May 9, 2015, marks 42 days since the last confirmed case of Ebola in Liberia was safely buried — the period of time set by WHO to declare an outbreak over. WHO now considers Liberia free of Ebola transmission. Reaching this milestone is a testament to the strong leadership and coordination of Liberian President Ellen Johnson Sirleaf and the Liberian Government, the determination and vigilance of Liberian communities, the extensive support of global partners, and the tireless and heroic work of local and international health teams. This story is about the factors that contributed to Liberia’s success.
Making the Ebola response a priority
The first decisive factor was the leadership shown by President Sirleaf, who regarded the disease as a threat to the nation’s “economic and social fabric” and made the response a priority for multiple branches of government. Her swift and sometimes tough decisions, frequent public communications, and presence at outbreak sites were expressions of this leadership. As President Sirleaf famously stated in her memoir, “The size of your dreams must always exceed your current capacity to achieve them. If your dreams do not scare you, they are not big enough.”
Community engagement plays a critical role
Second, health officials and their partners were quick to recognize the importance of community engagement. Health teams understood that community leadership brings with it well-defined social structures, with clear lines of credible authority. Teams worked hard to win support from village chiefs, religious leaders, women’s associations, and youth groups.
One of the first signs that the outbreak might be turned around appeared in September 2014, when cases in Lofa county, Ebola’s initial epicentre, began to decline after a peak of more than 150 cases a week in mid-August. Epidemiologists would later link that decline to a package of interventions, with community engagement playing a critical role.
In Lofa, staff from the WHO country office moved from village to village, challenging chiefs and religious leaders to take charge of the response. Community task forces were formed to create house-to-house awareness, report suspected cases, call health teams for support, and conduct contact tracing.
See-through walls around the treatment centre replaced opaque ones, allowing families and friends to watch what was happening inside, thus dispelling many rumours.
Calls for transportation to treatment facilities or for burial teams were answered quickly, building confidence that teams were there to help.
Generous support from the international community
The effectiveness of this response, which was duplicated elsewhere, points to a third factor: generous support from the international community, including financial, logistical, and human resources. This support added more treatment beds, increased laboratory capacity, and augmented the number of contact tracing and burial teams.
The deployment of self-sufficient foreign medical teams from several countries had a dramatic impact on the outbreak’s evolution.
Finally, strong coordination of the international and national response was essential for success. International support was slow to start, but abundant when it arrived. Innovations such as the Presidential Advisory Committee on Ebola and introduction of a incident management system helped ensure that resources and capacities were placed where needed.
Many of these lessons and experiences are reflected in WHO’s new response plan, which aims to identify all remaining cases in West Africa by June 2015.
Liberia succeeds in fighting Ebola with local, sector response
The story of how Liberia’s most populous county, Montserrado, turned around an exponentially-growing Ebola outbreak is intriguing. WHO’s team and national officials, aided by veterans from WHO’s polio eradication group in India, decentralized the response, using quality management principles that empowered local teams and held them accountable for results. These local sector teams involved more than 4,000 community members, using business best practices and an incident management system to vastly improve surveillance, case finding, contact tracing, and overall management of key response activities.
Liberia, where the Ebola outbreak seeing exponential growth in cases last September and treatment centers filled up the day they opened, started to turn back the epidemic when it organized and empowered local teams to handle the response.
Essentially the government decided to decentralize the Ebola management system and break it down into four smaller systems. This allowed for better quality control on surveillance, case finding, contact tracing, and overall management of key response activities necessary in tackling the Ebola outbreak.
In late November 2014, following the height of the Ebola outbreak in Montserrado, the largest county in Liberia, the country’s National Incident Management System began working to decentralize the Ebola response. Teams were organized and partners were integrated into a new “sector approach,” that divided the county into four sectors.
This new method worked by grouping smaller, localized teams for a more nimble and rapid response and empowering local staff for enhanced community engagement. It also introduced a new performance-based management system, which made every staff member involved accountable for their own work.
The zone-level approach reflected historical community identities and ties. Instead of dividing epidemiological zones by purely administrative district organization, it localized the areas, so communities could track their own Ebola cases and contacts. Health officials, local citizens and partners worked together in each sector and made operations more effective, taking advantage of the strong sense of community and identity.
The objective of the Montserrado sector approach was to “hunt the Ebola virus disease” in controlled zones of the sector, using timely local responses. In 2 months, the sector approach brought the Ebola outbreak under control in Montserrado. Sector teams coordinated with localized response teams, increasing outreach and handling issues locally using a ‘good neighbor’ approach and “door-to-door” engagement.
The sector approach worked because it was managed by the people of Liberia in their own communities. Also those who came from outside to help, respected local voices, laws and leadership.
Customized solutions to fight Ebola
Agile, customized sector solutions were encouraged, leaving sector leaders free to design localized responses around a strongly structured, technical “pillar” based organization. The Health Ministry, Incident Managers and partners agreed that these would cover case detection (investigation, tracing and active case finding), epidemiological surveillance, case management, psycho-social activities and community engagement. A similar framework was adopted at all levels of the “sectoral system” from the national level, to county, sector and zone levels.
Active daily coordination of sectors and cross cutting responsibilities reduced overlapping activities, fostered improvements and supported areas where performance was lagging. A WHO expert team from India, which had vast experience in combating polio in that country and knew the importance of good localized epidemiology and response, provided robust technical support, helping build strong cohesive sector teams.
This decentralized approach also enhanced quality management by building a customer service system that would work with potential cases in each community to diagnose every patient and get them the care they needed quickly.
The approach introduced a performance-based management system, which outlined goals and targets for each staff member with very specific indicators. Those in charge of meeting goals had to provide relevant data on their regions and report on whether they had been met.
Partner response by staff in each sector left no doubt about strategies, objectives and responsibilities, and in many cases partners appointed people from the communities to maximize their responsibility. The resulting public accountability in terms of effectiveness and sectoral performance enriched community engagement and made it easier to mobilize responders and citizens around specific issues.
The success in controlling the Ebola outbreak in Liberia is partially due to this sectorial approach, which is a good model for work in other affected countries and for future outbreaks.
Source: World Health Organisation