This report is unique. It is the first report to undertake an assessment of the Ebola virus disease (EVD) for each of the 15 West African countries, breaking away from the tradition of focusing on the three epicentre countries. It is also the first to assess the impact of EVD on poverty incidence and food security in both the three epicentre countries and other non-West African countries. The estimation approach of the socio-economic impact, which allows for consistency checks, is also different from that of other studies. The report emphasizes the imperatives of a regional dimension. With the intensity of the pandemic in Guinea, Liberia and Sierra Leone, and even if it is restricted to these three most affected countries, a long-term propagation of EVD in these countries will have a substantial impact on all West African economies. The disease is unprecedented in scale and virulence. The intensity and complexity of the outbreak in the three countries makes it difficult for individual countries to handle, requiring a coordinated approach. The relatively free movement of goods and people in the region and close community ties, which make it very difficult to contain the outbreak as well as the limited internal capacity to cope with the outbreak in terms of human, financial, operational and logistics capacity calls for a regional dimension. If the outbreak of EVD is not addressed collectively, the start of the domestication and implementation of the Sustainable Development Goals (SDGs) in these countries and their neighbours will be put at risk. A regional approach provides an opportunity to raise awareness on the socio-economic impacts of Ebola at the regional level and in each of the 15 countries in West Africa. Analysis of the shortand medium-term costs of the Ebola epidemic should spur governments of non-affected countries to act quickly to put in place preventive measures. The 2014 Ebola virus disease (EVD) outbreak in West Africa is the longest, largest, deadliest, and the most complex in history. Unlike past outbreaks, which lasted for a very short time, this outbreak has lasted for more than a year – and has not yet fully abated. As of 11 February 2015, there were 22,859 EVD cases and a total of 9,162 deaths. Compared to the cumulative sum of past episodes in 32 years (1976-2012) – 2,232 infected people and 1,503 deaths – there are now over ten times the total number infection cases and over six times the total number of fatalities. In less than six months, what started as a public health crisis in Guinea had degenerated into development crises (i.e. economic, social, humanitarian and security threats) in Guinea, Liberia and Sierra Leone. In contrast with past outbreaks, which were mostly restricted to remote areas, the West African case is complex and geographically widespread, and involves small rural and large urban centres including Conakry, Monrovia, and Freetown. Due to the multi-country outbreaks occurring simultaneously, this pandemic is very difficult to contain. The infection of 830 health workers, of whom 488 died, further complicated its containment. This is the first time that the EVD has been transmitted to other countries through air travel. Several factors make the containment of the pandemic very difficult. The health systems in Guinea, Liberia and Sierra Leone were unprepared for Ebola at the onset of the epidemic. They lacked sufficient amounts of all that is required to contain the epidemic: drugs, ambulances, facilities, trained health personnel, and many other items. Moreover, impoverished rural areas have more limited access to services than relatively well-off urban areas. The protracted civil wars in Liberia and Sierra Leone, and the intense political instability compounded the weak health and physical infrastructure. The inequitable distribution of human and financial resources has hampered the response to the epidemic. Due to ignorance or lack of knowledge and preparedness, health professionals misdiagnosed the EVD because its early symptoms resembled those of other diseases endemic to the region such as malaria, cholera and Lassa fever. In addition, some people thought that the disease was being spread by the government resulting in underreporting and thus contributed to the silent spread of the virus, which remained hidden and eluded containment measures. Fear spreads as fast and wide as a virus. The high mortality rate associated with Ebola threatens the performance of many interventions that could help contain the epidemic. Indeed, due to fear of infection, the public was reluctant to engage in contact tracing; infected persons were hesitant to present themselves for treatment; and health workers were frightened to provide care. This was further complicated by the loose migratory pattern in the region and risky cultural practices. The longstanding cultural practices that people were understandably reluctant to abandon contributed to the further spread of infection. Due to the culture of burying the dead near their ancestors, corpses were transferred long distances, which thereby fuelled new outbreaks. When