Ebola is an intimidating disease—it kills a large proportion of people infected, varying between 25 percent and 90 percent,1 and there is currently no effective cure. There have been thirty-five outbreaks recorded since its discovery in 1976, some of which have spread quickly around communities in West and Central Africa.2 In 2014, Guinea, Liberia, and Sierra Leone experienced the worst recorded outbreak of Ebola, resulting in a total of 11,310 deaths.3 The outbreak caused international concern and external donors spent $4.3 billion fighting the outbreak.4
Some critics have emphasized that although Ebola has had serious impacts on mortality and morbidity in West Africa, it has a lower casualty count than other diseases.5 Figure 1 shows the major preventable causes of death in Sierra Leone in 2014. 2014 was the worst year of the most devastating Ebola outbreak, in one of the three worst affected countries. Nonetheless, it killed fewer people than malaria, maternal and neonatal disorders, and lower respiratory infections, and around the same number as diarrheal diseases. In an environment of constrained funding, it is essential to deliver the best value for money, extracting the most benefit from each dollar spent. The Ebola response does not measure up well compared to more cost-effective treatments for tuberculosis, malaria, and HIV.6
The obvious recommendation would be to focus health aid spending on diseases with a larger impact on mortality, or where money can be spent most efficiently. Indeed, this argument has been made by the Copenhagen Consensus Center in numerous papers.7 Focusing aid spending on a specific disease (vertical spending), or even on a specific treatment for a specific disease, often outside the existing healthcare infrastructure of the country, has proven effective in reducing mortality and morbidity by that specific cause. But vertical spending has unintended side effects: higher salaries, improved working conditions, and international support draw health workers away from local healthcare centers, distorting the health system and reducing the availability and quality of care for other diseases.8 Vertical health aid spending also skews national health priorities, as Ministries of Health focus on specific diseases in order to bring in more donor money.9
One of the main reasons the 2014 Ebola outbreak had such an impact in Liberia, Sierra Leone, and Guinea was the weakness of the national healthcare systems. Before the outbreak, Liberia and Sierra Leone had about ninety and 136 doctors respectively,10 serving countries with populations of around four and seven million people.11 Sierra Leone only had fourteen laboratory health workers. Put another way, in 2012, the Liberian government spent $20 per person per year on health, Sierra Leone $16 and Guinea $9. The recommended minimum to provide essential health services is $86.12
The hospitals in the affected countries had woefully inadequate equipment, with little ability to set up safe isolation units for expected Ebola patients, a lack of chlorine for disinfecting wards, and a very limited supply of personal protective equipment (PPE) needed for safe Ebola treatment.13 As a result, many of the healthcare workers became infected with Ebola and died, compounding the understaffing problem. The lack of suitable healthcare facilities also meant that Ebola patients could not be safely isolated, and instead remained in the communities where they could spread the virus further.14
The lack of equipment suitable for the Ebola response could not be easily rectified because the necessary supply chains were not in place. Instead, the equipment needed to be airlifted in at great expense from Europe and the United States.15 Likewise, the Ebola outbreak was able to develop into an epidemic because there were too few local laboratories where samples could be effectively tested for Ebola. For example, there was not a single laboratory capable of testing for Ebola in the whole country of Liberia at the beginning of the 2014 outbreak.16 Once patients were identified, the surveillance to track down their possibly infected contacts was inadequate.17
Resistance from the public was another impediment to a swift and effective response to the Ebola outbreak. Citizens had such little trust in the government and healthcare workers that they did not accept the advice and guidelines provided by the Health Ministries. In Monrovia, the capital city of Liberia, the government set up an isolation unit in a district called ‘West Point.’ Angry residents, who hadn’t been consulted and didn’t believe that Ebola was real, stormed the facility and carried out seventeen patients who were probably infected with the virus. In response, the government quarantined the whole district, leading to violent riots.18 In Sierra Leone, people did not report suspected cases of Ebola because they did not want the inconvenience of quarantine, and when family members died of suspected Ebola many families failed to report the cause of death so that they could bury the bodies without government intervention, exposing themselves to a huge risk of contamination.19 There was an extreme incident in Connaught Hospital in Freetown, Sierra Leone where a patient had died in quarantine and his family accused the doctors of taking him to the isolation unit to kill him with a lethal injection, believing that Ebola was made-up.20 The mistrust in healthcare professionals and their guidelines prevented effective community control, hampering the quarantine and contact tracing efforts essential to contain disease outbreaks.
