SSHAP West Africa Hub: Health Emergency Cycles and Social Context in West Africa

The SSHAP West Africa Hub brings together academics, humanitarian responders and public health practitioners primarily working in Nigeria, Senegal and Sierra Leone to explore socio-political and historical issues shaping crises, with the intention of enhancing national and humanitarian programmes seeking to reach vulnerable groups.

In this landscape paper, we aim to summarise the contextual factors that shape health emergencies and responses to health emergencies in the West Africa region (termed ‘health emergency cycles’). Drawing on examples from Nigeria, Senegal and Sierra Leone, we explore the interrelationship of disease outbreaks with socio-cultural, economic and political contexts, and we address issues of response governance and local capacity within national health systems. We demonstrate how different emergencies are interconnected and related to long-term stressors in the region, arguing for a less siloed approach to response. Whilst we recognise the vast heterogeneity in the region, we draw on thematic commonalities that speak to wider regional issues. We conclude with some social science priorities for responding to crises.

Introduction

The West Africa region, including Senegal, Nigeria and Sierra Leone, has faced a series of well-known and large-scale health crises, including outbreaks of Ebola virus disease (EVD or Ebola), COVID-19, mpox and Lassa fever. These are in addition to other health crises that are smaller in scale or global recognition, such as cholera, measles, polio and the health ramifications from natural disasters including mudslides and fires. The region has faced cycles of health emergencies compounded by challenges in the political-economic and socio-cultural context; however, there is also vast experience and capacity to draw upon to respond to them.

The frequency of disease outbreaks contributes to intersecting challenges in health systems that are already stretched and which are also dealing with routine care and endemic issues. Countries with recent histories of current conflict and political instability further face worsening cycles of health emergencies. Local knowledge and ways of understanding these diseases are typically superseded by global technocratic knowledge and ‘one size fits all’ ways of managing disease outbreaks. Further, health emergencies have historically been securitised in the region, most notably with the involvement of military personnel in the response to the West African Ebola crisis between 2014 and 2016.

There is also public health capacity within the countries and region to respond to health crises. In Nigeria, for example, the Nigeria Centers for Disease Control leads on outbreaks and epidemic response. Academic institutions, civil society and ministries of health contribute to epidemic response and longer-term strengthening of integrated disease surveillance and response systems. Capacities have been strengthened and lessons learnt, for example, during major epidemics such as Ebola and COVID-19.

‘Emergency’ periods have long-lasting effects in the region due to strains on the wider health systems. Emergencies affect public health during ‘non-emergency’ times, in terms of people’s everyday experience, perceptions of the health sector and future engagement with emergency preparedness and response.

The West Africa region has also been affected by major shocks such as intrastate armed conflicts since independence, banditry and food crises.^1–4 Whilst civil wars and conflict have reduced since year 2000, other forms of political violence have emerged driven in part by persistent challenges such as youth inclusion, migration, the rapid development of extractive industries (e.g., mining and quarrying) and land management.⁴ These crises have had severe implications for social and political stability. The crises have caused crippling macroeconomic challenges to enhance the provision and financing of healthcare and other basic social services, such as water and sanitation, particularly for the most vulnerable.

The impact of climate change is another major, overarching stressor that contributes to these cycles of emergencies. Climate change has been tentatively linked to negative security, health, food stability and development implications in the region, though the evidence base is still developing to map specific pathways of impact.^5–10

One of the outcomes of these multiple crises is the reduced capacity of governments to adequately prepare for and respond to emergencies. Multiple crises have created an accumulation of short- and long-term stressors which makes it difficult to respond to emerging ones. A case in point is the Ebola epidemic, which showed that weaknesses in the public health systems crippled the capacity of the already overstretched health system to respond. In contrast, the COVID-19 pandemic did not have as large of an effect as predicted, though by March 2022 more than 900,000 cases and 12,000 deaths were recorded in the West Africa region. Whilst many challenges exist, there are also capacities for resilience at local and country levels given the vast learning and expertise in the region.

