The Ebola outbreak in eastern Democratic Republic of Congo (DRC), declared on 1 August 2018, is the secondlargest in history. The DRC shares its borders with nine countries, all of which are at high risk for an Ebola outbreak given the regular cross-border movement of people, goods and services in the region. NGOs are increasingly playing a critical role in Ebola responses, complementing and contributing to the efforts of national governments and UN agencies. Yet there is little guidance to support NGO preparedness for Ebola.
Ebola outbreaks can challenge NGOs’ capabilities in many ways; effectively preparing for Ebola within an NGO is a complex undertaking involving many departments across all levels of the organisation. The existing World Health Organization (WHO) Ebola preparedness checklist is intended for use by national governments preparing for Ebola, and as such does not fully consider the crossdepartmental and multi-dimensional actions required within NGOs. Furthermore, existing NGO general emergency preparedness plans and approaches, which typically take an all-hazards approach, do not fully align with the preparedness required for a specific and imminent risk such as Ebola.
The International Rescue Committee (IRC) currently has country offices and pre-existing programming in five of the nine high-risk countries. To assist Country Programmes operating within these countries, the IRC developed an Ebola Readiness Roadmap to support Ebola preparedness actions. This article looks at the IRC’s approach to Ebola readiness in these high-risk countries, and presents the Roadmap as one way to support operational practice for NGOs preparing for an outbreak.
IRC’s Ebola preparedness journey
The IRC’s approach to Ebola preparedness has evolved over the course of the outbreak in eastern DRC. At the beginning, there was no clear vision or expectations for IRC Country Programmes in neighbouring at-risk countries, and no specific Ebola preparedness tools to support them. The initial approach to Ebola preparedness involved meetings with Country Programme managers to discuss broad actions and general guidance on staff awareness and safety, and where IRC had any health programming in that country, guidance was provided on strengthening surveillance and Infection Prevention and Control (IPC), using WHO online resources. However, Country Programmes had multiple ongoing projects in a variety of sectors, and found it difficult to define, choose, sequence and operationalise actions. Around 10 months into the outbreak, and following requests from Country Programmes for practical tools outlining specific and concrete actions to take in preparing for Ebola, the IRC developed an Ebola preparedness checklist. The initial checklist was based on operational experience the IRC had gained responding to Ebola in Sierra Leone and Liberia during the outbreak in 2014–2016, in DRC in 2018 and in the ongoing North Kivu/Ituri outbreak. It consisted of components and actions designed to enable Country Programmes to rapidly scale and safely deliver Ebola programming.
After being rolled out in IRC at-risk countries, the checklist was updated to reflect feedback and learning, in particular how to safely maintain pre-existing programmes while also preparing to respond specifically to Ebola, and most importantly, the need to prioritise actions within the checklist, taking into consideration the variety of projects and the many competing priorities faced by Country Programmes, and the need for simpler tools, resources and concrete examples to support implementation.
The revision of the checklist resulted in the development of the IRC Ebola Readiness Roadmap. As part of this revision, a distinction was made in terminology between Ebola preparedness and readiness, terms often used interchangeably. The IRC currently has programmes in 12 countries at risk of Ebola outbreaks; as such, we wanted to separate Country Programmes where Ebola is a potential hazard from those where it is an actual hazard. This would enable the IRC to be more proportionate in the support provided to Country Programmes relative to risk. We have chosen to define Ebola readiness as the actions taken by at-risk countries in response to a confirmed Ebola outbreak (imminent risk). This is achieved through the implementation of the IRC Ebola Readiness Roadmap, and takes place in IRC Country Programmes neighbouring an active Ebola outbreak.
IRC Ebola Readiness Roadmap
The Roadmap is designed to facilitate effective implementation of Ebola readiness actions by IRC Country Programmes. It can be used by Country Programmes to assess their level of readiness, and identify key gaps. Spanning the systematic, structural and functional domains required for effective readiness, the Roadmap is split into two distinct phases, each with a corresponding set of actions (Figure 1). Phase 1 of the Roadmap, which centres on ensuring business continuity, includes 30 actions across seven components. At the end of this phase, IRC Country Programmes should be able to safely continue their current programming in the context of an Ebola outbreak. Priority is placed on ensuring the continuity of pre-existing programmes, recognising the broader impacts of Ebola outbreaks. Example actions within phase 1 include linking to existing external Ebola coordination mechanisms, and the establishment of internal coordination systems. A programme risk assessment is completed for the whole Country Programme portfolio to identify mitigation measures to be implemented to minimise risks associated with current programming in the event of an Ebola outbreak. From the operations side, actions in this phase centre on optimising existing support functions. The major emphasis during this phase is on staff safety, ensuring that IRC staff have the knowledge and supplies they need to work safely, and that the organisation has the right policies and safeguards in place to support staff and mitigate risk. Staff safety consists of different dimensions (Figure 2), each with corresponding actions.
Phase 2 of the Roadmap centres on Ebola-related programming, and includes 33 actions across five components. At the end of this phase, IRC Country Programmes are actively implementing programmes which contribute to the prevention of, or mitigate the impact of, an Ebola outbreak, and IRC is in a strong position for rapid response in the event of an outbreak. This encompasses how IRC Country Programmes can utilise and leverage existing programmes, as well as scale-up or implement new programmes. Actions in phase 2 include an analysis and identification of outbreak response components that the IRC Country Programme can contribute to. IRC’s approach to Ebola-related programming is integrated across health, WASH and protection sectors, with community engagement at the centre. Country Programmes develop a strategy and budget encompassing initial rapid response interventions. The actions on the operations side for this phase focus on enhancing and strengthening IRC support functions including logistics, procurement, human resources and finance. Examples include mapping and identifying additional vendors for accommodation, transport and supplies; evaluating warehouse capacity; identifying surge support requirements; and adapting HR policies.
