Ebola and health systems: What went wrong, and what we can do better next time

The 2014-2015 ebola epidemic was unprecedented in its scale and pattern, and prompted widespread reflection on the failure of national and international health systems. The focus was on the international response, on treatment, and on the need to rebuild health systems. Within health systems, most of the attention was on technical issues related to epidemic surveillance and control. The resulting recommendations have been primarily focused on this limited analysis. Three key facts received little consideration. The first was that Liberia in particular had, prior to the epidemic, received extensive funding and technical assistance to build its health system. Why did this assistance not lead to better performance? A second was that the key systems failings before and during the epidemic were related less to technical problems than to failures in governance, including problems with corruption, human resource management, and client trust. A third was that actors on the margin of the health system were arguably the most effective in curbing the epidemic. These realities, largely ignored both in media coverage and in official documentation of the outbreak, can yield specific recommendations to make health systems strengthening more effective than it has been in West Africa, and beyond. Some of these recommendations may be disruptive; but they are more likely to lead to sustained improvements.