In the following sections, we discuss the context and framing of crises in the region, how these crises are experienced ‘from below’ in communities and conclude with social science priorities for responding to health crises.

Health systems in context

In West Africa, healthcare systems, and in particular primary healthcare systems, suffer from neglect and underfunding. As a result, there are severe challenges in responding to public health emergencies.¹¹ To provide a better understanding of the health challenges in West Africa, we draw on examples from Sierra Leone, Nigeria and Senegal to describe health systems in context.

Sierra Leone

The Sierra Leone health system has struggled with the double burden of outbreaks and ongoing health problems. This has made it particularly difficult to cope with a crisis and to provide regular healthcare services, particularly for vulnerable populations such as women and children.¹²

Outbreaks that caused shocks to the healthcare system include cholera, Ebola and COVID-19. A cholera outbreak in 2012 impacted the health system, and then, between 2014 and 2016, the Ebola epidemic caused the death of 211 healthcare workers.¹³ More recently, the COVID-19 pandemic put additional pressure on the healthcare system. In the case of Ebola, pre-existing health system challenges included the already overstretched health workforce, inadequate medical supplies and a poor diagnostic infrastructure.¹⁴ Moreover, the country’s health emergency preparedness landscape was not well-developed, so there was limited capacity and clear scope to enhance a quick and a robust response. The result was the rapid spread of the disease, particularly in rural and marginalised urban settings.

Within the health emergency landscape, non-communicable diseases are also a slow emergency in Sierra Leone. Recent studies show that non-communicable diseases are on the increase particularly in urban areas, where lifestyle changes and lack of awareness are impacting the increase.^15–17 The capacity of the health system has not kept pace in responding to non-communicable diseases and other slow emergencies, partly due to limited public health financing. Moreover, the uneven policy response to public health problems, such as the prioritisation of infectious disease, has meant that limited resources are allocated to respond to non-communicable diseases. This has implications for the response to future emergencies such as infectious diseases, which has shown how people living with non-communicable disease can be vulnerable to conditions such as COVID-19.¹⁷

In Sierra Leone, the public health financing falls below the 2001 Abuja declaration – a commitment by countries within the Economic Community of West African States (ECOWAS) to allocate 15% of the annual budget to the health sector.¹⁸ There is a need therefore for the health system to be robustly financed. The health system also needs to be adaptive by integrating emerging public health threats into existing primary healthcare systems that consider ‘slow emergencies’ (e.g., non-communicable diseases) to effectively respond to future health crises.

Nigeria

Effective responses to disease outbreaks have historically been challenging for the Nigerian health system. As described below, an array of hurdles, including numerous health emergencies, poor health indicators, a growing population and low economic indicators, contribute to these challenges.¹⁹ These hurdles are not unique to Nigeria, however, and are found in other African nations which share its large size and complexity.

Nigeria is one of only five members of the World Health Organization (WHO) African Region to report five or more public health emergencies per year.¹⁹ These health emergencies are experienced on top of health indicators that are some of the worst in Africa, including the highest burden of malaria globally and ranking third in the world for the highest burden of HIV infection. At the same time, Nigeria is one of the fastest growing populations in the world.^20,21

With its rapidly growing population and development challenges, Nigeria has some of the worst socio-economic indicators for the entire African continent.²² This is further complicated by a lack of effective policy implementation, infrastructural gaps and lack of political will, alongside a health sector that has seen little development.¹⁹ Progress on the Sustainable Development Goal target 3.8 around universal health coverage has been insufficient in Nigeria and healthcare is not free at the point of access.²³ As of 2020, the annual national budget allocation to health in Nigeria has been roughly 7%, far below the 2001 Abuja declaration of allocating 15%.²⁴ Healthcare worker strikes are frequent, and this has complicated most aspects of healthcare service delivery.²⁵

Alongside the challenges, however, there have been some successes. These include the introduction of successful policies to contain the Ebola outbreak in 2014 and, in 2020, achieving the aim of becoming a country free of wild poliovirus after three years without any cases.^26,27

