over in Jan 2016, but re-
                                                                    emergence likely
                       Stage 2                                  • Support needs to continue to
                       • Most rapid increase in infections          ensure that we get to zero cases
                           during the outbreak                  • Communities play key role in
                       • The threat of spread to Europe             contact tracing and hidden cases
                           and North America was realised
                       • In September, the WHO
                           announced that the Ebola
                           outbreak was an “event of
                           international concern” and began
                           scaling up the response
                       • Large degrees of resistance were
                           displayed by the communities

16
Figure 2:
Geographical
distribution
of total
confirmed
cases in
Guinea,
Liberia, and
Sierra Leone
as of 01
November
2015 (15).

               Confirmed Cases

                    1-5

                    6 - 20

                    21 - 100

                    101 - 500

                    501 - 4000

                    No cases reported

                                        17
1.1.1   LASTING IMPACT ON COMMUNITIES

             The appalling suffering, enormous              and hundreds have died from it. The
             death toll and the catastrophic impact         International Rescue Committee (IRC)
             on affected communities cannot                 reports that as of January 2014, “65% of
             be overstated. All the community               health care worker infections occurred
             leaders interviewed for this report            among staff employed in non-Ebola
             cited the collective trauma felt by the        care facilities”. The most common cause
             communities.                                   was exposure because employees lacked
                                                            personal protective equipment (PPE) (22).
             Beyond the immediate horror and loss           Many people avoided health services
             of life, the Ebola crisis brought the usual    altogether because they feared infection
             routines of daily life to a halt: restricted   (15). This had adverse effects on all
             population movement, interrupted               major health programmes including TB,
             harvests, lead to the closure of markets       HIV, malaria and nutrition programmes
             and restricted regional and international      and routine vaccinations. The knock-
             trade. Economic activity in the region         on effects will be catastrophic (23). For
             was reduced, reversing recent economic         example, in many areas routine measles
             gains in Sierra Leone, Guinea, and             vaccination rates have fallen by at
             Liberia. The United Nations Development        least 25%. This could result in tens of
             Group (UNDG) predicted a loss of GDP           thousands of additional measles cases
             of up to 9.6% ($315m USD) in Guinea,           leading to between 500 to 4,000 deaths
             8.0% ($292m USD) in Sierra Leone and           (24).
             18.7% ($245m USD) in Liberia (18). This
             economic impact will continue to have a        Ebola has disproportionately affected
             considerable effect on employment and          women. In the outbreak’s early stages,
             household livelihoods in the region. The       women were more likely to be exposed
             region is predominantly rural and those        to the virus than men due to their
             communities which rely on subsistence          care-giving role in families. This gender
             farming are particularly exposed to an         disparity continues in the knock-on
             economic collapse (see case study below).      effects of Ebola; a disproportionate
                                                            number of women in Sierra Leone,
             This regional economic decline also            Liberia and Guinea are employed in
             caused a widespread crisis of food             sectors most affected by the outbreak
             security, affecting hundreds of thousands      such as informal services and agriculture
             of people in each country (19). In some        (18,25).
             areas there has been a slow economic
             recovery in recent months but household        Education has also been badly affected.
             income remains low, food production            Schools were closed in parts of Sierra
             has fallen and higher food prices have         Leone, Liberia, and Guinea for up to
             hit already poor communities (20). The         six or even eight months. Five million
             World Food Programme (WFP) found               children were affected (26). Loss of
             that in many communities in Sierra             household income may also mean more
             Leone, Liberia and Guinea, transport           children will drop out of school in the
             issues are a key factor in reducing food       longer term. Finally, some studies show
             security (21).                                 an increase in teen pregnancy and child
                                                            labour during this period (18,27).
             Routine healthcare services have also
             been disrupted in the region. The vast
             majority of healthcare workers were
             diverted to combat the Ebola outbreak

