# **Introduction**

The recent outbreak of Ebola in West Africa, which began in late 2013 and has claimed more than 11,000 lives to date,<sup><u>1</u></sup> has brought awareness to the issue of health system resilience. Much coverage of this issue has addressed resilience to the epidemic itself, highlighting how the limited capacity of health systems in the three most affected countries – Guinea, Liberia, and Sierra Leone – allowed Ebola to proliferate rapidly, with inadequate numbers of qualified health care workers and weak infrastructure (among others) precluding the development of an appropriate and timely response to the outbreak.<sup><u>2</u></sup> Beyond the deaths and suffering caused directly by Ebola, however, weak health systems hit by the disease are left without the resources to deal with other normally treatable conditions. Recent research and media reports speak of a “vicious cycle” in which, because of Ebola, there has been a significant increase in the number of people not being treated for malaria, cholera, measles, and HIV.<sup><u>3, 4, 5</u></sup> Women have reportedly been reluctant to visit or have been turned away from overextended hospitals for pre- and post-natal care.<sup><u>6, 7</u></sup>

**Table 1: Ebola Infection and Mortality Rates for Civilians and Health Care Workers**

||Civi|lians|Doctors, nurse|s, & midwives|
|---|---|---|---|---|
||Cases (% of<br>population)|Deaths (% of<br>population)|Cases (% of<br>workforce)|Deaths (% of<br>workforce)|
|Guinea|0·03%|0·02%|2·72%|1·45%|
|Liberia|0·25%|0·11%|10·30%|8·07%|
|Sierra Leone|0·21%|0·06%|10·67%|6·85%|

Source: Author calculations based on infection and mortality data from the WHO<sup><u>1,8</u></sup> and population data from World Development Indicators.<sup><u>9</u></sup> Note: For this analysis civilians means all inhabitants who are not doctors, nurses, or midwives. Data on health care worker deaths are from May 21st for Guinea, Liberia, and Sierra Leone.

Moreover, as shown in Table 1, Ebola deaths have, until now, been disproportionately concentrated among health personnel. As of May 2015, across the three countries a total of 35 doctors, 205 nurses and midwives, and 131 other health care workers had died from Ebola; Figure 1 presents stocks before and after Ebola. The fact that health care workers are at greater risk of contracting Ebola compounds the problem of weak health systems, as health care worker deaths will exacerbate existing skill shortages in countries which had few health personnel to begin with. According to the most recent data from the WHO, before Ebola hit, Liberia, Sierra Leone, and Guinea ranked 2<sup>nd</sup> , 5<sup>th</sup> and 28<sup>th</sup> from the bottom among 193 countries in terms of doctors per 1,000 of the population, with densities of 0·012, 0·022, and 0·084, respectively.<sup><u>10</u></sup> Even after Ebola has been eliminated, the reduction in the stock of health care workers from this already low base is likely to have negative effects on the health of affected populations. Furthermore, the disproportionate mortality among health care workers may dissuade students from specializing in health care, making it difficult to increase the density of health care workers.

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