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CHI and how local action stopped Ebola

The horrific story of the Ebola outbreak in Liberia and neighbouring countries in 2014 was well reported. However, few are aware that local actors played the largest role in stopping the spread of the epidemic. Dr Wapoe, County Health Officer for Montserrado County that includes the capital Monrovia, was central to the crisis containment efforts. She told of how they managed early cases when the disease was not well understood, and communities were suspicious. With almost no protective equipment for medical staff, five doctors died in the epidemic’s early stage, and fear prompted the collapse of the health system. At one point her clinic was besieged by community members threatening to burn it down if medical staff refused to return the body of a victim. Dr Wapoe explained that international agencies emphasised medical interventions. On the other hand, local NGOs led the response that stopped transmission by providing hygiene awareness training to communities. “Community engagement, community actors brought the disease down. When they took charge of their community, they said if you have fever do not go to the well and draw water. They would fetch water for this family […] and they would buy food and put it on the porch, because they did not want their communities to be infected.”

The Action

Naomi Tulay-Solanke, founder of the Community Health Initiative (CHI), echoed how the response was led by communities. “The local authorities were themselves running away from the disease. When you see who was on the frontline in the communities, it was mostly women. They were brave and fearless, and they understood that they could be killed by the virus. They understood they were exposing themselves to danger, but it wasn’t about self-gain, everybody just wanted to put a stop to the disease.” Localisation was not a familiar concept, she adds, they just saw the need to drive a response at the community level, using the resources they had. Naomi now understands localisation as simply being affected persons responding themselves, rather than seeking to involve outsiders.

CHI started out as a mobile clinic providing medical assistance to women and children. Three months later Ebola arrived in Liberia. The fear the disease provoked led CHI to initially suspend its work. However, as people began to die, including medical personnel, the team decided they had to work to stop the epidemic. Even though Naomi was a nurse, initially she did not know how to stop Ebola spreading. The CHI team quickly learnt and developed local approaches, such as using plastic bags where medical gloves were unavailable, to avoid contact with those potentially infected. CHI split into two teams. One team went to the national coordination meetings to learn about Ebola and how it spread. A second team was in the field working with communities to put the knowledge into practice.

Stopping Ebola meant educating affected populations on the disease and how to prevent transmission. CHI travelled to communities and taught people how to protect themselves, to take temperatures, to recognise the sick early and to quarantine those who develop fever. When the response started, Naomi was pregnant. Nevertheless every day she stayed in a separate room in her house to isolate herself from her family. As Naomi put it: “I wasn’t doing a job, I was saving lives. I was saving my country, I was saving my people, and that was at the core of everything I was doing.”

The importance of authorities listening to civil society was made clear by Frances Greaves, Chair of the National Civil Society Council of Liberia. The initial messaging of the authorities around Ebola was driven by a directive and dictatorial ‘do not touch’, with no explanation. Reception of this message was complicated by distrust and suspicion of government, and it failed to slow development of new cases. Many families live in a single room and therefore contact could not easily be avoided. Civil society held consultation meetings to understand how the message was understood and then met with the Ministry of Information to share their findings. Naturally, parents will always seek to hold a sick child and therefore the message should be to touch safely and protect yourself. Despite the lack of protective equipment, thanks to the use of plastic bags, rigorous hygiene and disinfection, families were able to medicate and transport loved ones to treatment units. This message contributed significantly to reducing transmission.

As the epidemic died down, schools were reopened, however people were afraid of children mixing again. As a precaution, school students would form lines to wash their hands as they entered the school. As a result, large public schools could barely function. CHI addressed this challenge by designing and building an 8-person wash stand. This simple intervention allowed a school to function and ensured hygiene levels that would both reassure parents and prevent transmission if Ebola returned. Monitoring committees operated alongside Parent Teacher Associations (PTA) to ensure awareness, temperature taking, and referrals. CHI provided training in these skills to local women, who were then able to travel to other communities and build capacity there.

Lorpu Paygar, Principal at the Sass Town school in Bomi county with 870 students, talked of how the response to Ebola was led by the community. During the epidemic they formed a team to prevent strangers entering the town that was on the road between highly affected Gbarpolu county and Monrovia. These precautions were justified when a man forcefully entered the town in his car and died shortly after entering the market. The school was unable to operate properly when it reopened, as the single tap, single bucket washing facility was too slow. So CHI built a 5-tap washstand and provided a bigger barrel to speed things up. This was accompanied by work in the community, training workshops for teachers, students, the PTA and parents, emphasising hygiene and the importance of segregating the sick. They built a waiting room for those with fever that could only be entered while wearing protective gear. The community also received support to build latrines, while paying for materials and building them themselves.