18
Case Studies: The impact of the Ebola outbreak on communities

“We are hungry”                           on health in the district. “Clinic
Gelengasiasu Town lost eighteen           attendance has been low … a lot of
people to Ebola. “The whole               other people died not from Ebola, but
community was destroyed. Our houses       from the fear to go to hospital when
spoiled. Human beings warm houses –       they are sick. Health service delivery
with the deaths nobody was inside the     has been seriously hampered, a lot of
houses” Folokula Gayn, the general        gains made in healthcare have been
town chief, explains. “Our rice harvest   lost as well.”
did not happen” Gayn continues. “We
are hungry; there is no way to even       Interviews from Port Loko Town, Port
harvest rice”. Jackson Miller, from a     Loko District, Sierra Leone
market town in neighbouring county
Gounwolaila, shares a similar story.      “Children are fending for themselves”
“We have moved from town to our           “Schools were closed, hospitals closed,
farms, disturbed our businesses and       pregnant women were not taken
interrupted our farming. We are a         care of, health practitioners were
market town”.                             afraid and children died of simple
                                          ailments. Businesses were affected
Interviews from Gelengasiasu              as parents were not going to work”
Town, Gbarpolu County, Liberia and        Ruth Johnson from Lakpazee explains.
Kpayeakwelle, Gou Gounwolaila             High School teacher, Lawrence Flomo,
County, Liberia.                          describes the impact on families in
                                          Fiama community. “Records show
“A witch flight fell”                     over five family heads [have died
“It started with a story that a witch     from Ebola]. Some children have
flight (plane) fell, so that is why       been orphaned. Some children are
people were dying”. Ibrahim Fonah,        fending for themselves. There are
a 32 year old from Port Loko Town,        also orphans that were brought from
describes one of the many rumours         other communities to Fiama”.
that spread through communities
during the early stages of the            Interviews from Lakpazee and Fiama
outbreak. Dr Sesay, a medical officer     Community, District 9, Liberia
shares the impact of fear and denial

                                                                                    19
1.2 THE RESPONSE

     Box 2: Key       Quarantine                                   (73). However, this sometimes
     tools of the     • Stopping an Ebola epidemic                 slowed down and inhibited
     Ebola response      means prompt identification               response workers.
     and their           and isolation of infected people.
     challenges          Ebola-infected patients must           Safe burial
                         be quarantined to prevent it           • Ebola-infected dead bodies are
                         spreading.                                 extremely infectious; transmission
                      • Many people have highlighted                through ceremonial body washing
                         the methods, extent and safety             was common. Governments of
                         of some quarantine policies                all three Ebola-affected countries
                         (189,190). The World Bank                  decided to provide safe burials for
                         highlighted the insufficient supply        everyone who died. Liberia also
                         of food and other necessities to           instituted cremation (195).
                         some quarantined individuals           • This required huge resources
                         (191). In some cases, families broke       (burial teams, vehicles and
                         quarantine in order to buy food            personal protective equipment),
                         (192).                                     coordination (with swab teams,
                                                                    laboratories, contact tracers) and
                      Contact tracing                               planning (graves marked and
                      • The identification and follow-up            families informed).
                         of persons who may have had            • The deployment of burial
                         contact with an infected person            teams and the engagement
                         (193). All potential contacts              of communities to ensure safe
                         of suspected, probable and                 burials lead to a reduction in
                         confirmed Ebola cases need to              unsafe burials and potential
                         be systematically identified and           transmission.
                         put under observation for 21 days
                         (the maximum incubation period         Social mobilisation and community
                         of the Ebola virus) (193). Efficient   engagement
                         tracing required a list of contacts    • Supporting communities to
                         and their location. In Sierra Leone        identify and implement behaviour
                         only 20-30% of the contacts in the         change to keep them and their
                         Ministry of Health’s database were         communities safe was key.
                         usable, others were too vague for      • Encourage people to come
                         outsiders to identify (194).               forward if they were sick.
                      • Many people do not have                     Patients and families needed the
                         permanent addresses. There was             confidence to know that they
                         opposition to some of the tracers          would be cared for.
                         (194).
                                                                Expansion of treatment infrastructure
                      Travel restrictions                       • Care needed to be effective,
                      • Governments of the most                    to create high survival rates,
                          affected countries imposed               and safe, so that Ebola was not
                          travel restrictions with the aim of      transmitted to health workers.
                          preventing the spread of Ebola

