The international response to the Ebola crisis was more generous than most health policy experts predicted, but the actual deployment of those resources has been extremely slow, according to an analysis of Ebola donations published today in the British Medical Journal. So far, only 40 percent of Ebola donation pledges have been paid out, and according to the author of the study, the delayed response from international health agencies might be to blame.

"The WHO and others didn’t ask for money soon enough," says Karen Grépin, a global health policy researcher at New York University and the author of the study. "There’s no doubt in my mind that the delay between the time when the WHO learned about the outbreak and the time when the WHO and others called for donations was really too long." The WHO failed to respond to The Verge's requests for comment.

"The WHO and others didn’t ask for money soon enough."

The current Ebola epidemic has infected over 22,000 people and has killed more than 8,500, according to the WHO’s latest report. Guinea’s Ministry of Health told the WHO about its Ebola outbreak in March 2013, but the WHO didn’t declare a state of emergency until August. As a result, most organizations waited to donate to the cause. And because there’s usually a long delay between the time when pledges are made to when they’re paid out, the money is still just trickling into affected countries. "When you have exponential growth of cases, any delay can have life and death consequences for people," she says. "For Ebola the consequences are pretty stark."

In the study, Grépin used data from the United Nations Office for the Coordination of Humanitarian Affairs’ financial tracking system to figure out a timeline of Ebola donations. She found that only 40 percent of pledges — or about two-thirds of the amount requested by affected countries — had been received by their intended recipients by the end of 2014. This amounts to about $1.09 billion of $2.89 billion in pledges.

$1.09 billion of the total $2.89 billion has been paid out

This delay wasn’t uniform. The US has been the largest donor thus far, with a total of $900 million in pledges, and it has paid out about 95 percent of the money it promised. The UK and the World Bank are the second- and third-largest donors, with pledges amounting to $307 million and $230 million, respectively, according to the study. Yet the World Bank has only funded abut half of its total pledges, Grépin says. She thinks this might be because the World Bank's donations tend to be shunted into a more complex program, where they do things like extend loans or pay health care workers' salaries.

The World Bank did not respond to our requests for comment prior to the publication of this article. A spokesperson from the World Bank got in touch with us after this story was published, however. According to the spokesperson, the World Bank has pledged $518 million to date, not $230 million — a number that the BMJ study says relates to pledges made prior to December 31st, 2014. Of that total, the World Bank says it has disbursed $283 million, or about 55 percent of what it has pledged. Moreover, total World Bank commitments to the Ebola response "are about $1 billion," the spokesperson said, which also includes at least $450 million from the World Bank's International Finance Corporation, their private sector arm, but isn't included in the UN's financial tracking system.

Grépin's analysis also revealed that Liberia received far more pledges than Sierra Leone, despite the fact that Sierra Leone has experienced double the amount of Ebola cases. This is largely due to political ties, Grépin explains. For historical reasons, "Liberia is a large recipient from the US government, and the US government is far more generous," she says, whereas Guinea largely received aid from francophone countries, and the UK gave to Sierra Leone.

Liberia received more pledges than Sierra Leone even though Sierra Leone had double the amount of Ebola cases

Overall, international organizations received more money than affected countries. This isn’t all that surprising, Grépin says; international organizations often have better results scaling up their efforts and recruiting foreign medical teams than a country whose health system is decimated. But it may have some long-term consequences. "Stand-alone treatment centers were constructed, and in some cases they are being knocked down now," she says. Building nonpermanent structures and bringing in foreign doctors is "probably the right call for expediency purposes," but these sorts of efforts don’t really help a country avoid public health crises in the future.

Understanding exactly what went wrong within the WHO won’t be easy. But it might be possible to fix the problem before we have full knowledge of them. Grépin thinks that creating an independent body charged with assessing these situations as they arise instead of relying on a declaration from the WHO's director could speed up the process. Countries have 24 hours to report a public health threat, she says, so "why isn’t there a comparable, automatic system at the international level?"

"Why isn’t there a comparable, automatic system at the international level?"

Grépin’s analysis doesn’t perfectly capture Ebola-related aid efforts. The database she used is updated daily, but it relies mostly on self-reporting. This means that some large donors probably weren’t in the analysis, she says. Moreover, the UN’s financial tracking system was very good about updating pledge dates, but didn’t always have information about when the donations actually came through. Finally, the database doesn’t include typical World Bank interventions like extending a country’s line of credit. "Tracking resources in times of crisis are challenging," Grepin says. And the Ebola epidemic carries a set of peculiarities that may have complicated the endeavor. "Never before has a public health emergency also been considered a humanitarian crisis," she says.

What’s perhaps most striking about the analysis is the fact that some donors started to give small sums before the WHO declared an emergency. "It’s kind of puzzling because it seems like this was more important to the donors than to the WHO," Grépin says. "I think we're going to try to account for the [delay] for years to come."

Update February 4th, 9:00AM: This article has been updated with a response from the World Bank.

Update February 4th, 2:07PM: The Verge asked Karen Grépin to comment on the World Bank's response to the BMJ study. This is what she told us: "Much of the resources given by the World Bank are underestimated in the Financial Tracking System. Given that my main conclusion is that donors have been generous, I see this as a justifiable position. I decided to rely upon the FTS because it is the most standardized source of data. Even if the figures don't reflect it, I believe the World Bank has been one of the most commendable donors in the fight against Ebola."