JUNE 2016

Governance and Health inPost-Conflict Countries:The Ebola Outbreak in Liberiaand Sierra Leone

EDITED BY MAUREEN QUINN

ABOUT THE AUTHOR

MAUREEN QUINN is Senior Director of Programs at the

International Peace Institute.

ACKNOWLEDGEMENTS

IPI owes a debt of gratitude to its many donors for their

generous support. In particular, IPI would like to thank the

Bill and Melinda Gates Foundation and core donors for

making this publication possible.

The editor would like to thank a number of individuals for

their contributions and support in conceptualizing,

providing feedback, and supporting the research: John

Hirsch, Adam Lupel, Lamii Kromah, Michael Snyder, and

Taimi Strehlow at IPI; and Angela Muvumba-Sellström at

Uppsala University for giving access to her network of

African researchers. IPI would also like to thank the

external review panel for their comments and suggestions

on the case studies. Albert Trithart provided expert editing

support.

Cover Photo: A burial team carries the

body of a suspected Ebola victim to a

grave in a new cemetery at Disco Hill,

Liberia, January 26, 2015. UN Photo/

Martine Perret.

Disclaimer: The views expressed in this

paper represent those of the author

and not necessarily those of the

International Peace institute. IPI

welcomes consideration of a wide

range of perspectives in the pursuit of

a well-informed debate on critical

policies and issues in international

affairs.

IPI Publications

Adam Lupel, Vice President

Albert Trithart, Assistant Editor

Suggested Citation:

Maureen Quinn, ed., “Governance and

Health in Post-Conflict Countries: The

Ebola Outbreak in Liberia and Sierra

Leone,” New York: International Peace

Institute, June 2016.

© by International Peace Institute, 2016

All Rights Reserved

www.ipinst.org

CONTENTS

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Maureen Quinn

Governance and Health in Liberia . . . . . . . . . . . . . . . . 4

Edward Mulbah

Governance and Health in Sierra Leone . . . . . . . . . . 15

Charles Silver

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Maureen Quinn

1

The outbreak of the Ebola virus disease in WestAfrica from 2014 to 2015 underscored the fragilityof public health services in countries emergingfrom protracted conflict. In both Sierra Leone andLiberia, the war had destroyed health infrastruc-ture, swelled the population of cities, and drivenmembers of the professional classes out of thecountry. As a result, the health sector was chroni-cally shorthanded and undersupplied, particularlyin rural areas. Ebola arrived as the large-scalepostwar international presence was downsizingand the responsibility for healthcare was shifting tothe governments. Both governments haddeveloped comprehensive health policies andplans, including devolution of health servicedelivery, but these were not fully implemented inpractice.In this context, both countries were unprepared

for the Ebola outbreak, and their responseunderscored the important link between healthcareand governance, particularly when both had beenweakened by conflict. The authors identify anumber of lessons emerging from the response tothe crisis in both countries:• Local engagement is critical: In both countries,the initial response suffered from a lack ofcommunication and coordination at the locallevel. The involvement of local actors whounderstood the local context and were trusted bytheir communities was crucial to eventuallycontaining the outbreak.

• Emergency measures can be effective but canalso have negative consequences: Both govern-ments resorted to bold containment measures tocurb the outbreak, including quarantines.

Although these measures helped contain Ebola,they could have been implemented in a way thatwould have led to fewer negative consequences.

• Top-down approaches are insufficient, andinclusivity is necessary: Both countries initiallytook a top-down approach in responding to theoutbreak, partly because they had not effectivelydevolved management of the healthcare sector.Over time, the response came to involve morestate and non-state actors, including civil societygroups and traditional leaders, which facilitatedprevention, control, and containment.Building on these lessons, the authors offer a

number of recommendations, including to:• Implement existing national health policies andplans;

• Build national capacities to detect and respondquickly to health emergencies;

• Improve governance and leadership at thenational and local levels;

• Strengthen community engagement in planningand managing health services;

• Rebuild trust in state institutions, includingthrough dialogue with non-state actors;

• Ensure adequate budgetary allocations to thehealth sector;

• Improve oversight of health service delivery atthe national and local levels;

• Build personnel capacity, particularly in ruralareas; and

• Coordinate national efforts with regional andinternational efforts.

Executive Summary

2

Instability and insecurity make people andcommunities more vulnerable to disease andprevent people from living healthy and productivelives. Conversely, stability and peace foster anenvironment conducive to public and privatedelivery of health services and the provision ofhumanitarian and development assistance. Violentconflict, even if its root causes are political, islinked to other areas of individual and social life,affecting humanitarian, development, and healthissues. Deteriorating healthcare feeds into thechallenges of conflict resolution by exacerbatinghuman suffering and diminishing the potential forsustainable solutions and can have spillover effectsin neighboring countries.In 2014 and 2015, the International Peace

Institute (IPI) undertook research and convenedevents on contemporary conflict dynamics andtheir impact on stability, governance, and develop-ment in Africa, particularly the Sahel-Sahararegion. This led to two reports on political partici-pation and governance: “Building Peace andDevelopment in the Sahel: Enhancing the PoliticalParticipation of Women and Youth” and “EffectiveGovernance in Challenging Environments.” In2015, IPI turned its focus to the delivery of, andimproved access to, health services, using the lensof health service delivery to assess the link amonghealth investments, social and economic develop-ment, and social cohesion and peacebuilding. IPI’sresearch sought to better understand the linksbetween peace, security, and health and to generatepolicy support to reduce vulnerability, mitigaterisks, and increase the resilience of communitiesand state institutions to threats and instability.Given that the Ebola virus disease emerged in

West Africa during the first stage of this researchproject, IPI decided to focus specifically on thechallenges of health service delivery in Liberia andSierra Leone, two post-conflict countries. The

outbreak of the Ebola virus disease in West Africafrom 2014 to 2015 underscored the fragility ofpublic health services in countries emerging fromprotracted conflict. Weak institutional conditionsand poor governance practices blocked optimaldelivery of health services and contributed tohealth emergencies.1 This report shares insightsfrom two African researchers who aim todemonstrate the inherent nexus between healthand governance and highlight recommendationsfor reform. The authors draw on interviews, focusgroups, and government policy documents as thefoundation of each case study.In both Sierra Leone and Liberia, war had

destroyed health infrastructure, swelled thepopulation of cities through rural-urban migration,and driven members of the professional classes outof the country, with many yet to return. Moreover,while postwar policy guidance called for decentral-ization, including in the health sector, limitedresources and lack of capacity outside the capitalshobbled implementation.As a result, the health sector was chronically

shorthanded and undersupplied, particularly inrural areas. In both countries, Ebola also arrived asthe large-scale postwar international presence wasdownsizing and responsibility for healthcare wasshifting to the government. But the governments ofSierra Leone and Liberia were not led, equipped,organized, or funded to undertake this new respon-sibility. They had both developed comprehensivehealth policies and plans, including devolution ofhealth service delivery, but these were not fullyimplemented in practice. Governance of the healthsector also suffered from mismanagement andcorruption.When the Ebola outbreak hit, both governments

were reactive, not proactive. Containment strate-gies involving the military were mistrusted, andcommunication was confusing and inadequate. In

IntroductionMaureen Quinn*

* Maureen Quinn is Senior Director of Programs at the International Peace Institute.1 United Nations Development Programme, World Bank, European Union, and African Development Bank, “Recovering from the Ebola Crisis,” 2015, available atwww.undp.org/content/undp/en/home/librarypage/crisis-prevention-and-recovery/recovering-from-the-ebola-crisis---full-report.html .

INTRODUCTION 3

parallel, the international response was slow inmaterializing and not always coordinated withnational and local efforts. For both countries, localengagement, particularly with traditional leaders,ultimately proved critical to stemming the crisis.In what follows, the authors explore the response

to the Ebola crisis as it unfolded in Liberia andSierra Leone and how health service providers,policymakers, communities, and volunteers

grappled with the challenges it posed. The objectiveis to present the crisis from the perspective of localobservers and explore the core elements of effectivegovernance in post-conflict service delivery,including national and local capacity, adequateresources, and the renewal of trust. We hope thereport provides insights to ongoing peacebuildingand development efforts, especially in the area ofhealth service delivery.

2 World Health Organization, “Ebola Situation Report,” December 30, 2015, available athttp://apps.who.int/ebola/sites/default/files/atoms/files//who_ebola_situation_report_30-12-2015.pdf?ua=1&ua=1 .

Figure 1. Total confirmed Ebola cases by county as of December 30, 2015

4

Introduction

When Liberia was hit by the Ebola virus disease inMarch 2014, it affected the fabric of the entiresociety, including its social, political, and economicconditions. The impact of the Ebola outbreakfurther demonstrated the fragility of the state,including its public health services, as it emergedfrom fourteen years of civil war (1989–2003),which came to an end through the 2003 AccraComprehensive Peace Agreement (CPA). The overall goal of this case study is to assesspresent and past governance and accountability inhealth service delivery and to consolidate keyfindings related to health and governance. Itassesses Liberia’s institutional frameworks, capaci-ties, challenges, and lessons learned. Interviewswere conducted with regional, national, and localofficials, as well as medical professionals and bothnational and international nongovernmentalorganizations (NGOs). Desk research of key litera-ture, documents, and reports related to governanceand the Ebola crisis was also carried out.