20
1.2.1   NATIONAL RESPONSE

        Guinea, Liberia and Sierra Leone had         “We believe a decentralised
        declared the Ebola virus disease epidemic    response is going to be critical
        as a national health emergency by mid-       to get us to zero in the shortest
        August 2014 and established National         possible time.”
        Task Forces. The respective National
        Ebola Outbreak Response Plans were           Liberia and Guinea set up similar
        subsequently developed; the aims of          decentralised national structures but
        which were collectively agreed at the        the information flows and local-level
        WHO Accra Ministerial meeting in July        structures varied among the countries
        2014 (28):                                   (30). An example of this decentralised
                                                     coordination can be seen in figure 3,
        1. Ensure effective coordination of the      which shows the social mobilisation
           outbreak response activities at all       pillars and sub-committees developed in
           levels.                                   Sierra Leone, Guinea and Liberia during
        2. Strengthen early detection,               the outbreak.
           investigation, reporting, active
           surveillance, and diagnostic capacity.    The enormity of the required response to
        3. Institute prompt and effective case       Ebola meant the governments of Guinea,
           management and psychosocial               Liberia and Sierra Leone quickly called
           support while protecting the health       for an international response effort.
           of health-care workers involved.          Foreign Minister Samaur W. Kamara of
        4. Create public awareness about Ebola,      Sierra Leone in September 2014 said (31):
           the risk factors for its transmission
           as well as the factors that do not
                                                     “Based on the knowledge we had,
           entail any risk, and its prevention and
           control among the people.
                                                     based on the advice we were given
                                                     by our international partners, we
        A key component of the national              mobilised to meet this unfamiliar
        response was to set up, with                 threat. But the staff, equipment,
        international support, coordinating          medicines and systems we had
        mechanisms to contain the spread of the      were inadequate and this slowed
        disease.                                     our effective response.”

        In Sierra Leone, the Government created
        a National Ebola Response Centre (NERC)
        that, together with the United Nations
        Mission for Ebola Emergency Response
        (UNMEER), served as a command and
        control structure for many partners in
        the Ebola response. The NERC oversaw
        15 District Ebola Response Centres
        (DERCs) with a feedback loop between
        the NERC and the DERCs. These DERCs
        also coordinated with the district health
        management teams for technical aspects
        of the response, and were joined by
        national and international partners.
        According to Stephen Gaojia (29), Sierra
        Leone Incident Manager for Ebola:

                                                                                                 21
Figure 3: Social Mobilisation pillars and sub-committees developed in Guinea, Liberia,
     and Sierra Leone: a example of decentralised coordination in the Ebola response (30).

                                          Liberia’s Social Mobilization Pillar
                           National-Level Coordination Structure for EVD Response (Current)

                                  Chair: Health Promotion Division MOHSW

                             Co-Chair: UNICEF

                                                         MOH + WHO +              MOH + Liberia +
         MOH + CDC             MOH + UNICEF
                                                       Crusaders for Peace         CSOs + RBHS            MOH + JHU/CCP
       Media Support and     Message and Materials                                  Interpersonal
                                                            Mobilization and                                Research, M&E
        Documentation             Development                                      Communication
                                                             Field Support             Training

                                       Sierra Leone’s Social Mobilization Pillar*
                                       National Emergency Management System (Ebola)

                                                       Social Mobilization
                                                        Chair: MOHS HED
           District SM                                  Co-Chair: UNICEF
                                                          EOC Liaison                                  Working Groups
           Committees

         Western (Urban)                            National Pillar Committee
                                                  (Coordination, Monitoring and                          Media Group
         Western (Rural)                             Evaluation): HED, UNICEF,
               Bo                                      Sub-committee Chairs
                                                                                                          Faith Based
             Bombali
                                                                                                      Organization Group
             Bonthe
                                                     National Sub-Committees                         Youth and Adolescent
            Kailahun
             Kambia                                                                                         Group

