A bottom-up approach to the Ebola response

Because we see our people, our brothers, speaking our language, we can believe what they say

Female focus group respondent,
John Thorpe Community

The Ebola crisis in West Africa was the defining humanitarian crisis of 2014 for Oxfam, and arguably for the humanitarian community at large. As the number of Ebola cases escalated, Oxfam – as a WASH agency in what was initially considered a medical emergency – struggled to find a constructive role. More needed to be done on prevention, so Oxfam decided to focus on Ebola prevention activities with community health volunteers in Liberia and Sierra Leone. In both countries, Oxfam had been working with communities through its WASH programming. In the Ebola response this was complemented by partnerships with medical agencies in the construction of WASH facilities for treatment and community care centres.

The importance of social mobilisation

Social mobilisation, building the capacity of affected communities to prevent and manage Ebola, is critical to increasing trust and confidence in outbreak control mechanisms, and consequently to breaking the chain of transmission. According to the UN Mission for Ebola Emergency Response (UNMEER): ‘areas exhibiting most success in reducing and eliminating the incidence of Ebola have been those where the local community has become educated and actively engaged’. UNMEER, Making a Difference: The Global Ebola Response: Outlook 2015, http://ebolaresponse.un.org.  Community involvement in the planning and setting up of Ebola management centres is key to early referral. This is a two-way process: actors involved in the response need to listen to communities and respond to their needs, and adapt their interventions and services accordingly. In Liberia and Sierra Leone Oxfam has built on existing WASH programmes and participatory approaches to promote prevention, early referral and safe burials, in consultation with community influencers such as religious leaders, traditional healers, women’s leaders and youth groups, actively engaging all community members in the development of their own response plans.

Community health committees in Sierra Leone

In Sierra Leone Oxfam is helping communities to form Community Health Committees, 821 of which are operating in the four districts where the agency is present. Working with Oxfam, the District Health Management Team and District Ebola Response Coordination, committees have identified barriers to effective prevention, case management and safe burials, and have drawn up action plans to overcome them. Barriers range from practical needs, such as fuel for ambulances and water access for quarantined households, to high-risk behaviours based on the belief that bathing in salt water can cure Ebola, or the practice of washing and touching dead bodies in preparation for burial.

Case study: the John Thorpe Community

The John Thorpe Community in the Western Area in Sierra Leone was badly affected by Ebola. Women from John Thorpe told Oxfam that, at the peak of the outbreak, ‘responders’ took people away and passed on messages about Ebola, but did not ‘build’ anything with them. They received no information once someone had been taken, and were simply left waiting. Living in fear, many of these women and their families suspected witchcraft had caused Ebola as they ‘had no other explanation’.

We lost 141 people, 141 brothers, sisters, children and parents. Everyone has lost someone … They left and never came back, without information on what happened.

Female Community Health Committee member who lost three children to Ebola, John Thorpe, Sierra Leone

Oxfam began working in John Thorpe in November with the formation of 20 community health committees. The committees fed into the plans for a community care centre in John Thorpe, to be constructed by Oxfam and run by the International Rescue Committee (IRC), and spent over a month persuading the community to accept the construction of the centre. This was done through discussions, meetings and drama performances that took villagers through their Ebola story and helped them to understand the benefits of having a community care centre. The centre was built such that community members could visit and see their family members from a safe distance, and community members were invited to attend an opening ceremony.

In January, with the community care centre open, Oxfam helped committees and their communities to begin referring people to the centre. Communications training was provided for the committees to increase their confidence in communicating effectively with their neighbours, developing positive ‘kangosa’ or gossip (informal chats where ways of supporting the sick were discussed). One committee member told Oxfam: ‘You cannot visit just once, we are there, every day, so they will change [their high-risk behaviour] slowly, because I am always there’. IRC medical staff provided further training on Ebola case identification, and committee members began identifying people who might be ill and referring them to the community care centre. At the time of writing, 40 people had been referred to the centre and, although many of them had malaria and none tested positive for Ebola, their willingness to go to the centre was a major step forward in terms of community confidence in making referrals. Women from focus groups in John Thorpe told Oxfam that the centre had made them feel safer. They spoke of people surviving and leaving the centre: ‘It was the first time we saw people discharged, they were coming home … The health centre encourages us to go with any symptom and that is how we stay safe’.

Active case finding in Liberia

In Liberia, the Ebola outbreak has been concentrated in the urban areas around Monrovia. Oxfam was the first agency to adopt the active case finding approach often used for cholera outbreaks as part of its Ebola response. This has taken place in three phases, as cases have declined: initial blanket household-level visits across target communities; hotspot targeting and the verification of ‘voids’ to check whether these were truly Ebola-free; and finally individual case investigation.

