Written evidence submitted by Adam Smith International
1 Introduction – Our work in Sierra Leone during the Ebola crisis
1.1 Adam Smith International was running a number of programmes in Sierra Leone at the time of the Ebola outbreak. Our staff – international and local – remained in the country despite the health risks and we adapted our activities to focus on helping to address Ebola. Our programmes related to private sector development, WASH and central government decision-making and we describe them below.
1.2 Sierra Leone Opportunities for Business Action (SOBA) is a DFID-funded private sector development programme that aims to generate inclusive green growth in agricultural and manufacturing markets. Since October 2013, SOBA has made targeted technical and financial investment in business practice innovations that grow businesses and improve smallholder farmer and small-scale entrepreneur performance and market position.
1.3 The onset of the EVD crisis in 2014 impaired programme activities and worsened prospects for intended beneficiaries. In response, SOBA maintained in-country operations throughout, and in November 2014 conducted an SME impact study and rapid review of trader and transport systems in key agricultural sectors. This identified key market constraints caused by the response to EVD, such as broken links between farmers, traders and buyers and reduced demand for local produce. Subsequently, we leveraged an existing partnership to ensure domestic rice purchase by a local rice processor, providing market access for 2,700 smallholder farmers, and subsequent distribution to 7,300 food insecure people in quarantined areas. Our influential EVD Impact & Recovery study, completed in June 2015, found the crisis to have exacerbated pre-existing challenges and made recommendations for economic recovery. It has been cited widely and has received Presidential endorsement. We are now rapidly expanding our network of partners, supporting business innovation and growth, and increasing linkages throughout value chains in agriculture, light manufacturing and green energy.
1.4 Adam Smith International has been at the core in reforming and providing strategic leadership within the WASH, Health, and Ebola response sectors. For over four years, the WASH support programme we run for DFID has guided and driven change within the Ministry of Health and Sanitation, the Ministry of Water Resources, District Councils and a wide range of state and non-state partners. Central to this is the establishment of key legislation that now governs health, water supply and sanitation issues across the country in the face of one of the biggest health emergencies of our time. The National Water Resources Act and the Sierra Leone Water Company Act define the governance of water supply and distribution across Sierra Leone, and has facilitated major improvements in the effectiveness of the national water suppliers. Additionally the SALWACO Act has helped the Ministry of Health and Sanitation and the Ministry of Water Resources in pioneering sanitation reforms across all districts of Sierra Leone.
1.5 This reform has resulted in major advancements in the sector: billing of water users has increased by close to 40%, and water companies revenue has increased by over 125%. Such progress has encouraged significant reinvestment into the sector, enabling the nation to roll-out lasting water services to wider swathes of the population.
1.6 We have also established central and local government institutions including the Electricity and Water Regulatory Commission and the National Water Resources Agency. Our team initiated a process of decentralisation, building the capacity of local government to support community water management groups. 28,850 water points have been mapped, providing sustainable water supply to 35% of the nation’s rural population. Further, more than 3 million people – or 50% of the nation’s citizens – now have access to a safe and reliable water supply; an increase of 20% since the project started, directly impacting 1,218,400 citizens.
1.7 The programme also incorporates a water, sanitation and hygiene facility: 36 critical projects across health, hygiene and water issues are supported in 14 districts. These have engaged over 300,000 people in remote areas.
1.8 Within the Ebola response, the WASH Support Programme has assessed the needs and water supply demands at nearly 100 Ebola facilities. It planned and designed WASH services at 160 Ebola Care Units; published guidelines for safe collection, treatment, transportation and disposal of human and medical waste; and coordinated the nationwide training for 840 Environmental Health Officers and Public Health Aids and 1,970 MCH nurses.
1.9 During the Ebola crisis, we continued with implementation of the DFID funded Building Capacity for the Use of Research Programme (BCURE). BCURE is supporting the Cabinet Secretariat to improve the cabinet’s capability to make better evidence-based collective Cabinet decisions. Support included the revision of revising Cabinet procedures to better manage its agenda and to provide Cabinet members with sufficient opportunity to fully consider complex policy proposals and seek advice on technical issues; the development of a standard format for proposals to Cabinet to ensure Ministers are informed of evidence on needs and on the likely impact of proposals, as well as financial and implementation issues; and the establishment of cabinet liaison networks with liaison officers in each Ministry to enable the Secretariat to support Ministries in preparing Cabinet proposals and implementing Cabinet decisions.
