BACKGROUND - LIBERIA HEALTHCARE
Founded in 1847, Liberia is the oldest republic in Africa. However, many years of minority rule and inequitable distribution of resources resulted in a civil conflict that lasted from 1989 to 2003. Liberia has come a long way in the nine years since the end of its civil war. In 2003, the country lay in ruins after 14 years of conflict. Few Liberians were untouched by the violence. Out of a population of 3.5 million, an estimated 270,000 people lost their lives, and more than 800,000 were displaced.2 Many sought refuge in neighboring countries, while others fled to the capital, Monrovia, which saw its population double to more than 1 million. Women suffered horrific violence; a postwar survey in one county found that 90 percent of interviewees had suffered physical or sexual abuse.3 Young people were traumatized by the war, in which many children enlisted as soldiers in the various rebel groups that marauded their way up and down the country. Liberia’s infrastructure was shattered, with roads and bridges destroyed and water and power supplies cut. The health system was not spared. Hospitals and clinics were looted, emptied of medicines, and burned down or vandalized. By the end of the war, only 354 health facilities remained operational, out of a prewar total of 5505. The vast majority of them were run by NGOs. The headquarters of Liberia’s health ministry, meanwhile, had become a temporary residence for refugees. Nine out of ten doctors had fled the country, and the medical training system had collapsed. Just 168 physicians remained, mostly in Monrovia.
The war had a catastrophic impact on Liberia’s health and development indicators. The statistics for maternal and child health were particularly stark. The 2007 Demographic and Health Survey, which covered the period 2002–2006, recorded an infant mortality rate of 71 deaths per 1,000 live births. Only 39 percent of children under the age of two had received their recommended vaccinations. At the time the survey was conducted, 31 percent of children under five were suffering symptoms commonly associated with malaria, and 20 percent had diarrhea. One in every nine children died before his or her fifth birthday. The survey found that Liberia was one of the most dangerous countries for expectant mothers. Less than two-fifths of women gave birth in a health facility, and only 46 percent had a skilled birth attendant with them at the time of delivery. The maternal mortality rate for the seven years up to 2007 was 994 deaths per 100,000 live births. This statistic was even more sobering when combined with survey data on total fertility rates, which showed that Liberian women have an average of 5.2 children
The figures on communicable disease also underline the scale of Liberia’s health challenge. Malaria is the leading cause of death in Liberia, accounting for more than 40 percent of deaths in hospital. Approximately 1.5 percent of the 15–49 age group had tested positive for HIV by 2007. Tuberculosis rates are 518 per 100,000, according to the World Health Organization.
The 2008 Liberia National Population and Housing Census reported a total population of 3,476,608. With an estimated growth rate of 2.8, Liberia’s population will reach five million by 2021. Fifty-two percent of the population is 19 years of age or younger, and the average life expectancy at birth is 59 years. Of the 15 administrative counties, the “big six” (Montserrado, Nimba, Bong, Lofa, Grand Bassa and Margibi) account for 75 percent of the total population, with one-third of the entire population living in the capital of Monrovia. Liberia continues to be one of the world’s poorest countries, ranked 162nd out of 169 countries in the 2010 United National Development Program Human Development Index, and (depending on source and definition) between 64% and 84% of the population live in extreme poverty, defined as less than $1.25 day.1 Thus, Liberia has a high proportion of its growing population living in poverty, concentrated in densely populated urban and sparsely populated rural areas.
Fast forward to 2014, and signs of progress are everywhere. Training facilities for nurses, mid- wives, and physicians are up and running. The number of operational health facilities is back up to prewar levels, and most buildings have been refurbished or rebuilt. Staff from the MoHSW have just completed their move into a new, Chinese-built headquarters on the outskirts of Monrovia. The resumption of basic health services has begun to have a positive impact on health outcomes. Sixty-four percent of children under the age of two have been immunized against diphtheria, pertussis (whooping cough), and tetanus, compared with 35 percent in 2003.
All these improvements have been built upon a solid policy framework. A National Health Policy (NHP), published in 2007, was integrated with the government’s Poverty Reduction Strategy, a blueprint for adding impetus to Liberia’s postwar recovery from 2008 to 2011. The center- piece of the NHP was a plan to deliver a basic package of health services (BPHS), free of charge, to Liberian citizens. These services included communicable disease control, emergency care, maternal and newborn health, and mental health care he emphasis was on ensuring that health facilities across the country provided a standard, measurable set of services regardless of whether they were run by the government, local or international NGOs, faith-based organizations, or private companies. An accreditation process found that by 2011 the BPHS was available at 82 percent of government facilities.