             Kenema                                                                                  C at Household-Level
                                                        Sub-Committees 1:
           Koinadugu                                     Capacity Building                                  Group
             Kono
                                                  Sub-Committees 2: Messaging                         IPC with Healthcare
           Monyamba
                                                       and Dissemination                                Workers Group
            Port Loko
             Pujehun                                                                                  Special Needs Group
                                                 Sub-Committees 3: Special Needs
            Tonkolili                                                                               (same as subcommittee 5)

                                          Guinea’s Social Mobilization Pillar

                                                              National
                                                            Coordination
                                                            Against Ebola

         Surveillance           Communications               Patient Care           Sanitation               Research

        Rumor               Public             Social             Prevention
      Management           Relations         Mobilization       Communications

22
1.2.1    INTERNATIONAL RESPONSE

Figure 4:       United States                                            $ 1,955M   By 14th October 2015, the international
Pledged         World Bank Group                                     $ 1,618M       community (over 50 nations and many
contribution    European Commission                             $ 955M              donor organisations) had mobilised over
                United Kingdom                              $ 687M
of funding                                                                          $8.2bn USD to finance the Ebola response
                African Development Bank                   $ 525M
to Ebola        International Monetary Fund                $ 394M
                                                                                    (32). The top five highest contributing
response        Germany                                    $ 281M                   donors included the US which gave $2.1bn
by donor        France                                  $ 265M                      USD, the UK $687m USD, the World Bank
(25 highest     Japan                                   $ 173M                      $1.6bn USD, the European Commission
                China                                   $ 129M
contributors)                                                                       $955m USD and the African Development
                Paul Allen Foundation                   $ 100M
(USD)(196)      Canada                                  $ 100M
                                                                                    Bank $525m USD (33) (see figure 4).
                Netherlands                             $ 83M
                Sweden                                  $ 81M                       It is difficult to estimate how many
                Norway                                  $ 63M                       health workers were involved in the
                Russian Federation                      $ 55M
                                                                                    response. The World Bank and the
                Bill & Melinda Gates Foundation         $ 54M
                Belgium                                 $ 51M
                                                                                    African Development Bank estimate that
                Australia                               $ 38M                       more than 39,000 health workers took
                Saudia Arabia                           $ 35M                       part alongside equally large numbers of
                Denmark                                 $ 32M                       surveillance and community mobilisation
                                                        $ 29M
                Special Relief Fund
                                                                                    staff (34). Thousands of response workers
                Mark Zuckerberg & Priscila Chan         $ 25M
                                                        $ 16M
                                                                                    were trained, including 4,500 frontline
                Islamic Development Bank
                Finland                                 $ 13M                       workers at the Institutional Organisation
                                                                                    for Migration’s (IOM) National Ebola
                                                                                    Training Academy in Sierra Leone. In April
Table 1:           Allocation of funds (%)                                          2015, the World Bank estimated that
allocation                                                                          more than 1300 foreign medical personnel
of disbursed       Country              Guinea                           13%
                                                                                    were taking part including more than 850
funds by                                Sierra Leone                     20%        volunteers from other African countries
country,                                                                            (through the African Union Support to the
                                        Ebola-affected country
recipient                               (not specified)
                                                                         28%
                                                                                    Ebola Outbreak in West Africa (ASEOWA).
category, and                                                                       Approximately 1,000 WHO and nearly
                                        Liberia                          31%
purpose (36)                                                                        200 UNMEER personnel supported these
                                        Other country                    1%         health workers mainly in logistic and
                                        Unspecified                      7%         coordination roles.
                                        Affected countries
                   Recipient                                             33%        This was a considerable mobilisation of
                                        (Multi-lateral)
                                        Affected countries                          resources but there has been widespread
                                                                         14%
                                        (Bilateral)                                 criticism of the time lag between the
                                        International NGOs               12%        outbreak and the response. Six months
                                        International                               into the crisis, only 30 medical response
                                                                         23%
                                        Organisations                               teams were on the ground. Most of the
                                        Research institutions,                      health workers and support teams and
                                                                         31%
                                        Regional & local NGOs
                                                                                    the financial and equipment/facility
                                        Other recipients                 13%        investment arrived mid-way through the
                   Purpose              Response                         71%        crisis (35). Table 1 shows the allocation
                                                                                    of funding ($6.6bn USD) from 46
                                        Recovery                         9%         contributing partners between September
                                        Research and
                                                                         4%         2014 and May 2015 as reported by
                                        Development
                                                                                    UNMEER, stratified by country, recipient
                                        Other                            16%        type and purpose.

