Liberia: Health/nutrition sector report

BACKGROUND AND SITUATION ANALYSIS
Fourteen years of civil war has adversely affected all sectors of Liberia's national life. In the health sector, there has been the destruction of health infrastructure, dislocation of health personnel, the massive looting of equipment, drugs and medical supply inventories.

The destruction of the country's limited housing stock, educational infrastructure, as well as the disruption of farming activities have all impacted the health status of the people. With many houses destroyed, a greater portion of the population has been forced to reside in make-shift shelters, thus exposing them to the outbreaks of various diseases. Also, with illiteracy vividly telling in the society (currently at 75%), sanitation and hygiene issues are marginalized within the general population to the detriment of the population being burdened by diseases that are largely preventable. Additionally, the massive displacement of especially the rural population (which constitutes about 80% of the subsistence farmers), has resulted in a new problem of malnutrition in the country's morbidity spectrum.

The destruction of an already mal-functioning national economy has exacerbated the problems of poverty and ill-health. Prior to 1990, the traditional sector of the economy sustained more than seventy percent (70%) of the population. Since 1990, the country has come to rely on relief and humanitarian assistance. During the past seven years, the crisis eclipsed virtually all modern sector activities, and a substantial share of subsistence production- a result of massive displacement.

With the cessation of production, output or income per head has steadily declined. On a net basis, during the last decade or so, the economy lost tremendous number of jobs. Export trade disappeared, while import of producers' goods declined. At present, Liberia has no external reserves and owes external sources an estimated US$3b. As a consequence, poverty has become very pervasive with more than three-quarters (76.2%) of the population living on less then US$1.00 a day, and over half (52%) living in abject poverty on less then US$.50 a day. With the current estimated population of 2.7m, about 2.06m people are currently below the poverty line, whilst 1.4m live in abject poverty.

The disruption in the Liberian economy occasioned by the war also compounded the problems of the country's health sector in the context of health care financing. The national budget for health declined considerably accounting for 6.1% of the total national budget. Total health budget as a proportion of GDP fell significant below the WHO stipulated minimum of 5%. The current expenditure level is less then US$1.00 per capita which is unacceptable. Thus, the low level of government resources allotted and expended on the sector grossly affected the level and quality of health services.

On the whole, the current situation in the health sector is deplorable and far from satisfactory. Access to basic health services is extremely low, which in turn accounts for the major causes of the country's high infant and child mortality rates. At present, infant and under-five mortalities stand at 134 per 1000 live births and 194 per 1000 live births respectively. With an under-five mortality rate of 194 per 1000 live births, Liberia is far above the Sub-Saharan Africa average of 175 per 1000 live births, and ranks 43 out of 46 countries.

Malaria, diarrhea, acute respiratory infections, neonatal tetanus, measles, and malnutrition are the major causes of morbidity. The country's crude death rate has historically been high. The average crude death rate between 1982 -1986 was 13.7 per 1000 population per annum. During the war years, the crude death is put at 30 per 1000, accounting for the approximately 150,000 estimated deaths. Average hospital deaths between 1993 - 1996 was 60.3 per 1000 population

On account of the prolonged conflict, life expectancy has reduced from 55 years two decades ago to 47.7 in 2002. Mal-nutrition continued to be widespread with 39% of children under five years of age stunted, 26% underweight and widespread micronutrient deficiencies among children and women. Infant feeding is far from optimal with less then 20% of children exclusively breastfed at six month.

The situation of maternal health is even more appalling, as a result of inadequate access to health and reproductive care and poor nutrition. As a consequence, maternal mortality has increased from 578 per 100,000 prior to the war to 780 per 100,000 by 2002. With such current rate, the country ranks among the very high category of maternal mortality rate countries in the world.

The prevalence of communicable diseases such as HIV/AIDS, TB and River Blindness continues to escalate at an alarming rate. HIV/AIDS is estimated to affect 8.2% of the population between the ages of 15-49 years. The lack of knowledge, exacerbated by poverty, and multi-sexual behavioral practices, continue to pose great challenges for the survival of young adolescents especially females who have been the main victims of rape and sexual abuse through out the crisis.

As regards health infrastructure, 30% of all major hospitals in the public sector since 1996 have been reduced to health centers, while 70% remain out of commission. These facilities were all badly looted and vandalized. Also, services at the secondary level (Primary Health Care) have virtually collapse throughout the country.

