Rethinking the Healthcare Delivery System in Liberia
No Health, No Sustainable Development and Progress in Liberia
It is not an exaggeration to say that our country, Liberia is now in crisis – from the high levels of insecurity to the daily tales of the Ebola epidemic, fraud and corruption in government to health workers on strike at a major state-run Ebola treatment center (JFK) in Liberia over pay and poor working conditions last week. All these are symptoms of the fundamental affliction facing our society – poor governance and culture of impunity.
This week, the US Centers for Disease Control and Prevention (CDC) and Word Health Organization (WHO) reported Ebola Virus Disease (EVD) killed 4,033 people out of 8,399 cases. The death toll includes 2,316 in Liberia, 930 in Sierra Leone, 778 in Guinea, eight in Nigeria — and one in the United States. A separate Ebola outbreak in the Democratic Republic of Congo has killed 43 people out of 71 cases. The Doctors without Borders also known as Medicins Sans Frontiers (MSF), recently called for United Nations intervention -- military medical expertise-- to effectively combat the scourge in West Africa. Médecins Sans Frontières has described the outbreak in Liberia as “catastrophic.” The UN's Food and Agriculture Organization have warned that Ebola outbreak is putting food harvests in West Africa “at serious risk.” CDC Director Tom Frieden also warned that time is running out to contain West Africa’s Ebola outbreak, Without more powerful disease control measures in West Africa, more than 1.4 million will be infected by January, according to a WHO report, yet President Ellen Johnson Sirleaf of Liberia dismisses grim Ebola forecast despite Liberia been the only Ebola-affected nation in the region with rising cases in the capital, Monrovia.
Our nation has conceived several development plans from Independence until the 2000s. The overthrown of the Tolbert-True Whig Party administration marked the death of multi-year development plans. Since then, we had toyed with perspective plans and rolling plans under Samuel Doe, Vision 2024 under Charles Taylor, and the so-called Agenda for Transformation, what is now Vision 2030. No sectors suffered more than education and health care from our abandonment of development planning in our government strategies.
Ebola brought a response, but the people of Liberia face a very fundamental health crisis. All over the place you find a population that suffers from malnutrition and has severely deficient immune systems. Measles, AIDS, Hepatitis, Tuberculosis and Malaria are ever present. And it is symptomatic of Madam Ellen Johnson Sirleaf led government failures to grow our educational and health system through creative planning, sensible spending prioritization and focused implementation.
The Challenges of Liberia Health sector bring to bear the popular philosophical postulation: “a person that fails to plan, plans to fail.” The first casualty of non-planning was the relegation of preventive, mostly primary health care, the abolition of sanitary inspection and increasing focus on procurement-driven curative, secondary and tertiary health care.
Dr. Walter T. Gwenigale tenure as health minister has brought back some needed focus on primary health care, with the publication of a National Health Policy and Plan in 2007. The health policy was refined, revised and updated under Minister Gwenigale and was globally acclaimed as a near-perfect blueprint for the provision of standard healthcare in a growing nation. The policy had all that was needed to make our health sector functional and world class. Unfortunately, it has been characterized by weak implementation and diversion of funds to recurrent spending.
The condition is further worsened by inadequate facilities and low remuneration of public sector health care workers. Also, inconsistent implementation of the structuring led to the situation where people abandoned the Jackson Doe Hospitals and other rural health facilities in order to come to Monrovia for treatment. The condition is further worsened by inadequate facilities and low remuneration of public sector health care workers. These resulted in the mushrooming of private hospitals and clinics with only a fraction well-equipped, but could only be afforded by an opulent and sometimes foolish few. So in spite of all these efforts, the sector challenges remain and the story of Representative Albert Toe, Dr Samuel Brisbane, Dr. Samuel Muhumuza Mutoro of Uganda, etc., above remains the best metaphor for the dysfunctional state of our health care delivery system.Although "health” as a sector does not feature prominently in the measurement of GDP of a country, health expenditures account for between 4% (Turkey, Nigeria), 8% (UK) and 15% (USA) of the GDP of most countries, and the sector is a major employer of the labor - from doctors to pharmacists to laboratory technologists to nurses and midwives, and now includes HMOs and insurance companies! Quality and affordable healthcare is critical to sustainable development and progress because it is human capital that drives the other factors of production. Health infrastructure (hospitals, laboratories, pharmaceuticals, health insurance organizations and other Ancillaries) is essential for the efficient functioning of a health care system and consequently, a productive and prosperous nation.
Our health sector is bedeviled by a myriad of challenges that resulted from lack of planning - policy disconnections, inadequate capital spending, poor pay, outdated technologies, poor infrastructure, sharp disparities in the availability of medical facilities across the country, coupled with the severe political and economic stresses of the past years. The net effect is inadequate medical supplies, drugs, equipment, and personnel. Similarly, poor sanitation and water supply in our rapidly growing cities have increased the threat of curable, avoidable and other infectious diseases, while health care facilities are generally unable to keep pace with urban population growth. One needs not visit hospitals without doctors or drugs, or evaluate the poor quality of health personnel, nor undertake a computation of the lost production to poor health to underscore the fact that our national development aspirations will remain just that – aspirations - if we do not embark on a concerted improvement of our human capital, especially revamped education and improved health care.