Criticisms of the huge costs of the Ebola response were countered with the argument that Ebola was an emerging pandemic threat that must be contained at all costs, and the disease stamped out.21 This defense is flawed in two key areas: first, Ebola was able to spread around Guinea, Liberia, and Sierra Leone precisely because of their weak healthcare systems, which could not isolate or undertake contact tracing of Ebola patients. When Ebola spread to other countries such as Nigeria, it was effectively contained. Second, the Ebola virus’ natural reservoir is in wildlife, possibly in bats.22 Wildlife populations in West and Central Africa are not exhaustively monitored, and bats in particular have difficult-to-reach habitats.23 This makes it almost impossible to eradicate the disease or to predict the next outbreak—future Ebola outbreaks are inevitable.24 Responses of the scale and cost of the 2014 Ebola outbreak are neither desirable nor sustainable.
A pragmatic view of the aid landscape reveals a mixture of motives and funding sources that were mobilized to fight the 2014 Ebola outbreak. Organizations such as USAID, DFID, and WHO were already trying to improve the healthcare systems of the affected countries, albeit with much smaller sums than were leveraged to fight Ebola. But significant funding and personnel were also mobilized by national security sources (for example, the U.S. military).25 While their mission statements may differ, all the organizations shared the same immediate goal: ending the Ebola outbreak. Investments that will reduce the impact of the next Ebola outbreak will also reduce the resources needed to stamp it out, saving all of the actors money regardless of their underlying motives.
Instead of focusing on specific diseases, donors should aim to improve the overall health systems of recipient countries. Strengthened healthcare systems will reduce the likelihood of another Ebola epidemic by improving surveillance and building capacity to handle cases. There are a host of other benefits to this strategy. This spending will improve the treatment of the most efficiently targeted diseases (tuberculosis, HIV/AIDS, and malaria), while also reducing major causes of mortality such as neonatal disorders and diarrheal diseases. Furthermore, it can increase public trust in the healthcare system, which was a major barrier to an effective Ebola response, as populations would have more frequent positive interactions with healthcare workers. Finally, better healthcare provision can improve the overall health of the population through downstream effects on the social determinants of health such as increasing productivity, economic output, and school attendance. Together these determinants can positively interact to further improve health outcomes.
This approach is optimal for all the organizations that funded the 2014 Ebola response, meeting each of their goals more effectively. Development organizations can improve health outcomes while spending less, donors concerned with global health security can improve preparedness for an outbreak of Ebola or any other pandemic threat, and the national governments can improve their countries in the multiple ways outlined here.
Recommendations for implementation
Building effective and sustainable healthcare systems in developing countries in West and Central Africa will require action on six fronts:
1. Healthcare facilities
There need to be enough healthcare facilities, appropriately located and maintained, for sufficient national healthcare coverage. There must also be enough equipment inside the facilities for effective treatment of common diseases as well as preparedness for disease outbreaks.
2. Doctors and nurses
There is a significant shortage of trained medical staff. A healthcare system cannot function without a workforce of well-trained, adequately paid, and politically supported medical professionals to staff the healthcare facilities.
3. Laboratories, lab staff, and robust delivery systems
Nationally located laboratories, with appropriate equipment and trained staff, are essential for the rapid identification of disease outbreaks. There needs to be a system in place that ensures swift delivery of samples from anywhere in the country to the laboratories, and rapid delivery of test results.
4. Supply chains
Healthcare facilities need drugs and equipment to function, so a healthcare system needs mechanisms to make sure facilities are adequately supplied. These supply chains can also be used to quickly deliver the necessary supplies (PPE, disinfectants, drugs, vaccines) in the event of a disease outbreak.
5. Disease surveillance
Disease surveillance systems at the national and regional levels can identify emerging disease threats and outbreaks and trigger a rapid response. Disease monitoring is necessary in both humans and animals for zoonotic diseases. Surveillance programs need public and animal health professionals, a robust reporting network, coordination between healthcare facilities and national governments, and the laboratory system outlined above.