With respect to health manpower training institutions, only two have remained partially functional complimented by a mission institution owned and operated by the Catholics. This has resulted in the shortage of critical health manpower. In 1989, there were an estimated 5,056 health workers within the sector; with 3,526 in the public sector and 1,855 in the private sector. These included 237 physicians/specialists, 656 nurses and nurse midwives, 2,782 trained traditional midwives, and 1,381 other supporting personnel. By 1998, the number of health workers had reduced drastically by 28% to 1,396, disaggregated as follows; 89 physicians/specialists, 329 nurses, and 274 midwives including other support personnel. There are currently less than twenty (20) medical doctors and specialists in the country. Other cadres of health workers have also been reduced by sixty percent (60%).

International non-governmental organizations continue to provide the lion share of health care services as the capacities of both government (Ministry of Health and Social Welfare and JFK Medical Center) and church missions have been eroded on account of the conflict. Funding for these activities has come mainly from donors and U N Agencies.

In general, the fourteen years of civil conflict has reversed the gradual progress the country was making in health care development. The country now finds itself in a very peculiar situation. Emerging from a state of war, and with all of its health system and infrastructure destroyed or collapsed will pose serious challenges for the government and the population as a whole.

In the context of the present financial situation, there is the real danger that the implications of an adequate public investment program might not be fully appreciated. While the country's resource requirements are formidable, the likely resource availability, have necessitated the urgency to effectively address the critical situation of the health sector. Without concerted international efforts in assisting the country address the challenges facing the health sector, it does not seem likely that the country will meet its health target of increasing access of the population to health care services from the current low level of twenty-six percent (26%) to an appreciable level of eighty or ninety percent.

OBJECTIVES

An effective and efficient health care delivery system is sine-qua-non for socio-economic development and poverty reduction. Therefore, the overall objectives of the post-war rehabilitation and reconstruction of the country's health care delivery system will include;

• Increase access to health services to 80%
• Reduce under-five morbidity and mortality rates by 50%
• Reduce infant mortality from 117/1000 to 90/1000
• Increase life expectancy at birth from 47.7 to 60 years
• Increase various categories of health manpower to 80%
• Reduce maternal mortality rate from 780/100,000 to 450/100,000
• Increase immunization coverage from 30% to 80% , and
• Increase knowledge of STDs/HIV/AIDS and other communicable diseases prevention and control by 80% of the population
• Increase access to safe drinking water and sanitation facilities by 50%

POLICY AND STRATEGY ISSUES

The Government in 2000 adopted a new National Health Policy which emphasizes the provision of health care services to all Liberians through a rationale health care delivery system designed to provide a in complementary manner preventive, curative, promotive, and rehabilitative services. To achieve this goal, the government adopted two major strategies; Primary Health Care and Decentralization. The major thrust of these strategies is to ensure community participation, intersectoral collaboration, autonomy and leverage at the district and peripheral levels for effective management of resources and service delivery. It is therefore within the framework of the National Health Policy that the rehabilitation and reconstruction of the post-war health sector is being conceived. Other legal instructments and reforms will be pursued in support of the special circumstances of the health sector.

TIME FRAME

Therefore in consonance with the National Health Policy, the various components of the rehabilitation and reconstruction package will be implemented in phases within a two year period; 2004-2005. Year one will be devoted to restoring basic services and institutional strengthening, whilst year two will focus on the reconstruction of the sector restoring it to its pre-war functioning capacity.

STRATEGIES AND PROGRAMMES

The immediate challenge of Liberia's post-war health sector will be to rehabilitate services nation-wide to at-least pre-war (1990) levels, to be followed by a reconstruction phase. Rehabilitation will however, not seek to restore the old order, but will seize the current opportunity and address fundamental imbalances and inefficiencies in the system. As such, rehabilitation will be innovative, comprehensive, and for a short term period; two to three years. Rehabilitation will therefore focus mainly on those strategies for capacity building and institutional strengthening that will provide an enabling environment for service delivery. The main components of this thrust will include; strengthening of Health Care Management and Organization, strengthening of Health Care Delivery Systems (including training institutions), and strengthening County (District) Referral Systems.

The second thrust, the reconstruction phase (long-term) will focus on sectorial (sub-sectors) reform, and strategies that address the many inherent weaknesses in the system. This will include, instituting effective policies, restructuring organization, management and delivery system through which effective and efficient services will be provided well into the future. The main component of this thrust include; reforming of organization and management, policies, human resource development, etc.