people thought that their social, cultural and economic rights were being violated, they often resorted to physically assaulting health workers. The difficulty of coordinating Ebola-related aid and of treating infected patients using existing infrastructures is another impediment to stopping the epidemic. Most other countries are in the same health sector conditions as those in Guinea, Liberia and Sierra Leone. The countries are not prepared for any serious public health crisis like the EVD outbreak; this calls for a regional approach to preventing EVD in the future. EVD does not respect age. All age groups are affected, but the heaviest toll is on the most active segment of the population (15-44 years) – the labour force. This has serious negative implications on the labour market and national productivity. The toll is also heavy on children. Around 20 percent of the infected cases are children. Over 16,600 children either lost one or both parents to EVD, which makes them more vulnerable to poverty. They lost school hours, ranging from 486 hours in Guinea and 780 hours in Sierra Leone. There is a feminization of the EVD, and the disease’s impact is more on women than men in the three epicentre countries. As of 7 January 2015, the number of EVD cases was higher among women (50.8%) than among men (49.2%) in the three epicentre countries. On per 100,000 population, women are more affected than men (118 against 115). The gender disparity is more pronounced in Guinea and Sierra Leone. As care providers, women are more likely to be exposed to the disease transmission vectors such as vomit or other bodily fluids of an infected family member. Furthermore, certain traditional practices and rituals performed on the deceased mostly by women can also pose an increased risk. Women’s access to non-Ebola-related services has been constrained. For instance, in Sierra Leone, the number of women giving birth in hospitals and health clinics has dropped by 30 percent. In addition to being physically affected by the epidemic, women have suffered reversals in economic activities and empowerment, due to EVD control measures that restrict the movement of people and goods. Women in the three countries are disproportionately clustered in the least productive sectors, with 90 percent employed in the informal services and agricultural sectors. The EVD has increased their vulnerability to the loss of livelihoods and incomes. The financial capital of women’s savings and loans groups in these countries, especially in Liberia and Guinea, has also been reduced. The pandemic has threatened the social fabric that glues society together. The pandemic and the associated hardships have changed people’s consumption habits; many have had to eat less than before the EVD outbreak. There is evidence that the EVD is eroding the age-long communal behaviours of the people including attendance at ceremonies, adjustment in burial rights and less caregiving to family and community members. Feelings of distrust between communities and between the people and their governments are still strong. The health system had been weakened in terms of access to health services including non-Ebola-related services such as family planning, pre- and post-natal services, antiretroviral therapies and treatment of endemic diseases in the region such as malaria and cholera. Most people in the epicentre countries expressed a fear for the future of their family, community and for the whole country. The recovery and future preventive measures must take cognizance of people’s feelings and expectations. Building an enviable social contract between citizens and their governments should be a priority in the recovery interventions. An effective management of the recovery process will help build people’s trust and confidence and also boost their expectations for the future. EVD is pushing people into poverty and making them more vulnerable. With the brilliant economic outlook of the past few years, and given the growth elasticity of poverty for Guinea, Liberia and Sierra Leone, the incidence of poverty should be 49.78 percent in Guinea, against 31.20 percent in Sierra Leone and 63.47 percent in Liberia in 2016. However, EVD seems to have reversed this trend. Compared to baseline, incidence of poverty is expected to worsen. For Guinea, the rise in poverty could range from 2.25 percent in 2014 to 7.9 percent in 2015; between 13.8 percent and 14.1 percent for Sierra Leone; and between 5.5 percent and 17.6 percent during 2014-2015. The outlook for 2016 is worse for the three countries. The poverty impact of EVD on non-EVD affected countries is also high, especially in Mali, Senegal, Côte d’Ivoire and Niger. Stigmatization, which reduces international trade and foreign investments between these countries and their main trading and investment partners, as well as the loss of jobs and livelihoods due to closure of borders to neighbouring countries to Guinea, Liberia and Sierra Leone made the poverty impact high. Food security impact of EVD is high in affected and some non-affected countries. The restriction of movements