Field test of Ebola communication materials conducted in Montserrado County, Liberia. Photo courtesy of WHO /Aphaluck Bhatiasevi
The story of how Liberia’s most populous county, Montserrado, turned around an exponentially growing Ebola outbreak is intriguing. The World Health Organization (WHO)’s team and national officials, aided by veterans from WHO’s polio eradication group in India, decentralized the response, using quality management principles that empowered local teams and held them accountable for results. These local sector teams involved more than 4,000 community members, using business best practices and an incident management system to vastly improve surveillance, case finding, contact tracing, and overall management of key response activities.
Liberia, where the Ebola outbreak seeing exponential growth in cases last September and treatment centers filled up the day they opened, started to turn back the epidemic when it organized and empowered local teams to handle the response.
Essentially the government decided to decentralize the Ebola management system and break it down into four smaller systems. This allowed for better quality control on surveillance, case finding, contact tracing, and overall management of key response activities necessary in tackling the Ebola outbreak.
A WHO analysis later found a direct link between implementing a full package of control interventions, including community engagement, acceptance, and ownership of the response, and the decline and then end of new cases in Liberia.
In late November 2014, following the height of the Ebola outbreak in Montserrado, the largest county in Liberia, the country’s National Incident Management System began working to decentralize the Ebola response. Teams were organized and partners were integrated into a new “sector approach,” that divided the county into four sectors.
This new method worked by grouping smaller, localized teams for a more nimble and rapid response and empowering local staff for enhanced community engagement. It also introduced a new performance-based management system, which made every staff member involved accountable for their own work.
The zone-level approach reflected historical community identities and ties. Instead of dividing epidemiological zones by purely administrative district organization, it localized the areas, so communities could track their own Ebola cases and contacts. Health officials, local citizens and partners worked together in each sector and made operations more effective, taking advantage of the strong sense of community and identity.
The objective of the Montserrado sector approach was to “hunt the Ebola virus disease” in controlled zones of the sector, using timely local responses. In 2 months, the sector approach brought the Ebola outbreak under control in Montserrado. Sector teams coordinated with localized response teams, increasing outreach and handling issues locally using a ‘good neighbor’ approach and “door-to-door” engagement.
The sector approach worked because it was managed by the people of Liberia in their own communities. Also those who came from outside to help, respected local voices, laws and leadership.
Agile, customized sector solutions were encouraged, leaving sector leaders free to design localized responses around a strongly structured, technical “pillar” based organization. The Health Ministry, incident managers and partners agreed that these would cover case detection (investigation, tracing and active case finding), epidemiological surveillance, case management, psycho-social activities and community engagement. A similar framework was adopted at all levels of the “sectoral system” from the national level, to county, sector and zone levels.
Active daily coordination of sectors and cross cutting responsibilities reduced overlapping activities, fostered improvements and supported areas where performance was lagging. A WHO expert team from India, which had vast experience in combating polio in that country and knew the importance of good localized epidemiology and response, provided robust technical support, helping build strong cohesive sector teams.
This decentralized approach also enhanced quality management by building a customer service system that would work with potential cases in each community to diagnose every patient and get them the care they needed quickly.
The approach introduced a performance-based management system, which outlined goals and targets for each staff member with very specific indicators. Those in charge of meeting goals had to provide relevant data on their regions and report on whether they had been met.
Partner response by staff in each sector left no doubt about strategies, objectives and responsibilities, and in many cases partners appointed people from the communities to maximize their responsibility. The resulting public accountability in terms of effectiveness and sectoral performance enriched community engagement and made it easier to mobilize responders and citizens around specific issues.
The success in controlling the Ebola outbreak in Liberia is partially due to this sectorial approach, which is a good model for work in other affected countries and for future outbreaks.