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

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.