January 14, 2013
Liberia is a post-conflict country that is quickly rebuilding after over 14 years of two civil wars that ended in 2003. Everything I have learned in health systems strengthening, priority setting, and maternal health in a class room at HSPH has come to life in Liberia. My first day of work, January 7, 2013 was also the return of the Ministry of Health and Social Work (MOHSW) employees from their holidays. Thus it was time to set the budget for the year. The government of Liberia is contributing $336,000 in funding for 13 programs that comprise the MOHSW, this budget is heavily subsidized by international donors. There was a lot of yelling and gesticulating, in the typical Liberian manner, trying to parse out this small sum. The Family Health Division (FHD) has a budget with a similar structure, and relies primarily on international donors.
Without question there is strong political will to reduce maternal mortality as Liberia has the 6th highest maternal mortality ratio in the world with 994 maternal deaths per 100,000 live births. As president Ellen Sirleaf Johnson has said “the nation thrives when mothers’ survive; we must strive to keep them alive.” In a country with such poor infrastructure and ingrained poverty, there are a myriad of ways to tackle this massive problem, and the MOHSW is prioritizing human resources as a primary mode of capacity building. They are working in conjunction with many partners and using many resources for this cause. The political will is here, but the implementation barriers are vast.
January 18, 2013
I spent some time working with the Clinton Health Access Initiative (CHAI) Change Team to look at how they can streamline their three various funding streams for health workers. These three streams are problematic, and cause delays in payment for many, while some employees are being paid double. Thus, the CHAI team is working to standardize the definitions of job titles and roles and move all employees to the government payment system. This will be a lengthy process, but it is progressing in the right direction. But as I traveled out to one of the county hospitals and spoke with a Certified Midwife and I asked about her pay she told me that with the government payment system her salary is now directly deposited to her bank account, which sounds like a huge success. However, a major oversight is that there is not a single bank in her county, and there are other counties in the same position. In order for her to receive her paycheck she must go into the capital city, which is a manageable distance for her, but others are not so lucky. A compounding issue is that these employees may be the only skilled health care workers in the area and must leave their post empty for long periods of time to go to town to get their pay check. Thus, again proving the complexities of improving systems in a post-conflict country.
This midwife walks up to 3 hours to reach some of her villages, her catchment area includes 64 villages and she was very proud to have never had a mother die in child birth. She adamantly uses the working ambulance in the county when there are any early warning signs. She also lets pregnant mothers stay at her home and feeds them healthy foods from her garden so that they can give birth in a facility with a skilled birth attendant when their time comes. This extraordinary midwife has greatly reduced maternal mortality in her catchment area, but the government of Liberia cannot depend on such extraordinary and autonomous acts. Incentives for these midwives in rural areas are another huge area of opportunity for Liberia.
Yet another area for some major improvement in Liberia, is addressing the 36% unmet need for family planning. On January 10, 2013 I partook in a stakeholders meeting to set targets for the “Reduction of Unintended pregnancies.” All of the key maternal and child health players in the country participated, including: Planned Parenthood Association of Liberia (PPAL), United Nations Population Fund (UNFPA), Merci, JHPIEGO, International Rescue Committee (IRC), Project Concern International (PCI), USAID, and Rebuilding Basic Health Services (RBHS). At the root of unmet need again there are service delivery issues, as all parties cited the lack of access to family planning commodities; the supply chain proves to be problematic throughout Liberia and “stock outs” happen all too often. While the issues are numerous, the MOHSW is working hard and convening key stakeholders to agree and collaborate on these important issues, which makes for a hopeful future in maternal and child health in Liberia.