“There is no Ebola here”: lessons from Uganda and Liberia on the political economy of epidemics

By James Akhungu

It was not supposed to be this way. Especially after the west Africa Ebola outbreak in 2014 that saw renewed determination that epidemics of such magnitude should not be allowed to happen again. UN agencies restructured their emergency response teams, research teams plowed millions of dollars into new pharmaceuticals, and academic journals were full of new insights and understandings into this previously poorly understood disease.

The World Health Organisation (WHO) on 17th July, 2019, declared Ebola in Democratic Republic of Congo (DRC) a “public health emergency of international concern”. The outbreak since August 2018 has claimed more than 1800 deaths. While central to unearthing the underlying factors behind slow response to the Ebola outbreaks, the influence of political-economic factors remains under-researched, yet they determine the degree of decentralization, health systems resilience, political commitment and community participation. This article argues that despite the existence of a vaccine developed during the recent West Africa Ebola epidemic, the current outbreak in DRC has not yet been fully brought to control.

This article borrows a leaf from a comparative case study analysis of two countries in sub-Saharan Africa: Uganda and Liberia. It highlights why Uganda was successful in responding to Ebola outbreaks effectively in a short period of time as compared to Liberia despite both reeling from effects of civil war. Second, the comparative analysis for Uganda and Liberia brings out that the political commitment of a government and resilient health system and community participation play great role in combating an epidemic. Countries in the sub-Saharan Africa can entrench their health systems with a bottom up approach and decentralize health care systems to be effectively respond to future outbreaks.

The first Ebola hemorrhagic fever, linked to Ebola Sudan Virus, was reported in August 2000 in Gulu district, north of Uganda. Coincidentally, Gulu area was at the epicenter of civil strife involving the Lord resistance Army, a rebel group, and the Government of Uganda (GoU) which had lasted for 20 years. With the zeal to tackle the Ebola epidemic, Yoweri Museveni, Uganda’s president commissioned: National Task force (NTF), the District Task Force (DTF) and an inter-ministerial task force in the early stages of the outbreak to provide the political direction.

The DTF at the village level played a prompt role of sharing information to NTF. Through the decentralized office of prime minister, a strategy was formed to support mobilization and innumerable components of communication. The communication strategy was inclusive and engaged a team from: local communities, health workers, international team and surprisingly the rebels. Through engagement with other partners like WHO, GoU was able to raise US$1.3 with focus on DTF operations. At the end of the operations, GoU was able to bring to halt the epidemic after 4 months and 11 days with 224 deaths out of the 424 reported cases.

In Liberia, the Ebola outbreak occurred in June 2014 and was linked to the Ebola Zaire virus strain. At the time of the outbreak, the health system in Liberia was centralized. The Government of Liberia (GoL) had little appreciation for localized methods of combating the epidemic like the “Fatu Kekula’s” was not adequately embraced, yet at the community level it was a success. At one time during the outbreak, youth of King Gray Community led in resisting GoL response efforts in combating the Ebola. There was a lot of mistrust between the affected communities and GoL due to perceived plundering of resources by top leadership. Due to the centralized health system and inadequate communication and coordination between government and affected communities, 10,666 cases were reported and 4,806 deaths occurred in Liberia.

While recent literature primarily links weak dysfunctional health systems to the slow response, it was the degree of Liberia’s centralised and Uganda’s decentralised governance structures and levels of community participation that were crucial in determining coordination and allocation of resources. The creation of these governance structures was driven primarily by political-economic factors, as crucial determinants of the financing needed for the highly-debated robust and resilient health systems.

The impact of Structural Adjustment Programmes (SAPs) instituted by the International Monetary Fund (IMF) in the 1980s has not been a proven a factor in this article, but there is value in future studies examining how IMF loan conditionality limited decentralization of health care and government spending on social services such as public health.

In contrast to Liberia’s Ebola response, one explanation of Uganda’s success in a relatively short period is that, because of transitioning from the political economy of disorder associated with civil war and broken social contracts, Uganda was able to reconstruct and develop its state society relations and capacities. This fairly stable political-economic environment with a cohesive government that was favoured by 90 per cent of the population, made it easier to win the trust and ownership of the community while coordinating and implementing national and international recommendations.

The DRC health care system according to WHO, doesn’t have a blueprint for effective leadership and governance. Due to the civil strife that faced DRC for more than three decades, the centralized health care system got distorted and has been characterized by: duplication and waste of resources, inefficient work force deployment and duplication of supply chain and disproportionate management cost. Its health care expenditure has the bulwark proportion financed by households (40%), followed by multilateral co-operation at 26%, central government of DRC contributes 11% whilst the rest is attributed to other stakeholders like non-governmental organisations and cooperation.

WHO as a multilateral cooperation has always been on the forefront to participate in combating the reported Ebola outbreaks, as reported in the Uganda and West Africa cases. WHO, as the technical lead has partnered with other organizations: East Africa Community (EAC) secretariat, Africa Union (AU), Center for Disease Control (CDC) and German Society for International Cooperation (GIZ) in June 2019 to perform a cross border field simulation to access level of preparedness in the East Africa region. Media Force Communication (MFC) a subsidiary of ADRES Group has been documenting the cross-border field simulation exercises since 2018.

USAID is advocating for a decentralized health care system in DRC to enable efficient service delivery. Eventually,  trust, coordination and community ownership from various actors in the health sector will lead to a better combating strategy. It is not too late for the government of DRC to employ similar methodology and record another success story like Uganda in the Ebola epidemic.

On the brighter side, on 13th August 2019, Dr. Jean Jacque Muyembe and his team announced that they had come up with treatment which was effective in curing an Ebola patient within an hour of administering, if the patient’s case is reported early. But to declare victory against the virus would be to overlook fundamental truths about outbreaks. In some circumstances at least — and the current long-running outbreak is one — Ebola will not be vanquished by vaccines and drugs alone. Political-economic factors at the national and international level determine the degree of community participation and allocation of resources needed to build resilient health systems to effectively respond to future outbreaks.