As the death toll from the latest Ebola epidemic passes 900, West African governments, with support from the international community, are mounting a comprehensive regional effort to respond to the outbreak.  We have reviewed recent IEG evaluations on the World Bank Group’s support to different global crises (financial, food security, and health) in order to identify key lessons for an effective response.  Our most relevant work is the review of the WBG response to the avian influenza, discussed in an earlier blog

We have gleaned the following 10 key lessons to enhance the development effectiveness of project support from the international community in response to the Ebola epidemic.

  1. Weaknesses in health systems are a major contributing factor to disease risk, especially from the lack of trained and equipped medical personnel, contract tracing capacity, sample collection and transport capacity, laboratory diagnostic capacity, and intensive care units with isolation capacity.  The crisis response should support not only immediate emergency interventions but also medium-term risk reduction through public health system strengthening, recognizing that future opportunities to engage may be limited once the crisis has passed.
     
  2. Capacity building efforts should be done in a way that are relevant to more than just a single disease, and should consider from the outset means to build sustainable systems that last beyond the current emergency.  This would likely include support for animal health and veterinary systems, in addition to public health systems, and for managing other zoonoses and infectious diseases.
     
  3. Develop a strong and effective partnership platform to coordinate the diverse support from different international actors, within the WHO-led strategic framework approved last month.  Partners should focus on their specific areas of comparative advantage – for the World Bank Group, this would include building public health system capacity.

  4. Complement national level investments with regional approaches for cross-boundary collaboration on regional public health goods, particularly in the areas of surveillance and monitoring.  However, efforts to try to prevent disease transmission through border control may be ineffective, especially in countries with weak border control services and porous land borders.
     
  5. Communication and awareness campaigns and outreach play an important role in responding to disease outbreaks, especially in areas where the population may have little information about the disease, its transmission mechanism and safe behaviors, and where people may be skeptical of medical interventions.  Communication training for key public officials can be useful, as can efforts to engage with the news media to reduce misinformation and overly alarmist messages. 
     
  6. Hit the right balance between responding quickly and conducting the necessary technical analysis and project preparation to ensure effective design of interventions.  Postponing important technical design work until after project approval can lead to costly delays to the startup of project activities and the procurement of critical goods and services.
     
  7. Balance investments in physical infrastructure, such as laboratories and equipment, with institutional development and capacity building, to ensure that sufficient capacity exists to use and sustain the infrastructure technically and financially.
     
  8. The procurement of specialized laboratory equipment and other supplies can be complicated and time-consuming – it is essential that implementing agencies of governments and regional economic communities have strong institutional capacity to fast-track procurement and manage project implementation.
     
  9. Monitoring and evaluation system design should not be neglected in the rush to provide a rapid response.  Intermediate outcome indicators that track the performance of particular functions (surveillance, sample collection and transport, diagnosis, treatment, etc.) against benchmarks are essential to assess implementation performance and readjust plans in response to real-time developments.  Surveys should assess behavioral practice, not just knowledge.
     
  10. Preventative epidemiology, including effective disease reporting systems, is a necessary means of identifying and tracking disease outbreaks.  Contact tracing of infected individuals is urgent to guide responses to outbreaks.  Many serious zoonotic diseases have significant reservoirs in wild animals, such as bats or birds, and the threat level posed by these diseases may be poorly understood without surveys of wild populations in the medium term.

The international community is poised to help West Africa contain the spread of Ebola infection, cope with the humanitarian and economic impacts of the crisis, and improve public health systems.  We evaluators have an important role to play in sharing knowledge on what works and what doesn’t, and why -- do you have other important lessons to flag to help the governments, regional organizations, and development partners get this right?