Therefore, the broad and strategic areas of intervention will consist of the following programmes;

• Communicable and non- communicable disease control and prevention
• Nutrition
• Child and Adolescent health
• Reproductive health services
• Emergency Preparedness and Response
• Health Promotion
• Enhancing special protection
• Developing human resources for health
• Rehabilitation and reconstruction of health infrastructure
• Availability of Essential Drugs and Medical Supplies
• Water and Environmental Sanitation

PROGRAMME SUMMARY

1.0 Communicable Disease Prevention and Control

Communicable diseases are the most prevalent in Liberia accounting for a large percentage of morbidity and mortality in the general population. The commonest ones are malaria, diarrhea diseases, acute respiratory infections, tuberculosis, epidemic prone diseases, and HIV/AIDS. During the plan period, efforts will be exerted to reduce the high prevalence and incidence of communicable diseases. The strategic focus will be on key interventions for prevention and care through integration and partnerships. Also, the national disease surveillance systems will be revitalized and strengthened for the prompt detection of epidemics and for monitoring trends and assessing the impact of prevention and control interventions.

The estimated cost of this programme is US$2.0 million

2.0 Non-communicable Disease Prevention and Control

While available data on the magnitude of non-communicable diseases on the general population is scanty, however, they pose a serious public health problem. Primary prevention has not been given adequate attention and optimal treatment is not nationally available or affordable. Therefore, the strategic focus will be on strengthening the capacity of government to develop policies and implement programmes for the prevention and control of non-communicable diseases (substance abuse including tobacco, mental health, diabetes, hypertension, etc.) using multisectoral approaches to address the broad determinants.

The estimated cost of this programme is US$2.0 million

3.0 Nutrition

The nutritional status of the population is unfavorable especially pregnant women and under-fives. Mal-nutrition has contributed significantly to stunting and under-five mortality in Liberia. Currently, there is a high prevalence rate of iron-deficiency anemia among the under-fives and pregnant women, and a high prevalence of vitamin A deficiency in the under-five. To address this situation, program emphasis during the plan period will be placed on nutrition education programs targeting children under-five, pregnant and lactating mothers. Community growth monitoring and support to national supplementary feeding programs (Therapeutic feeding, Vitamin A Supplementation, Iron-Folate Supplementation) will be accorded highest priority.

The estimated cost of this programme is US$1.5 million

4.0 Reproductive Health Services

The rates of maternal deaths in Liberia are among the highest in the world, estimated at between 560-780/100,000 live births. The gross inefficiency of midwifery and medical staff, and the low or non-functional health facilities throughout the country severely limited access to quality maternal health care services, thus contributing to the high maternal mortality rates. With 42% of the population within the reproductive age group; 15-49 years, program emphasis will be placed on the delivery of comprehensive reproductive health care services.

The estimated cost of this programme is US$1.5 million

5.0 Child and Adolescent Health

Efforts in reducing the high morbidity and mortality rates of children has posed a tremendous challenge for Liberia attributed to under development and the impact of two decades of civil conflict. As a result, the national capacity to provide basic services and to develop innovative interventions to benefit children and young adolescents has been dramatically compromised. Thus, the opportunity to develop and implement programs to significantly improve the health and survival of children and young adolescents was lost for nearly two decades. Given the current dismal situation of children and young adolescents calls for renewed and strengthened focus on the basic health and survival interventions.

The estimated cost of this programme is US$2.0 million

6.0 Emergency Preparedness and Response

The collapse of the health care delivery system has made the country vulnerable to both man-made and natural disasters. Available data suggest a rising tide of epidemics which are now of major public health concerns because of the resulting human suffering, morbidity and mortality, and dislocation of the population. Unless urgent steps are taken to address the current situation, the country will remain vulnerable various disasters. Therefore, program emphasis will focus on building strong community-based emergency preparedness health programs as a means of reducing vulnerability to and management of disasters.

The estimated cost of this programme is US$2.0 million

7.0 Health Promotion

The situation of health promotion and protection is appalling exacerbated by the high level of illiteracy and the lack of an organized program. Legislation and policies on relevant health issues are also inadequate or lacking. The need for health promotion with particular emphasis on the community level has increased exponentially in the country. Hence, during the plan period, program emphasis will concentrate on providing the information about decisions affecting health, promoting healthy lifestyles and enhancing quality of life. Attainment of these end goals will be through appropriate information, education and communication (IEC) campaigns and programs to be promoted at all levels of the society. The critical role of women will be accentuated through the implementation of the women health and development programs.