So what are the facts on the ground?
According to the 2013 United Nation Development index (HDI), Liberia population is 4.2 million. Liberia’s population is projected to double by 2040. 2.2 million of Liberia’s population lives in urban areas. The urban growth rate is estimated at 5.6% per annual which indicates that most Liberians now reside in urban centers according to the United Nations World Urbanization prospects 2013 report. It has a very young age profile with about 43% of Liberia’s population under the age of 15. In 2012, Liberia’s expenditure on health was $102 per capita, representing about 15.5% of GDP. Donors finance 50% of total health expenditures and households 33.3%. Also about 80% of the health services are provided by NGOs.
A research by McKinsey has shown that from 1900 to 1973, less than 4 per cent of the decline in mortality in developed countries resulted from medical care, with over 90 per cent being due to public health measures like to improve sanitation and provision of clean water! This strongly suggests that focus on public health measures and primary health care should be the priority of governments that wish to improve the health of their populations. It is when preventive healthcare fails that a visit to a medical professional becomes necessary. At the moment, our healthcare facilities are grossly inadequate and can only serve 4-8% of their potential patient load. Huge sums of money in foreign exchange are spent by Madam Sirleaf, her cronies and the selective few that seek medical services abroad in places like USA, Ghana, and Europe, etc. While spending so much to keep foreign medical professionals employed, are we healthier?
According to the United Nations Population Fund (UNPF) in 2013, the maternal mortality rate per 100,000 births in Liberia is 770. What this means is that out of every 100,000 women who go to give birth, 770 die. So more and more of our pregnant mothers are dying during labor. The under-5 mortality rate, per 1,000 births is 75. These are mostly caused by inadequate access to quality care in rural and remote areas and shortage of midwives. As a result, the country is not on track to meet its health MDGs targets (5 and 6).
The 2013 Demographic and Health Survey (DHS) found that 56% of births were delivered in a health facility. 73% of births of urban mothers were attended to by a skilled provider and 66% were delivered in a health facility, compared with 50% and % percent, respectively, of births to rural women. Among urban women, those residing in Monrovia were more likely than those living in other urban areas to be attended to by a skilled provider (84% compared with 62%) and to deliver in the health facility (76% compared with 56 percent). This imbalance in access to specialist care between urban and rural areas has been evident in all DHS surveys in Liberia since 1986, but the gap has not narrowed over time. And as usual, the disparities between the Monrovia and rural Liberia are wide, indicating the President and cronies in Monrovia have a lot more to do, and must wake up and invest more to prevent the avoidable deaths of mothers, infants and many children under the age five.
The problems of the Liberia health sector are numerous and require collective effort from every one of us, and creative planning, focused management and sensible application of resources on the part of the government of Liberia as well as the private sector. Liberia population is expected to double by 2040 to 8 Million plus. Liberia should recall that life expectancy in our country is still 62 years, one of the lowest in the world. In Egypt, it is 71; Britain, Sweden and Japan have 78.5, 80.5 and 81.3 years respectively. Given the huge revenue Liberia has earned from foreign direct investments and oil exploration, this is unacceptable! We can do, and must do better.
The key factors in measuring health status are: access to clean water, safe air, adequate food and the society’s willingness to practice healthy lifestyles. There are issues to be worried about: from the report of UNDP MidPoint Assessment of the Millennium Development Goals (MDGs) in Liberia 2008, only 25% of Liberian had access to basic sanitation. Over 1,000 children die every year from diarrhea caused by unsafe water and poor sanitation in Liberia. At the same time, 60% of Liberians cannot access sustainable safe drinking water supply, according to the World Bank Water and Sanitation Program (WSP). The WHO estimates that every dollar invested in improved water and sanitation produces economic benefit that ranges from $3 to $34, depending on the country and technologies applied. Unfortunately, we are not in any way near the attainment of such beneficial status. In the 2013/14 budget, only US$ 3.7 million was allocated to the Liberia Water and Sewer Corporation.
The prolonged neglect of water, sanitation and health, education in our schools is also impacting negatively on our health system.
One factor responsible for the worsening state of health care in Liberia is the shortage of skilled medical personnel. Liberia population is estimated at 4 million, and the nation has less than 60 doctors left in the entire country, according to the Dr. Roseda Marshall chairs the school of pediatrics at the country's only medical school, the University of Liberia's A.M Dogliotti College of Medicine. Our situation is further compounded by the lopsided doctor-to-population distribution. Statistics from the health sector of Liberia presents a grim picture that indicates that the country’s doctor-to-patients ratio is 1 Doctor to 30,000 or more patients. In comparison, South Africa has 393 nurses and 74 doctors per 100,000 people - about twice better off than we are, while the United States has 901 nurses and 247 doctors per 100,000. Cuba a developing country with a better health care system than the USA has a ratio of 1 doctor to 125 people!