Participation

The women’s group in Sass Town saw CHI’s intervention as being very different from what they had seen before. CHI encouraged them to take ownership and make change by themselves. One lady suggested that this empowerment was a direct result of its local nature: “Those from other organisations make us afraid, they were big people. Naomi is from the village. She encouraged people, brought herself to our level, wore the same slippers as us, and encouraged us not to be ashamed.” Another woman explained how other agencies came and made decisions for them: “They think we know nothing […] In contrast, Naomi told us ‘it is for you – you should build it’, and made us understand we could do more than she could.” The women pointed out that the hall in which we were talking was a result of women in the community having an idea, buying the required materials and building it. Now they no longer need to sit under a tree when they meet.

Funding

CHI had no formal funding and began raising money in any way. Volunteers washed cars and sold tea on the street. These initiatives raised enough to fund the first two washstands in schools. The action was scaled up only when CHI met the INGO ActionAid who helped them build washstands in 117 schools in more than half of Liberia’s counties. With ActionAid’s support, women in the community could be trained and material supplied so they could build and maintain the washstands themselves. The centrality of funding to CHI’s experience demonstrates its importance in localisation. Naomi believes there is a need to remove the INGO layer between donors and local actors. Local NGOs should be funded directly leaving INGOs to focus on capacity building: “what INGOs do is not rocket science, local people could learn to do this too”.

Capacity

In the humanitarian sector, capacity is usually understood as intrinsically technical: it is a consequence of expertise and can be taught. The CHI Ebola response demonstrated the falsity of this. Communities who led the Ebola action had a range of capacities, including proximity to those affected, cultural awareness, the trust of their neighbours and willingness to work as volunteers. These are capacities that international actors cannot bring and are the reasons that they seek local partners. The capacity building required in the Ebola response was indeed technical as community members needed to know what Ebola was and how to prevent transmission. However, Ebola was halted by contextualising technical knowledge and combining this with other capacities from local communities.

Accountability

International actors have often used a commitment to maintaining standards as a reason for caution in localising humanitarian action. However, local actors’ challenges in satisfying standards are a direct result of them being defined by agencies in the global North. CHI, for example, works with grassroot CBOs who are unable to satisfy international accounting standards as they have no bank accounts and no finance professional. CHI’s response to this is not to abandon financial standards but to contextualise and indigenise them, creating new locally relevant policies and practices that reinforce standards. Disbursements of cash from CBOs for example are managed by one individual holding the cash box and 3 others holding separate keys. Money can only be taken when all are involved, creating a formal community-based accountability trail. Such practices improve accessibility without lowering standards. Accountability to beneficiaries is provided through long-term and constantly renegotiated relationships between communities and CHI rather than formal procedures. This distribution of power ensures communities can make decisions to drive action.

Partnership

CHI’s experience highlights unequal partnerships with INGOs, where local actors are seen as ‘implementing partners’, and excluded from planning, ownership of project impacts and access to donor budgets. A healthy partnership with an INGO will be empowering for the local actor, ensuring it plays a role in donor meetings, drives project design and has access to budgets. Aisha Kolubah from ActionAid Liberia discussed their approach to partnership and commitment to localisation, as a natural consequence of a rights-based approach, in which communities are empowered as first responders. ActionAid saw their role during the Ebola crisis as facilitating and supporting local actors, assisting CHI and others even though they were unregistered community organisations. ActionAid did not fly in any expatriates, believing that ‘experts’ would ultimately have to learn from locals how to respond. Aisha said: “Localisation matters in effectiveness because local groups in communities are closer to the people: it is easier to effect change. [...] You can’t be effective if you don’t work with the local people.”

Impact and challenges

Naomi’s experience has helped her understand that participation is at the heart of localisation, encouraging people to engage with issues, rather than doing work for them, and so driving ownership. This applies at all levels: local, national and global, with the challenge being to make communities aware of the policies that impact them and then allow them to lead advocacy, alongside changing behaviour on the ground. CHI’s response to Ebola has permitted them to see both the power of localisation and resistance to the idea. Localisation is seen as challenging the authorities since it informs and empowers communities, and challenging INGOs since it increasingly sees their role taken by local actors. The promise of localisation is that it can guarantee greater sustainability, more ownership, and a faster response. In addition, the Ebola response shows that local approaches are naturally focussed on prevention and preparedness. A challenge in Liberia is that there is now no international funding for preparedness to support local actors, particularly authorities, planning for a future epidemic. The Liberian experience is not just that local engagement can help in crisis response, but that stopping Ebola would have been impossible without it.

Produced with the support of Bill and Melinda Gates Foundation

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