Senegal

Senegal performs similarly to other Western and Central African countries in terms of health service coverage, and it is also seen as an exemplar in vaccine delivery.^28–30 As in many countries, a lack of resources for health systems and longstanding experiences of a political-economy of structural neglect hamper preparedness for, and responses to, health emergencies.³¹ However, various initiatives have been launched over the past decade to protect the Senegalese population against health hazards, comprising multiple compulsory, voluntary and social assistance schemes.³⁰ Whilst there is an aim for universal health coverage and a universal health insurance policy by June 2019, only an estimated 45.39% of the population has some form of social protection for health.³⁰

The need for a strong health system in Senegal was reinforced by COVID-19. Despite an early response to COVID-19 and significant financial mobilisation, the organisation of the response was marred by social protest and numerous dysfunctions at all levels of the health system.³² Therefore, strengthening the health system is a major challenge that needs strong political will and financing. However, in recent years, Senegal has faced a major political crisis with negative social and economic consequences.

Health implications of emergency cycles

Intersecting crises. Disease outbreaks and other humanitarian crises are interconnected and must be considered as such in response efforts. Historically, disease outbreaks have often come after humanitarian crises, such as natural disasters, political crises or war.³³ For example, one study highlighted that measles was a secondary outbreak during the Ebola epidemic in West Africa, for example.³³ This is likely due to the disruption in vaccination campaigns, non-functional healthcare systems (including detection and reporting of measles cases), lack of specific treatment and reluctance to seek health assistance due to a sense of fear of contracting Ebola.³⁴

Impact on vaccination. During the West African Ebola outbreak, a study found that the measles vaccination rate dropped by over 25%.¹⁴ Despite catch-up campaigns, coverage remained lower than before the outbreak. Similarly, during the recent COVID-19 pandemic, it has been estimated that globally about 30 million children missed doses of the combined diphtheria, tetanus toxoid and pertussis vaccine (DPT3) and over 27 million children missed doses of the measles-containing-vaccine first-dose (MCV1).³⁵ This impact on vaccination demonstrates the ways in which one crisis may build on another. In Nigeria, only 31% of Nigerian children aged 12 to 23 months had received all recommended vaccinations, according to the most recent Demographic and Health Survey (2018).³⁶ While the vaccination rates were already low in Nigeria, and further data are needed to assess this post-COVID-19, the impact of COVID-19 on children’s routine immunisation cannot be overemphasised.

Impact on mortality. In Senegal, according to the 2019 Demographic and Health Survey, infant and child mortality have been falling steadily over the past few decades, while life expectancy has been rising.³⁷ However, the effects of COVID-19 have disrupted the operation of the Expanded Program on Immunization, which has led to a drop in immunisation coverage and the re-emergence of measles and polio epidemics, which are still ongoing in 2024. For the first time, life expectancy has fallen from 69 in 2019 to 67 in 2021.³⁸

Emergency lenses and perspectives on response

Political-economic context of West African health systems

No West African country has met the 2001 Abuja declaration target to allocate 15% of the government budget to health. Since the declaration was signed, countries in West Africa have only marginally increased health spending overall.^39,40 Health spending is complex; though generally more spending on health is beneficial in the region, health outcomes may vary based on the same level of spending due to inefficiencies in the system.³⁹ In relation to the health funding in West Africa, changes are also needed to improve the timeliness of health resource financing, fix problems in health worker staffing and improve the procurement and distribution of medical commodities and supplies.

The political-economic context underpins the region’s inadequate financing of health systems. Nigeria’s inflation rate reached a 19-year high of 30% in March 2024 and the number of people living in poverty was recorded at 133 million (63% of the population) in 2022.^41,42 In Sierra Leone, political instability has included street protests against President Julius Bio and a coup attempt in November 2023.^42,43 Senegal has seen a soaring cost of living and the country had to release USD 762 million in emergency financing to combat rising costs and put price caps on essential goods.⁴² Considering that accessing health services will usually incur out-of-pocket costs, these rises could mean that families have to make difficult decisions between paying for essential goods and healthcare.

