The UN-coordinated scale-up of the Democratic Republic of Congo's rapidly expanding Ebola response could run out of available funding within weeks, threatening efforts to contain an outbreak that has already killed more than 2,500 people.

Since the outbreak was declared on May 15, 5,290 confirmed infections and 2,516 deaths have been recorded, according to the latest health authority figures cited by the United Nations. Another 1,152 people have recovered, and nearly 840 remain in isolation or hospital, putting the case fatality rate at 47.6%.

“We're only covered for the next weeks, and very soon funding will run out,” UN Senior Ebola Coordinator Julien Harneis said, as quoted by UN News. “Every delay in funding and implementation makes this epidemic more deadly, more difficult to stop and more expensive. So, we need that international support immediately.”

OCHA said about $80mn had already been invested to launch five government led integrated response packages bringing together the World Health Organization (WHO), World Food Programme, UNICEF, International Organization for Migration and other partners. But the funding available for that scale-up is expected to last only a matter of weeks.

The packages are intended to strengthen surveillance and community engagement, accelerate safe burials and expand treatment capacity from about 900 beds to 3,000 within three months.

The overall financing requirement is meanwhile being revised sharply higher. DR Congo's initial three-month national response plan was budgeted at about $240mn, while a new government plan being finalised has been costed at around $940mn, according to WHO representative in DR Congo Anne Ancia, The EastAfrican reported on August 23.

The prospective $940mn national plan is separate from the $80mn already used to launch OCHA's five integrated response packages.

The United States announced an additional $242mn in August, taking its commitments for Ebola response and regional preparedness to more than $512mn. DR Congo says it has itself committed about $50mn. But headline pledge figures do not translate directly into funds controlled by the government because substantial donor financing is channelled through UN agencies and non-governmental organisations.

That has opened a second front in the response: a dispute over who controls the money and how spending is coordinated.

Health Minister Roger Kamba has called for “one plan, one budget, one coordination”, arguing that multiple funding streams can produce parallel programmes, different pay scales and gaps between activities that should operate together.

Kinshasa is not demanding that every dollar be deposited into a single government account. Instead, it wants a common financial framework, a harmonised budget and fuller visibility over who is financing what and how much is actually being spent.

The government says fragmented financing has already created operational problems. Different partners have hired health workers directly and set their own remuneration, contributing to disputes and strikes in some affected areas. Authorities have since moved to standardise risk allowances and Ebola specific payments for doctors, nurses and other response personnel.

Kamba also raised concerns about payroll integrity. He said a recent payment exercise covering more than 1,000 people found that an estimated 15%-20% of names on the lists were allegedly fictitious. Authorities plan to introduce biometric registration to tighten payroll controls.

Kamba said about $1.2bn was mobilised during the country's 2018-2020 Ebola response, arguing that too little durable health infrastructure remained once the emergency ended.

More than half of current Ebola response funding comes from the United States, Harneis said, while an updated operational plan is expected to set out the additional resources needed as the outbreak expands.

The epidemic, caused by the Bundibugyo species of Ebola virus, is already the largest ever recorded in DR Congo and has spread to 56 health zones across six provinces: Ituri, North Kivu, South Kivu, Haut-Uélé, Tshopo and Bas-Uélé.

Harneis said the epidemic was “growing exponentially”, with roughly half of all deaths occurring during the previous 20 days.

“The epidemic is spreading to an area that is bigger than France,” he said, adding that the outbreak was growing “faster and wider than the Ebola response”.

The outbreak is unfolding in areas already dealing with armed conflict, mass displacement, malnutrition and other disease outbreaks.

Dr Tyler B Evans, an infectious disease specialist who previously worked in Congo, told The EastAfrican that Ebola could not be treated as an isolated public health emergency because those structural conditions make transmission and the response more difficult.

“The virus is the spark. The structural conditions are accelerant,” he said.

Decades of conflict have weakened public institutions and health services, displaced large populations and left roads and financial infrastructure underdeveloped.

Harneis said one recent journey to an Ebola hotspot took three hours to cover only 60 km, illustrating the logistical difficulties facing response teams.

The financial system is creating an additional bottleneck.

“In this area, the banking system barely functions,” Harneis said. “We're unable to bring in the amount of money that is required to pay the workers, which has led to great unhappiness amongst frontline workers.”

Harneis said the liquidity problem worsened after commercial flights into Bunia were suspended, disrupting one of the channels used to deliver physical cash to local banks. Weak mobile connectivity has limited alternatives, while moving large amounts of cash overland is risky because of insecurity.

Frontline workers are paying a particularly high price. The latest figures cited by the UN show 160 healthcare workers infected and 43 dead.

Medical teams are also facing physical attacks. Harneis said healthcare workers and Ebola responders had been assaulted, ambulances stoned and burned and health facilities attacked as fear, misinformation and hostility towards the response spread through some communities.

More than 260 attacks against health workers were recorded across DR Congo during the previous six months, killing eight healthcare workers, although not all of the attacks were directly linked to the Ebola response.

“Conditions on the ground are extremely difficult, but we will continue deploying all the humanitarian and medical assistance needed until the job is done,” Harneis said.

The financing crisis comes as authorities prepare to deploy experimental vaccine protection against the outbreak.

WHO and the Africa Centres for Disease Control and Prevention said on August 20 that 70,000 doses of the Ervebo Ebola vaccine had been allocated to DR Congo. Of those, 20,000 will be used in a Phase 3 clinical trial to determine whether the vaccine protects against the Bundibugyo virus, while 50,000 are intended for frontline healthcare workers.

Ervebo is licensed against Ebola disease caused by the Zaire species, but it is not yet known whether it protects humans against Bundibugyo virus. There is currently no licensed vaccine or specific treatment for the strain behind the current outbreak.

That makes surveillance, rapid isolation, contact tracing and community cooperation particularly important.

Authorities reported an 82.9% follow-up rate among registered contacts, although Africa CDC has warned that only a relatively small share of the contacts expected from the scale of transmission are being identified in the first place.

The scale and speed of the outbreak have already eclipsed DR Congo's previous Ebola emergencies. Health authorities now face the dual challenge of expanding medical capacity while ensuring increasingly large flows of donor money do not become fragmented across competing programmes.

The economic consequences could also grow if transmission continues. The affected provinces include important mining and trading areas where insecurity already constrains transport and commerce. Ebola controls can further restrict movement of labour and goods, while pressure on health budgets and humanitarian resources diverts funding from other essential services.

For Kinshasa, the financing debate is therefore about more than the size of international pledges. The government wants greater oversight of spending, consistent payment structures and tighter controls against fraud, while donors and aid agencies need to retain the speed and operational flexibility required during a fast moving epidemic.

With the government's emerging national response plan approaching $1bn, the cost of poor coordination is becoming increasingly significant. Delays, duplication or gaps between programmes risk consuming scarce funds while allowing infections to spread.