Building and maintaining effective healthcare systems is a challenging task. As the suggestions above show, there are multiple concurrent facets of the system that all need to be implemented well for the healthcare system to function effectively. It is important to have robust measures of progress that cut across all of the facets of the system, as well as individual measures that can show the effectiveness of each separate aspect of the system. This is a challenge for monitoring and evaluation (M&E) professionals, but without specific measures, it will be difficult to identify the weak points in the system and adapt efforts to build effective healthcare systems in different national contexts. It is therefore crucial to develop some way of collecting data to ensure the most effective implementation of healthcare system building, keep projects on target, and account for money spent. Effective M&E is also essential for the support of donor organizations.
The sustainability of these efforts is paramount. There has already been significant investment in healthcare in West and Central Africa, and billions of dollars were spent in the 2014 Ebola response, but little of this has led to long-term improvements in the healthcare infrastructure. Many of the facilities that have been built at great expense now lie empty and dilapidated.26 For future efforts to be sustainable, they need to be led by national governments. If the nations themselves take ownership of building their healthcare system, they are much more likely to fully utilize the system and provide continued support in the future. Furthermore, national and regional governments are more likely to understand the local and cultural sensitivities that need to be considered when implementing programs, and the broader concerns of infrastructure, education, training, and regional coordination.
One further concern relates to the training of healthcare workers. There is no short-term solution for this. Training a doctor takes many years of tertiary and professional education, but to get to this stage personnel need to already have a robust primary and secondary education. Education systems in developing countries therefore may have an impact on how effectively healthcare systems can be developed. Furthermore, there is a risk of ‘brain drain’ as the highly trained doctors see opportunities to earn higher salaries and enjoy better living and working conditions in developed countries. In order to maintain a sufficient workforce, this problem will need to be overcome, either through higher salaries and benefits, requirements to work for mandated periods after qualifying, or training an excess of doctors.
About the Author
1Ebola Virus Disease Factsheet. World Health Organization, 2018. https://www.who.int/news-room/fact-sheets/detail/ebola-virus-disease.
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4Wright, S., Hanna, L. and Mailfert, M., A wake-up call: Lessons from Ebola for the world’s health systems (London: Save the Children, 2015).
5B. Lomborg, “Ebola kills far fewer than Aids, TB and malaria. What should we prioritise?,” The Guardian, January 19, 2015.
7Geldsetzer, P., Bloom, D., Humair, S. and Bärnighausen, T. Health HIV/AIDS Perspective Paper. Copenhagen Consensus Center, 2015; Raykar, N. and Laxminarayan, R. Benefits and Costs of the malaria targets for the post-2015 consensus project. Copenhagen Consensus Center, 2014; S. Helleringer and A. Noymer, “Magnitude of Ebola relative to other causes of death in Liberia, Sierra Leone, and Guinea,” The Lancet Global Health Vol 3 Issue 5 (May 2015): 255.
8E. Natuzzi, Benefits and costs of the health targets for the post-2015 development agenda. Copenhagen Consensus Center, 2014.
10Global Health Workforce Statistics, Global Health Observatory data repository. World Health Organization, 2010. https://www.who.int/gho/en/.
11World Development Indicators, DataBank. World Bank, 2015. http://databank.worldbank.org/data/reports.aspx?source=2&country=SLE.
12Wright, Hanna, and Mailfert, A wake-up call.
13S. Walsh and O. Johnson, Getting to Zero. (London: Zed Books Ltd, 2018).
14L. O. Gostin, “Ebola: towards an International Health Systems Fund,” The Lancet Vol 384, Issue 9951 (October 2014): 49.
15Natuzzi, 2014; Walsh and Johnson, 2018.
21K. Kennedy, “CDC chief says Ebola must be contained,” USA Today, August 7, 2014.
23C. H. Calisher, J.E. Childs, H.E. Field, K.V. Holmes, and T. Schountz, “Bats: important reservoir hosts of emerging viruses” Clinical microbiology reviews, American Society for Microbiology Vol 19 Issue 3 (July 2006): 531.
24Walsh and Johnson, 2018.
25R. L. Nevin and J.N. Anderson, “The timeliness of the US military response to the 2014 Ebola disaster: a critical review” Medicine, Conflict and Survival Vol 32 Issue 1 (July 2016): 40.
26Walsh and Johnson, 2018.