In Senegal, Bassirou Diomaye Faye was sworn in as president in April 2024 after a contentious election and a 20-day period in jail.⁴⁴ Coups and coup attempts in the West African region have destabilised the region politically. There have been increasing attacks from armed groups, as fears that Sahel violence will spill over into coastal West Africa.⁴² In March 2024, armed bandits kidnapped 287 school children in Northern Nigeria, though they have since been released.

Taken together, these political-economic developments have shaped governments’ capacities to fund and maintain health systems, which are both a question of political-economic stability and political will.

Colonial legacies for responses to epidemics and outbreaks

Colonial history, combined with the history of slavery, is unique to this region and adds another layer of social and historical context not found in other regions of the world. Colonial management of outbreaks and epidemics has had long-lasting implications for West African health systems.⁴⁵ In West Africa, the COVID-19 experience in some ways reflected past epidemics like yellow fever and plague.⁴⁵ Ngalamulume (2023) points to the legacies of colonial medical practices, the uncertainty of experts in the face of evolving pathogens and an initial lack of knowledge on how the virus is transmitted.⁴⁵ Further, colonial legacies (in both medicine and resource extraction) have shaped the way that epidemics and epidemic discourse is constructed as not only ‘medical events’ but also ‘political’.^45–47 Both yellow fever and bubonic plague in the 19th and 20th centuries became major social and urban crises in the region.⁴⁵ In Saint-Louis, Senegal, yellow fever outbreaks led colonial authorities to remove African urban poor to periphery areas to segregate them from European residents, whilst in Sierra Leone, malaria provided justification for residential segregation based on ‘sanitary’ reasons.^48,49 Similarly, in Dakar, a 1914 epidemic of bubonic plague contributed to segregation policies and plans for forced removal from the city.⁴⁵

Securitisation, militarisation and emergency exceptionalism

Governments around the world are increasingly using global health security as the framework for preventing, detecting and responding to pandemic threats. There has been a rise of a discourse of security as one of the most important lenses through which global health is understood.⁵⁰ Theorists of securitisation argue that the language of security and threat is used to justify extraordinary measures to protect or advance security which normally bypass the normal procedures of democratic deliberation.⁵¹ Emergency exceptionalism refers to the idea that emergencies (e.g., natural disasters, conflicts, disease outbreaks) are treated as unique and separate from the normal development agenda, leading to distinct and sometimes isolated responses. The COVID-19 pandemic is an example of these ‘exceptional’ emergency responses such as expanded police powers, national lockdowns and border closures.⁵¹ The consequences of this can be a reduction of liberties and rights as well as the stigmatisation of vulnerable groups and militarisation of the public health response, which is not always conducive to long-term solutions to health problems; see Box 1.⁵⁰

Box 1. Militarisation of the Ebola epidemic in West Africa: Case study from Sierra Leone

Localisation of aid

In the health sector, definitions of ‘localisation’ among international institutions vary based on organisation, funder and sector. The definitions, however, focus primarily on two approaches: one on funding streams and technical assistance, and the other on concepts of community participation or engagement, including with traditional or ‘local’ knowledge.

The approach focusing on funding streams and technical assistance means an increasing proportion of aid goes directly to ‘local organisations’. Aid localisation ‘commits and directly provides for development and emergency aid to grassroot organisations, where the goal is to eliminate intermediaries and bring aid closer to where it is most needed.’⁵⁹

The community-centred approach means that ‘local knowledge’ is integrated into programmes and interventions; see Box 2.

The literature explores the importance of local perspectives, capacities and ownership in aid delivery.⁵⁹ Critiques often focus on the challenges of fully implementing localisation, including power imbalances, funding structures and the need for meaningful collaboration.