Also within the country, huge inequalities exist between regions, with South Eastern Liberia lagging behind. Disparities also exist between urban and rural areas as well with 90% of doctors working in the urban areas where only about 29% of the populations reside. Many of our qualified doctors and nurses have migrated abroad due to our senseless armed conflicts while others migrated abroad to avoid poor pay, non-existent or archaic diagnostic tools and deplorable working conditions. Liberia doctors have migrated to North America, Europe, and even other African countries. We must ask: why do our young and talented medical professionals leave Liberia after we have invested vast resources in their training? Regrettably, many that have stayed back in the country remain here only because they are unable to secure other opportunities elsewhere. We have come to expect a health sector perennially dogged by labor crises. The activities of quacks in the health care sector and counterfeit drugs cannot be discounted.
Infectious but treatable diseases are also major threats to our country. According to the WHO 2014 updated report on Liberia, malaria account for 33%of in-patient deaths. Acute Respiratory infections continue to be the second leading cause of morbidity, after malaria. Further projection by WHO revealed deaths from infectious diseases, maternal, prenatal conditions and nutritional deficiencies will also increase by 6% in 2015 worldwide. Alarmingly, and If not checked, all these have adverse effects - economic and social impact on our families, communities and the entire country.
The health industry is very dynamic: patients' needs, innovative processes, regulated environment and demographic factors constantly changing. A responsible government must therefore be proactive in figuring out how to address expanding population and outbreak of new diseases by developing and sustaining a health care service mechanism that is both effective and efficient. According to the United Nations Population Fund (UNPF) in 2013, the population of Liberia nearly tripled in 60 years (911,000 in 1950 to over 4.1 million in 2012). If this growth rate continues, our population would hit nearly 8 million plus in 2040. The message is clear: if we cannot adequately care for our population now, and plan for the future today, what becomes of our health care system when our population reaches nearly 8 million plus in 2040; in just a few years’ time?
Medical research and collaboration in Liberia is limited principally or not in existence due to the funding level (in the national expenditure) for both research and collaboration. Liberia must fund its universities; medical research and other health institutions enable them to exchange information on research about tracking, treating, preventing, and curing diseases and enhance domestic manufacturing of medicines. We lag behind the global trend of intensive investments in all facets of medical sciences, life sciences and biotechnology and must redress this urgently.
What do we do in light of all these issues and challenges identified?
The First thing to do is to recognize that preventive healthcare rests on improvement in enlightenment as well as provision of water supply and sanitation facilities. For too long, water, sanitation and hygiene education in our communities and schools have been given less priority. Well-structured water, sanitation and hygiene education would make a huge difference to our health system. Improvements in sanitation and hygiene behaviors combined with a safe water supply could significantly prevent diarrhea, cholera, dysentery and other contagious infections.
Second is to ensure the existence of basic laboratories and diagnostic tools in each facility. And then rapidly employ and train otherwise unemployed graduates of biochemical sciences to be physician's assistants after 12 months of education and internship, and deploying them to a community clinic, health clinic, health center, county hospitals, and tertiary to handle patient with some of the commonest ailments like malaria, typhoid, and the diarrhea which take up to lots of doctor's time in the BPHS. Doctors will then properly spend their time on more serious ailments.
Thirdly, to rescue the Liberia health sector, our Primary Healthcare System has to be functional, properly managed and funded. The most anticipated National Health Insurance Scheme (NHIS) needs to be implemented! NHIS should be strengthened and its activities expanded to cover every Liberian. Given that good governance and health are intertwined, facilities should be provided to keep our environments healthy. Our political leaders should lead by example and exhibit confidence in our health system by patronizing the health facilities available in Liberia instead of travelling abroad for even basic checkups.
It will be nice if the President Sirleaf, Ministers and members of the National Legislature, Justices of the Supreme Court (and their families) openly declare that they will never go abroad for medical checkups, treatment and the like, and will go to government-owned facilities only! Then the rapid improvements will begin.
Finally, more effective spending for preventive, primary and secondary care. Can more funding lead to better health? Not necessarily. We would need more health care worker regardless of any level of spending to get better outcomes. However, spending generates some impacts. According to WHO, every $100 per capita spent on health creates a 1.1-year increase in Health-Adjusted Life Expectancy (HALE).
The Liberia health industry is potentially big, possibly bigger than the successful telecoms sector. True, telecom services are necessities, but everybody needs health care to survive and grow, and even make phone calls! Ultimately, we must accept the maxim that ‘health is wealth’ and take appropriate steps to improve the sector. At the moment, it is creating a huge hole in our political and economic development aspirations. If Liberians are not healthy, we cannot build a wealthy country. And the examples of healthy living and confidence in our sector must begin from the political leadership. The ball is firmly in their court.