The first phase began in November when Oxfam staff and volunteers visited households in New Kru Town, Clara Town and West Point in a large-scale, intensive and targeted approach, reaching 350,000 people a week with repeat visits. This led to the discovery of several hotspots which the local coordinating body, the Ebola Task Force, was unaware of. In the second phase field officers used a GPS app to record the coordinates of referrals, which were plotted on google maps and colour-coded, with referrals in green, negative cases in yellow and positive cases in red. Areas with no referrals triggered extra supervision to understand whether the Oxfam teams were being accepted by the community. Hotspots triggered increased supervision to refer and isolate cases and contain Ebola in the immediate area. In December 2014, Oxfam referred 27% of national confirmed Ebola cases, including 45% of cases in Monrovia and 90% in the three townships areas, New Kru Town, Clara Town and West Point. At the time of writing, 94 people had been referred to Ebola Treatment Units by ambulance, with 23 positive cases confirmed and a further 11 unconfirmed by the Ministry of Health.

Active case finding only worked because of the trust which community health volunteers and Oxfam staff had built up with communities. Case finding was combined with prevention and awareness-raising about Ebola and efforts to encourage people to seek treatment for any health problems, re-establishing trust in the health system where previously there had been fear that everyone would be treated as an Ebola patient. Consequently people began self-referring for a range of health issues.

Oxfam worked with families to ensure effective referral of potential Ebola cases. This meant talking through what would happen to them, explaining why it was important to seek early treatment and presenting options about where to go and how to get there. For example, some sick individuals were more willing to go for referral if the ambulance arrived quietly without the sirens on. One Ebola survivor from Doe explained that he was scared of going for Ebola testing, but ‘the Oxfam team encouraged [his] family’. An Oxfam volunteer called for an ambulance and the team followed up the case, so that when his wife and brother became ill they too were referred in the early stages of illness. All three survived.

Strengthening the referral pathway through the Ebola Task Force and on to Ebola Treatment Units was a critical factor in securing early referrals. Oxfam teams made follow-up calls to treatment centres on behalf of families to find out about their relatives and to ensure that ambulances arrived. Oxfam liaised between the service providers and the communities, talking to communities about the kind of treatment they could expect to receive and feeding back community concerns to improve the referral process.

Successes and challenges

In both Sierra Leone and Liberia Oxfam has drawn on its experience of working with communities in emergencies, seeking and responding to their feedback and adapting the programme in line with it. However, there have been significant challenges in terms of coordinating social mobilisation activities in a context where multiple agencies are active in the same communities, each with their own way of working. In Sierra Leone, for example, the Social Mobilisation Pillar (SMP) is the largest of the programme implementing platforms, with more than 40 international and national members. The SMP, an umbrella structure led by the Ministry of Health and co-chaired by UNICEF, provides a forum for agencies working with communities to contribute at national and district meetings. Oxfam is an active member of the SMP, both in Freetown and in the districts where it operates, and supports the SMP’s activities. For example, in hard-to-reach locations of Koingadugu Oxfam facilitates the SMP’s field activities because it is the only organisation that covers the entire district through community health committees.

Some of the areas where Oxfam worked were geographically remote, so setting up operations was logistically difficult. In terms of staff capacity, Oxfam has also needed to be flexible in order to maintain relationships with communities in areas where the outbreak was established, while being mobile enough so that teams could be deployed quickly to hot spots in new areas as the virus spread.

Active case finding added an important proactive element to social mobilisation by identifying cases and connecting communities with service providers. This was particularly important where contact tracing methods were insufficient, for example with groups such as taxi drivers and drug users, who may be unable or unwilling to disclose all contacts. In Sierra Leone, actively involving community members in the development of their own prevention and protection approaches has built trust within and among communities and increased people’s willingness to refer themselves and seek treatment.

Active listening groups are being set up to enable Oxfam to respond to the suggestions and concerns of communities and to explore the contribution communities believe health committees have made to reducing Ebola transmission. More in-depth research is being carried out on community attitudes towards seeking treatment in case of illness.

Going forward

Ebola is not over, and Oxfam is continuing its emergency response, while transitioning into longer-term programming. This includes rehabilitating and improving WASH facilities in schools in Sierra Leone and Liberia and working with children, parents and teachers to help them stay alert to the threat of Ebola as they begin to recover and return to normal as the outbreak subsides. Oxfam’s recent report Ebola Is Still Here shares feedback gathered from communities about their needs and hopes for the future. One theme that has emerged is that people want to see community health committee activities continue. Improved hygiene practices and water and sanitation facilities, along with active community organisation to prevent disease, should help make communities in Liberia and Sierra Leone more resilient against future healthcare threats, whether from Ebola or other diseases. Preventive behaviours, surveillance and referral pathways need further strengthening to effectively function independently.

Catherine Meredith is Oxfam’s Regional Communications Coordinator, Ebola Response. This article was written in collaboration with Meriam Asibal, Public Health Promotion Coordinator, Liberia, Eva Niederberger, Public Health Promotion Coordinator, Sierra Leone, Margaret Asewe, Public Health Promotion Team, Sierra Leone, and Simone Carter, Public Health Promotion Team.