Box 2. Case study: ‘Local’ knowledge in Guinea

Humanitarian response in Nigeria is guided by the Humanitarian Response Plan.⁶² The federal government of Nigeria through the Ministry of Humanitarian Affairs is responsible for the coordination of humanitarian response in the country. The response plan indicates that international and local actors’ intervention must be sustainable and linked to long-term development of the affected communities.⁶² Intervention programmes are expected to be localised through participatory approaches, involving state actors, relevant non-governmental agencies and community members in the planning and implementation of interventions.⁶³ Participatory approaches can also guide social interventions for crisis zones in the north-eastern part of Nigeria confronted with issues of terrorism. However, the safety and security of local responders, including healthcare workers, must be maintained and remain a challenge to localisation of aid. Two examples include:

• Humanitarian response for girls and women to protect them from gender-based violence by international organisations has been planned and implemented through collaboration with state and local government actors, relevant non-governmental organisations that have been working with internally displaced people, and the affected communities to ensure sustainability and ownership of the programme by the community and government.⁶⁴
• Humanitarian aid in Nigeria, especially in the north-east like Borno State, has contributed to the development of such communities through rehabilitation and reconstruction of communities and the provision of critical infrastructures such as schools, clinics and potable water. Programmes on gender-based violence, which were not even available before the crises in affected communities, have also been included.⁶⁵

Experiences of health emergency cycles ‘from below’: Perspectives and action from communities in the region

Whilst the view of health emergency response ‘from above’ reveals discourses and practices of securitisation against a backdrop of long-term and intersecting precarities, a view ‘from below’ highlights heterogenous community experiences of these precarities and also vast capacities to respond.

Local action during health emergencies

In Sierra Leone, local groups have played important roles in supporting communities during health emergencies. During the Ebola epidemic, local groups helped enhance information sharing about Ebola, took part in community surveillance and helped enforce by-laws to limit movement and the spread of the virus in the western area peri-urban town, Waterloo and Dwarzark, a deprived urban settlement in Freetown.⁶⁶ More recently during COVID-19, local groups such as the Federation and Urban and Rural Poor (FEDURP) worked with the Freetown City Council and non-governmental organisations. The groups provided food aid and water to informal residents in Freetown, reported gender-based violence to city authorities, disseminated information and took part in outreach activities.⁶⁷ Box 3 highlights local activities in provincial Sierra Leone.

Box 3. Case study: Local involvement in the Ebola response in Sierra Leone

Women and girls

In West Africa, women played a vital role in communities’ COVID-19 prevention and adaptation responses.⁶⁹ However, during the COVID-19 pandemic, women in West Africa faced disproportionately high socio-economic effects and were also left with the largest burden of caring for their families.⁶⁹ Women in the informal sector, for example in Senegal, disproportionately lost income during the pandemic.⁷⁰

Women also faced worsened rates of gender-based violence and simultaneous reduced access to services, including psychosocial support and clinical care, during the COVID-19 pandemic.⁷⁰ Unwanted pregnancies as a result of coercion and sexual abuse increased during the Ebola epidemic; in Sierra Leone, for example, teenage pregnancies increased by an estimated 65%.⁷¹

Livelihoods and socio-economic conditions

Efforts to reduce poverty in Senegal have been undermined by health emergencies and other crises. The health crisis linked to COVID-19 interrupted a strong economic growth trend in Senegal, as the measures taken in response to COVID-19 and the subsequent recovery increased the country’s indebtedness and reinforced the budget deficit.⁷² Political tensions, persistent inflation (6% in 2023) and delays in hydrocarbon production affected growth in 2023.⁷² The effects of the war in Ukraine led to a rise in food prices as well as in the price of hydrocarbons and fertilisers.

The informal sector represents a significant part of the Senegalese economy and was particularly affected during the COVID-19 pandemic. In 2020, nine out of 10 workers in Senegal were in informal employment, and 97% of businesses were in the informal sector, according to a report from the International Labour Organization.⁷³ The government’s public health measures, notably social and physical distancing, curfews and confinement, were constraining factors for workers in the informal sector and the general population. These factors led to a drop in production, job and income losses, and a slowdown in overall consumption.⁷³

Children and education

Children’s education was severely impacted during the COVID-19 and Ebola health crises, as highlighted in examples from Senegal and Sierra Leone.