Framework for HealthGovernance before theOutbreak

EFFECT OF THE WAR ONHEALTHCARE

Liberia’s health system was seriously affected by thecountry’s fourteen-year civil war. Hospitals andclinics were looted of medical equipment anddrugs, and many were burned down or vandalized.By the time the war ended, only 354 of the 550

health facilities that had previously existed wereoperational, with the vast majority managed byNGOs. The headquarters of the Ministry of Healthand Social Welfare (MOHSW) had become atemporary shelter for refugees and internallydisplaced persons (IDPs). Nine out of ten medicaldoctors had left the country in search of safehavens, the system for training medical personnelhad collapsed, and only 168 physicians remained inthe country, mostly in Monrovia.1

HEALTH POLICY ANDDECENTRALIZATION

Before the outbreak, Liberia’s MOHSW developeda National Health and Social Welfare Policy andPlan for 2011–2021. The plan’s overarching goalwas to increase access to healthcare, make health-care more responsive to people’s needs, and makeaffordable healthcare available to all Liberians. Inrelation to governance, the plan aimed to shiftfunctions, authority, and resources for healthcareto the local level; restructure the MOHSW;establish a framework to support the decentraliza-tion process; and strengthen local governmentstructures.2

A number of additional policy frameworks alsoaimed to facilitate development and enhancecapacity in the health sector. The Agenda forTransformation, a five-year development frame -work (2012–2017), emphasized that the govern-ment will build and operate responsive democraticinstitutions at the national and local levels andstrengthen good governance and peacebuilding. Italso provided for decentralization, beginning withdeconcentration of essential government services,including healthcare, to each of the fifteen counties.

Governance and Health in LiberiaEdward Mulbah*

* Edward K. Mulbah is Senior Advisor and Head of Program at the Peacebuilding Office in the Ministry of Internal Affairs, Liberia. He has written and supported anumber of research projects in Liberia and the Mano River Union subregion, including as a co-author of “Picking up the Pieces: Liberia’s Peacebuilding EffortsPost-Ebola” (2015) and “A Study of the Economic Impact of the Ebola Crisis on Monrovians Living on US$1 a Day or Less” (2015). The author would like to thankMaxim Kumeh, Director of the Initiative for Positive Change; Caluchi Bieh, a graduating senior at the University of Liberia’s Graduate Program in RegionalScience; Wilfred Gray-Johnson, National Executive Director of the Liberia Peacebuilding Office and Director of the New African Research and DevelopmentAgency; Oscar Bloh, Country Director for Search for Common Ground; Christopher Toe of the National Civil Society Council of Liberia; the staff of the Ministryof Health and Social Welfare and Ministry of Internal Affairs for assisting in collecting documents and granting interviews; and several members of IPI, includingMaureen Quinn and Albert Trithart for editing the report and Dianna Tavarez and Taimi Strehlow for administrative support.

1 Richard Downie, “The Road to Recovery: Rebuilding Liberia’s Health System,” Center for Strategic and International Studies, August 2012.2 Ministry of Health and Social Welfare, “National Health and Social Welfare Policy and Plan 2011–2021,” 2011, available atwww.mohsw.gov.lr/documents/Final%20NHPP%20%28high%20res%29.pdf .

GOVERNANCE AND HEALTH IN LIBERIA 5

This aimed to strengthen the role of local organiza-tions and leaders in making decisions andmonitoring interventions.3

The Agenda for Transformation built onLiberia’s decentralization and local governancepolicy, which included Guidelines for NationalDecentralization developed by the MOHSW in2008. These guidelines provided for buildingcapacity to manage health services at the countyand district levels.4 Implementation of this policyhas been slow, as the MOHSW’s decentralizedunits had insufficient capacity to coordinate andmanage services. Based on an analysis of theministry’s needs conducted in 2012, the Agenda forTransformation recommended strengtheningcounty and district health systems to supportoperationalization of the decentralization policy.5

In addition to these health policy frameworks,the government developed a Strategic Roadmap forNational Healing, Peacebuilding and Recon -ciliation (2013–2030) consistent with the govern-ment’s Vision 2030, which was launched inDecember 2012.6 While the National Health Planfocuses directly on building capacity in the healthsector, the roadmap, like the Agenda forTransformation, is broad in focus. It complementsand supports efforts to achieve equitable access tobasic social services, including health, education,and agriculture, that enable overall peace andhuman security. These policy frameworks wereexpected to mutually reinforce each other inhelping government institutions to prepare for,mitigate, and respond to emergencies. Although relatively good health regulations werein place, these regulations were inadequatelyenforced. At the time of the outbreak, Liberia wasstill struggling to implement the 2005 InternationalHealth Regulations, compared to other countries inthe subregion. Heath policies and regulations were

weakened by lack of adequate technical and institu-tional capacities, which was exacerbated by corrup-tion and politics, including appointments based onpolitical patronage. For example, inexperiencedmedical students were sometimes assigned tomanage critical divisions of the health sector due tocorruption.7 Setta Fofana Saah, the national coordi-nator of Liberia’s National Traditional Council,remarked that “implementation of health regula-tions and policies was a big problem because ofweak systems and processes, and so citizenssuffered the consequences.”8 Implementation ofpolicies, regulations, and laws in the health sectorrequired greater human and technical resources.FINANCING HEALTHCARE DELIVERY

As Liberia moved away from direct humanitarianaid to recovery and development, medicalcharitable institutions and organizations beganphasing out, and medical assistance was transi-tioned to indirect support to the national budget.The health component of the budget, with aid anddirect budgetary support constituting 65 percent,grew strongly between 2012 and 2014, from $38 to$60 million.9 This budget covered a free universalhealthcare system for basic services, such asmaternal healthcare, at major government facili-ties, including the John F. Kennedy Medical Centerand Jackson F. Doe Memorial Regional ReferralHospital. Other facilities, including theRedemption Hospital and clinics and hospitals inrural areas, were fee-for-service, with subsidiesfrom the government with the support of donorsand NGOs.10

This transition required the government to takeover employment of nurses and doctors previouslyemployed by international NGOs and philan-thropic organizations. A scale was created in 2007to standardize the salaries of health workers andtop up civil service salaries.11 But nonetheless,

3 Ministry of Planning and Economic Affairs, “Republic of Liberia Agenda for Transformation: Steps for Liberia Rising 2030,” 2012, available atwww.lr.undp.org/content/liberia/en/home/ourwork/library/liberia-agenda-for-transformation.html .

4 Ministry of Health and Social Welfare, “Guidelines for National Decentralization,” 2008, available at www.basics.org/documents/Decentralization-Guidelines_Liberia.pdf .

5 Ministry of Planning and Economic Affairs, “Agenda for Transformation.”6 Peacebuilding Office, “Strategic Roadmap for National Healing, Peacebuilding and Reconciliation in Liberia (2013–2030),” 2012.7 Interview with representative of Search for Common Ground, Monrovia, Liberia, November 17, 2015.8 Interview with Setta Fofana Saah, Monrovia, Liberia, October 20, 2015.9 International Crisis Group, “The Politics behind the Ebola Crisis,” October 2015, p. 5, available at

www.crisisgroup.org/en/regions/africa/west-africa/232-the-politics-behind-the-ebola-crisis.aspx .10 Interview with Dr. Nowiah Gorpudolo, women's health specialist at Redemption Hospital, April 20, 2016.11 Ministry of Health and Social Welfare, “Annual Report of the Health Sector Pool Fund: July 1, 2014, through June 30, 2015,” 2015, available at

www.mohsw.gov.lr/documents/HSPF_AR_2015_lr.pdf .

6 Edward Mulbah

health workers employed by international organi-zations enjoyed higher salaries and betterincentives. Moreover, the government only hired3,500 of the 8,500 workers international organiza-tions had employed, which sparked protests andviolence.12 The transition thus resulted in fewer,less motivated health workers. Financing of public service delivery in Liberia hashistorically been centralized, under the directcontrol of various government ministries andagencies. The government attempted todecentralize financing by creating a CountyDevelopment Fund in 2005 and a SocialDevelopment Fund in 2009 to devolve publicinfrastructure spending to the county and districtlevels. This, for the first time, allowed local officialsto use their discretion in managing funds, but italso exhibited management problems.13

INSTITUTIONAL CAPACITY

At the time of the outbreak, health infrastructure inLiberia was inadequate, and drugs and neededequipment were in short supply, despite financialsupport received over the years from both thenational government and donors. There wereinsufficient trained health professionals, withreports of one medical doctor to more than 200patients in hospitals.14 Health professionalssometimes focused their attention on demandingbetter wages and benefits rather than on healthissues. Moreover, the MOHSW’s vital statisticssystem was underdeveloped, with a low rate ofbirth and death registration. A 2010 health surveyestablished that surveillance and early-warningsystems were extremely weak, with limited capacityto detect and respond appropriately to events suchas the Ebola outbreak.15

This weak institutional capacity contributed tothe rapid spread of Ebola. According to thesuspended secretary general of the National Health