The estimated cost of this programme is US$2.0 million

8.0 Enhancing Social Survival and Special Protection

It is estimated that there are currently between 8,000 - 10,000 child soldiers, and a significant but unquantifiable number of unaccompanying children. A large number of persons have been maimed, and a lot more experiencing psycho-social trauma. Additionally, some have been raped, tortured, humiliated and disposed of their assets.

Also, a large proportion of women and adolescent girls have been affected by the war through various forms of violence, particularly sexual and gender based violence. There are other women and girls who are extremely traumatized because of the lost of child, husband or the means of sustenance, etc. All of these categories of women require special psychosocial counseling to return to normality and rebuild their lives.

The magnitude of the situation therefore warrants putting into place appropriate interventions. Hence, program emphasis will focus on appropriate community-based counseling, support to community empowerment and rehabilitative programmes to reduce the vulnerabilities of persons in difficult circumstances, and increase care and special protection.

The estimated cost of this programme is US$2.0 million

9.0 Developing Human Resources for Health

The country in 1988 had a network of health manpower training institutions that to a large extent met the needs of the trained personnel to work in the health sector. At present, only two (public) manpower training institutions are operational, however, operating in abysmally poor conditions, and very low capacities. Therefore, the provision of suitable and timely training programs for all categories of health workers is essential for effective health care delivery. Accordingly, program emphasis will be placed on the development of a comprehensive National Human Resource Policy and Plan. This would take into account demand and supply of all categories of health personnel in both the public and private sectors. Other areas of program concentration will include; rehabilitation of physical infrastructure, refurbishing, improvement in working conditions, staff development, and institutional strengthening.

The estimated cost of this programme is US$2.0 million

10.Rehabiliattion/Reconstruction of Health Infrastructure and Reforms

The situation in the health sector has been documented. The immediate challenge of the sector is to rehabilitate/reconstruct, refurbish and re-equip destroyed, damaged, and looted facilities, and restore services. This is essential as it will improve the capacity for service delivery. In consideration of post-war conditions, and taking into account the fundamental weaknesses and biases in the pre-war health system, the rehabilitation/reconstruction and reforms will be carried out in phases. The first phase will include the following;

a. REVITALIZING HEALTH CARE MANAGEMENT AND ORGANIZATION

• Restoration of essential health facilities
• Revitalizing programme management
• Institutional strengthening and capacity building at central level
• Revitalizing and strengthening county health teams

b. REVITALIZING HEALTH CARE DELIVERY

• Revitalization of Primary Health Care
• Strengthening county hospitals
• Human resources deployment
• Provision of drugs and medical supplies

The estimated cost of this programme is US$4.0 million

The second phase will include;

a. REVITALIZING HEALTH CARE MANAGEMENT AND ORGANIZATION

• Re- organization of the structure and functions of the MOH
• Decentralization

b. REVITALIZING HEALTH CARE DELIVERY SYSTEM

• Rationalization of the health delivery systems to reduce the number of facilities
• Strengthening tertiary level services
• Revitalizing support systems
• Resource mobilization

The estimated cost of this programme is US$5.0 million

11. Availability of Essential Drugs and Medicines

Critical to the provision of health is the availability of essential drugs and other medicines. Drug stocks in the system were all looted. Schemes implemented to recovery drug cost have collapsed. The availability of essential drugs can therefore not be overemphasized. The National Drug Service currently operational will need to expand its coverage with the opening up of the country. As such, programme emphasis will focus on making available essential drugs and medicines, revision of essential drugs list, and updating of the formulary.

The estimated programme cost is US$2.0 million

12.0 Water and Environment Sanitation

Available data suggest that access to clean water and safe means of excreta disposal prior to the war was 25% and 36% respectively. The current situation is worse. The situation outside Monrovia is even more appalling. Places outside Monrovia which once had means to piped borne water have been dispossessed of those facilities. Most the installations and distribution systems have been destroyed or vandalized. Thus, the sources of safe drinking water are now open wells, creeks, etc. The situation of excreta disposal is even more distressful. The Liberia Sewer System has collapsed and yet to be operational. Means of excreta disposal are now beach sites, bushes, etc. Therefore, programme emphasis will focus on the provision of safe drinking water and the construction of facilities for excreta disposal.

The estimated cost of the programme is US$2.0 million

FUNDING REQUIREMENT SUMMARY