Senegal has a relatively young population: half of its inhabitants are under the age of 18. Children attending school were impacted when, on 16 March 2020, all schools were closed as part of the strategy to prevent the spread of COVID-19. To avoid the risk of children dropping out of school, the education system had to readapt its learning standards by making digital teaching materials available. Nevertheless, three out of 10 students aged under 16 reported studying alone or not participating in learning activities.⁷⁴

Similarly, during the 2014-16 West African Ebola epidemic, schools in Sierra Leone were closed for eight months, resulting in one year of lost learning. This added to existing setbacks in education progress during the civil war. However, one strategy that engaged students during the epidemic was the use of educational radio programming on core academic subjects such as mathematics, English and civic education.⁷⁵

Displacement and migration

Populations may be displaced by an emergency, and people may migrate for employment or other reasons.

Displacement has a synergistic effect on health emergencies – populations may be displaced by an emergency, and this shapes their vulnerability to other emergencies, like an infectious disease outbreak. Increasing conflict in the West Africa region has both direct and indirect effects on public health, including an increased susceptibility to outbreaks amongst displaced populations. The health workforce is not well-equipped to respond to the complex interactions between conflict and public health emergencies.⁷⁶

Studies have also shown increasing migration from rural communities to urban centres in the region.^77–79 People migrating may often end up living in urban informal settlements, characterised by unregulated or informal housing and a lack of adequate water and sanitation facilities. This contributes, in part, to the wider contextual drivers of infectious disease spread in the region.⁸⁰

Psychosocial well-being

In Senegal, the Agence Nationale de Statistique et de la Démographie (ANSD) survey on monitoring the impact of COVID-19 on household well-being in 2020 found that nearly eight out of 10 households experienced a negative change in their well-being in 2020 as a result of COVID-19, while three-fifths of households were optimistic and thought that the situation would improve within 12 months. Economic and social measures were considered helpful interventions to address the socio-economic drivers of mental health disorders.

The psychosocial well-being of healthcare workers also needs to be addressed. Work has shown the psychosocial impact of public health emergencies on healthcare workers in Senegal, including their experiences of vulnerability which exacerbate mental health issues.⁸¹

Youth experiences and drug use

One major concern in the region is the kush epidemic in Sierra Leone.⁸² Kush is a new chemically treated herbal substance used to ‘ease stress and hunger’ and for recreational purposes that puts users into a trance-like state.⁸³ The kush epidemic highlights the impact of intersecting crises – legacies of conflict, Ebola and COVID-19 – on vulnerable youth.⁸³ In 2024, Sierra Leone’s President Julius Maada Bio declared a war on kush and a state of emergency was declared in April. Closures and lockdowns during the pandemic, for example, led to secondary and tertiary implications for young people who may have increased use of kush as a coping mechanism. Use is higher amongst urban resident young men, who face multiple, intersecting challenges related to joblessness and lack of socio-economic opportunity stemming from this legacy of intersecting crises.⁸⁴

Local experience of health emergency ‘priorities’

Health emergencies, such as infectious disease outbreaks or epidemics and pandemics, are declared at a national or global level, but they may not reflect the priorities affecting communities at a local level. Further, the declaration of an emergency often draws attention, time and resources away from healthcare infrastructure that is already strained.

