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Humanitarian morals and money: health sector financing and the prelude to the Liberian Ebola epidemic

The 2014 West African Ebola epidemic prompted reconsideration of West African health systems’ resilience to external shocks. To understand the post-conflict histories of West Africa’s health systems reconstruction, it is necessary to understand the health systems in place when the epidemic emerged. This paper recounts the debates that shaped Liberia’s post-conflict health sector from 2003 to 2014, with particular attention to 2006–2008, when two Médecins Sans Frontières (MSF) units withdrew, and World Vision closed clinics across Liberia, prompting a national healthcare crisis. These debates highlighted medical non-governmental organizations' (NGOs') obligations to provide health care to vulnerable post-conflict populations; the restricted support available for health care in low-income post-conflict countries; and the demand for Liberian sovereignty over the national healthcare sector. They juxtaposed financial, bureaucratic, and logistical demands against public health, political, and post-conflict security risks. Through interviews with insiders in the Liberian government, medical NGOs, and Liberian healthcare providers, this paper presents a narrative of post-conflict health sector transition that reveals how post-conflict transitions create moral, bureaucratic, and procedural dilemmas requiring ad hoc responses from humanitarian and national government actors. Although funding for the Liberian health sector was ultimately obtained, the surveillance, coordination, testing, and social mobilization vulnerabilities then in place set the stage for the 2014 Ebola epidemic.