1.10 In addition we seconded the staff to the National Ebola Response Centre on a pro-bono basis for six months. DFID Sierra Leone commented that: “All three of the ASI funded and recruited staff into the NERC have been professional and flexible, bringing strong contextual skills and experience to a fast moving, demanding and intense environment. All have made significant contributions to the Ebola response and have had a very positive impact within the NERC, filling essential posts and helping with training and mentoring of counterpart staff.”
2 Timeline of response – what could have been done better and quicker? How can this be prevented from happening again? Does DFID have the capacity to deal with future outbreaks? Is there enough expertise in DFID?
2.1 The response by-passed the Cabinet and this served to increase the degree of distrust between the international community and government. The urgency demanded a more hands-on role for some of the international support, which differs markedly from normal development support and this therefore required careful negotiation of responsibilities, and bringing key stakeholders, including the Cabinet, on board. This did not happen.
2.2 The response should have been better aligned to existing institutional structures that DFID has invested in especially the Office of National Security (ONS), Local Government and Cabinet. This would have helped address governance issues around the outbreak and would have prepared the ground for more effective post Ebola recovery. Local Councils despite being side-lined by the MHS Ebola Operations Committee in the early stages and by the imposition of politically appointed District Coordinators under the later NERC often performed well in local coordination of effort. MHS treated the outbreak as a purely Infection Prevention & Control ignoring security/wider social/economic/WASH issues. DFID was criticized for not creating rapid temporary facilities to get treatment and quarantine under way (as the US did in Liberia) but going for slow build of permanent facilities such as Hastings. Water and sanitation were largely ignored at the beginning of the outbreak, but in the middle and later stages it was realized by supporting organisations such as CDC and WHO that WASH is absolutely critical to the response.
2.3 In the early 2000s, when the ONS was being set up, part of the DFID funded advisory assistance was directed to identifying state risks, including natural and epidemic disasters as well as conflict related and economic risks. This obviously dropped off the radar – partly because the ONS leadership was politicized. Looking forward – and beyond Sierra Leone – identification of such risks should be a focus
2.4 The quarantine and other response measures adopted to contain EVD exacerbated existing challenges to growth, constraining much of the Sierra Leonean economy and removing opportunities for agriculture, trade, and normal business. SMEs and larger companies saw their levels of business diminished by the curfew and bans on public gathering (Coke’s levels of business declined 40%), while movement restrictions constrained imports and the movement of goods, simultaneously increasing their cost base. DFID programming is currently focused on fundamental obstacles to growth (such as access to markets and financial services), which were exacerbated by the response to EVD. It should maintain and broaden its focus on these long-term economic constraints (including also technical skills and the business environment), rather than on short-term symptomatic challenges.
2.5 Similarly, the precipitate influx of well-intentioned monetary and food aid has reduced demand for local produce. Government hand-outs of imported food staples ride roughshod over existing market structures, reducing demand for smallholder farmers and thus reducing purchasing power within the broader marketplace. DFID private sector programming in Sierra Leone has led the way in channelling aid funds through existing markets, facilitating the purchase of rice from local smallholders, its processing by local traders, and distribution to the food insecure. DFID should continue to advocate for a market-based response to food shortage in this and other outbreaks.
2.6 Many rural communities who first experienced Ebola are marginalised and on the periphery of Government support. Insufficient attention was provided to assisting remote rural communities. One central element of the Ebola response was/is working out how assistance can be provided to these remote communities where often basic health and testing facilities are absent.
3.1 The Ebola crises exposed significant weaknesses in Sierra Leone's health system in epidemic preparedness. This was largely due to a breakdown in the capacity to collect, share and analyse appropriate data. The system was not robust. The priority for strengthening the system is an adequate, integrated and standardised data system. Harmonisation around one electronic medical records and surveillance system, and continuous capacity strengthening to manage is important.
3.2 The EVD crisis represented a steep learning curve for all organisations. It required close integration between health, WASH and social mobilisation sectors. Experience has shown that rapid response teams are required and localised holding centres need to be established immediately as more sophisticated health facilities are constructed.
4.1 Clearly, cultural practices in areas such as the burial and washing of dead bodies and the consumption of bush meat contributed to the spread of the Ebola virus. Close attention needs to be paid to communicating the risks of some cultural practices at an early stage of an outbreak. It would be worthwhile building up a body of evidence on cultural practices in West Africa and their impact on health.