of goods and services, the quarantine of communities that are food baskets of the affected countries, the fear of trading with affected areas, the closure of borders and international stigmatization that has raised premiums on ships berthing in West Africa have affected access to food. There is a strong correlation between EVD outbreaks and the prevalence of undernutrition. In this report, the food security impact is evaluated by the prevalence of undernourishment measured by the proportion of the population estimated to be at risk of caloric inadequacy. Relative to the observed trends during 1992 and 2012, the prevalence of undernourishment during 2014-2016 could increase by 2.8 to 5.3 percent in Liberia; 1.30 to 1.39 percent in Sierra Leone, and 0.49 to 1.72 percent in Guinea. The EVD has reversed the previous trend in the projected improvement in food security in Liberia and Sierra Leone. Among the non-heavily affected countries, the impact on Guinea Bissau and Côte d’Ivoire is relatively higher than on other countries in the region. Increasing access to food and nutrition, and restoring agricultural production capacity are essential parts of the recovery interventions. The cost of the pandemic on GDP is very high, and Ebola-free West African countries are not immune from the devastating effects. The findings reveal earlier results on the three epicentre countries, but are more pronounced given the intensified EVD cases and fatalities. In the medium term (2014-2017), the gains in economic growth of the past decade seem to have been reversed. The loss ranges an annual average of 4.9 percent (low Ebola scenario) to 9.6 percent (high Ebola scenario) for Guinea, 13.7 to 18.7 percent for Liberia, 6.0 to 8.0 percent for Sierra Leone. The actual loss in GDP for the low Ebola scenario is highest in Sierra Leone (US$219 million), followed by Liberia (US$188 million) and Guinea (US$184 million). For the high scenario, it ranges from US$315 million (Guinea) to US$245 million (Liberia), while Sierra Leone could lose as much as an annual average of around 7.1 percent between 2014 and 2017. The loss in per capita income is highest in Liberia. The toll on the GDP is considerable in the three countries lightly affected by the EVD. On annual average during 2014-2017 for the low scenario, the loss ranges from US$81.6 million (Mali) to US$145.2 million (Senegal) and US$1.4 billion (Nigeria). For the remaining West African countries that are EVD-free, the loss in the GDP growth varies from 0.1 to 4 percentage points. The loss of GDP for the whole region for the low scenario will be US$3.6 billion on average per year (i.e. 1.2% of the average GDP of the region). It could also lose around US$18 per capita per year. This is a substantial economic loss to a region that is struggling to catch up with other sub-regions of the world to translate past growth into improved living conditions for its people. The loss in GDP and per capita income of this magnitude has substantial implications on the jobs and livelihoods, with a serious negative impact on households’ survival. Rejuvenating lost livelihoods through appropriate social protection to farmers in the upcoming planting season and boosting microfinance to small-scale enterprises are vital. Given the fiscal stress associated with the EVD, priority should be given to efforts to boost the fiscal capacity of the Governments of Guinea, Liberia and Sierra Leone, such as providing debt reliefs and concessional loans. Addressing international stigmatization that weakens international trade and foreign investment in West African also deserves urgent attention. Ebola is not only a threat to national security, but also an impediment to sub-regional, regional and global security, which therefore requires supranational and global attention. The role of regional and continental organizations in fighting the pandemic is yielding some results. The Mano River Union’s concerted efforts in calling on the international community to support their capacity building for surveillance, contact tracing, case management and laboratory testing as well as facilitating sharing of information, expertise and resources among member states are commendable. The unparalleled efforts of the Economic Community of West African States (ECOWAS) Authority in establishing the Ebola Solidarity Fund, mobilizing experts for the epicentre countries, and creating the Regional Centre for Disease Control and Prevention are epochal. The African Union’s Support to Ebola Outbreak in West Africa (ASEOWA), which has deployed a considerable number of Ebola volunteer workers (launched by the African Union in collaboration with Nigeria and Ethiopia), forged partnerships with the private sectors, especially telephone service providers, mobilized resources and mandated the establishment of Africa’s Centre for Disease Control and Prevention, is laudable. The United Nations Development Group for West and Central Africa (UNDG-WCA) calls for synergy between the regional and continental disease control centres and commits its support to their operationalization. Strategies