This spring, when my team from the Ebola Response Anthropology Platform evaluated Community-Based Ebola Care Centres (CCCs) in Sierra Leone, one thing we constantly heard complaints about was human-resource management. Residents of the communities where the Centres were located grumbled about favouritism: well-paying jobs in the Centres were given to friends and family of the local paramount chiefs. Local health authorities questioned the medical competency of CCC staff. Staff in primary health units complained about unequal pay and benefits. We focused on the views on the development, implementation and relevance of the CCCs from the perspective of the communities next to and near where they were located. Meanwhile, a different evaluation team which focused on the quality of care in the Centres was coming to a very different conclusion. They did report that the Ministry of Health and Sanitation, implementing partners, staff at Community Care Centres, and community members agreed that the initial intention to hire local laypeople had been abandoned. But they concluded that the human-resource management model that had been used was acceptable and feasible. Both evaluations found that the medical care, the provision of food for patients and the attention and skills of medical staff in the CCC were highly appreciated by the residents.
How can these different findings be understood? It is perhaps useful to start with a distinction between the process of establishing the CCC and the result. The CCCs were developed at an uncertain time when predictive models warned of potentially millions of new cases transmitted in communities. There was a perceived possibility of a system-wide shortage of beds. In response to this threat, the UK Department for International Development (DFID) and its international and national partners supported the development of new care centres located in communities. Local people could come forward voluntarily to be isolated if they suspected that they had the disease. Communities in Sierra Leone had low levels of trust in government authorities and services before Ebola. The Ebola response used traditional hierarchical political structures to reach communities, in consultation with District Ebola Response Centres that were specially set up in parallel to existing district-level state systems. Some of these district-level facilities were still functioning, while others had collapsed.
The selection of the site for the CCC went through the traditional paramount chiefs, who govern several chiefdoms with different levels of traditional authority. When our evaluation team asked different groups of people living in these communities about how the CCC was developed, it was natural for them to express their discontent over how the site and staff were selected. We also heard grievances about the use of land and water. But for a team discussing only the quality of care inside the CCC, the topic might not have come up. CCC workers were offered hazard pay and free meals, at a time when few jobs were available due to a severe recession. It is natural for those in the community who do not receive such jobs (or who do not have relatives who do) to be envious, even if they may simultaneously be gladdened by the free health services the centres provide. In a context with such inequality this is not surprising.
Most CCCs saw few or no Ebola patients, which may have made the jobs in the CCC especially attractive. By the time most CCCs were implemented several Ebola Treatment Units (ETU) had been put in place, offering high-quality medical care. Ambulance services expanded rapidly, meaning that suspected Ebola cases could be sent directly to the ETU, bypassing the CCC. With few Ebola cases to treat, and with the local population having lost its access to medical care (the already-weak health system with fees for service having collapsed), medical staff in many CCCs started to provide free health care beyond Ebola treatment. This could be seen as a form of mission creep that raised false hopes and expectations about the post-Ebola health system. It is also—as many international non-government organisations and policy makers pointed out to both evaluation teams—a parallel system. But the provision of health care to people in need is arguably in line with medical professional ethics and duties.
The positive evaluation of the care and staff in CCCs demonstrates that people appreciate good and affordable (i.e. free) health services even when these are provided in an Ebola care centre. It also suggests that some of the reports about people’s fear of Ebola and distrust of health staff may be exaggerated. Communities had already taken innovative actions such as using plastic bags as makeshift protective gear and adapted traditions to meet biomedical concerns. Our evaluation team found that many people of different ages in affected communities have detailed knowledge of case-management and transport procedures, and accept that some special measures were needed. What is important in relation to people’s compliance with Ebola-specific rules is that they feel that the facilities are safe and that they and their loved ones, living or dead, are treated fairly and with respect.
The CCCs were supposed to be a temporary emergency response. But as there are still small outbreaks, they have not been closed. Their role is now unclear, which is potentially confusing for Ebola suspects and a stumbling block for the recovery of the health system. Now that the CCCs exist, people want their materials and staff to be used to improve public health and educational services in their communities. What people don’t want to see are the CCCs packed and stored far away until the next big outbreak.
Meanwhile, the fact that the two evaluation teams had such different findings highlights the need to make sure that evaluations look at the political economy and history in which interventions are developed and ask beneficiaries to offer feedback about the process of the intervention, not just the results.
By Pauline Oosterhoff – Pauline Oosterhoff is a Research Fellow at the Institute of Development Studies with over 20 years of international experience in public health research and advisory services and media production.
The formative evaluation of the Community-Based Ebola Care Centres was conducted by Pauline Oosterhoff (Institute of Development Studies), Esther Yei Mokuwa (Njala University College, Sierra Leone), and Annie Wilkinson (Institute of Development Studies) as members of the Ebola Response Anthropology Platform.
- Pauline Oosterhoff – @PPJOosterhoff