                                                                                                                                 23
1.2.3    THE UK’S ROLE IN THE EBOLA RESPONSE

                    With its 450-year connection to Sierra               Njala University and collaborations such
                    Leone, the UK government took the lead,              as the King’s College Hospital Sierra
                    committing over £427m to support the                 Leone Partnership. Table 2 shows some
                    battle against Ebola. Its links included             of the key projects in the UK Ebola
                    Sierra Leoneans working for DFID, links              response.
                    to NGOs, an existing partnership with

          1.2.3.1   MEDICAL AND TECHNICAL SUPPORT

                    DFID funded the construction of                      equip communities with the knowledge
                    6 treatment centres, around 200                      and tools to tackle Ebola. Their review,
                    community care units and supported                   ‘Reducing Transmission of Ebola in Sierra
                    over 1,400 treatment and isolation beds              Leone Through Changing Behaviours
                    - more than half the beds available for              and Practices’ reports an increase in
                    Ebola patients in Sierra Leone (37). In              community knowledge of Ebola from
                    addition to this, DFID focused much of               39% to 69%, reduction in stigma from
                    its resource allocation on improving                 94% to 41% and an average of 97%
                    safe burials, supporting a total of 140              of burials being classified as safe and
                    burial teams, and expanding social                   dignified medical burials (38).
                    mobilisation efforts to educate and

     Table 2:
                    Project Title                                      Budget                  Start Date
     Summary of
     projects in    Emergency Support to Respond to the Ebola          £79.41m                 Jul-14
     the UK Ebola   Virus Disease in 2014 (Urgent Needs)
     response
                    Sierra Leone Kerry Town Ebola Treatment Facility   £89.10m                 Sep-14

                    Ebola Treatment Centres in Sierra Leone            £45.90m                 Oct-14

                    Reducing Transmission of Ebola in Sierra Leone     £12.55m                 Oct-14
                    Through Changing Behaviours and Practices

                    Ebola Care Units in Sierra Leone                   £43.40m                 Oct-14

                    UK Response to Ebola Crisis Through Support for    £22.13m                 Oct-14
                    UNMEER and the Wider UN System

                    UK Support to Ebola Crisis Through Support for     £33.44m                 Oct-14
                    the Joint Inter Agency Task Force (JIATF)

                    UK Response to Ebola Crisis Through Establishing   £12.15m                 Nov-14
                    Laboratories

                    Ebola Central Health Care Supply Chain Platform    £7.20m                  Nov-14

                    Match Funding for Ebola Response                   £6.20m                  Dec-14

                    Regional Preparedness                              £19.20m                 Jan-15

                    Transition from Ebola Response to Early Recovery   £54.0m                  Mar-15

                    Ebola Vaccines Insurance                           £1.10m                  Apr-15

24
These projects faced many challenges.       deployed over 100 staff to run three new
          One such challenge was deciding where       laboratories in Sierra Leone. This reduced
          to prioritise the resource allocation.      the turnaround time for samples from 4-5
          High risk groups included communities       days to less than 24 hours (39). However,
          geographically related to others with       problems with backfilling in the NHS
          known Ebola cases; communities with         prevented more staff contributing.
          attitudes and practices known to increase   There were reports that more than ten
          Ebola transmission risk; as well as         times as many staff volunteered as were
          vulnerable or marginalised groups, such     able to go to Sierra Leone (39,40). Some
          as women and young people (38). DFID        have argued that the UK’s West African
          also faces the challenge of ensuring that   diaspora healthcare professionals could
          the use of donor contributions and other    have been utilised further, especially
          forms of received capital are verified,     considering their unique position to
          especially as programmes draw to a close.   shape culturally appropriate and socially
          Nonetheless, the primary challenge DFID     legitimate response programmes (41)
          faces in terms of funding resources is      (see box 3).
          a temporal one: whether to prioritise
          short-term or long-term interests.          The IDC has recommended in its recent
          Unpredictable spikes in the demand for      report on the Ebola response that DFID
          resources to tackle health emergencies,     fund a formal structure to facilitate more
          make it more difficult for DFID to          volunteering by NHS staff (40). However,
          adequately fund the more sustainable,       as highlighted by Health Poverty Action,
          longer term goals necessary for health      sending large Western teams of health
          systems strengthening (38).                 workers has questionable benefit
                                                      when compared to the long-term
          The UK also provided human resources        strengthening of local health systems
          through NHS volunteers. Over 150            (42,43).
          NHS Staff travelled to Sierra Leone,
          with salaries covered by the NHS and
          Public Health England and in addition