Workers Association, demotivation and lowmorale of health workers, coupled with shortage ofdrugs, low wages, and absence of personal protec-tive equipment, all contributed to the spread ofEbola.16

Responding to the EbolaOutbreak

EMERGENCY MEASURES

The national government was slow to respond tothe health emergency with proactive measures.According to one Liberian, “Our government didnot act fast so as to save lives.”17 The first Ebolacases in Liberia were reported in March 2014, butthe government did not close its borders withneighboring countries and quarantine the worst-affected neighborhoods until July. The presidentdeclared a ninety-day state of emergency onAugust 6th, due to incidences of insecurity, and thegovernment cordoned off the neighborhood ofWest Point in Monrovia on August 19th (see Figure1). When the government did finally respond to theoutbreak, its measures sometimes exacerbated thecrisis.18 The government mobilized the military toenforce the cordoning off of West Point in August2014, leading to the death of a young boy andseveral injuries, as well as a strongly negativereaction from the community. There were manyrisks involved in using the Liberian military toquarantine West Point and other communities.Previous regimes had used the military to represscitizens, so its use in response to Ebola created fear.Many citizens felt provoked and thought it anoverly harsh measure. According to one formergovernment official, “We challenged the military[instead] to use the weapons of brooms, shovels,and diggers to clean the community and invest in

12 International Crisis Group, “The Politics behind the Ebola Crisis.”13 United Nations Capital Development Fund, “Final Evaluation: Liberia Decentralization and Local Development Programme,” 2013, available at

www.uncdf.org/sites/default/files/Documents/liberia_ldld_final_0913_eng_0.pdf .14 Interview with the secretary general of the National Health Workers Association of Liberia, November 7, 2015.15 Ministry of Health and Social Welfare, Liberia Health System Assessment, 2015. This assessment covered Liberia’s fifteen counties and 159 health facilities and

involved thirty focus group discussions and sixty key informant interviews. It lasted for two months (February–March) and focused on leadership andgovernance, health financing, essential medicines, supplies and supply chain, health financing, human resources for health, health infrastructure, health services,and health information systems and surveillance. The overall objective of the assessment was to generate evidence for the formulation of the post-Ebola healthsector investment plan.

16 Interview with the secretary general of the National Health Workers Association of Liberia, November 6, 2014. He was suspended by the MOHSW for incitinghealth workers to go on strike for almost a week in 2013.

17 Interview, Jallah town, October 27, 2015.18 Interview with youth leader, Banjor, Liberia, September 5, 2015.

GOVERNANCE AND HEALTH IN LIBERIA 7

2014

March 24th

Liberian government announces first suspectedEbola cases in the country, which are confirmedsix days later

June 17th

Ebola reaches Liberia’s capital, Monrovia

July 27th

President Ellen Johnson Sirleaf closes Liberia’sborders, bans football events, closes schools anduniversities, places some areas under quarantine,and establishes a National Ebola Task Force,which she chairs

The military is deployed to enforce quarantinesthree days later

August 6th

President Sirleaf declares state of emergency

August 19th

President Sirleaf declares nationwide curfew andorders the West Point neighborhood of Monroviato be cordoned off

September 16th

US President Barack Obama announces anexpanded US role in responding to the outbreak,including the deployment of troops

September 19th

UN Mission for Ebola Emergency Response(UNMEER) is established

September 28th

Ebola outbreak peaks in Liberia

October 29th

WHO reports the rate of infections in Liberia hasslowed

November 13th

President Sirleaf lifts state of emergency

2015

January 24th

Just five confirmed and twenty-one suspectedEbola cases are reported across Liberia

February 16th

Schools reopen in Liberia

February 22nd

President Sirleaf lifts curfews and reopens theborders

March 5th

Last confirmed Ebola patient in Liberia is released

May 9th

Liberia is declared Ebola-free, although severalsubsequent cases are confirmed

July 31st

UNMEER is closed, having officially achieved itscore objectives of scaling up the response

Figure 1. Timeline of Ebola Outbreak in Liberia19

19 Global Ebola Response, “Timeline,” available at https://ebolaresponse.un.org/timeline .

8 Edward Mulbah

relationships with the community that will help tochange negative perceptions of vulnerable citizensabout the government.”20 Given some citizens’negative perceptions of the government—that itwas insensitive to the needs of the majority of thepopulation, and that the favored few were enjoyingthe wealth of the country—these governmentactions had the potential to create political unrest. Moreover, when state authorities quarantinedcommunities and restricted movement, they didnot provide adequate information on the processand procedures in advance, out of concern thatadvance warning might create panic and causeresidents to flee to unaffected communities.Restrictions on movement, especially in populatedareas like West Point and Dolo Town, also limitedaccess to food, basic medications, and othernecessities. According to one resident of WestPoint, government relief aid did not adequatelycompensate for these restrictions.21 Tensionsensued between the government and citizens inquarantined communities, which may haveundermined the state’s efforts to control andcontain the epidemic by reducing cooperation onthe part of the citizens.CITIZEN TRUST AND PARTICIPATION

A confluence of factors—the use of the Liberianmilitary to constrain movement and spearhead a heavily centralized response, the mixedmessaging of public information campaigns,limited community involvement, worsening state-society relations, deteriorating health services, andthe escalating Ebola death toll—created mistrust inthe healthcare and governance systems.22 Thecitizens did not trust the government when itpronounced the Ebola outbreak in March 2014.This mistrust was exacerbated by rumors that thepresident of Liberia had received funds from theUS government to conduct a trial test of the Ebolavirus. Many people did not believe the virus evenexisted, perceiving that the government wanted tomake money out of the crisis.23 West Point andDolo Town, among other communities, refused

access to government workers carrying out publicinformation and awareness campaigns. This initialreaction to information about the virus may havestemmed from previous experiences in the 1990s,when the government abandoned its citizens tofend for themselves against rebel and governmentforces. General mistrust reduced awareness ofEbola by health practitioners, local traditionalleaders, and civil society organizations. The lack of participatory governance, especiallyin the design and implementation of the Ebolaresponse, also fueled mistrust. There was generalconsensus among national and internationalpartners on the post-Ebola recovery plan,undertaken by the United Nations DevelopmentProgramme (UNDP) in conjunction with otherinternational organizations in early 2015. Critics,however, believed it was not developed transpar-ently and did not benefit from the contributionsand aspirations of critical stakeholders, such aswomen’s and youth groups, traditional leaders, andvictims of Ebola. Critics also accused the govern-ment of excluding certain populations fromdevelopment interventions and public services,particularly slum communities in southwestMonrovia, such as West Point, Banjor, and Doe. The Ebola response was eventually successful dueto the increased role of local actors deeply rooted intheir communities. As part of the response strategy,the government set up task forces at the national,county, and district levels, with parallel interven-tions by civil society organizations and indigenouscommunity groups below the district level. Thetask forces increased awareness and providededucation on Ebola prevention, control, andmanagement. These task forces made it possible forordinary people to participate in containing andreversing the spread of Ebola. Involvement of localgroups and communities, such as the Peace -building Office’s county and district peace commit-tees and the Community Health Education andSocial Services (CHESS), helped build trust.24Communities welcomed and trusted local groups,

20 Interview with former Minister of Public Works Kofi Wood, July 26, 2015.21 Interview with resident of West Point, Monrovia, Liberia, August 19, 2015.22 Erin McCandless, Nicolas Bouchet, et al., “Tackling and Preventing Ebola while Building Peace and Societal Resilience: Lessons and Priorities for Action from

Civil Society in Ebola-Affected New Deal Countries,” Civil Society Platform for Peacebuilding and Statebuilding, 2015, available atwww.cspps.org/documents/130616042/130793247/CSPPS+Ebola+Report.pdf/33092e41-bd4a-4ccf-8ddf-4464e5c6ce37 .

23 Interview with health worker, Monrovia, Liberia, October 7, 2015.24 Geneva Global, “Meet Jzohn, a Local Leader in the Fight against Ebola,” Global Citizen, March 11, 2015, available at

www.globalcitizen.org/en/content/meet-jzohn-a-local-leader-in-the-fight-against-ebo/ .

