Post-Conflict Liberia

By Richard J. Brennan and Jacob Hughes

Liberia is the oldest republic in Africa, having been settled by freed American slaves in the 1820s and becoming a sovereign nation in 1847. Decades of oppression of the indigenous population by the ruling elite culminated in a vicious coup in 1980 and, subsequently, 14 years of civil conflict between 1989 and 2003. Following free and fair elections, President Ellen Johnson-Sirleaf assumed the presidency in 2006, becoming the first female head of state in Africa. She inherited a nation with major disruption of every sector.

With it came very low levels of trust between this former “pariah state” and the international community, as well as between the citizens of Liberia and their government. It is never easy for the leadership of a country emerging from conflict to set a course for national reconstruction in the face of enormous loss, or to make the difficult choices among overwhelming and competing demands.

But in many ways, Liberia’s recent progress has been as impressive as any post-conflict country. Over the past five years, the Sirleaf government has gained widespread respect both nationally and internationally for the return to peace and stability, the progress of its poverty reduction strategy, and the successful negotiation of $4.6 billion in debt relief.

One sector that has documented considerable success is health – in large part due to the leadership and vision of the country’s Ministry of Health and Social Welfare. In many ways the ministry is on its way to fulfilling its ambitious 2007 goal of becoming a “model of post-conflict recovery in the health field.” Nonetheless, the challenges facing Liberia are considerable, including the persistent corruption, the global recession, and the recent arrival of an estimated 158,000 refugees from the conflict in neighboring Côte d'Ivoire. 

Evolution of the Health System

Liberia’s health sector has recently evolved through several discernible phases. Throughout the war years and into the early post-conflict period, service delivery was based on a largely a humanitarian model – heavily dependent on short-term funding from international donors and on operational support from non-governmental organizations. Because of the war, during the humanitarian phase people lost faith in the intentions and priorities of their government – the social contract had been broken.

Beginning with the launch of a new National Health Policy and Plan in 2007, the sector entered a transition phase, including a clear medium-term vision and plan, a well-defined basic package of health services, and a wider donor funding base. More recently, the MOHSW has embarked on the exciting process of developing a 10-year development policy and plan that will include a longer-term vision, an expanded package of services, and detailed strategies for decentralized management of service delivery and health systems strengthening.

Time of Transition – The 2007 Plan

Before the transition phase, most substantive discussions on service delivery were held outside of the domain of government. The high-level Health Sector Coordinating Committee meeting was held in the office of the World Health Organization. Donors funded their non-governmental organizations to implement their health projects. The international footprint overshadowed government in almost every aspect. Under the Sirleaf administration, and with new leadership in the Ministry of Health and Social Welfare, government began to gradually assume leadership functions and assert its authority. Within the first year of the administration, virtually every interagency committee in the health sector had a new chairperson – a senior member of the ministry.

The ministry then successfully engaged a broad range of stakeholders in the development of the 2007 National Health Policy and Plan, which were designed to guide the sector through the following five years. An impressive array of government ministries, donors, United Nations agencies, NGOs and technical experts contributed to the process. The cornerstone of the new service delivery strategy was the basic package of health services, which clearly outlines those services to be provided at each level of the health system.

These three key documents – the policy, plan and basic package of health services – were well conceived, technically strong and based on sound public health principles. They set ambitious, but not unrealistic, targets for the period 2007 – 2011. Moreover, they were well written and concise, making them accessible to most health managers. The consultative, participatory approach employed by the health ministry in their development resulted in a strong sense of ownership at all levels– as well as affirming that it was the role of government to lead, although all would be welcome to participate.

Throughout the implementation of its five year plan, the health ministry has continued to collaborate effectively and transparently with its partners, earning considerable trust and cooperation. Importantly, all major donors were deliberately and strategically engaged from the outset to garner their commitment to the ministry’s objectives, strategies and basic package of health services. By going to the sources of most funding for health, the ministry was able to quickly initiate health activities according to its policy and plan. Perhaps most impressively, it was the first of any government ministry or agency to do so.

Subsequently, several donors made large contributions to a common financing mechanism, the Health Sector Pool Fund – an innovative, government-managed multi-donor fund that breaths life back into the national system and ensures continuity of service delivery by funding NGOs. In early 2012, U.S. Agency for International Development will also begin to channel its direct support for health service delivery through the government’s national systems, with on-going technical assistance from U.S. government-supported projects. By mid-2012, three-fourths of all NGO-supported facilities in Liberia will be funded through the Ministry of Health and Social Welfare, thus making further progress to restoring public confidence in government’s commitment to providing basic services – a major factor in sustaining the peace and prosperity gained thus far.