1.2.3.2   LOGISTICAL SUPPORT

          The UK provided emergency food,             for children. DFID also funded health
          equipment, and logistical support           promotion radio programmes in eight
          to the Sierra Leonean government’s          local languages, in part through working
          Ebola response. It also financed Small      with BBC Media Action (44).
          and Medium Enterprises (SMEs), and
          psychosocial and social protection

                                                                                                   25
1.2.3.3    RESEARCH

                     The UK has also been at the forefront of     response and recovery programmes.
                     academic research into Ebola including       DFID co-funds vital research on Ebola,
                     epidemiological, anthropological,            including clinical trials which have led to
                     social and economic research critical to     the development of promising vaccine
                     understanding the underlying causes          candidates (6,45).
                     of the Ebola outbreak and informing

     Box 3:             Examples of UK’s African Diaspora         The wider role of the African Diaspora
     The UK’s           involvement in the Ebola Response:        in African development:
     African            • Sierra Leone UK Diaspora Ebola          • Remittances to Africa outweigh
     diaspora in            Taskforce (SLUKDET) has been              Western Aid to the continent,
     the Ebola              involved in negotiations with             accounting for an average of 5
     response               Public Health England, the NHS            per cent of GDP and 27 per cent of
     and health             and DfID to recruit volunteers.           exports (197,198).
     systems                They also delivered cultural          • Members of the African diaspora
     strengthening          awareness training to NHS and             have contributed significant
                            international volunteers prior to         financial capital to African
                            their deployment (172).                   countries in investment capital
                        • SLWT have worked with local                 and the purchase of goods and
                            grassroots organisations to               services from the continent (175).
                            provide protective raincoats to       • Many professionals from
                            750 commercial motorbike riders,          the diaspora temporarily or
                            as well as PPE and hand-washing           permanently return to their
                            facilities and protective raincoats       country of origin. This brain
                            (173).                                    circulation and return migration
                        • EngAyde has provided protection             strengthens knowledge
                            and care for Ebola children and           production in African countries
                            psycho-social support for Ebola           (177).
                            affected families and local health
                            care workers (174).

26
1.2.3.4   RESTRICTIONS ON TRAVEL

          The UK government and 39 other nations        and could consequently increase the
          restricted direct flights to the region and   uncontrolled migration of people from
          quarantined all returning health workers.     affected countries, raising the risk of
          These measures have been described as         international spread of Ebola”(48). Fears
          disproportionate and without scientific       of such an overreaction contributed to
          justification and may have deterred           the WHO’s decision to delay putting out
          other international health workers            an international alert.
          (46,47). The WHO raised concerns that
          they could “cause economic hardship,

  1.3 UNDERLYING CHALLENGES: HEALTH
      SYSTEMS AND INFRASTRUCTURE

          The Ebola outbreak in West Africa             reconstruction efforts. This legacy
          was centered on a region with a               of conflict and shortcomings in the
          shared recent history of weak health          reconstruction efforts are key to
          systems, transnational civil war and          understanding many of the weaknesses
          internationally led post-conflict             exposed by the outbreak.

                                     “The health system became seriously exposed
                                     by Ebola, because when it came it killed a lot
                                     of health workers and community people …the
                                     basic principles of prevention and hygiene were
                                     lacking.”