GOVERNANCE AND HEALTH IN LIBERIA 9

even at the height of fear and distrust in thehardest-hit villages.DELIVERY OF HEALTH SERVICES

Ebola exposed the weaknesses of health servicedelivery in Liberia. At the outset, nurses anddoctors did not use gloves and protective gear, andhospitals were not equipped with emergencyresponse capabilities. Shortages of ambulances,medical practitioners fully knowledgeable aboutEbola, and adequate space for proper burial ofEbola victims overwhelmed the health sector andthe government.25

The government established a burial team in lateAugust 2014 to collect dead bodies from homesand communities. But the capacity of the team wasoverstretched due to inadequate logistics andlimited manpower, which was recruited fromamong willing young people in the communities.In some locations, bodies of Ebola victimsremained in homes and in the streets for many daysbefore the burial team properly disposed of them. The National Drugs Service, the government’scustodian of medical supplies and equipment,underperformed at the county and district levelsdue to poor warehousing facilities that lacked anuninterrupted power supply. Not even one ofLiberia’s fifteen counties had adequate cold-storagefacilities for efficient supply-chain management. Inmost cases, hospital facilities, already overbur-dened, were used to store drugs.26 Lack of basiccommunications capacity was also a majorchallenge to emergency responders in ruralcommunities.27

When the Ebola outbreak started, the govern-ment lacked the needed logistical capacity. Inresponse, the government directed all ministriesand agencies to redirect their vehicles andmotorbikes to use by health personnel and thosedirectly involved in Ebola containment andprevention activities.28 The General Services

Agency, the government’s procurement arm, tookresponsibility for managing the Ebola fleet. Thegovernment also lacked needed medical supplies.Personal protective equipment was not in stock,which put health workers at risk of contracting thevirus from infected persons seeking treatment fromhospitals and health posts. This contributed to thereported infection of 378 health workers, of whomabout 192 died.29

October to December 2014 was the most criticalperiod in the Ebola response, and significantimprovement was demonstrated by mid-December.30 County health teams, which had beenestablished in all fifteen counties in 2003, werestrengthened to work in partnership with localauthorities and communities to deliver Ebolaresponse services across the country. By the end ofDecember, the county health teams had recorded1,400 Ebola survivors and held regular meetingswith an established survivor network based inMonrovia, with plans to open chapters at thecounty level. By this time, the logistics hub waslocated at the main football stadium, the SamuelKanyon Doe Sports Complex, with five additionalforwarding bases with improved access to land, sea,and air transportation for response personnel andcargo. Additional utility vehicles, motorcycles, andambulances had been procured.31

During the outbreak, the government and itspartners considered restoring essential healthservices as a top priority. In 2014, several fundingmechanisms were established in an attempt torestore services, including the World Bank EbolaRecovery and Reconstruction Trust Fund and theNational Ebola Trust Fund, which was managed byboth the government and international partners.32The World Bank fund, for example, aimed tosupport diagnostic services, procurement of drugsand medical supplies, and hazard pay for healthworkers. Efforts were also undertaken to make thehealth system more people-centered and resilient

25 Ministry of Health and Social Welfare, “Annual Report of the Health Sector Pool Fund,” 2015, p. 10.26 “Poor Management at the National Drug Service,” Daily Observer, October 19, 2015.27 Frank Schott, “Ebola Lessons Learned: Context, Coordination Are Key to Addressing Crises,” 1776.vc, February 20, 2015, available at

www.1776.vc/insights/ebola-lessons-learned-context-coordination-are-key-to-addressing-crises/ .28 Ministry of State, Circular no. 34, 2014.29 Ministry of Health and Social Welfare, “Annual Report of the Health Sector Pool Fund," 2015.30 Ministry of Health and Social Welfare, “Quarterly Report of the Health Sector Pool Fund, 2015: October 1, 2014, through December 31, 2014,” p. 9, available at

http://reliefweb.int/sites/reliefweb.int/files/resources/HSPF_AR_2015_Q2_final_lr.pdf .31 Ibid., p. 10.32 Ibid.

10 Edward Mulbah

by increasing the role of local communities in everyaspect of health planning through consultations,constant community engagement, and decisionmaking.33 All these initiatives were intended toaddress the country’s weak health system.PUBLIC INFORMATION CAMPAIGNS

At the outset, public sensitization by the govern-ment on state radio was confusing and contradic-tory. At one point, the government advised thateating bats, monkeys, and bush meat, as well asfruits eaten by bats, was forbidden, as they couldtransmit Ebola, but at another point it encouragedpeople to properly cook these meats before eating.34In addition, information mostly reached those whohad access to state and community radio stations,at the expense of the rural majority without accessto radio. The radio station of the UN Mission inLiberia (UNMIL) complemented state radio, but allinformation was in English, which many Liberiansdo not speak or understand.35

Later in the response, public informationcampaigns were conducted with radio messages inLiberia’s sixteen local languages, as well as withbillboards and newspapers, all repeating crucialprevention and control tactics, including washinghands, reporting Ebola cases, and not touching sickor dead bodies.36 These campaigns were vital in thefight against Ebola. The government also requestedmobile phone companies to provide hotlines to anIncident Management System, with the numbersavailable to the public. By August and September 2014, local communi-ties had organized and gotten involved in thepublic information campaigns, extending them tothe community level.37 With the support of thecounty administrations, teams were formed invarious communities for monitoring, surveillance,and contact tracing. These teams included interna-

tional NGOs, such as the Carter Center, GlobalCommunity, and Save the Children, as well asexisting community organizations and networks,including county and district football teams.38 LocalNGOs also formed networks, including the CivilSociety Organizations Ebola Response Taskforce.39These groups undertook a combination of preven-tive work, by helping ensure that informationcampaigns reached as many people as possible, anddirect response, such as by encouraging infectedpeople and their families to seek help rather thanhiding infected relatives at home.40

INTERNATIONAL RESPONSE

Not only the government but also the internationalcommunity was slow to act.41 The internationalresponse to the crisis only became serious when, inAugust 2014, international medical professionalsgot infected and were flown to Europe and the US.42The roadmap for containing the virus was madeavailable almost two months after the WHOdeclared the crisis to be a Public Health Emergencyof International Concern on August 9, 2014. TheUS government announced it would deploy troopsto Liberia to help construct Ebola treatment centersand provide logistical support on September 16th,and the UN Security Council declared that theEbola epidemic was a threat to international peaceand security on September 18th (see Figure 1).43

Considering Liberia was still suffering from theeffects of its brutal fourteen-year civil war, theinternational community’s slow response furtherincreased the fragility of healthcare governance.44Because the WHO, in particular, was slow torespond to the initial health emergency, andbecause what began as a health crisis quicklyevolved into a humanitarian and security crisis, theUN Security Council was compelled to establish anew body to coordinate the response, the UN

33 Interview with Lancedell Mathews, director of New Africa Research and Development Agency (NARDA), October 21, 2015.34 Liberia Broadcasting System (LBS), January–June 2014.35 Mercy Corp Community Radio Program, “Listening Survey,” 2004.36 Philippa Atkinson, et al., “Social and Economic Impact of Ebola, Jallah Town and Banjor Community,” September 21, 2015.37 Interview with Pewu Flomoku, Carter Center Chief of Party, October 17, 2015.38 Incident Management System, “Ebola Update,” September 24, 2014.39 Interview with Christopher Toe, Executive Director of the National Civil Society Council of Liberia, October 16, 2015.40 Peacebuilding Office, “National Volunteer Program to Combat Ebola: July, August, and September Reports,” 2014.41 Atkinson, et al., “Social and Economic Impact of Ebola, Jallah Town and Banjor Community.”42 Interview with Wilfred Gray-Johnson, Director of Peacebuilding Office, November 16, 2015.43 Security Council Resolution 2177 (September 18, 2014), UN Doc. S/RES/2177.44 Interview with community leader, Jallah Town, Liberia, September 23, 2015.

Mission for Ebola Emergency Response(UNMEER).45 Due to the international commu -nity’s failure to respond more quickly andeffectively to prevent the increased rate of infectionand death, seven out of ten Liberians believed theinternational community should provide someform of reparations to Liberia.46

INTERNATIONAL, NATIONAL, ANDLOCAL COORDINATION

Coordination among response agencies at theinternational, national, and local levels was initiallyweak, undermining resource management andresponse systems.47 County, district, and commu -nity interventions were not well coordinated untillate 2014, with many parallel efforts and initiativesthat further weakened community engagement inthe Ebola response.48

The government established a National EbolaTask Force headed by the president and co-chairedby the minister of internal affairs in March 2014 tocoordinate the response, but it suffered from a lackof capacity. The government subsequently replacedthe task force with a national IncidentManagement System and Emergency OperationsCenter to coordinate the Ebola response at variouslevels. A Sub-Regional Ebola Operations andCoordination Centre was established on July 24,2014, following a meeting in Accra, Ghana, as aplatform for UN agencies and governments towork together as partners in responding to theoutbreak. However, it was not until three months later, atthe height of the response, that the governmentcoordinated the responses of the internationalorganizations flooding the country and movinginto rural areas with those of county and districtadministrations. The minister of internal affairs,former co-chair of the National Ebola Task Force,advised all superintendents to coordinate the Ebolaresponse in the various counties at the district andcommunity levels.49 These superintendents, with

support from international organizations such asthe World Food Programme (WFP), UNDP, andUN Children’s Emergency Fund (UNICEF),worked with the Incident Management System inAugust 2014 to decentralize and coordinate theresponse. The government encouraged interna-tional organizations to assess progress and coordi-nate all activities through the superintendents, aswell as to recruit service providers locally.50

The MOHSW also established County HealthTeams, which were decentralized into district andcommunity health teams. The teams and interna-tional partners were organized into four sectors tofacilitate and strengthen a coordinated approachand encourage communities to take responsibilityfor their own safety. Cross-sectoral coordinationhelped to reduce duplication of activities, improveresponse efforts, and increase performance in areasof overlap.51 In addition, government agencies,including the Ministry of Internal Affairs andMinistry of Youth and Sports, and other institu-tions recruited and trained volunteers to work atEbola Treatment Units, increase awareness, andcarry out contact tracing. The contributions ofthese volunteers were crucial to the fight againstthe virus.CORRUPTION AND ACCOUNTABILITY

There were repeated reports of systematic corrup-tion and pillaging of healthcare funds, which hadlong undermined the postwar transition from reliefto recovery and which the government did little ornothing to address. Health workers sometimesimposed unnecessary bottlenecks just to get moremoney from patients. Health posts, clinics, andhospitals with drugs and medical supplies providedby the National Drugs Service are required to givethese to patients for free, but they usually gave onlymedical prescriptions, requiring patients topurchase drugs from privately owned clinics.52According to one health worker in Monrovia,“Health administrators stockpiled their clinics and

GOVERNANCE AND HEALTH IN LIBERIA 11

45 International Crisis Group, “The Politics behind the Ebola Crisis,” p. 246 “Weak Health Sector,” New Democrat, February 12, 2015.47 Interview with Fong Zuagele, Superintendent of Nimba County, October 2014.48 Interview with John Buway, Superintendent of Margibi County, August 2014.49 Interview with Morris Dukuly, former Minister of Internal Affairs, November 28, 2015.50 Interview with Thierry Cordier-Lassalle, WHO, Liberia, August 2014.51 World Health Organization, “Liberia Succeeds in Fighting Ebola with Local, Sector Response,” April 2015, available at

www.who.int/features/2015/ebola-sector-approach/en/ .

