Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak

118 Pages Posted: 27 Mar 2020 Last revised: 8 Jun 2020

See all articles by Darin Christensen

Darin Christensen

UCLA Luskin School of Public Affairs

Oeindrila Dube

University of Chicago - Harris School of Public Policy

Johannes Haushofer

Princeton University - Woodrow Wilson School of Public and International Affairs

Bilal Siddiqi

University of California, Berkeley - Center for Effective Global Action

Maarten Voors

Wageningen UR

Date Written: June 3, 2020

Abstract

Underuse of health systems and a lack of confidence in their quality contribute to high rates of mortality in the developing world. How individuals perceive health systems may be especially critical during epidemics, when they choose whether to cooperate with response efforts and frontline health workers. Can improving the perceived quality of healthcare promote community health and ultimately, help to contain epidemics? We leverage a field experiment to answer this question in the context of Sierra Leone and the 2014 West Africa Ebola crisis. Two years before the outbreak, we randomly assigned two accountability interventions to government-run health clinics – one focused on community monitoring and the other conferred non-financial awards to clinic staff. These interventions delivered immediate benefits under "normal" conditions. Even prior to the Ebola crisis, both interventions increased clinic utilization and satisfaction with healthcare, and community monitoring additionally improved child health, leading to 38 percent fewer deaths of children under five. Later, during the crisis, the interventions also increased reporting of Ebola cases by 62 percent, and significantly reduced Ebola-related deaths. Evidence on mechanisms suggests that the interventions improved confidence in the health system, encouraging patients to report Ebola symptoms and receive medical care. These results indicate that promoting accountability not only has the power to improve health systems during normal times, but can also make them more resilient to crises that emerge over the longer run.

Keywords: Disease control & prevention, Ebola, Epidemic containment, Government accountability, Health systems, Monitoring, Non-monetary incentives, Public service delivery

JEL Classification: I18, J33, M52, O15

Suggested Citation

Christensen, Darin and Dube, Oeindrila and Haushofer, Johannes and Siddiqi, Bilal and Voors, Maarten, Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak (June 3, 2020). University of Chicago, Becker Friedman Institute for Economics Working Paper No. 2020-28, Available at SSRN: https://ssrn.com/abstract=3562391 or http://dx.doi.org/10.2139/ssrn.3562391

Darin Christensen

UCLA Luskin School of Public Affairs ( email )

Box 951656
Los Angeles, CA 90095-1656
United States

HOME PAGE: http://darinchristensen.com

Oeindrila Dube (Contact Author)

University of Chicago - Harris School of Public Policy ( email )

1155 E 60th St
Chicago, IL 60637
United States

Johannes Haushofer

Princeton University - Woodrow Wilson School of Public and International Affairs ( email )

Princeton University
Princeton, NJ 08544-1021
United States

Bilal Siddiqi

University of California, Berkeley - Center for Effective Global Action ( email )

310 Barrows Hall
Berkeley, CA 94720
United States

Maarten Voors

Wageningen UR ( email )

Hollandseweg 1
Wageningen, 6706KN
Netherlands

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