The cost of Ebola

At the time of writing, Liberia had just seen the return of Ebola virus disease after nearly 2 months of being offi cially Ebola-free. An unexpected cluster of cases was also detected in Sierra Leone’s previously Ebola-free capital Freetown. Eff orts are now focusing on recovery, but clearly Ebola is not done with west Africa yet. If we needed reminding, Ebola has killed more than 11 000 people in Sierra Leone, Liberia, and Guinea in the past 18 months, including more than 500 health workers. David Evans and colleagues from the World Bank have estimated just what this might mean for the now skeletal health systems in these countries. Taking maternal, infant, and child mortality as proxies for health system performance, they demonstrate that the loss of 78, 83, and 79 doctors, nurses, and midwives from Guinea, Liberia, and Sierra Leone, respectively, probably led to somewhere in the order of a 75% increase in maternal mortality across the countries, ranging from a 38% increase in Guinea to an 111% increase in Liberia. Confi dence intervals for infant and child mortality crossed zero, and so no conclusions about the potential increases seen could be drawn. A modelling study in The Lancet Infectious Diseases additionally showed that cessation of usual care for malaria in 2014 as a result of the Ebola epidemic probably resulted in increases in untreated malaria cases of 45% in Guinea, 88% in Sierra Leone, and 140% in Liberia, and an additional 10 000 deaths. Beyond the health system, Ebola has also taken a terrible toll on the countries’ economies and social fabric: schools closed for extensive periods, agricultural output (including domestic food production) dropped dramatically, activities in key sectors such as mining were scaled back, and cross-border trade stopped completely. A World Bank report estimated the eff ects on gross domestic product (GDP): Sierra Leone, which achieved stellar GDP growth of 20·2% in 2013, has been plunged into recession, with a predicted 23·5% contraction of the economy in 2015, and Guinea’s preEbola GDP growth of 4·3% has been projected down to –0·2% for 2015. Only Liberia’s economy is predicted to grow at all this year, by 3%, yet the pre-Ebola rate was 6·8%. The three countries have put in place Ebola Recovery Plans, which lay out, and cost, the strategies needed to respond to the human and economic devastation of the epidemic. The price tags are substantial: US$812 million for Liberia, $844 million for Sierra Leone, and $2·89 billion for Guinea for 2015–17. How much donor fi nancing has been received so far, from whom, and for what exactly? The answer is that no one quite knows. As a blog post by the ONE Campaign’s Aria Grabowski and Erin Hohlfelder points out, the amounts apparently pledged by any one entity can vary seemingly without good reason from one reporting mechanism to the next, and can include—or not—the monetary value of in-kind benefi ts such as hospital beds, buildings, and vehicles. Donors are often keen to disclose pledged amounts but not actual disbursements. Yet keeping track of who has pledged what, whether it has been delivered, and what the outcome was is a crucial component of accountability and impact assessment. Grabowski and Hohlfelder put forward the necessary components of a globally accepted tracking system and the commitments required of donors to make appropriate data available. On July 9, three Ebola-aff ected countries will present their recovery plans to the UN Secretary-General’s International Ebola Recovery Conference, and a donor pledging session will follow on July 10. It is an important moment to take stock of the realities of the ongoing outbreak and to focus eff orts going forward on the most critical element of recovery: namely the restoration and strengthening of basic health services, including the health workforce. In a Comment, Ranu Dhillon and Rob Yates press for beginning this process with a new cadre of community health workers, which would help to reach remote communities, re-establish trust in the health system, and create jobs in rural areas. The countries’ recovery plans vary in their emphasis: while Sierra Leone rightly bases its on the two pillars of immediate recovery, including getting to and maintaining zero infections, and building national systems for resilience and sustainable development, Liberia’s prioritises “getting the economy back on track”, with “health and social welfare activities” a small part of a secondary aim. As the recent resurgence of Ebola in Liberia shows, the region cannot aff ord to take its eye off the ball. Economic recovery cannot be sustained without fi rst attending to the health of the health system.


