Presidential responses to Ebola in Sierra Leone
Authors: Sebastian Kevany, Fatu Yumkella, Robert-Sam Kpakra, Yakama Manty Jones
Journal: The Lancet Global Health (2018)

In Sierra Leone, the 2014 Ebola crisis and the international response placed impossible demands on the local health system.1Kieny MP Evans DB Schmets G Kadandale S Health-system resilience: reflections on the Ebola crisis in western Africa.Bull World Health Organ. 2014; 92: 850Crossref PubMed Scopus (114) Google Scholar The capacity of a war-torn infrastructure to manage a large-scale international outbreak of an infectious disease reflected a disconnect between supply and demand of health services of momentous proportions. The funds that flowed in at an unprecedented rate, prompted both by donors' altruism and enlightened interest in health, therefore, were as much a relief as they were a burden. Similarly, capacity to use funds was disproportionately low in a health system in need of long-term rebuilding from the ground up—sometimes literally so.2de Jong K Mulhern M Ford N van der Kam S Kleber R The trauma of war in Sierra Leone.Lancet. 2000; 355: 2067-2068Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar Thus, the combination of a post-conflict environment and the urgency of the response made development of innovative investment systems essential. Never has the concept of a sector-wide approach3Cassels A Janovsky K Better health in developing countries: are sector-wide approaches the way of the future?.Lancet. 1998; 352: 1777-1779Summary Full Text Full Text PDF PubMed Scopus (75) Google Scholar been so relevant or important: a pan-sectoral effort to address Ebola disease through a harmonious mix of enhanced political will, local ownership, accountability, monitoring and evaluation, and donor relations. In retrospect, one effort stands out as both successful and avant-garde. Under the Government of Sierra Leone's National Ebola Recovery Strategy for Sierra Leone 2015–2017,4Government of Sierra LeoneNational Ebola recovery strategy for Sierra Leone 2015–2017.https://ebolaresponse.un.org/sites/default/files/sierra_leone_recovery_strategy_en.pdfDate: 2015Date accessed: November 1, 2017Google Scholar both the President's Early Recovery initiative and the follow-up President's Recovery Priorities5The President's recovery priorities.https://docs.wixstatic.com/ugd/767c32_5cefbb0c2b184caeb0d97809957709f5.pdfDate: 2016Date accessed: November 1, 2017Google Scholar initiative adapted elements of the structure of other emergency response models (eg, the Prime Minister's Delivery Unit6Richards D Smith M Central control and policy implementation in the UK: a case study of The Prime Minister's Delivery Unit.J Comp Policy Anal. 2006; 8: 325-345Google Scholar in the UK and the United States President's Emergency Plan for AIDS Relief [PEPFAR]7Bendavid E Bhattacharya J PEPFAR in Africa: an evaluation of outcomes.Ann Intern Med. 2009; 150: 688-695Crossref PubMed Scopus (121) Google Scholar) to the setting of Sierra Leone. Acutely cognisant of the limitations of the health system, this national strategy created a similar post-epidemic supportive hierarchy to that in the UK and US initiatives which (1) spanned all government departments, (2) enhanced monitoring and evaluation of national development efforts, and (3) had unprecedented authority to direct national and international resources to the epidemic. A further logic to the President's Recovery Priorities approach was a kind of benign quid pro quo: just as the country's trade, industrial, and agricultural sectors were all affected by the outbreak, all of them were drafted into the national recovery. In practice, this was represented by all ministries reviewing portfolios to see where their purviews might yield positive outcomes for public health. Where such opportunities were identified, such as through the Ministry of Education introducing improved sanitation in areas affected by Ebola, presidential momentum and authority (as was the case with PEPFAR)8Dietrich JW The politics of PEPFAR: the President's Emergency Plan for AIDS Relief.Ethics Int Aff. 2007; 21: 277-292Crossref Scopus (54) Google Scholar ensured that they were prioritised. The resulting system-level effect was threefold: it helped to rebuild trust in Sierra Leone's overstretched health system, it improved the functionality of the health system through collaborative community ownership, and it taught involvement in the national health response among non-health actors. As a result, synergies between sectors as diverse as education and water were harnessed for the national recovery. The subsequent evaluation of the President's Recovery Priorities effort was posed with three main challenges: how to measure progress in nebulous realms such as good governance; how to collect timely local information on long-term effects and their associated sustainability; and, perhaps most importantly, how to capture synergies that resulted from collaborations between sectors. The evaluation report,9Government of Sierra LeoneDalan Development ConsultantsGoSL 6–9 month early recovery priorities.https://docs.wixstatic.com/ugd/767c32_00256f549ff943b8b7dfcbe7adfe60e1.pdfDate: 2017Date accessed: November 1, 2017Google Scholar published in 2017, described the establishment of small data collection teams equipped with interview guides aimed at community members, which added an element of immediacy to input from grassroots. Feedback was then collected on possible interactions between the delivery of commodities such as cleaner water supplies and the extent of their connection with national recovery efforts. Similarly, hard-to-quantify programmatic areas such as good governance were addressed through interactions with programme coordinators at the district and national levels. In many cases, the latter described the redistribution of power and responsibility (at both the district level and the highest echelons of government) as a driving force behind the successes of the President's Recovery Priorities initiative. The recalibration of power and authority that is necessary for initiatives such as the President's Recovery Priorities and PEPFAR can, however, be a double-edged sword. Czar is both an intimidating and pejorative term; however, in this case the answerability of government ministries and agencies directly to the (then) President of Sierra Leone meant that queries were addressed in unprecedentedly responsive, centralised ways. In emergency situations, it seems, centralised control of global health responses can sometimes be the most effective choice of management.10Gostin LO Sapsin JW Teret SP et al.The Model State Emergency Health Powers Act: planning for and response to bioterrorism and naturally occurring infectious diseases.JAMA. 2002; 288: 622-628Crossref PubMed Scopus (149) Google Scholar Public health emergencies in conflict or post-conflict environments make it necessary to consider not just lateral responses but counter-intuitive ones as well. For the President's Recovery Priorities intervention, the principle of a holistic response—considering not just Ebola but also broader infrastructural, social, economic, and even political contexts—has been one of the most valuable innovations. As a result of the related augmentation of local leadership, the President's Recovery Priorities demonstrated that cohesive and coordinated efforts that include non-intuitive stakeholders enhance the response. That domestic actors in a resource-limited and traumatised country led the development of this paradigm is testament to the value and insights of local knowledge and ownership.11Kevany S Global health diplomacy, “San Francisco Values,” and HIV/AIDS: from the local to the global.Ann Glob Health. 2015; 81: 611-617Crossref PubMed Scopus (5) Google Scholar We declare no competing interests.