12 Edward Mulbah

drugs stores with drugs provided by donors.”53 Inother instances, drugs were not delivered to thefacilities.54 Monitoring of the health sector was alsoweak, and health professionals often offered prefer-ential treatment to those they knew.55

International NGOs provided drugs andincentives to support the health sector, but theMOHSW was reported not to have provided thesein full to health workers. This caused the ministry,in the last few months of 2014, to experience strikesfrom health workers demanding payment ofarrears, including the Ebola risks benefits entitledto former workers of the Ebola Treatment Units.These former workers mounted roadblocks inOctober 2015 at the central office of the MOHSWin Congo Town, Monrovia.ROLE OF TRADITIONAL LEADERS

At the outset of the Ebola response, traditionalleaders were not involved. On the contrary,traditional practices, such as burial rights andhandshakes, were criticized for spreading the virus.The government and international partnersinsisted that people stop these practices, causinganger, withdrawal, and ignorance that, to an extent,may have caused more deaths and infections. Thechairman of the National Traditional Council ofLiberia remarked on state radio on August 17th that“the government did not respect our culture, andthis make me feel bad.” Stronger partnerships between traditionalleaders and county and district administrationseventually contributed to reducing the rate oftransmission. The chairman of the NationalTraditional Council of Liberia called on all chiefs toparticipate in education and awareness campaigns.The chiefs went to villages and towns and heldradio talk shows, speaking in their respectivevernaculars to ensure the message would beunderstood by Liberia’s sixteen tribes. For example,at a workshop organized by the Carter Center inJune 2014 in Gbarnga, Bong County, citizenslistened to traditional leaders as they advised on the

prevention and control of Ebola, and this wasreplicated in several districts. “People listen to thetraditional leaders, at times even more then thegovernment,” noted a coordinator with theNational Traditional Council.56 The council alsohelped to ease the tensions resulting from disagree-ments among citizens who believed in the govern-ment’s pronouncement of the virus and those whodid not, which could have created ethnic rifts.

Lessons Learned

LOCAL ENGAGEMENT IS CRUCIAL

Once the epidemic hit, the national government, atbest, failed to adequately communicate and engagewith communities and, at worst, stifled localcooperation with disease control efforts, includingthe quarantine. Moreover, the Ebola outbreakexacerbated competition among national-levelgovernment ministries and agencies over authorityand resources, as well as between the governmentand NGOs over donor funding. The government’smessaging on the prevention, control, and contain-ment of the virus was inconsistent andunconvincing. Poor communication and mistrustof the government meant that citizens werehesitant to believe information that could havesaved lives.57

Active communication and coordination at thecounty and district levels were crucial to eventuallycontaining the outbreak. County and district offi -cials improved coordination among responders,communicated effectively and regularly with thecounty and district health teams, providedlogistical support for rapid response and referrals,enforced guidelines about the transportation ofEbola patients, and sensitized people. Constantpublic reminders to wash hands, establishment ofisolation centers, and use of proper burial processesalso had a positive effect. The involvement of localactors in this process was significant, as these actorsunderstood the local context, were able to developtrust and confidence with the communities, were

53 Interview with NGO health worker, Monrovia, Liberia, September 13, 2015.54 For example, on September 21, 2015, Liberia’s Drugs Enforcement Agency stopped and confiscated a truckload of medical drugs on its way to Guinea. Many of

these were discovered to be essential drugs, and further investigation uncovered drugs missing from UNICEF warehouses. The Drugs Enforcement Agencyinvestigated the National Drugs Service for attempted theft of essential drugs and medical supplies.

55 Interview with Samuel Wilson, Community Liaison Officer for the UNICEF/Peacebuilding Support Office Social Cohesion Project, August 13, 2014.56 Interview with coordinator of National Traditional Council, October 25, 2015.57 Edward Mulbah, Lesley Connolly, and Nontobeko Gcabashe Zondi, “Picking Up the Pieces: Liberia’s Peacebuilding Efforts Post-Ebola,” African Centre for the

Constructive Resolution of Disputes, August 2015, p. 4, available at http://lab.isn.ethz.ch/service/streamtest.php?id=193353 .

GOVERNANCE AND HEALTH IN LIBERIA 13

easily accessible, and understood and spoke thelocal language.EMERGENCY MEASURES CAN BEEFFECTIVE BUT CAN ALSO HAVENEGATIVE CONSEQUENCES

At the onset of the epidemic, Liberia’s healthsystem was unprepared, and the governmentimplemented only limited preventive measures toarrest the outbreak. The government was thereforeleft with no alternative but to take a number of bolddecisions, including declaring a ninety-day state ofemergency, putting nonessential civil servants onsixty-day compulsory leave (initially thirty days),closing schools and markets, and imposing quaran-tines. These control and preventive measuresangered some citizens, who perceived them asviolating their rights, and had some negativeeconomic and social consequences.58 Nonetheless,these measures, particularly the quarantining ofheavily-infected communities and restrictions onmobility of people across borders, helped containEbola.TECHNICAL RESPONSES ARE MOREEFFECTIVE

The government initially set up a National EbolaTask Force chaired by the president and co-chairedby the minister of internal affairs, and the ministerof information, tourism and cultural affairs wasrequired to provide daily briefings to the public onthe scale of the disease. At times, informationprovided was inaccurate and misleading. Becauseof these technical inadequacies, the governmentquickly dissolved the National Task Force andreplaced it with the Incident Management System,which was chaired by a public health specialist andco-chaired by two other health professionals. Thisshift from treating the epidemic as a nationalpolitical issue to treating it as a technical issueimproved the effectiveness of the response.INCLUSIVITY IS NECESSARY

Liberia’s health system is centralized, with majordecision-making and planning processes followinga top-down approach. Despite the creation ofhealth districts and decentralization of healthservices in theory, Liberia lacked subnational

health structures and systems to implement theEbola response in practice. The recovery plan hasalso followed a top-down approach, driven by theinternational community but with national author-ities made to believe they are in charge. In line with this top-down approach, the govern-ment’s initial response to Ebola was not inclusiveand collective. It was not until late 2014 that civilsociety organizations and traditional and localleaders became involved. The absence of collectiveengagement and inclusive participation of bothstate and non-state actors, especially local chiefsand youth groups, made prevention, control, andcontainment of the virus difficult. The eventualinvolvement of these actors contributed toreducing the infection rate and keeping it low.These actors, which have a significant role to playas part of good governance practices in general,should also be engaged in finding solutions tochallenges during emergencies. The different groups involved in the fight againstEbola each had different comparative advantages.For example, local and traditional leaders played animportant role in encouraging people to take stepsnecessary to prevent, control, and manage theEbola outbreak, such as by not eating bush meatand avoiding traditional burial practices. Civilsociety organizations carried out advocacy toencourage the government and internationalorganizations to support the fight against theoutbreak. They also provided relevant informationand data on affected communities to policymakersand carried out public information campaignsusing community radio stations and traditionalchannels of communication, such as town criers.59

Moreover, while Liberia’s post-Ebola recoveryand development processes call for inclusivity inbuilding sustainable peace, women and youth tendto be left out in the design and implementation ofpolicy frameworks.60 The government’s healthpolicy frameworks lack robust analysis of efforts topromote women and youth participation indesigning and executing these frameworks and toensure women and youth have access to qualityservices.61

58 Ibid.59 Town criers are local people who provide information to the communities on important issues of collective interest and concern.60 Ministry of Health and Social Welfare, Liberia Health System Assessment, 2015.61 Ibid.