5.1 A number of barriers to safe health practices currently exist in Sierra Leone. These include the national barrier where service delivery and decision-making remains overly centralised. Cultural practices clearly link to behavioural barriers and people do not see the health risks associated with them. The perception barrier is also widespread and many communities viewed Ebola as being “manufactured.” The lack of WASH services in rural areas – the poverty barrier – was also a contributing factor. Additionally, the direct involvement and communication with local chiefs and traditional leaders regarding the danger that many traditional practices had in spreading the disease proved to be a major turning point in reducing cases. A clear channel of communication to these traditional leaders should be established.
6.1 The issues laid bare by the Ebola outbreak are those of governance, management, human capacity and Sierra Leone’s unique political economy. The country does not need a Marshall Plan – there has been little infrastructure damage for example. What is needed are the same kinds of reforms that DFID has been supporting before the outbreak – on governance, institutional and public sector reform, PFM, and private sector development. These reform efforts need to be intensified. DFID particularly needs to augment effort to establish a well-functioning Cabinet – one that is able to swiftly make collective decisions, informed by evidence, during crises. Unfortunately large amounts of Ebola funds – or the promise of them – have put back hard won gains in these areas as government focuses on gaining control of procurement in relation to these funds. DFID’s rethink of its approach to aid delivery is positive. This centres on close control over delivery with programmes identified with beneficiaries. DFID should ensure that local councils and the private sector are the focus of support with central government ‘pulled along’ in relation to this. DFID also needs to heed its own political economy analyses of Sierra Leone: these are good but it is not clear whether they sufficiently inform country planning. Of particular relevance is the weakness and politicization of decision making, along with the role of informal elite networks.
6.2 ‘Recovering’ to the pre-Ebola status quo -- economic growth deriving largely from the foreign-owned mining industry, which conceals deep inadequacies in governance, infrastructure, and economic markets -- is not nearly enough. Much of the route to revived, sustainable economic growth lies in the private sector and this is supported in GoL’s Agenda for Prosperity: “to build a stable economy, founded on private sector-led growth.” In the short term, the availability of functioning markets, in place of free government inputs, as well as access to finance will increase opportunity for local enterprise. DFID programming is currently engaged in these areas. Longer term, technical and vocational skills development is necessary to fulfil the well-placed aspirations of the Sierra Leone Local Content Policy (currently supported by the DFID-assisted Local Content Unit). Moreover, fundamental improvements must be made to the business environment to enable future growth. DFID programming is aiming to expand into these long-term areas in 2016.
6.3 There is political support for an emphasis on private sector development, post-Ebola. HE the President of Sierra Leone told us in a recent interview on September 7th that one of his top priorities was “The private sector, especially the agricultural sector, the small and medium businesses that were affected because of non-activity – this is where you have most of the people and if we place emphasis on it and try to reactivate it we will be addressing the major issues that have been holding the country back.”
6.4 DFID and its programmes have thus far taken a proactive role in thought leadership in Sierra Leone, advocating for the importance of the private sector and the role of market systems in the economic response to this outbreak. Amid the maelstrom of international organisations and conflicting approaches, DFID should position itself as a convenor, seeking to facilitate a coherent approach to the post-Ebola transformation agenda between the various agencies (such as USAID and GIZ), as it has done so in response to the initial crisis.
7.1 Fundamental strengthening of health systems is required to reduce the impact of further disease outbreaks. Adequate leadership and management capacity to plan and resource a robust health system. All six of WHO's health systems building blocks would have to be strengthened to prevent further expensive responses to outbreak crises. Furthermore, strengthening the Ministry of Health's community strategy and capacity at decentre, behaviour change and data collection initiatives.
7.2 Leadership support at the MOH is also important to improve harmonisation of development partners and all health actors, in agreeing a standardised data management and reporting system for example.
7.3 The crisis exposed the systemic problems at WHO, as well as the danger of placing too much reliance on slow, bureaucratic and inefficient UN organisations. Unfortunately the track record of reforming such UN organisations is not good. The 2013 Multilateral Aid Review Update described WHO as ‘adequate.’ A more realistic view of these UN organisations and the prospects of improving them is required. It is not prudent to rely on WHO in crises such as these.