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

Reprint No. 2021:24

Author(s): Darin Christensen, Oeindrila Dube, Johannes Haushofer, Bilal Siddiqi and Maarten VoorsYear: 2021 Title: Quarterly Journal of Economics Volume (No.): 136 (2) Pages: 1145–1198
Online article (restrictions may apply)

Skepticism about the quality of health systems and their consequent underuse are thought to contribute to high rates of mortality in the developing world. The perceived quality of health services may be especially critical during epidemics, when people choose whether to cooperate with response efforts and frontline health workers. Can improving the perceived quality of health care promote community health and ultimately help to contain epidemics? We leverage a field experiment in Sierra Leone to answer this question in the context of the 2014 West African Ebola crisis. Two years before the outbreak, we randomly assigned two interventions to government-run health clinics—one focused on community monitoring, and the other conferred nonfinancial awards to clinic staff. Prior to the Ebola crisis, both interventions increased clinic utilization and patient satisfaction. Community monitoring additionally improved child health, leading to 38% fewer deaths of children under age five. Later, during the crisis, the interventions also increased reporting of Ebola cases by 62%, and community monitoring significantly reduced Ebola-related deaths. Evidence on mechanisms suggests that both interventions improved the perceived quality of health care, encouraging patients to report Ebola symptoms and receive medical care. Improvements in health outcomes under community monitoring suggest that these changes partly reflect a rise in the underlying quality of administered care. Overall, our 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 emergent crises.

Christensen, Darin, Oeindrila Dube, Johannes Haushofer, Bilal Siddiqi and Maarten Voors (2021), "Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak". Quarterly Journal of Economics 136(2), 1145–1198.

Interdisciplinary European Studies

The European Union and the Return of the Nation State


This book explores the complex and ever-changing relationship between the European Union and its member states. The recent surge in tension in this relationship has been prompted by the actions of some member state governments as they question fundamental EU values and principles and refuse to implement common decisions seemingly on the basis of narrowly defined national interests.

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