14 Edward Mulbah

CRISES CAN SERVE AS A LAUNCHINGPAD FOR IMPROVED REGIONALCOOPERATION

The Ebola crisis highlighted the need for moreregional cooperation in the health sector. Regionalbodies like the Economic Community of WestAfrican States (ECOWAS), African Union (AU),and Mano River Union, provided support in thefight against Ebola and formed partnershipsaround key preventive and curative issues.Establishing a regional platform for informationsharing and knowledge transfer would build onand strengthen these partnerships, as well asincrease interaction and engagement, not only foremergency response but also for illegal cross-border activities (e.g., smuggling, prostitution,small arms and light weapons trafficking). Thiscooperation could advance the regional Ebolastrategy and enhance national capacities for post-Ebola recovery programs and initiatives. Regionalinstitutions, particularly the Mano River Union,will need to redefine and rebrand themselves tobecome more relevant in meeting contemporarydemands of citizens.

Recommendations

As Liberia emerges from the Ebola crisis and movesforward, the following policy recommendations areadvanced for consideration. These recommenda-tions are aligned with the government’s 2015–2021Investment Plan for Building a Resilient HealthSystem for Liberia and other important healthprograms.• Implement existing health policies: The govern-ment, in partnership with bilateral and multilat-eral organizations, should strengthen thecountry’s health system by implementing theNational Health and Social Welfare Policy andPlan to remove physical, financial, and sociocul-

tural barriers to healthcare; improve the qualityof services and adhere to health standards; andmake sure that infection, prevention, and controlmeasures are undertaken in concert with localcommunities. This could help build a morerobust, resilient health system that can withstandfuture shocks.

• Build detection and response capacity: Thegovernment should strengthen surveillance andearly-warning systems, as well as laboratory anddiagnostic systems, all through a decentralizedapproach. It should also build core nationalcapacities to detect, assess, report, and respondpromptly and efficiently to public health risksand emergencies, as required by the WHO’sInternational Health Regulations of 2005.

• Improve governance and leadership: Thegovernment should strengthen governance andleadership at all levels—national, county, district,and community—to ensure effective delivery ofhealth services and meet targets in the comingyears.

• Strengthen community engagement: Thegovernment should strengthen communityengagement in planning and managing healthservices and bolster community structures toeffectively undertake more roles and functions,including promoting health and disease preven-tion, while ensuring that the private sector isregulated to meet quality standards.

• Rebuild trust in state institutions: The govern-ment should explore how trust can be (re)built instate institutions. This will include promotingdialogue and communication between state andnon-state actors, as well as developing an institu-tionalized approach to community engagementthat complements efforts undertaken in otherpriority areas set forth by the government andthe MOHSW.

15

Governance and Health in Sierra LeoneCharles Silver*

Introduction

The goal of this report is to highlight the linkbetween health governance and health servicedelivery in Sierra Leone prior to the outbreak of theEbola virus disease, as well as how this affected thecountry’s ability to respond to the outbreak and thesubsequent outlook. It also presents the lessonslearned and makes suggestions for dealing withpublic health emergencies in the future. This research was conducted using both primaryand secondary sources. Primary data include in-depth personal interviews with key stakeholders,including public health officials, civil servants, andtraditional leaders, as well as focus group discus-sions. Interviews were conducted in Moyamba, Bo,Freetown, and Kailahun, and two focus groupsessions were organized in Freetown and Makeni.Focus group participants and interviewees wereselected based on their experience in healthgovernance, the war, and health service delivery inSierra Leone.1 Secondary data derive from relevantscholarly works on healthcare delivery andgovernance, local and international policydocuments, and databases on health service delivery.

Framework for HealthGovernance before theOutbreak

EFFECT OF THE WAR ONHEALTHCARE

Sierra Leone’s eleven-year armed conflict (1991–2002) caused untold damage to almost all sectors ofthe country, including the health sector. The waraffected the health sector in two major ways. First,the intensification of the war, particularly in rural

areas, not only destroyed existing health facilitiesbut also forced health workers and residents ofrural communities to flee to urban safe havens.Second, many medical personnel, especiallydoctors, fled the country. Even though the warended in 2002, some of these personnel have yet toreturn. Moreover, postwar governments did notprioritize public health in the reconstructionprocess. Participants in a focus group discussion withhealth workers at the Connaught Hospital inFreetown unanimously pointed to the war as amajor reason for the apparently insurmountablepublic health crisis in the country. One of theparticipants stated that overcrowding in the capital,Freetown, was a major reason for the alarmingspread of Ebola in the city. She described living in athree-room house with fifteen people and needingto get up at 5:00am every morning to have a bath.This overcrowding makes it difficult to deal with apublic health emergency. At the same time, oneparticipant disclosed that health workers, as well asordinary citizens, remain reluctant to return to thecommunities where they lived before the war,largely due to deplorable socioeconomic conditionsand health facilities in those communities. Thesefactors related to the civil war made it difficult forthe nation and the health sector to combat theoutbreak.2

HEALTH GOVERNANCE BEFORE THEOUTBREAK

Sierra Leone’s 2010–2015 National Health SectorsStrategic Plan (NHSSP) was the blueprint forhealth sector governance and service delivery inSierra Leone before the outbreak. According to theNHSSP, “Governance in health addresses theactors involved in governing the health sector(MoHS [Ministry of Health and Sanitation] and

* Charles Silver is a Lecturer in the Department of Political Science at Fourah Bay College and a researcher at the Centre for Peace and Conflict Studies, Freetown,Sierra Leone.

1 In order to provide an enabling environment for participants to freely express their views, special sessions were organized for health workers, members of thepublic, and civil society, respectively. Questions raised during the focus group sessions included: What was the state of the health sector in Sierra Leone before theEbola outbreak? Was the government’s response to the outbreak appropriate? What do you think the government and its partners should do to forestall futurehealth emergencies?

2 Focus group discussion, Freetown, November 22, 2015.

stakeholders), what needs to be governed and, to alimited extent, how it will be done.” The NHSSPconferred multiple responsibilities on the MoHS,including formulating policy, setting standards andregulations, collaborating and building coalitions,and monitoring and overseeing resource mobiliza-tion. The MoHS was expected to provide leader-ship and coordinate the efforts of all healthcareproviders and financiers at all levels. This enhancedrole required the MoHS to develop capacity at boththe local and national levels, especially consideringthe ongoing process of devolving health servicedelivery to Sierra Leone’s nineteen local councils,which began in 2008.3

But no matter the degree of innovation in astrategic plan, its implementation depends onadequate budgetary allocations (coupled with theactual disbursement of resources), availability oftrained and qualified personnel, logistical support,and, above all, effective and efficient governancestructures. Did the NHSSP and devolution processlead to any practical progress in health servicedelivery on the ground? A former councilor in Bo city in southern SierraLeone described the devolution process as notyielding the desired dividends. She pointed out thatdevolution of the health sector, like many other

sectors in the country, was not accompanied byadequate and regular financial and logisticaltransfers. Hospitals and clinics faced shortages indrug supplies and personnel. Transfer of responsi-bility was not followed by transfer of resources,which is necessary to implement devolution inpractice.4

Inadequate budgetary allocations to the MoHSconstrained it in meeting its core objective ofdelivering accessible and affordable healthcare tothe citizenry. According to the 2013 NationalHealth Accounts, the sector remained heavilyreliant on donor support and out-of-pocketpayments from patients (see Table 1). This led tounmitigated shortfalls in service personnel acrossthe sector. A public health officer in Moyambatown in southern Sierra Leone intimated that oneof the major problems confronting the healthsector in Sierra Leone, even before the Ebolaoutbreak, was lack of adequate funding andpersonnel to operate the various health units in thecountry: “There are only two of us in the wholedistrict. I am the only public health officer in thistown. Hence, once I go out of town, there is no oneto fill the gap.”5

Research carried out by the Institute forGovernance Reform, a Sierra Leonean research

16 Charles Silver

Government of 171,690,064,040 $40,142,638 6.8%Sierra Leone

Donors 614,220,929,261 $143,610,224 24.4%

Nonprofit 180,615,391,664 $42,229,458 7.2%organizations

Out-of-pocket 1,551,096,883,189 $362,660,015 61.6%payments

Total 2,517,623,268,154 $588,642,335 100%

Financing Source Amount (SLL) Amount (USD) Percent of Total

Table 1: Health expenditures in Sierra Leone (2013)6

3 Ministry of Health and Sanitation, “National Health Sector Strategic Plan 2010–2015,” 2009, available atwww.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Country_Pages/Sierra_Leone/NationalHealthSectorStrategicPlan_2010-15.pdf .

4 Interview with former councillor, Bo city, November 27, 2015.5 Interview with public health officer, Moyamba, November 20, 2015.6 Ministry of Health and Sanitation, “Sierra Leone National Health Accounts,” 2013, available atwww.mamaye.org/sites/default/files/evidence/MoHS%20SL_2015_Sierra%20Leone%20NHA%202013.pdf .