Despite the relative success of the 2007-11 NHP, Liberia continues to have very poor health indicators – especially among women and girls in rural areas – with a heavy burden of infectious disease. The 2007 Liberia Demographic and Health Survey (DHS) measured the Maternal Mortality Ratio (MMR) at 994 deaths per 100,000 live births, a total fertility rate of 5.2 (7.5 for rural areas), and a modern contraceptive prevalence rate of just 10 percent (7 percent for rural areas). Only 37 percent of deliveries take place in a health facility (26 percent in rural areas), and adolescent pregnancy has increased from 29 percent in 2000 to 32 percent in 2007.
In contrast to the rising MMR, Liberia has seen improvements in the under-five mortality (U5M) rate, which declined from 220 deaths per 1,000 live births in 1986 to 110 deaths per 1,000 live births in 2007; however, this U5M rate of 110 is still high, and Liberia is not on track to meet its MDG of 64.2 Similar to the U5M rate, Liberia has experienced improvement in childhood malaria prevalence, which has been reduced from 66 percent in 2005 to 32 percent in 2009; however even at this lowered prevalence, malaria remains the leading cause of morbidity and mortality in Liberia.3 Despite improvements in malaria and the overall U5M rate, child health in Liberia still faces daunting challenges, most notably chronic undernutrition, as the stunting prevalence has steadily risen over the last decade and is currently measured at 42 percent.4
Liberia is also faced with other infectious diseases burden that hampers development. In 2007, Liberia’s HIV prevalence was reported as 1.5 percent in the general population (ages 15-49), and in 2008 the World Health Organization (WHO) estimated the incidence rate for all forms of tuberculosis to be 326 per 100,000. And finally, epidemiological mapping shows a wide spread of neglected tropical diseases (NTDs), such Onchoceriasis, Lymphatic Filariasis, and Soil-Transmitted Helminthes affecting all 15 counties in Liberia, and in Bong, Lofa, and Nimba, the prevalence of Shistosomiasis is over 20 percent.
Building on this policy foundation, the MoHSW broadened its scope, launching an essential package of health services (EPHS) in 2011. The EPHS widens the number of services the government commits to providing to include treatment for noncommunicable diseases, child nutrition, dental and eye care, and neglected tropical diseases. The EPHS also aims to strengthen the referral system, formalizing a tiered structure of primary, secondary, and tertiary facilities with the objective of rationalizing services and making the system more efficient. The EPHS is the central element of a new national health plan for the country, drawn up in 2011 following almost a year of consultations with both domestic and international partners. Its end product is the Liberia National Health and Social Welfare Policy and Plan, a document that sets out the health priorities for the MoHSW for the next 10 years.
Government spending on health, while still modest, has risen dramatically from its postwar nadir, when national revenue was just $85 million. Liberia’s economic recovery was given a huge boost when it fulfilled World Bank requirements for debt relief in 2010, allowing virtually all of
its $4.9 billion national debt to be forgiven. By 2012, the national budget was a healthier-looking $500 million, allowing a greater share to be allocated to health. In spite of this improving picture, the government’s contribution to total health spending remained small. Preliminary data from the National Health Accounts, compiled by the MoHSW, showed that government expenditure made up just $19 million of the $179 million spent on health in 2009. By far the largest share, $122 million, was spent by donors, while households took on a large burden, spending $35 million.
Overall, Liberia’s health system shows some positive features despite the almost overwhelming public health challenges it faces. There is strong political will on the Liberian side and a desire to transition from donor-recipient status to locally led ownership of the health system. The govern- ment is taking on a larger share of front-end health service delivery from international NGOs, which helps strengthen its legitimacy in the eyes of the public. At the same time, the MoHSW and its international partners have tried to strike a balance between the immediate need to deliver services and the importance of making longterm investments in establishing sustainable systems and structures. Although there is still a long way to go, policy makers have put increasing emphasis on getting the right health systems in place, from procurement and human resources to monitoring and evaluation mechanisms and health management information structures. Planning functions are improving, and the move toward medium-term financial planning is a welcome development. The Ministry of Health has some capable leaders who can draw on the experience gained during long careers in the health sector. The minister of health and social welfare, Walter Gwenigale, and other senior officials are committed, professional, and consultative. The government has a well- formulated policy for improving the health system. Documents such as the 10-year health plan, while highly aspirational in tone, offer a compelling vision for moving forward.
The challenges, however, remain immense, and many mistakes have been made along the way. In assessment of health services, for example, too much emphasis was placed through the BPHS on measuring the quantity of inputs rather than the quality of service provided. The overall standard of services remains low, with long waits for patients, few available drugs, and poor health outcomes. The large role that donor contributions and out-of-pocket payments play in health expenditure leads to basic access issues, particularly for the least well off. The poorest fifth of the population spends up to 17 percent of its annual income on health, according to one estimate.
United States Government Global Health Initiative Liberia Strategy, September 2011
The Road To Recovery: Rebuilding Liberia's Health System. Richard Downie, August 2012