                                     Samuel Borbor Vandi, NGO worker
                                     (Kailahun District, Sierra Leone)

                                                                                                    27
1.3.1      HEALTH SYSTEMS IN GUINEA, LIBERIA
                       AND SIERRA LEONE
                       Some health systems in West Africa,              particularly by providing services for
                       such as those in Nigeria and Senegal,            child and maternal health and HIV/AIDS.
                       have the capacity to control Ebola               However, crucial problems in the health
                       epidemics (49,50). Sierra Leone, Guinea          systems of these three countries were re-
                       and Liberia have all made some progress          exposed by the Ebola epidemic (50–53).
                       in strengthening their health systems,

           1.3.1.1     GAPS IN HEALTH FINANCING AND GOVERNANCE

                       The WHO’s estimate of minimum                    in Guinea and Liberia between 2006
                       spending to provide basic lifesaving             and 2012. However, spending is still
                       health services per person per year is           well below what is needed to fund a
                       $44 USD (54). The governments of all             functioning health system. The resulting
                       three Ebola-affected countries spend             gap in funds for essential services is
                       significantly less than this, as shown           manifested in out-of-pocket expenditure.
                       in table 3. All three countries receive          Sierra Leone and Guinea have more
                       aid for health from donor countries              than triple the WHO recommended
                       and agencies, however much of the                proportion of spending on health by out-
                       funds provided are for specific disease          of-pocket expenditure (55). This makes
                       programmes, such as HIV/AIDS, malaria            it more likely that poorer people will be
                       and TB (55,56). Spending on health               pushed further into poverty as a result of
                       per person per year has increased in             paying for their health needs.
                       the region and has more than doubled

     Table 3: Health
                                                   GUINEA         SIERRA LEONE             LIBERIA
     financing
     figures (57)      Expenditure per person      $9             $16                      $20
                       per year spent on health
                       (USD)

                       Estimated Proportion of     66%            76%                      21%
                       total health funding from
                       out-of-pocket expenditure

                       Amount of External          $46m           $93m                     $89m
                       support for health per
                       annum (USD)

                       Strong governance is needed to enable            highlighted the absence of accountability
                       effective health systems strengthening.          mechanisms and conflicting policies. The
                       In all three Ebola-affected countries,           trickle down effects of delayed decisions
                       there have been attempts at health               at national level are key barriers to the
                       systems reform, such as the notable Free         development of health systems in all
                       Health Care Initiative in Sierra Leone.          three countries (58–60).
                       Governance experts, however, have

28
1.3.1.2   CHRONIC SHORTAGE OF HEALTH WORKERS

               Strong governance is needed to enable         highlighted the absence of accountability
               effective health systems strengthening.       mechanisms and conflicting policies. The
               In all three Ebola-affected countries,        trickle down effects of delayed decisions
               there have been attempts at health            at national level are key barriers to the
               systems reform, such as the notable Free      development of health systems in all
               Health Care Initiative in Sierra Leone.       three countries (58–60).
               Governance experts, however, have

Box 4:            Guinea                                     Liberia
Health            • 1 health worker per 1,597 people         • 1 health worker per 3,472 people
workforce         • 1 public health institute with           • “Emergency Human Resources
prior to             limited capacity                            Plan” (2007) designed to rebuild
the Ebola         • $25 USD health expenditure per               its health workforce and double
outbreak             capita (4.7% of GDP)                        the number of nurses but had
(64,65)                                                          limited overall success
                  Sierra Leone                               • $44 USD health expenditure per
                  • 1 health worker per 5,319 people             capita (10% of GDP)
                  • 10,917 nurses and midwifes in the
                      country
                  • $96 USD health expenditure per
                      capita (11.8% of GDP)

               Health worker absenteeism is also a           than 2% in 2014. A ReBUILD research
               significant problem, particularly in rural    consortium attributes this to the
               or remote areas and with those who            introduction of the Free Health Care
               work in lower-level health facilities (66).   Initiative (FHCI) in April 2010 which
               However, national rates of absenteeism        included fee exemptions for healthcare
               are quite low in Sierra Leone – at less       workers (67).