to make them functionally effective should be put in place. The international community must fulfil their pledges and support the establishment of a mechanism that allows for rapid disbursement. As of 31 December 2015, only one third of the pledges was disbursed, and a substantial part of the disbursement came in October when the pandemic had already devastated lives and livelihoods. The slow pace of converting pledges to commitment calls for immediate correction. Fulfilling the pledges is vital to ending the pandemic and accelerating early recovery. The international community should establish a mechanism that would allow rapid disbursement of funds during public health threats like Ebola. To ensure sustainability, ownership and capacity strengthening, the international organizations should work with governments to mobilize resources for the recovery process. The global community is ill-prepared for a devastating pandemic like Ebola, and the next outbreak should not take the world by surprise. An important lesson emerging from the pandemic is that the global community is not ready to address virulent pandemics like Ebola. The global health governance structures are inadequate, the international commitment to bolster pandemic preparedness and response capacity in poor countries is tardy, and the global support for strengthening health systems is still weak. This, therefore, points to the urgent need to reform the global health management system in order that it will be able to cope with such pandemics when they occur. Current partnerships with research institutions and pharmaceutical companies should be translated into strategic actions that will lead to the invention of the requisite vaccine for the disease within a very short time. The strategic engagement of the UN System on the EVD response has enhanced its relevance in the region, and UN agencies still have a major role to play in overcoming the outbreak. While most partners withdrew at the peak of the crisis, UN agencies not only remained, but also increased their presence in the epicentre countries and the corridor countries (Senegal and Ghana). This helps mobilize partnerships and action as well as resources for the Ebola response. Consequently, the UN System became a trusted partner in the region. Its available resources have been reprogrammed for Ebola containment and the associated early recovery efforts. Working with national and regional institutions to strengthen coordination mechanisms further aided the response actions in the region. The United Nations Development Assistance Framework (UNDAF) for the region should be concerned with strengthening the health services’ capacity to cope with future epidemics without compromising the fight against other priority diseases, and ensuring the provision of quality care. Combined national and regional preventive mechanisms are imperatives. The containment of the outbreak is beyond the capacity of a single country. Complementary actions from sub-regional, regional, continental and global bodies are important for maximum success. Both national and regional preventive measures for the entire region, especially in countries with a high probability of EVD occurrence as predicted in this report report (e.g. The Gambia, Ghana and Côte d’Ivoire) are needed for enhanced results. This includes developing early warning plans based on multidisciplinary approaches and strengthening the capacity for early reaction and disaster management system at the national and regional levels. A combined strategy works best. Intensifying contact tracing to remove infected individuals from the general population, placing them in a setting that can provide both isolation and dedicated care, and dealing with associated psychological factors have proved effective. A densely populated country like Nigeria used this approach to bring EVD under control in a very short time. Cross-border contact tracing is more effective than a single country contact tracing when EVD occurs in multi-countries simultaneously. Learning from the experiences of countries that succeeded in containing the epidemic is key. The rapid responses from Senegal and Nigeria are positive lessons learned. In these countries, there were competent and relatively adequate health personnel, decentralized health systems, community engagement and strong leadership commitment. A regional approach to containing EVD will be more effective than just focusing on national preventive actions. When there are simultaneous outbreaks in multiple countries that are contiguous to each other, joint cross-border contact tracing, joint treatment and holding centres should become more effective. National actions then become complementary. The outbreak in Guinea, Liberia and Sierra Leone is a warning to others in the region because the health systems and their vulnerabilities are the same. EVD does not know boundaries, and not a single country is immune from the outbreak. This report calls for a combined national and regional preventive and early response mechanisms for West Africa. The region cannot afford to be unprepared.