Ebola: it’s governance, stupid


The latest World Health Organisation (WHO) statistics on the current Ebola virus disease (EVD) outbreak are startling.

As of 11 November, there have been 14,413 reported cases of Ebola and 5,177 deaths across eight countries (Guinea, Liberia, Mali, Sierra Leone, Nigeria, Senegal, Spain and the United States) since the outbreak began in March 2014.

Of that figure, 570 are healthcare workers, 324 of which have died.

WHO believes that the number of cases and deaths are being significantly under-reported, meaning that the real toll of this epidemic could be significantly worse.

Then there is also the economic cost. In its “low Ebola” scenario, the World Bank estimates GDP losses in 2014 and 2015 of around US$3.8 billion. The “high Ebola” scenario puts that figure at US$7.4 billion for 2014 and US$25.2 billion in 2015.

But how did we get to the point where the bulk of the responsibility for tackling the world’s worst Ebola outbreak fell to a single, private NGO?

As the Guardian recently put it: “While western donors dithered and other aid groups pulled out, MSF [Médecins Sans Frontières] deployed hundreds to the Ebola “hot zones” and treated more than 3,000 patients.”

The aforementioned question, recently posed by MSF UK Executive Director Vickie Hawkins at a think-tank event on Ebola, may be a provocative one but it offers a profound critique of our era of neoliberalism, privatisation and the roll-back of social protection, as well as state fragility and failure.

As debates rage on in the UK about the creeping privatisation of the NHS, Hawkins’ question is as relevant in developed countries as it is in developing ones.

Dr Paul Farmer, Harvard Medical School Professor of Infectious Diseases and founder of the Boston-based NGO Partners in Health, says that the Ebola crisis in the worst-affected countries of Guinea, Liberia, and Sierra Leone, is exacerbated by a lack of “staff, stuff, and systems”.

A recent budget speech made by Sierra Leone’s Minister of Finance and Economic Development, Dr Kaifala Marah, puts Dr Farmer’s assertion into sharp focus:

“Sierra Leone needs 3,300 medical doctors. There are at present 386 doctors including only nine dental surgeons in the country, leaving a gap of 2,914 doctors. The estimated number of nurses and midwives is 1,365. Estimates from the Ministry of Health indicate that an additional 8,615 nurses and midwives are required.”

Root causes

But while weak healthcare systems provide an immediate explanation for the spread of Ebola in west Africa, we need to look far deeper.

Starkly put, the Ebola epidemic is first and foremost a failure of governance. Only once that problem has been addressed can a lasting solution be achieved.

These failures are multidimensional. Globally, there is massive in-fighting between WHO’s Geneva headquarters and its Africa regional office.

Professor Peter Piot, who discovered the Ebola virus in 1976, says the latter “isn’t staffed with the most capable people but with political appointees”. But WHO HQ’s own failings are slowly coming to light, too.

And as MSF’s international president, Dr Joanne Liu pointed out at the UN General Assembly in September, despite the fact that MSF had been “been ringing alarm bells for months,” the international response, when it did come, was “too little, too late,” with leaders failing “to come to grips with this transnational threat.”

On a regional or sub-regional level, the response of the African Union (AU), the Economic Community of West African States (ECOWAS) and the Mano River Union (Guinea, Liberia, Sierra Leone and Ivory Coast), could most charitably be described as muted.

At a national level, things are even worse.

The Ebola outbreak is just the latest indicator that something is profoundly wrong with governance in these three countries.

A cholera outbreak in 2012 that killed close to 400 people in Guinea and Sierra Leone (but failed to garner anything close to the level of attention devoted to the current Ebola outbreak) highlighted similar systemic challenges.

An audit following a corruption scandal in Sierra Leone involving funds from GAVI, the global Vaccine Alliance, found that: “financial controls in the Ministry of Health and Sanitation were weak, leading to misuse of GAVI HSS [health system strengthening] funds. The audit established that US$523,303 had been misused.”

Consecutive reports by Sierra Leone’s Auditor-General highlight some of the problems with healthcare provision in the country, such as overcrowding, chronic doctor shortages and limited supplies and equipment.

Quite tellingly, the fact that the auditor’s report indicates that many queries went unanswered demonstrates low levels of accountability for the country’s public officials, even though these audit reports are submitted to the parliament.

One of the most common explanations for the extent of the current Ebola outbreak in Liberia and Sierra Leone is that both countries went through debilitating civil wars which devastated their healthcare systems.

This is true in part, but it is worth bearing in mind that even as early as 1990 – a year before the war in Sierra Leone started and the first year of the United Nations Development Programme’s (UNDP) Human Development Report, Sierra Leone ranked fourth from the bottom in the Human Development Index ranking.

The Ebola response has been characterised by too many square pegs in round holes: officials appointed because of political patronage rather than merit; groupthink; too many meetings and not enough action; a murky business-as-usual approach to public procurement that has resulted in inferior equipment which greatly endangers the lives of patients and healthcare workers.

While the international public outcry – and rightly so – has been on the delay in the provision of Ebola treatment centres by the international community, and of adequately trained healthcare workers, this has been at the cost of more critical scrutiny of the way in which local constraints have had as much impact as international shortcomings for the abysmal response so far.

Local agency, positive deviance

There are some bright spots, however.

While the general thrust of international media coverage has defaulted to the tiresome narrative of helpless Africans utterly dependent on their former colonial powers, rich countries and ageing rock stars for help, the considerable evidence of promising local agency that’s emerged in response to the crisis has been widely ignored.

In the Ebola hotspot of Lunsar in northern Sierra Leone’s Port Loko district, Isata Kabia, an MP with the ruling All People’s Congress party, was approached by young constituents who wanted to know how they could help.

This was at a time when calls to the emergency hotline were going unheeded, when bodies were left uncollected by burial teams in houses for three or more days, when quarantined households would not receive the basic essentials needed for their survival.

These young people became de facto first responders. They saved lives by ensuring ambulances arrived, by monitoring quarantined households to ensure they got the food and supplies they needed and by calling the authorities if people fell ill.

This isn’t an isolated case; there have been countless other examples of local agencies supplementing the often inadequate national response, and, in the process, pointing to what is actually missing in not only healthcare systems but in governance arrangements more generally.

These coalitions of grassroots actors and local elites – individual MPs, chiefs, professionals, business persons – are promising examples of positive deviance.

These significant coalitions of the willing mount their own powerful critique of the business-as-usual approach to (bad) governance that blights these Ebola-hit countries.

In the contours of their response, we can detect public service, compassion, integrity and competence – all vital ingredients for any post-Ebola institution.

The most useful role the international community could play would be to give more space to these emergent examples of good practice: through media coverage to offer the oxygen of publicity and visibility; and by facilitating the required space for the evolution of learning, problem-solving and collective action to move forward from this point with renewed vigour and vision for the future.

But most importantly, the international community must avoid crowding out local initiative.

It’s time for a new era of ground-up institutional building that augurs for development and progress – not just for Ebola-hit countries but for all of us searching for a new beginning in a world that seems to offer few options.