The tension between national and local priorities can be illustrated through an example from the Ebola outbreak in Nigeria in 2014. During the West African Ebola epidemic, the first Ebola index case in Nigeria was detected in July 2014 in Lagos after which it spread to two other states.⁸⁵ While Nigeria recorded a significant achievement by being able alter the spread of Ebola across the country within three months, the response impacted vulnerable populations.⁸⁶ For instance, it was observed that health officials were too focused on Ebola management, while women and children were dying from malaria, measles and other preventable diseases.²⁵ In some Nigerian states, it was observed that funds budgeted for other health initiatives were channelled to control Ebola.²⁵

Capacity to respond to emergencies

Organisational structures

The African continent has developed institutions and systems for health emergency regional cooperation based on learning from previous emergencies.⁸⁷ These include:

• New WHO Regional Emergency Hubs in Senegal, Kenya and South Africa to coordinate regional efforts. The WHO Health Emergency Hub in Nairobi, Kenya will include a Centre of Excellence for the Health Emergency Workforce.⁸⁸
• The Africa Infodemic Response Alliance, a unique and independent platform and network for sharing science-based facts on health and countering misinformation.⁸⁷
• The Africa Centres for Disease Control and Prevention (Africa CDC) has five Regional Collaborating Centres which focus on surveillance, preparedness and emergency response activities. The centres also coordinate regional public health initiatives with national institutes of public health, and they have developed new frameworks for supply chains with coordination through the African Union (Africa CDC). In December 2022, the centres convened a conference focusing on the world beyond COVID-19.

Case study: Capacity in Nigeria to respond to health emergencies

Public health crises are one of the most frequent emergencies in Nigeria. There were over 20 public health emergencies between 2016 and 2018, and five or more public health events are reported annually.¹⁹

Nigeria responds to disease outbreaks of public concern through Public Health Emergency Operation Centres established by the Nigeria Centre for Disease Control and Prevention (NCDC).⁸⁹ Public Health Emergency Operation Centres have been established in 28 of 37 states in Nigeria, including in the Federal Capital Territory.⁸⁹ These emergency centres respond promptly to outbreaks of endemic or new diseases. The NCDC is responsible for overall coordination of these emergency centres through its national incident coordination centre and technical working group when there is an outbreak.

Despite the establishment of the Public Health Emergency Operation Centres, gaps in the coordination across the centres affects responses to public health emergencies.⁹⁰ In 2019, the NCDC and Federal Ministry of Health and Social Welfare conducted an internal assessment of its core capacities needed to respond to public health emergencies. The assessment used the WHO Joint External Evaluation Tool and observed that there were gaps in the operation and structures of emergency centres, especially with finances and physical space.⁹⁰ The report also revealed gaps in the responses to zoonotic diseases.⁹⁰ This aligned with earlier report that Lassa fever spread rapidly in Nigerian rural communities due to lack of an infectious disease isolation ward, logistical limitations that usually hinder effective and timely testing of suspected cases, and a shortage of personal protective equipment for healthcare workers tending to patients that led to transmission of the disease among healthcare workers and their families.⁹¹

Priorities for responding to crises: A social science perspective

Controlling and reducing the human costs of health crises requires knowledge of social, economic, cultural and political processes, including drivers of trust, vulnerability and risks amongst different parts of population.⁹² Recent events have shown the importance of social science, and De Ver Dye (2020) recognised that ‘COVID-19 is equally — if not more — a socially-driven disease as much as a biomedical disease’.⁹³ Even before COVID-19, researchers have long noted the connections between socio-economic inequalities and infectious disease, and there is growing recognition that epidemics are also social and political.⁹⁴ Therefore, if the mistakes of past pandemics are not to be repeated, social, economic and political issues must be as fundamental to preparing for health crises as biological ones.

Anthropological and social science research have contributed to responses to health crises. Together, they bring attention to the cultural and politico-economic context, reframe community ‘resistance’, bolster community engagement in preparedness and response, and inform response activities, including risk communication.^60,94,95 It is important to remember that ‘one size does not fit all’ when responding to health crises. For example, social science has demonstrated the negative effects of a vertical, disease-specific ‘health security’ response on livelihoods, food security and healthcare for other conditions during the COVID-19 pandemic.⁹⁶ Using this social science perspective, we conclude by summarising the priorities for responding to health crises.