                                                                                                         29
1.3.1.3     RESOURCES FOR HEALTH SERVICE DELIVERY: LACK OF
                       SUPPLY WILL KILL DEMAND

                       Compounding the human resource                 delivery, as summarised in Box 5. The
                       crisis is a lack of healthcare facilities.     Ebola outbreak has revealed the inability
                       Community mobilisation is often                of many communities to mobilise
                       fraught with geospatial complications in       resources from both national and
                       disconnected urban slums (68) and vast         international sources, such as medical
                       rural areas (69) hindering the efficient       equipment, trained health workers, and
                       distribution of goods.                         supplies for quarantined Ebola victims
                                                                      (40,42).
                       Sierra Leone, Guinea and Liberia have
                       all made some improvements to the
                       delivery of services in recent years. For      “[We need] training and posting
                       example, the Free Health Care Initiative       of qualified health staff, logistics
                       in Sierra Leone, mentioned in the              support, construction and
                       previous section, removed user fees from       rehabilitation of health facilities
                       public maternal and child health services.
                                                                      (PHUs), and more drugs. It has to
                       However, Sierra Leone still has some of
                       the highest rates of maternal and child
                                                                      do a lot with resources.”
                       deaths worldwide and the health system
                                                                      Dr Tom Sesay, Acting District Medical
                       still fails to deliver most of the WHO’s
                                                                      Officer (Port Loko District, Sierra Leone).
                       ‘building blocks’ of good health service

     Box 5:               •   Comprehensive: A comprehensive          •   Person-centred: Services are
     Characteristics          range of health services is                 organised around the person, not
     of good                  provided, appropriate to the                the disease or the financing.
     health service           needs of the target population.         •   Coordinated: Across types of
     delivery,            •   Accessible: Services are directly           provider, types of care, levels
     adapted from             and permanently accessible                  of service delivery, and for
     WHO building             with no undue barriers of cost,             both routine and emergency
     blocks (70).             language, culture, or geography.            preparedness.
                          •   Continuous: Service delivery across     •   Efficient: To achieve the core
                              the network of services, health             elements described above with a
                              conditions and levels of care.              minimum wastage of resources.
                          •   High quality: Services are effective,
                              safe, centred on patient’s needs.

30
Poor service delivery has been a               services, the attempts to carry sick people
significant challenge to community             for miles on stretchers and the desperate
mobilisation and community-led                 lack of medicinal drugs. The Ebola
efforts in the Ebola response. It is well      Response Anthropology Platform (ERAP)
documented that in Sierra Leone the            suggested that provision of a “solidarity
inability of health institutions to keep       kit” to quarantined patients – including
up with the demand for Ebola treatment         a charged phone, mobile credit, and
led to patients seeking out understaffed       food – could mitigate the isolating
community health clinics not integrated        consequences of quarantine (75).
into to the broader health system.
                                               The sparse healthcare available
Lack of resources is not a purely              was underscored by fragile physical
economic issue. When clinicians or             infrastructure, according to evidence
technology are missing because of              submitted by The Malaria Consortium
inadequate ancillary health services           (76). An adequate level of general
(71,72), trust in health services is eroded.   infrastructure is essential for the effective
In an extreme example, in Nimba county         coordination of public health strategies.
and Bomi county, Liberia, families in          For example, an outreach campaign is
some communities were boarded up               unlikely to be successful when schools
in their homes without food or water           are closed, households have little access
because there was no medical care or           to the media, literacy levels are low and
isolation facilities (73). This fostered       there are not enough clinicians to convey
fear, resentment and stigmatisation in         a particular message (77,49,78,79). The
the affected communities, presenting           success of community mobilisation
patients with what felt like a death           efforts is crucially dependent on
sentence. Similarly, the lack of consistent    adequate resourcing and the continued
food delivery to quarantined patients in       development of infrastructure.
Monrovia resulted in feeling of exclusion
from their communities (74). Many of
the rural responses in our interviews
described the absence of medical

                            “We talked to people in quarantined homes
                            and counselled them, because most people in
                            quarantined homes are heart broken.”

                            Mrs Mariatu Songo Kanu,
                            Religious Leader (Port Loko District, Sierra Leone).

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