GOVERNANCE AND HEALTH IN SIERRA LEONE 17

institute, indicate that people trained in health andeducation were reluctant to work in ruralcommunities.7 This could be attributed to the ever-growing socioeconomic disparities between urbanand rural communities in the country. A nurse inFreetown blamed health workers’ reluctance to goto rural areas on the poor working conditionsthere. Another focus group participant claimedthat, until the government of Sierra Leone and itspartners make a genuine effort to improve workingconditions of health workers, especially in remoteparts of the country, as well as to ensure adequateand regular supplies, it will be difficult to attracthealth workers to rural communities.8Unfortunately, these efforts fell short, and SierraLeone’s limited health facilities and personnelremained concentrated in urban areas. The NHSSP did not include any specificprovisions on the needs of women and youngpeople. The government did, however, introduce aFree Healthcare Initiative for pregnant women,lactating mothers, and children under five in 2010.9At the outset, this initiative was relatively effective,but the situation deteriorated over time. Therewere allegations that, despite the Free HealthcareInitiative, fees were often charged for services thatshould be free.10 A lactating mother in Makeni cityin northern Sierra Leone aptly described thesituation:Initially, the free healthcare was very effective.Throughout my pregnancy, I did not spend anythingon drugs up to the time I delivered my child. Unfor -tunately, things have changed. Even before the Ebolaoutbreak, it was extremely difficult to access the freehealth service. You go to the hospital today, thenurses will tell you we do not have drugs. You gothere the other day, no nurse is available. This hasbeen the trend until the Ebola outbreak collapsed theentire system.11

The problems associated with health servicedelivery in Sierra Leone were further compounded

by high-level mismanagement and corruption inthe health sector. Government services in SierraLeone, including health services, are associatedwith making money, and in extreme cases, healthservices are sometimes denied until payment.While Sierra Leone does not have a system of freeuniversal healthcare, its health services, like otherpublic services, are not intended to be profit-making; the ultimate goal is to maximize publicinterest, including through judicious and account-able use of limited resources. But this has often notbeen the case in Sierra Leone, as in 2013, whenallegations of high-level fraud saw donors suspendfunds to the MoHS.12

One health worker lamented that, due to thishigh level of corruption and mismanagement,many medical doctors preferred administrativepositions in the ministry, where money gravitates.Almost all major projects in the MoHS werespearheaded by medical doctors, which exacer-bated their shortage. This situation also arosebecause the general working conditions for healthworkers, including doctors, were unsatisfactory,leading many to prefer the administrative side ofthe sector, where they could write and manageprojects. Moreover, monitoring mechanisms in thehealth sector were very weak, particularly fordoctors. One health worker in Makeni city positedthat medical doctors are free to do whatever theychoose and that, recently, many have come to paylittle attention to their profession.13

Due to these factors, there is a mismatch betweenpolicy and practice in Sierra Leone’s health sector.The NHSSP’s strategic goal—“to reduce inequali-ties and improve the health of the people, especiallymothers and children, through strengtheningnational health systems to enhance health relatedoutcomes and impact indicators”—remainsunfulfilled.

7 Institute for Governance Reform, “Service Delivery Index in Health, Education, Sanitation and Water,” 2015.8 Focus group discussion, Freetown, November 18, 2015.9 The Free Healthcare Initiative was part of the government’s policy reforms under the auspices of the Global Health Initiative for the country. 10 Amnesty International, “At a Crossroads: Sierra Leone’s Free Health Care Policy,” 2011, available at

www.amnestyusa.org/sites/default/files/pdfs/sierral_maternaltrpt_0.pdf .11 Focus group discussion, Makeni, November 27, 2015.12 GAVI, “GAVI Review of Health System Strengthening in Sierra Leone,” April 11, 2013, available at

www.gavi.org/library/news/statements/2013/gavi-review-of-health-system-strengthening-in-sierra-leone/ .13 Focus group discussion, Makeni, November 27, 2015.

Responding to the EbolaOutbreak

NATIONAL RESPONSE

Sierra Leones’s health sector was not financially,logistically, or technically equipped to respond tothe Ebola outbreak. The first Ebola case wasconfirmed in Sierra Leone on May 25, 2014 (seeFigure 1). The government’s response to theoutbreak was largely reactive, at least at the earlystages. This reactive response could be attributed in

part to the deplorable condition of the health sectoron the eve of the outbreak, which prevented thegovernment from quickly addressing the situation.One senior civil servant in the MoHS described theoutbreak as not only a public health emergency buta painful exposure of the deplorable and neglectedcondition of the health sector over the years:As a ministry, we are in a quandary. In addition tolack of adequate financial and logistical supportneeded to combat the disease, we do not have [the]requisite staff, [not to mention] the expertiserequired to deal with such a volatile disease. We are

18 Charles Silver

2014

May 25th

World Health Organization (WHO) reports thefirst Ebola cases in Sierra Leone

June 11th

Sierra Leone closes its borders with Liberia andGuinea and closes a number of schools

July 15th

Sierra Leone’s Ministry of Health and Sanitation(MoHS) establishes an Emergency OperationsCentre (EOC) in Freetown

July 31st

President Ernest Bai Koroma declares a state ofemergency and sets up a presidential task force

September 19th

Three-day national lockdown begins

UN Mission for Ebola Emergency Response(UNMEER) is established

October 26th

Ebola outbreak peaks in Sierra Leone

2015

January 23rd

President Koroma lifts movements restrictions

February 13th

Hundreds of homes in Freetown are placed underquarantine for twenty-one days

February 18th

Door-do-door search for Ebola patients islaunched in Freetown

February 28th

Surge of cases in Sierra Leone prompts reintroduc-tion of some restrictions

March 27th

Three-day national lockdown begins

June 16th

Operation is launched to eradicate Ebola from twonorthern districts

July 31st

UNMEER is closed, having officially achieved itscore objectives of scaling up the response

November 7th

Sierra Leone is declared Ebola-free

Figure 1. Timeline of Ebola Outbreak in Sierra Leone.14

14 Global Ebola Response, “Timeline,” available at https://ebolaresponse.un.org/timeline .

GOVERNANCE AND HEALTH IN SIERRA LEONE 19

constrained in all areas. We have only twelveambulances to serve the entire country. Unlessoutsiders come to our aid, the situation remainsprecarious.15

Upon confirming the outbreak, the first measureby the government was to invoke a public healthemergency, based on a provision in Sierra Leone’s1991 constitution. The Ministry of Education,Science and Technology immediately announcedthe closure of all learning institutions in theaffected eastern districts of Kenema and Kailahunand, later, of all learning institutions nationwide.The government also set up a National EbolaResponse Centre (NERC), with its headquarters inthe Office of the President and branches in allregions and districts. The NERC served as the coordinating unit for allinformation relating to Ebola. By decentralizing itsactivities to branches across the country, the NERChelped to collect and collate information on theoutbreak at the chiefdom, district, and regionallevels. The information gathered provided the basisfor interventions by the government and interna-tional partners. The decentralization of the NERC’sactivities also helped the government and interna-tional partners identify the similarities and differ-ences in public perceptions about and attitudes tothe outbreak. This may have guarded against a one-size-fits-all approach to dealing with Ebola. The health emergency included a ban on inter-district, inter-chiefdom, and inter-village visitsuntil the Ebola outbreak subsided. A paramountchief in Kailahun District revealed that one of hiswives died of Ebola and that one of her relativesattempting to visit from Freetown was decisivelystopped from entering the township. According tothe chief, “Some of us consider such measures asappropriate as of now, since we are dealing with apublic health crisis and, more importantly, anenemy no one can readily identify.”16

Some, however, expressed reservations about thelockdowns, arguing that they could worsen thesituation. One local NGO cited the “poor training”

of the volunteers enforcing the lockdowns, andmany Sierra Leoneans suffered from widespreadfood shortages and lost income.17 Médecins SansFrontières (MSF) likewise observed that thenationwide lockdown imposed by the governmentcould exacerbate an already precarious situation by“driving people underground and jeopardizing thetrust between people and health providers.”18

LOCAL RESPONSE

In the wake of the outbreak, information about thedisease was not only scant but scary. The initialmessage from the government and the NERC wasthat Ebola was a killer without remedy. Thisdescription of the virus instilled enormous fear inpeople, who eventually considered visits to healthcenters, even for other illnesses, to be suicidal. The situation changed dramatically, however,when, after setting up the NERC, President ErnestBai Koroma called on traditional leaders, parlia-mentarians, faith-based organizations, civil societyand community-based organizations, and localartists to come on board to fight the Ebolaoutbreak. This gave momentum to massive localsensitization campaigns to educate the populace onthe virus and suggest precautionary measures toprevent infection. Despite acute financial andlogistical constraints prior to the outbreak, theoverwhelming support and cooperation thegovernment received from these groupscontributed immensely to containing Ebola inSierra Leone. For example, during the lockdown fromSeptember 19th to 21st, about 30,000 volunteers,with support from the police and army, embarkedon a house-to-house search for people infected orsuspected of being infected with Ebola. The home-visit teams were also tasked with educating thepopulation about the disease and how to prevent it.In addition, some private businesses, miningcompanies, learning institutions, and individualssupported the government’s efforts to fight thevirus through cash donations.19

15 Interview with civil servant, Freetown, November 23, 2015.16 Interview with chief, Kailahun District.17 Sarah Roache et al., “Lessons from the West African Ebola Epidemic: Towards a Legacy of Strong Health Systems,” O'Neill Institute for National and Global

Health Law, briefing paper no. 10, October 2, 2014.18 Umaru Fofama and David Lewis, “Sierra Leone Lockdown Will Not Help Halt Ebola: MSF,” Reuters, September 8, 2014. 19 For example, the University of Sierra Leone presented the sum of 50 million leones ($10,000) to the national fight against Ebola.