Comments

Submitted by John O Brien on Thu, 08/07/2014 - 22:50

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1. This e-mail supported sharing of thoughts is a very welcome and potentially powerful initiative. Well done to those who started it. I and many others will, I am sure, be happy to help, without cost, as much as we can. 2. Health care initiatives need to be situation and development-level specific. This means mirroring the local approaches and "ways-of-doing and respecting and where possible, building on and enhancing local culture and belief systems. Specifically, I intend the intelligent and respectful use of local village health workers and, where available, ( I had first written "appropriate" ), healers and witch-doctors. All outside methods and expertise should be adapted to local conditions, not the other way around, as too often happens. 3. All and any initiatives should actively guard against and make " as impossible as possible" the " well-intentioned but destabilising theft" of local personnel and promising young professionals from the host country to the donors own agencies and countries. Too often, donor actions result in the attraction of scarce personnel from IT, health or other sectors who are badly needed at home but are naturally attracted to the better living conditions offered by well-meaning but misguided benefactors. The host populations are the priority, not lucky individuals with exceptionaal but scarce talents. Very, very few return home to share the benefits. 4. Duplication robs space and energy just when both are very precious. Practical people need to streamline inputs with existing resources. Some "topic experts" are geniuses in their own field but thoroughly incapable of practical co-ordination or communications. Good evaluators need to be able to translate concepts and transfered "situation-learning" to existing, often deficient and stressed systems in ways that really help go forward, rather than simply listing the legion of faults easily discernible to those of us with time and office space. ( I write, honestly and humby as I review with hindsight my own much earlier "less-than-fully-adequate" personal practice in the field ) 5. Where possible, choose "grey haired", experienced managers and evaluators, with proven judgement, empathy and humanity, who have relevant and adequate/extensive practical experience in the fields involved. Theory and optimal computer and research skills can build a fine career, but, in tackling real systems issues at front-line levels calls for so many skills and personal qualities, in short order, that even the most promising young experts from universities cannot hope to be able to cope and contribute effectively, in such environments. 6. Go basic with measurement tools. E.g. head circumference of babies at birth gives a wonderfully cheap, simple and effective long-historical indicator of maternal health and nutrition and requires no fancy equipment, electricity supply or PhD from an expensive foreign university. Reject all expenditure plans that require emulation of high-tec, expensive and doubtfully essential tools from western "technological-imperatives-driven " approaches. How often have we used up too much of the budget gearing up local systems to a "once-off" high-skill capacity, at the cost of effective and more effective "low-tech" initiatives that work for more people?? 7. "Health economics are critically important. Too often politicians want their statue in the garden for having "imported" the latest high-tech tecnology for triple or more by-passes or transplant surgeries, at the expense of wide-spread basic health education programmes. The health ed is much less sexy and not much use to the super wealthy elite wwho go to Switzerland for dental appointments, but it would certainly be much more effective in this Ebola outbreak ! 8. Maybe bringing much-needed light on this health care policy choice, in developing nations, is one of the few positive points to emerge from this outbreak ?? The drug companies will not support my ideas, nor will the politicians, local or international, or the many health care services marketing agencies who want to build and staff western systems in other cultures. But, if we are really interested in saving lives and stopping the spread of such epidemics in the future, we should at least be asking pertinent questions. I am a former health educator and evaluator, now retired.

Submitted by Stephen Hutton on Thu, 08/07/2014 - 23:53

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Thanks John for the interesting comments, I agree that communication efforts between international and local agencies and institutions will be key, and coordination to avoid duplication will be important, as will health education and awareness raising. Practical indicators that can be utilized under severe local capacity constraints will also be needed. These challenges also came up in the Bank's efforts to respond to avian influenza over the last several years.

Submitted by Marlyn Aniwa on Sat, 08/09/2014 - 04:32

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These 10 point key lessons are very relevant and hold true to the situation in the West Africa sub-region. It is a myriad of factors that have led to the quick spread of the disease in West Africa. Key being the poor health infrastructure and the failure of Government and Leadership to act swiftly and decisively. Time and time again African Leaders have been told to invest in education, healthcare and basic infrastructure etc. But this has gone unheeded for years and this is the resulting outcome. That when an epidemic strikes, it will spread like wildfire and the systems and structures will not be able deal with it. We hope that the governments within the sub-region will learn from this experience as efforts are being made to contain the outbreak.

