Table 5 EVD CBS Lessons Learned

Coverage

• The ratio of 1:35 CHW to households and 1:15 CHW to household visits per day assured equal and adequate coverage. The level was appropriate for an active EVD epidemic but would be excessive outside of an emergency and resulted in CHW and household fatigue.

• The ratio of 1:10 supervisors to CHW was a manageable workload for staff while assuring adequate supervision and high reporting rates.

• The increase in supervisors, transparent selection, and change in profile improved alert investigation and supervision quality, and enabled health center staff to focus on triage and patient care. Multiple partners meant management positions were inflated. This had benefits in division of tasks but translated to ambiguous reporting lines and inconsistent decision-making.

Community Engagement

• Early and consistent community involvement proved vital to the success of the system, reinforcing system performance, local acceptance of activities, and health service provision.

• Community feedback, including recommendations to add additional CHW, run separate meetings in rural villages, and strengthen PHC services, improved system coverage and performance.

• Phased roll-out of activities ensured time for community discussion and approval.

• Engaging local chiefs and other community leaders as supervisors and CHW meant traditional hierarchies were integrated into the response

• Leadership came from outside of the community. Future response should ensure there is community representation in senior, decision-making positions.

• Engagement with local chiefs may have exacerbated existing imbalances in local power structures. A community advisory committee with diverse representation may have been a better way to facilitate engagement, assure more voices were heard, and create space for underrepresented groups.

Rural Villages

• Additional time and resources were needed to accommodate rural villages.

• Holding separate community meetings close to rural villages and increasing visits provided better support to the CHW and improved system performance in these areas.

• Increasing access to PHC services in rural areas would have increased capacity for early disease detection and assured more sick persons received care.

• If resources allow, dedicated surveillance staff should be recruited to oversee CBS in rural areas.

Reporting

• Data collection should be limited to information that (1) is useful to the response and (2) can be analyzed in a timely manner. A review of reporting requirements early in the response may have mitigated reporting challenges.

• Targets should be used with caution, interpreted in the broader scope of CBS performance, grounded in evidence and adapted to the specific context in which they are used.

• The partnership between organizations was useful under the heavy reporting requirements, enabling team members to spend time on analysis which informed operations.

Case Definition

• The expanded case definitions were highly sensitive but not specific enough to have clinical significance. The change overwhelmed response efforts in surveillance, and laboratory and isolation capacity.

• If a more sensitive case definition is needed, actors should ensure there is increased operational capacity for alert investigations, testing, and isolation.

Health System Approach

• In addition to providing a continuum of care, the free PHC services, referral system, and ambulance network addressed community-prioritized health needs. When community priorities were addressed, EVD activities were better accepted.

• Efforts could have been made to invest more in the PHC component. The EVD testing and isolation unit took priority, disproportionately consuming staff time and project resources.

• The support of the locally recruited health promotion team helped greatly with communication and alleviation of concerns around ITC admission.

• A clear exit strategy would have allowed the CBS to be reintegrated into the health system, focusing on other infectious diseases, with redefined roles.