REGIONAL AND INTERNATIONALRESPONSE

Despite pronouncements in international fora thatthe Ebola outbreak in West Africa was unprece-dented and posed security threats to affectednations, a robust international response came late.The World Health Organization (WHO), whichwas expected to take the lead in mobilizing externalsupport to contain the disease, only declared it aPublic Health Emergency of International Concernon August 8, 2014, and released a responseroadmap on August 28th.20

Some health workers interviewed noted thatdonor funds were neither controlled nor coordi-nated by the MoHS. Nonetheless, subregional,regional, and international intergovernmentalorganizations and the donor community madesignificant contributions to implementation of theNHSSP before the Ebola outbreak under the GlobalHealth Initiative Strategy for Sierra Leone, whichwas spearheaded by the US Embassy in Freetown.21The core objective of these organizations was tocomplement the role of the government inimplementing the NHSSP.22

This lack of national ownership also character-ized the international response to the Ebolaoutbreak. One health worker pointed to the healthsector’s overdependence on external assistance asrendering the country powerless to respond to theoutbreak promptly: “Whilst we were eagerlywaiting for international response, the virus wasravaging our people. As a nation, we have learned abitter lesson.”23

Lessons Learned

LOCAL ENGAGEMENT IS CRITICAL

One lesson learned from the Ebola outbreak wasthat local ownership is instrumental in dealing withpublic health emergencies. Initial governmentmessaging was counterproductive, and it was notuntil local groups became involved in sensitizingthe public about the outbreak that efforts to

contain Ebola were successful. The strength of localactors in combating the Ebola outbreak lay partlyin the fact that they belonged to and lived in theirrespective communities and were thus alreadyfamiliar with their customs, traditions, norms, andtaboos. This allowed them to readily interact withthose communities. The pivotal role of localinvolvement in the fight against the outbreak wasdemonstrated in the dramatic subsiding of thedisease in the Kenema and Kailahun districts wherethe outbreak began. These two districts wereamong the first in the country to record forty-twodays without new Ebola infections, in part due tothe efforts of local actors.EMERGENCY MEASURES CAN BEEFFECTIVE BUT CAN ALSO HAVENEGATIVE CONSEQUENCES

The invocation of the public health emergencyteaches Sierra Leoneans, the government, andpartners an important lesson about dealing withcrises. Despite local and international efforts, verylittle could have been achieved had it not been forindividual and collective support and cooperationby Sierra Leoneans during the emergency. Thelockdowns and house-by-house surveillanceinitiated by the government contributed tremen-dously to local strategies to break transmission ofEbola. Nonetheless, lockdowns need to be eitherpreceded or accompanied by the provision ofessential commodities such as food and water inorder to ensure compliance. Moreover, precautionshave to be taken to avoid isolating communitiesand local healthcare workers.OVERRELIANCE ON THEINTERNATIONAL COMMUNITY CANUNDERMINE RESPONSE CAPACITIES

The Ebola outbreak in Sierra Leone is a cleartestimony to the fact that overreliance on interna-tional assistance, particularly in times of healthemergencies, can sometimes have devastatingconsequences. If workable processes and systemshad been in place in Sierra Leone prior to theoutbreak, a quicker initial response could have

20 Charles Silver

20 Lawrence O. Gostin, “Ebola: Towards an International Health Systems Fund,” The Lancet 384, no. 9951 (2014).21 US Embassy Freetown, “Global Health Initiative Strategy for Sierra Leone,” 2011, available at www.ghi.gov/wherewework/docs/SierraLeoneStrategy.pdf .22 Notable organizations involved in health service delivery in Sierra Leone prior to the outbreak included: the US Agency for International Development (USAID);

UK Department for International Development (DFID); World Health Organization (WHO); UN Children’s Emergency Fund (UNICEF); UN Population Fund(UNFPA); European Union; Japanese International Cooperation Agency (JICA); Global Fund to Fight AIDS, Tuberculosis and Malaria; and West African HealthOrganization.

23 Focus group discussion, Ministry of Health and Sanitation, Freetown, December 29, 2015.

GOVERNANCE AND HEALTH IN SIERRA LEONE 21

mitigated the consequences. In the case of Nigeria,for example, no sooner had a case of Ebola beenconfirmed than an Emergency Operations Centrewas established, and communications and datasharing between urban areas helped to contain theoutbreak. Adequate preparation can help ensure acoordinated and effective response should a futureoutbreak occur.24

Recommendations

Based on the lessons learned emerging from thestudy, the following recommendations areproffered:• Ensure adequate budgetary allocations: Thegovernment of Sierra Leone should not onlyprioritize healthcare in terms of policy initiativesbut should also make adequate budgetary alloca-tions to the health sector to translate policy intotangible results. This could include setting up anational health trust fund as part of the post-Ebola recovery strategy. The country already hasa National Road Maintenance Fund and aNational Social Security and Insurance Trust, towhich all public and private sector workerscontribute. These could be replicated in thehealth sector, with funding from sources such asa certain percentage of proceeds from thecountry’s mining sector. This fund couldcomplement government allocations and reducethe country’s reliance on external assistance.

• Improve oversight: The government shouldestablish oversight committees at both the

national and local levels to monitor health servicedelivery and ensure compliance and accounta-bility. These oversight committees should notrely only on national institutions but should alsohave support from international donors. Thismove could help reduce corruption, ensureadequate and sustainable progress towardmeeting benchmarks, and, most importantly,encourage coordination within and among thevarious organs of the health sector.

• Build personnel capacity: The government andits partners should build capacity within thehealth sector to address alarming personnelshortfalls. As part of this effort, workingconditions of healthcare workers should beimproved, with special allowances for thoseworking in remote parts of the country to closethe growing disparities between health servicedelivery in urban centers and rural communities.

• Coordinate with regional and internationalefforts: To enhance the capacity of countries todeal with public health emergencies in the future,international support to health service delivery inAfrica should be in line with the 2007–2015Africa Health Strategy, which puts a premium onareas such as development of human resources inthe health sector, information and communica-tion technology to foster data collection anddissemination, transportation, facilities, andmedicines and supplies.25 There is also a need forrobust coordination of donor agencies involvedin health service delivery in Sierra Leone andelsewhere in Africa.

24 Faisal Shuaib et al., “Ebola Virus Disease Outbreak: Nigeria, July–September 2014,” Centers for Disease Control and Prevention, October 3, 2014, available atwww.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm .

25 African Union, African Health Strategy: 2007–2015, 2007, available at www.who.int/workforcealliance/knowledge/resources/africahealthstrategy/en/ .

22

The authors of these two cases assess the nationalhealth policy frameworks of Sierra Leone andLiberia as adequate. Yet both critique the lack ofresources—financial, physical, and human—allocated to the sector, as well as poor oversight andinsufficient implementation, which hobble publichealth service delivery. The national healthinfrastructure does not reach into rural communi-ties, and health service delivery is not effectivelydevolved to local actors. Moreover, national healthleaders usually turn to international actors forexternal assistance, such as the UNDP, the WorldBank, and bilateral donors, rather than collabo-rating at the regional level.Ebola left a path of disease, suffering, and death

in its wake over the course of 2014 and into 2015.Local, national, and international authorities werenot adequately prepared and did not have effectivepreventive measures in place, despite long-standing international health regulations, require-ments, and policy commitments. When theinternational community stepped in to address theEbola outbreak as an “international threat to peaceand security,” its response was late and externallydriven. The crisis did not come under control untilinternal and external actors cooperated. Throughthis cooperation, external actors brought expertiseand resources (including military forces andcapabilities), traditional and community leaderswere engaged in outreach and messaging, andtraditional burial practices were challenged andsafe practices adopted through joint efforts.Lessons learned from the perspectives of both

authors in these post-conflict settings center oncommunity engagement and the need to address

the different health service needs in urban andrural settings. Tapping traditional leaders andcommunicating in local languages were alsoessential to reaching the population. Both authorsmention the role of the military (national and non-national) in the emergency response. Directly andindirectly, the authors question the role of themilitary but acknowledge that quarantines andcontrols, while unwanted, were essential to bringthe outbreak under control.For the governments of Sierra Leone and Liberia,

the Ebola crisis offers an opportunity to assumeleadership in preventing and preparing for the nextepidemic. To create a networked approach tohealth service delivery that can contain the nextepidemic or manage the next health crisis, they willneed effective leaders at multiple levels who takethe initiative to work in conjunction with the UN,WHO, and major NGOs. In neither Liberia norSierra Leone did international partners and localactors work to address the crisis while simulta -neously building sustainable capacity to managehealth emergencies.Drawing upon the lessons from this painful

experience, national leaders should initiate reformsto prepare and strengthen the health sector.Commitments have been made to invest in thefuture of the health sector as the crisis abates, andpolicies and programs are now available tostrengthen the health sector. This is a rare momentfor national leaders to engage the internationalcommunity and commit to strengtheninggovernance and specific health managementpractices.

ConclusionMaureen Quinn

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