# **1. Introduction**

Over 8 million people die annually in low- and middle-income countries from treatable conditions. In addition to the human suffering, in 2015 these preventable deaths generated USD 6 trillion in economic losses (Kruk et al. 2018). These deaths are particularly tragic because care is often available at little to no cost, but there is under-utilization of available health services (Dupas 2011). Low quality of care is thought to be a major factor responsible for low utilization (Banerjee et al. 2004; Das et al. 2016). More than half of patients surveyed by the Lancet Global Health Commission across 12 countries report that they did not seek necessary medical care in the preceding year, because they lacked confidence in their local health system (Kruk et al. 2018, e1211).

This point has been underscored by the recent intractable Ebola outbreaks — in West Africa from 2014–2016, and in the Democratic Republic of Congo since 2018. In September 2014, the World Health Organization (WHO) described West Africa’s Ebola epidemic as “the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people, so quickly, over such a broad geographic area, for so long” (WHO 2014). At that point, less than 7,000 individuals had been infected. By the end of the crisis in early 2016, the Centers for Disease Control and Prevention (CDC) estimated more than 28,000 confirmed, suspected, or probable cases (CDC 2019). Sierra Leone, one of the three most heavily impacted countries, accounts for roughly half of those cases and just under 4,000 deaths.

As with other infectious diseases, Ebola containment efforts emphasize early isolation and treatment. Ebola spreads through the transmission of infected bodily fluids; reducing the reproduction rate, thus, requires “reducing the time between when people first show symptoms and are isolated” (Whitty et al. 2014, 193).<sup>1</sup> Yet, fears about sub-standard care and a lack of trust in health workers and the health system deterred symptomatic patients from visiting clinics: “Local communities were suspicious of efforts to test, treat, and isolate patients with Ebola symptoms and engaged in practices of hiding sick family members, running away from local communities, or attempting to manage the course of Ebola within local households and communities” (Abramowitz et al. 2016, 24). Thus, low utilization of health services, reflecting a lack of confidence in the quality of care, is thought to have been a major obstacle to early treatment and containment of the Ebola epidemic in West Africa. This is not specific to Ebola: public confidence in health systems affects efforts to contain other epidemics, including the novel coronavirus (COVID-19).

What can be done to improve confidence in health workers, and the perceived quality of care of health

> 1 Seeking treatment not only prevents transmission, but also increases the patient’s survival prospects: Garske et al. (2017, 5) report case fatality rates of over 90 percent for patients in Sierra Leone with no or unknown hospitalization status, but that rate drops to less than 60 percent for patients admitted to Ebola treatment units or holding centers in Sierra Leone (see also Waxman et al. 2017).

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