• Decolonise response and consider local priorities for health emergency response: Diseases capable of causing pandemics have been observed to captivate the attention of national and international health stakeholders in Nigeria. This is in contrast to endemic diseases that affect rural communities significantly and which are usually ignored.⁹⁷ As an example, the first outbreak of avian influenza in Nigeria in 2006 attracted funds and support from national and international stakeholders; this is in contrast to rabies, which has been endemic to rural communities and is a major cause of mortality in Nigerian rural communities. Diseases affecting rural communities may not attract attention from national and international health stakeholders. Ensure resources and support are allocated to endemic diseases like rabies, which pose significant mortality risks in rural West African communities.
• Emphasise social science in responses to health crises: Acknowledge the importance of social science in understanding and addressing health crises. Recognise that diseases like COVID-19 are as much socially driven as they are biomedical and that they need a holistic approach to crisis management.^93,94
• Prioritise understanding of socio-economic context: Recognise the social, economic, cultural and political processes influencing health crises. Understand drivers of trust, vulnerability and risks among different population segments to effectively mitigate human costs.⁹²
• Tailor response strategies to local contexts: Avoid a one-size-fits-all approach to health crisis responses. Utilise anthropological and social science research to understand cultural and politico-economic contexts, engage communities in preparedness and response, and ensure response activities are culturally sensitive and effective.
• Incorporate perspectives from the political economy: Incorporate perspectives from political economy analysis to allow for a comprehensive understanding of how political and economic factors influence crisis dynamics. The perspectives can also guide policymakers to develop responses that address both immediate needs and systemic issues within the region. Responses must include recognising how power structures may affect vulnerabilities and access to aid.
• Integrate lived experiences and insights into illness perception and help-seeking behaviour: Use social science to capture the perspectives of individuals and communities ‘from below’ to provide crucial insights into their lived experiences during a crisis. This nuanced understanding is essential for designing empathetic and effective response initiatives tailored to the local context.^31,96
• Understand and build on community responses: Social science helps understand and anticipate the responses of communities to outside intervention during health emergencies, allowing for approaches that align with local norms, values and community dynamics. Social science can enable adaptation of interventions to ensure greater adherence and uptake of protective behaviours.
• Consider impacts of crisis on the wider healthcare system: Social science is instrumental in assessing the dynamics of the healthcare system during a crisis. Social science helps ensure that responses align with the system’s capacity, address challenges and optimise healthcare delivery to effectively manage health emergencies in West Africa.
• Understand formal and informal institutions: Social science provides insights into the formal and informal institutions and authorities relevant for responses at the local level. This aids in the coordination of efforts and leveraging of existing structures for an effective crisis response tailored to the specific context of West Africa.
• Identify the capacities of local organisations to manage responses: By examining local relations, networks and institutions, social science helps identify and harness existing capacities for response at the community level. This facilitates a more decentralised and community-driven approach to crisis management, enhancing resilience and response effectiveness.

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Authors: This brief was written by Ayodele Jegede (University of Ibadan), Abu Conteh (Sierra Leone Urban Research Centre (SLURC)), Khoudia Sow (Centre Regional de Recherche et de Formation a la prise en charge de Fann (CRCF)), Mariam Boyon (CRCF), Catherine Grant (IDS) and Megan Schmidt-Sane (IDS), with input from Melissa Leach (IDS).

Acknowledgements: This brief was reviewed by Diane Duclos (LSHTM), Syed Abbas (IDS), Isaac Albert (University of Ibadan) and Alhaji Njai (University of Sierra Leone). Editorial support was provided by Harriet MacLehose (SSHAP editorial team).

Suggested citation: Jegede S., Conteh, A., Sow, K., Boyon, M., Grant, C., Schmidt-Sane, M., and Leach, M. (2024). SSHAP West Africa Hub: Health Emergency Cycles and Social Context in West Africa. Social Science in Humanitarian Action (SSHAP). www.doi.org/10.19088/SSHAP.2024.023

Published by the Institute of Development Studies: July 2024.

Copyright: © Institute of Development Studies 2024. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

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