DR Congo

The Democratic Republic of Congo’s 10th Ebola response: Lessons on international leadership and coordination

Evaluation and Lessons Learned
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Nicholas Crawford and Kerrie Holloway with Jock Baker, Anne-lise Dewulf, Pascal Kaboy Mupenda, Emmanuel Kandate Musema, Antoine Mushagalusa Ciza and Rosamund Southgate

Key Messages

Attempts to get the UN Country Team and humanitarian operations in country to work more closely with the government and WHO led to the creation of parallel coordination systems. In future outbreaks, there's no room for a 'go-it-alone' approach. Leadership and coordination structures must work together from the outset of the response and avoid parallel structures and dual-leadership models.

This was the first Ebola outbreak in a conflict area. Yet, at the beginning, the response structure was airlifted from the 9th outbreak, which was not in a conflict setting. This did not take into account context-specific approaches, including with community engagement, security and financial management. Nor did it build on existing health and community structures already in place in country. For future responses, particularly in complex settings like eastern DRC, context analysis must be done from the start, and existing structures used.

One of the key questions during the outbreak was whether the response should be treated as a public health response, a humanitarian response or a health security response. By and large, it was initially treated as a health security response, which meant that many of the everyday humanitarian needs, such as food and water, went unmet, while other diseases, including cholera, measles and malaria, continued unabated. Future Ebola outbreaks should be dealt with as part of a community's overall health needs – now that there are successful vaccines and therapeutics – and emphasis should be put on building better and more sustainable public health structures.

The 10th Ebola outbreak was the first time the IASC Scale-Up for Infectious Diseases was put into effect. However, it wasn't activated until almost one year after the outbreak began – in part because there are no trigger points written into the Scale-Up. Before another large-scale response is required, triggers for the activation of the Scale-Up that aren't reliant on the good will of the agencies involved should be decided. These could include thresholds based on the deterioration of the humanitarian situation in the outbreak area, the deterioration of security in the affected areas, trends in incidence or geographic expansion, spread within urban or mobile populations or cross borders or simultaneous outbreaks elsewhere in the country that will result in reduced capacity.

The initial focus on disease eradication above all else ignored many of the other issues in the area and actually led to increased cases of Ebola. Community resistance, armed violence and what became known as 'Ebola business' waged out of control. High payments made to doctors, security personnel and others in the response created perverse incentives for the response to continue. Instead, future responses that take place in complex contexts should build community acceptance, by engaging through recognised community structures, pursuing a security by acceptance rather than security by protection approach, implementing transparent financing of the response and offering payments in line with area pay scales.

On 1 August 2018, the Democratic Republic of Congo (DRC) declared the country’s 10th Ebola outbreak in North Kivu. By the time the outbreak was declared over on 25 June 2020, 3,481 people had been infected, of whom 2,299 died – the largest ever outbreak in DRC and the second largest in the world after the West African outbreak of 2014–2016 (WHO, 2020).

Overall leadership and coordination of the EVD response was in the hands of the Government of DRC, which brought significant technical and operational experience to the task, having successfully contained nine previous outbreaks in the country since Ebola was first identified there in 1976. What first seemed like it might be another small and relatively isolated outbreak quickly grew in size and complexity, challenging the government’s ability to contain the virus and testing its leadership and coordination capacities.

This case study examines the effectiveness of international leadership and coordination in supporting the Ebola outbreak response and identifies lessons and recommendations to inform similar future responses. It considers the extent to which international partners, through their evolving leadership and coordination structures, enabled and shaped the government-led response. It also aims to draw lessons from how international partners deployed their expertise and assets in order to help shape future responses – particularly in contexts where a public health emergency overlaps with an ongoing, complex humanitarian crisis.

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