The cost of Ebola
At the time of writing, Liberia had just seen the return of Ebola virus disease after nearly 2 months of being offi cially Ebola-free. An unexpected cluster of cases was also detected in Sierra Leone's previously Ebola-free capital Freetown. Eff orts are now focusing on recovery, but clearly Ebola is not done with west Africa yet.
If we needed reminding, Ebola has killed more than 11 000 people in Sierra Leone, Liberia, and Guinea in the past 18 months, including more than 500 health workers. David Evans and colleagues from the World Bank have estimated just what this might mean for the now skeletal health systems in these countries. Taking maternal, infant, and child mortality as proxies for health system performance, they demonstrate that the loss of 78, 83, and 79 doctors, nurses, and midwives from Guinea, Liberia, and Sierra Leone, respectively, probably led to somewhere in the order of a 75% increase in maternal mortality across the countries, ranging from a 38% increase in Guinea to an 111% increase in Liberia. Confi dence intervals for infant and child mortality crossed zero, and so no conclusions about the potential increases seen could be drawn. A modelling study in The Lancet Infectious Diseases additionally showed that cessation of usual care for malaria in 2014 as a result of the Ebola epidemic probably resulted in increases in untreated malaria cases of 45% in Guinea, 88% in Sierra Leone, and 140% in Liberia, and an additional 10 000 deaths. Beyond the health system, Ebola has also taken a terrible toll on the countries' economies and social fabric: schools closed for extensive periods, agricultural output (including domestic food production) dropped dramatically, activities in key sectors such as mining were scaled back, and cross-border trade stopped completely. A World Bank report estimated the eff ects on gross domestic product (GDP): Sierra Leone, which achieved stellar GDP growth of 20·2% in 2013, has been plunged into recession, with a predicted 23·5% contraction of the economy in 2015, and Guinea's pre-Ebola GDP growth of 4·3% has been projected down to -0·2% for 2015. Only Liberia's economy is predicted to grow at all this year, by 3%, yet the pre-Ebola rate was 6·8%. The three countries have put in place Ebola Recovery Plans, which lay out, and cost, the strategies needed to respond to the human and economic devastation of the epidemic. The price tags are substantial: US$812 million for Liberia, $844 million for Sierra Leone, and $2·89 billion for Guinea for 2015-17.
How much donor fi nancing has been received so far, from whom, and for what exactly? The answer is that no one quite knows. As a blog post by the ONE Campaign's Aria Grabowski and Erin Hohlfelder points out, the amounts apparently pledged by any one entity can vary seemingly without good reason from one reporting mechanism to the next, and can include-or not-the monetary value of in-kind benefi ts such as hospital beds, buildings, and vehicles. Donors are often keen to disclose pledged amounts but not actual disbursements. Yet keeping track of who has pledged what, whether it has been delivered, and what the outcome was is a crucial component of accountability and impact assessment. Grabowski and Hohlfelder put forward the necessary components of a globally accepted tracking system and the commitments required of donors to make appropriate data available.
On July 9, three Ebola-aff ected countries will present their recovery plans to the UN Secretary-General's International Ebola Recovery Conference, and a donor pledging session will follow on July 10. It is an important moment to take stock of the realities of the ongoing outbreak and to focus eff orts going forward on the most critical element of recovery: namely the restoration and strengthening of basic health services, including the health workforce. In a Comment, Ranu Dhillon and Rob Yates press for beginning this process with a new cadre of community health workers, which would help to reach remote communities, re-establish trust in the health system, and create jobs in rural areas.
The countries' recovery plans vary in their emphasis: while Sierra Leone rightly bases its on the two pillars of immediate recovery, including getting to and maintaining zero infections, and building national systems for resilience and sustainable development, Liberia's prioritises "getting the economy back on track", with "health and social welfare activities" a small part of a secondary aim. As the recent resurgence of Ebola in Liberia shows, the region cannot aff ord to take its eye off the ball. Economic recovery cannot be sustained without fi rst attending to the health of the health system.