Improving Health Services in a Fragile State: Liberia
After enduring decades of civil war and violent conflict, Liberia has spent the last several years rebuilding its physical infrastructure and human resources for all social services, including health care. As part of the Rebuilding Basic Health Services (RBHS) project, Management Sciences for Health (MSH) is partnering with the Liberian Ministry of Health to provide more effective basic health services by building the capacity of local non-governmental organizations and Ministry of Health counterparts to lead and manage health projects. MSH also provides technical leadership for quality assurance and accreditation, malaria interventions, pharmaceutical management, and governance and anticorruption activities.
MSH spoke with Luke Bawo, the RBHS project's Organizational Capacity Development and Human Resource Management Development Specialist, about the challenges of improving health services in a fragile state.
The RBHS project was launched at the end of 2008, only five years after the transitional government first took power in late 2003. What was the state of the health system at that time?
We have to go back a few years to 2005 when MSH got engaged with the health system in Liberia. I would like to start with the events that eventually led to the launch of the RBHS project in 2008.
The 14-year civil conflict officially ended in 2005 with the first democratic elections since 1985. The consequences of the protracted war were glaring and appalling. The Gross Domestic Product had declined from US $1,269 in 1980 to US $163 in 2005 with around three fourths of the population living below the poverty line of less than a dollar a day.
Health infrastructure around the country was either damaged, looted, or in serious state of disrepair. The number of functional facilities had reduced significantly as compared to the pre-war numbers. Even functional facilities were struggling to perform at an acceptable level due the severe shortage of qualified staff and frequent stock-out of drugs and other inputs. Health service delivery was grossly uneven and largely supported in an uncoordinated manner by emergency and relief-orientated health non-governmental organizations. This was a means of providing critically needed interventions particularly when the central Ministry of Health & Social Welfare (MOHSW) did not have the human or resource capacity to coordinate service delivery.
Access to health services was poor with estimates suggesting just 41% of the population had access to services. Full immunization coverage of children under the age of one was below 30%. Women and newborns were at risk due to high and early fertility, the threat of malaria, HIV & AIDS, poor sanitation and hygiene, and lack of safe birthing services. There was a very high rate of maternal mortality and frequent outbreaks of disease.
From 2006 to 2008, a number of efforts aimed at revitalizing and strengthening the health sector were carried out with the involvement of MSH. In 2006, the US Agency for International Development's (USAID) Office of Foreign Disaster Assistance asked MSH, through the Basic Support for Institutionalizing Child Survival (BASICS III), to help Liberia's Ministry articulate a new National Health Plan, National Health Policy, and basic package of health services as part of critical post-conflict, transition period foundational work.
MSH worked closely with the MOHSW to establish policies and plans, and to coordinate donor support that ensured continuous provision of essential services during the relief-to-development period. Then, from December 2007 until September 2009, MSH, through the BASICS/Liberia Project, worked with the MOHSW to roll out the basic package of health services, strengthening its capacity to provide decentralized support.
What have been the biggest challenges the project has overcome in the past two years?
The RBHS project is a huge initiative and the major challenges are challenges that afflict the larger health sector in Liberia.
The acute shortage of qualified counterparts at the MOHSW initially led to delays in implementing activities. Over the past years, the MOHSW has made efforts to recruit and provide long term training to bridge the staffing gaps. RBHS in turn is the building the capacity of the Ministry at the central and county levels.
Poor and uncoordinated health messaging is another challenge. The RBHS project has overcome this by assisting with the development and implementation of a behavior change communication community strategy.
How are these challenges different in Liberia compared to other developing countries?
The challenges in Liberia may not be far removed from those of other developing countries, particularly those that have recent history of armed conflict. What is unique about Liberia is the ability and rapidity with which the health sector, through support from partners like the RBHS Project, can overcome these challenges and forge ahead.
Tell me about the performance-based financing (PBF) portion of the project. Why is this an important intervention in states emerging from conflict?
The RBHS project entered into a performance-based financing arrangement with five NGOs for the management of 112 health facilities in seven counties in Liberia. Performance monetary bonuses are paid or withheld by RBHS to the NGOs based on the attainment of agreed performance indicators within a given time period. These indicators are blends of management, service delivery, and quality improvement.
The Ministry, trying to model after the RBHS project, has also entered in performance-based contracts with a number of organizations.
One of MSH's roles in the project, in addition to quality assurance, costing, and capacity development, is providing technical assistance to the RBHS and MOHSW in harmonizing approaches to PBF and rolling out PBF at the county level.
Performance-based financing, drawing from the successful Rwanda example, is seen as a way of increasing access to health care, improving quality, and making effective and efficient use of available resources. There is currently a moratorium on users' fees in Liberia especially at the primary care level, but the government is studying various funding mechanisms. Irrespective of whatever system is adopted, the government is keen on building on and expanding the PBF efforts.
What have been the projects greatest successes thus far?
The RBHS project has three major objectives: expanding service delivery through PBF to NGOs, capacity development at the central and county level, and mainstreaming adolescent and reproductive health.
The project has made considerable strides in many areas. It is currently providing services to a third of the population through contracts with NGOs. In addition, the project has developed a quality improvement of service component which is intended to improve service delivery at health facilities to complement all the inputs made available to the facilities. The RBHS is engaged with capacity development at all levels of the health system and is an active member of over twenty technical working groups.
What do you hope to accomplish in the remaining three years of implementation?
By the end of the project, we are confident the Liberian Ministry of Health & Social Welfare will have developed sufficient capacity to manage a decentralized and well-coordinated health system that will guarantee maximum coverage to the Liberian people while at the same time ensuring quality delivery of services.
RBHS is a 5-year USAID-funded project to support the Ministry of Health in Liberia to implement its National Health Policy and Plan, specifically, the delivery of Basic Package of Health Services (BPHS). The RBHS project is managed by JSI Research & Training Institute, Inc., Johns Hopkins University/Center for Communications Programs, and JHPIEGO are implementing partners.