The Roadmap approaches readiness from a programmatic perspective, but also focuses on core operational and logistical functions. It is designed to be sequential, with Country Programmes starting at a minimum with actions in phase 1, given the focus on safety and business continuity. Whether a Country Programme completes actions in phase 2 should be determined at the country level, taking into consideration internal and external capacity to respond to Ebola, as well as existing funding opportunities to support Ebola-related programming. Actions within the Roadmap also balance the need for dedicated financial resources, which can be a key barrier to readiness efforts. Many actions can be completed without additional financial resources. However, they do require staff time and effort, which is another reason for prioritising the actions into phases.
The Roadmap is presented in the form of an Excel tool. All of the actions are presented as a checklist, separated by phase and component. Guidance is provided on who should be involved with each action, and the tools and resources relevant for each action, including examples, are hyperlinked. There is also a status column, where Country Programmes can track actions that have been completed, are in progress or have not started. The document will auto-calculate scores, to enable progress to be monitored over time. The Roadmap also includes a template to support completion of the actions, as well as to identify additional support required by the Country Programme from the IRC Regional and Global teams. The Readiness Roadmap is accompanied by the IRC Ebola Toolkit, a series of technical and operational guidance and resources, as well as global Ebola focal points who provide support with roadmap implementation.
Lessons learned from implementation
Following the implementation of the Ebola Readiness Roadmap, the IRC observed improvements in Ebola readiness scores across all five high-risk neighbouring countries from the baseline checklist assessment in July 2019, compared to reassessment in November 2019 (an average 18% increase). Variations were noted in overall progress, as well as progress between countries, related to a number of factors and challenges:
- Availability of tools and resources: the Readiness Roadmap was implemented a year aꢀer the beginning of the outbreak in DRC. This affected overall readiness progress in Country Programmes as clear and focused readiness efforts started late. In addition, the Ebola toolkit was developed in parallel with the Roadmap, resulting in a delay in the availability of technical guidance, tools and resources to support early preparedness and readiness efforts. The lack of a clear framework also meant that there were variable levels of motivation to engage in readiness efforts in the first place.
- Variations in technical support: some Country Programmes received visits and technical support on introducing programme staff to the Roadmap and facilitating some of the key actions within it. These visits were critical in ensuring all relevant staff had a baseline understanding of Ebola and Ebola readiness efforts. Differences were observed in Ebola readiness scores between Country Programmes that received incountry visits versus purely remote technical support, where baseline knowledge was lower, often resulting in less capacity and prioritisation of readiness actions. For example, in-country technical support to IRC Tanzania resulted in improvements in Ebola readiness scores from 19% baseline to 50% in November 2019. Similarly, IRC Burundi improved Ebola readiness scores from 16% baseline to 47% in January 2020 following in-county technical support.
- Funding: variations were also noted in Ebola readiness scores and the level of Ebola readiness funding received. Only one of the five IRC high-risk neighbouring countries received external funding for Ebola readiness efforts (Uganda). Two received small-scale internal funds (Burundi and Tanzania). Even where funding opportunities were available, the lack of a clear framework meant that Country Programmes were not able to articulate readiness needs clearly enough, or develop proposals rapidly enough, to take advantage of them. The availability of funding affects progress in phase 2 of the Readiness Roadmap, as the focus of actions in that phase is on Ebola-related programming. The availability of funding for Ebola readiness efforts is also crucial for maintaining ongoing commitments and engagement with Ebola readiness strategies. Many of these contexts also have competing priorities related to complex humanitarian drivers and response efforts.
- Readiness fatigue: given the duration of the outbreak in DRC and their many competing priorities, Ebola readiness fatigue had set in across all County Programmes. The IRC adapted approaches and support to Country Programmes to maintain interest in Ebola readiness by transitioning from bi-weekly to monthly readiness calls, developing targeted support to each country, prioritising actions that were feasible within the broader scope of each Country Programme’s work and streamlining support via clear Ebola readiness focal points at country level.
The Ebola Readiness Roadmap complements the existing WHO Ebola preparedness checklist, providing specific and concrete actions for NGOs. The IRC has implemented the Readiness Roadmap in five at-risk countries (Burundi, Central African Republic, South Sudan, Tanzania and Uganda). Since implementation, all IRC Country Programmes have improved their Ebola readiness scores. The Roadmap and progress in Country Programme readiness has enabled IRC headquarters to prioritise technical support, both in-country visits and remotely, as well as the use of internal funds to support Ebola readiness. The Roadmap has served as an extremely useful tool internally to support Ebola readiness efforts and overcome challenges at the country level, and continues to play a vital part in the IRC’s readiness efforts in relation to the Ebola outbreak in eastern DRC. A clear direction has also been set for how the IRC will approach Ebola readiness at the country level for future outbreaks.
Dr Stacey Mearns is Deputy Director Ebola, International Rescue Committee. Kiryn Lanning is Senior Technical Advisor Emergencies Violence Prevention and Response, International Rescue Committee. Dr Michelle Gayer is Director Emergency Health, International Rescue Committee.