Ambulance being dispatched to westren area of Freetown, Sierra Leone to attend a suspected case of Ebola. The cleaner disinfects the house of the susptected case with chlorinated water. Photo by UNMEER/Martine Perret. 15 December 2014

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Ebola Epidemic 2014-2015

A wake-up call for sustainable health governance and development policy


After the first appearances of the Ebola epidemic in December 2013, the disease spread wide and fast, exceeding any previous Ebola epidemic with regard to incidence and prevalence and was declared a pandemic by WHO. Before 2013, the outbreaks of this highly infectious disease were locally restricted and primarily situated in rural areas. The latest outbreak of this epidemic, however, expanded to the urban population as well as across borders. Above all, it extremely stretched local health care systems as well as international organizations when a coordinated response was required. This epidemic revealed fundamental failures in establishing consistent health policies within those countries, of regional governance institutions as well as in development policies of industrialized nations. Not only were the questions thereby raised such of medical and pharmaceutic nature, but they equally concerned transnational coordination of aid and international health governance.

One factor that facilitated the rapid spread of the disease was cross boarder migration. Another factor was the weakness or absence of social structures in urban settings, lowering the social and medical control in case of illness. In addition, fear of getting infected was spreading very fast and led many health workers to leave the health facilities. This resulted in an acute shortage of staff in hospitals and health centers. Other sectors, like agriculture, were severely affected by the “missing hands” as well. Consequently, there were food shortages as well as massive declines in the gross national product of the respective countries. All these are issues that aggravated the crisis and negatively impacted timely and effective aid.

A revelation of major health governance deficits

The epidemic as such was not primarily a medical problem. Rather, it revealed that education, participation and strengthening the self-responsibility of individuals as well as the local community received only little attention. Obsolete practices such as the re-use of inadequately sterilized materials in health services as well as the transmission through unprotected contacts and funeral rites are evidence of neglecting the education of professionals and the general public for a long time. From a public health point of view it is striking that there were a lot of “collateral damages”, e.g. declining vaccination coverage in the population, declining consultations, untreated malaria, diarrhea, pneumonia. The creation of respective Ebola-Task forces/institutions/departments and of more vertical control programs can further undermine or marginalize other programs or activities of the Ministry of Health (MoH). In Guinea this is already the case.

The local response by the affected countries was delayed. In the beginning, symptoms were not recognized and not associated with Ebola. There was also no effective risk communication system in place at local, national and regional level. The already low level of trust in the governments was further weakened by the initial response measures, which were inadequately attuned to the cultural and traditional practices of the population.

This epidemic revealed enormous deficits of national health governance structures especially in Guinea, Liberia and Sierra Leone, whereas countries like Senegal and Nigeria managed to contain the epidemic. At regional level the community of states (Economic Community of West African States (ECOWAS) and the African Union (AU) as well as specialist public health institutions such as the West African Health Organisation (WAHO)) were neither prepared well enough to rapidly detect and identify infectious diseases, nor to combat them. Unfortunately, the WHO’s International Health regulations (IHR) were not implemented on time, risk assessment and risk communication failed, followed by late response and a lack of coordination. As to global health governance and leadership, WHO was much criticized for its late response.

The international response was triggered by mass media drawing worldwide attention to the occurrences of the disease, but also spreading fear of Ebola. Even though external aid started very late, it led to a so far virtually unknown volume of investment in a very short time. Compared to recent years, the amounts provided are a multiple of national health budgets and health-related development aid of the affected countries, also posing challenges regarding its administration.

From a health systems perspective the following requirements for better preparedness and response can be stated:

  1. At regional level (ECOWAS/WAHO) communication structures, processes and tools are still insufficient to address future outbreaks of highly infectious diseases. The enormous influx of funds into WAHO and RCDC, the capacity of the region and organisations to absorb these funds should be addressed by donors and recipients. Risk assessment and risk communication will be paramount in close collaboration with the countries and across the region.
  2. Sustainable health and development policies are determinant: based on SDG the development policy has to promote the establishment of health care systems being able to function on a long-term basis.
  3. Efficient allocation of resources is required beyond political and media preferences. Funding security beyond the usual 2-3 year cycle of projects is important. To date, Ebola apparently has a high priority in national and international health and development policies. But political attention is short. Even though the current attention is both important and appropriate, we must not repeat the mistakes of the past.
  4. We need a health systems approach cutting across the six building blocks of the WHO and tearing down the classical silos: the focus on vertical programs combating individual diseases leads usually to multiple structures, increased costs, inefficiency and inequity.
  5. Early warning systems and mathematical models of disease dynamics are needed. The continuous collection and analysis of solid epidemiological data as well as high-quality system indicators are essential to early warning systems.


The Ebola epidemic is a wake-up call for higher efficiency, rationality and evidence in the health policy of partner countries and the development policy of donors. If we fail to learn the necessary lessons from this epidemic it can be expected that similar or graver outbreaks of Ebola or other infectious diseases will occur in upcoming years, accompanied by highly negative economic and humane consequences.


Prof. Dr. med. Michael Marx (Institute for Public Health, University of Heidelberg/Evaplan at the University Hospital) is Specialist in internal and tropical Medicine, Public Health, Health Systems Research, Quality Management, Human Resource Development, HIV & AIDS.

Important parts of the manuscript are drawn from an editorial of The European Journal of Health Economics by Flessa S & Marx M. Ebola fever epidemic 2014: a call for sustainable health and development policies. The European Journal of Health Economics 2016;17(1):1-4. DOI 10.1007/s10198-015-0710-0


Cite as: Michael Marx, “Ebola Epidemic 2014-2015 – a Wake-Up Call for Sustainable Health Governance and Development Policy”, Völkerrechtsblog, 11 April 2016, doi: 10.17176/20171201-114741.

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