Submitted by Rick Scobey on Mon, 08/11/2014 - 07:45

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Marilyn -- Thanks for the feedback. We agree that effective and transparent government action is critical, and hope the evaluation lessons from past interventions will help inform the best public policy choices and investments. We also see essential roles for the Regional Economic Communities in promoting trans-boundary solutions, NGO's in augmenting service delivery in local communities, international partners in sharing the latest knowledge and technology developments, and the media in reporting and ensuring accountability for results -- we are all in this one together!

Submitted by Shashika Wiejsinha S on Mon, 08/11/2014 - 21:20

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Here in Sri Lanka a special unit is been placed at the Katunayake International Airport to check whether any Ebola patients are visiting our country. Public awareness by the media for prevention is also prominent. S Wijesinha Sri Lanka

Submitted by Rick Scobey on Tue, 08/12/2014 - 07:15

In reply to by Shashika Wiejsinha S

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Thanks for sharing the new measures in Sri Lanka.

Submitted by Makena Wakena on Tue, 08/12/2014 - 04:34

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The points that stand out for me are 4, 5, 6 and 10; I think it is imperative to apply regional approaches and coordinated efforts in tackling disease outbreaks endemic in some regions in Africa, possibly by sharing epidemiological data and lessons learnt among the public health officers and even contextualizing preventive measures and roles to be played by communities concerned in order to curb further spread. Certain practices, rights and rituals tend to be regionally similar and so the vital messages of prevention and awareness of the disease can be shared especially after the first few confirmed cases or fatalities. I think this allows for adequate response to the outbreak especially with community involvement.

Submitted by Rick Scobey on Tue, 08/12/2014 - 07:16

In reply to by Makena Wakena

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We share your view on the importance of regional approaches -- this was a major finding of our recent work on the World Bank Group response to avian influenza, which can be found at: https://ieg.worldbankgroup.org/Data/reports/avian_flu1.pdf. The World Bank has launched a new operation to strengthen regional disease surveillance and response system of ECOWAS, but IEG will not review its performance or results until after the project is completed (estimated around June 2017) and the team has completed its self-evaluation. If you are interested, the World Bank's self-assessment of current implementation can be found at: http://www.worldbank.org/projects/P125018/west-africa-disease-surveillance-response?lang=en&tab=overview

Submitted by Katia Diaz (IEG) on Mon, 08/25/2014 - 07:53

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For those very intereseted in data and getting the inside of the numbers with interactive data graph, I'm sharing very useful and stunning data visualizations that track the Ebola outbreak in West Africa 2014, dealing with data at country-level and at sub-national level from reports of data from the World Health Organization (WHO). * Chronology of all Ebola virus outbreaks, 1974-2014 http://healthintelligence.drupalgardens.com/content/chronology-ebola-virus-disease-outbreaks-1976-2014 Information about the number of outbreaks of Ebola virus disease in history and affected countries * Current Ebola outbreak in West Africa - sub-national level http://healthintelligence.drupalgardens.com/content/ebola-virus-disease-outbreak-west-africa-2014 Data from this outbreak as June 22nd, 2014 is visualized helping to see the current situation based in three main metrics.1.cumulative number of cases, 2.cumulative number of deaths, and 3.case fatality ratio. * Tracking the Ebola virus disease outbreak,West Africa 2014 - country level http://healthintelligence.drupalgardens.com/content/tracking-ebola-virus-disease-outbreakwest-africa-2014 This data visualization allows: 1.explore the evolution of cases and deaths since the beginning of the outbreak to the most recent reported data. 2. A trend line chart of cases and deaths by country.

Submitted by Shashika Wijesinha S on Wed, 09/03/2014 - 22:12

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More awareness about the Elola Virus and how it is spread and prevention methods should be introduced to every individual, for example what are the symptoms of Ebola etc. should be known by the public as they will know when to visit the doctor etc. is it cased by a common cold etc.

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