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Article Article June 18th, 2015

Target zero: the eradication of Ebola

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Collection of data and informed decision making were key to the whole response

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Different countries and different agencies can sometimes have different priorities

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Our focus on government ownership and relationships stands up in a really tough environment

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Ebola. Few words can inject such fear and apprehension. From the poorest parts of West African capitals to the UN headquarters in New York and beyond; its very mention sparks vivid images of suffering and death that remind us all of humanity's inherent vulnerability.

As the scale of the challenge and threat became clear last autumn, the global response gathered pace. Teams both military and medical were deployed from countries around the world. They joined development professionals from UN agencies, national governments and humanitarian aid organisations, all of which were tasked with halting and then reversing the spread of this most deadly of diseases.

Already working in the affected countries were professionals from the Africa Governance Initiative (AGI), a London-based charity that, since its launch seven years ago, has sought to strengthen the governance systems of selected African countries. Founded by former British prime minister, Tony Blair, AGI installs small teams to work alongside African policymakers and equip them with the capacity to deliver improved public services, address deep-rooted poverty and attract sustainable investment. While the merits of their mission are self-evident, there are big differences between overseeing a civil service reform programme and joining the fight against Ebola - or so it would seem.

Step up or step back?

The first Ebola case in West Africa was reported in March 2014. It soon became clear that this was an outbreak borderless in scope, one that was the deadliest in history. The AGI teams in Liberia, Guinea and Sierra Leone opted against leaving the region and instead stayed to offer their services. Andy Ratcliffe, AGI's deputy CEO and director of strategy and development, says that it came down to what the governments wanted.

“Our starting principle is that we are at the service of the governments,” he says. “When Ebola happened, we knew there would be a lot of international support flowing in. So we just asked the governments if they wanted us to stay - that was our first question - and, if they did, if they wanted us to stay focused on our ‘regular' work. There was a very clear answer that the governments wanted us to work with them on the Ebola response. This was interesting because we're not in any way medical, but it became clear that the crisis was as much a systems problem as it was a medical problem. Collection of data, command and control, and informed decision making were really key to the whole response.”

AGI's teams have been in Liberia and Sierra Leone for nearly six years and Guinea for four. AGI was therefore a familiar presence within these governments' corridors of power and had enjoyed strong relationships with key government leaders - a fact that proved pivotal, continues Ratcliffe. “When hundreds of international experts from various organisations turn up it can feel quite overwhelming for a government,” he says. “It is hard to know how to get a grip of it, especially if these outsiders want to set up their own individual systems. One of the things that the governments said to us was that the fact we had already been there for a long time and understood the system, and they knew us and trusted us, was incredibly valuable - it wasn't just a systems thing, it really was down to relationships.”

As a result, AGI refocused its efforts - transitioning from issues such as identifying where to build a power station to helping the affected countries coordinate their response. “It was actually really interesting how similar working on Ebola was to AGI's normal work,” reflects Ratcliffe. “We normally help political leaders and government manage their priorities and implement them as they happen. This involves work on systems, performance management. Ebola has been all these issues but just in fast-forward. This is because the facts have been changing so fast the system has had to continually evolve.”

On the trail

Ebola spreads through human-to-human transmission via direct contact with surfaces and materials contaminated by the bodily fluids of an infected person. Healthcare workers have frequently been infected - for example, Sierra Leone has lost nearly all of its doctors during the outbreak - and burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in its transmission.

“At the beginning the main focus was on scale - can we get enough treatment centres, enough doctors, enough beds?” says Ratcliffe. “And over time, as the numbers have thankfully come down, it has become much more fine-grained as you're chasing Ebola into smaller and smaller hiding places. It is more like counterinsurgency - far less about overall capacity and instead more about really tight targeting. Once down into the single-figure cases it is about tracing each and every contact the person who has been infected has had. It works out at hundreds of contacts for every person and it really is like detective work. It's almost as hard to get from 20 cases to zero as it is from 1,000 to 100. So, the actual response has changed massively since the beginning.”

The outbreak took hold for many reasons. Clearly, the inadequacies of the healthcare systems in the affected countries were an issue. Another was the fact that preceding outbreaks had often been in isolated places, whereas this time the disease seeped into the general population in both the countryside and cities. Ratcliffe says the severity of the crisis meant that the international community and African countries had little option but to work together.

“With development spending, for example, different countries and different agencies can sometimes have different priorities,” he explains. “This means it can feel a bit of a negotiation between the government and the agency about what should happen. But Ebola was one problem and everyone was really focused with everyone working together, and it felt like a really strong partnership. I think there are a quite a lot of lessons there for how to deliver the recovery - can you capture that same sense of focus, urgency and partnership and apply that to fixing the roads, for example, or reopening the schools?”

Ratcliffe also says that a key lesson from the response is that there is a real balance to be struck in order to create a sense of urgency without creating a sense of panic. “It's a really fine line to tread,” he points out. “The biggest thing that has slowed the rate of transmission is not hospitals but behaviour of individuals. This can involve persuading a parent not to touch or nurse their infected child - which is obviously a very difficult message to get across, especially when you don't want people to panic.”

To illustrate his point, he cites the 117 hotline that AGI worked on in Sierra Leone. This is the number to ring if citizens think they have Ebola. “One of the side effects of the hotline was that we started hearing all these rumours or urban myths that were going around,” he reveals. “Things like ‘there wasn't really Ebola' or it was ‘just a way for people to get aid money'. People are scared and they don't necessarily have access to all information. So, one of the things we started to do with the government is collect all the rumours we heard on the hotline every day and put out a daily public service announcement correcting every false rumour we had come across. Think Ebola and you think of doctors and hospitals but this type of communication shows how broad the response had to be.”

Much done, much still to do

The falling number of cases and deaths in the affected countries is a testament to many factors, not least the heroic efforts of the health workers who risked their lives to fight the disease. That said, it is clear there is some way still to go before there are zero cases and countries can be declared ‘Ebola-free'. This is a status vital to long-term economic recovery, points out Radcliffe. “Think of the effects on the economy. If you're an investor, you want that reassurance that the disease is gone and not still bubbling away; they need to know they can get down to business with no ambiguity.”

But while conceding that Ebola is clearly a big setback to the development of the affected countries, he remains confident that they can quickly get back on track. “There is still the leadership and goodwill from the international community and there are quite a lot of positive lessons from the Ebola experience,” he says. “When a government is incredibly focused on what it wants to achieve, and maintains a relentless sense of urgency, it can make a hugely positive public impact. This can apply not only to problems like Ebola but also delivering positive change in different, less testing environments.”

And as for AGI, which is now preparing to scale up its teams in order to help contribute towards the longer-term recovery, Ratcliffe believes the experience has shown that its approach is the right one. “For me, it showed that even in the hardest contexts, our focus on government ownership and building trusted relationships stands up in a really tough environment. Our task now is to use our experience and knowledge to help these countries get back on their feet and back on the development journey - as soon as possible.”



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