Impressive progress has already been documented since the roll-out of the strategy and the basic package of health services.  Institutionalization of government standards has been reinforced across the country by the ministry’s annual accreditation survey, which evaluates health facilities against inputs and services outlined in the basic package. In the January 2011 survey, 82 percent of health facilities were assessed as providing the basic package of health services – up from 36 percent just two years earlier. Facility-based deliveries have increased nationally and have tripled in some areas over the past two years, household ownership of insecticide-treated nets has more than doubled to 49 percent, and malaria prevalence among children has reduced by almost half. The mortality rate of 110 deaths/1,000 live births for children younger than 5-years-old represents a 50 percent decline from war time estimates, although this improvement preceded the 2007 Policy and Plan, and can likely be attributed as much to improvements in peace as to expansion of services.

Other important developments include the re-opening and strengthening of several nursing schools, the upgrading of the national Health Management Information System, the establishment of important technical units within the ministry (e.g. nutrition department), and early successes with the introduction of performance-based financing of health services. Moreover, a number of important policies, plans, and technical documents have been developed, including a Community Health Strategy and an in-service training strategy and plan.

Nonetheless, many challenges persist. Some important health outcomes have not improved (e.g. maternal mortality ratio of 994 deaths/100,000 live births) and coverage rates for some key services have made little progress (e.g. full immunization coverage of 51 percent). There are still major gaps in health worker numbers and skills, especially in rural areas. The institutional capacity of the ministry is limited and county-level capacity remains weak. Gaps in key policies and plans persist, while others remain to be implemented; and several support systems remain underdeveloped, such as the supply chain.

Toward Development – The 10-year Policy and Plan

Against this backdrop, the Ministry of Health and Social Welfare is now developing an updated strategy that will guide the health sector through the next decade. It is being informed by newly available data on demographics, the health workforce, infrastructure, financing and outcomes. The process is also being informed by and linked to other government initiatives, including civil service reform and the National Decentralization Policy.

The participatory, 10-month policy and planning process is outlined in a comprehensive roadmap that includes several parallel, but inter-connected, tracks. Among the most important is county-level planning, which reflects the government’s commitment to making investments that address needs identified by the citizens. By July 2011, the MOHSW expects to unveil the 10-year National Health and Social Welfare Policy, Plan, and expanded essential package of health services at its annual national health review.

The draft policy, plan and essential package of health services all embrace several common principles and strategic approaches. The policy clearly articulates the government’s affirmation that access to quality health and social welfare services is a basic human right. The Ministry of Health and Social Welfare’s commitment to equity, efficiency, gender sensitivity and pro-poor focus are also evident throughout the documents. The primary health care model is the strategic foundation of the Liberian health system. Consistent with national priorities, the process of decentralization will result in resources and responsibilities being devolved from the central level to County Health and Social Welfare Teams over the next 10 years.

Important lessons have been learned through implementation of the 2007 Policy and Plan that are being incorporated into the new strategy. For example, the earlier documents outlined a rather rigid model for facility-based care, with fixed staffing patterns, salary scales and service packages. But it did not take into account variations in facility catchment population size, distances from communities to facilities, or provider workloads. The draft 10-year policy and plan sanction a new type of clinic and outreach, more flexible staffing patterns, and a process for optimizing the distribution of facilities by county health and social welfare teams that will better meet the needs of their populations.
 
Although the priorities are seemingly endless, national development in Liberia, as evidenced by the health sector, continues to follow a thoughtful, logical and incremental path. Health has provided an opportunity for government to reestablish trust with its international partners and to demonstrate its commitment to fulfilling its role in the social contract. Although many constraints persist, some impressive gains have already been documented. Central to this success has been the clear vision and strong leadership of the Ministry of Health and Social Welfare. By adhering to principles of participation, transparency and accountability, the government is earning the support and cooperation of development partners as well as of its most important stakeholders – its citizens. It is expected that this strong foundational work will continue to translate into improved health outcomes. 

Richard J. Brennan, MBBS, MPH, is chief of party, Liberia, Rebuilding Basic Health Services at JSI Research and Training Inc. Jacob Hughes, MPA, is a consultant for USAID and JSI.