Command and control of Sierra Leone's Ebola outbreak response: evolution of the response architecture.

Management, coordination and logistics were critical for responding effectively to the Ebola outbreak in Sierra Leone, and the duration of the epidemic provided a rare opportunity to study the management of an outbreak that endured long enough for the response to mature. This qualitative study examines the structures and systems used to manage the response, and how and why they changed and evolved. It also discusses the quality of relationships between key responders and their impact. Early coordination mechanisms failed and the President took operational control away from the Ministry of Health and Sanitation and established a National Ebola Response Centre, headed by the Minister of Defence, and District Ebola Response Centres. British civilian and military personnel were deeply embedded in this command and control architecture and, together with the United Nations Mission for Ebola Emergency Response lead, were the dominant coordination partners at the national level. Coordination, politics and tensions in relationships hampered the response, but as the response mechanisms matured, coordination improved and rifts healed. Simultaneously setting up new organizations, processes and plans as well as attempting to reconcile different cultures, working practices and personalities in such an emergency was bound to be challenging.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.