Analysis of the Liberian Health Policy

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

ORIGINAL ARTICLE

The status of health services in the 15 counties of Liberia

Roland Y. Kesselly
1
, Nuaker K. Kwenah

1
, Ernest Gonyon

1
, Stephen Byepu

2
, Luke Bawo

1
,

George Jacobs
1
, Justin Korvayan

1
, Melanie S. Graeser

1
, Moses Kortoyassah Galakpai

3
,

Sandford Wesseh
1
, Ulrich Laaser

1
Ministry of Health, Monrovia, Liberia;

2
INHA University, Incheon, Korea;

3
EPOS, Bad Homburg, Germany;

4
University of Bielefeld, Germany.

Corresponding author: Prof. Dr. med. Ulrich Laaser DTM&H, MPH

Address: University of Bielefeld, Faculty of Health Sciences, POB 10 01 31, D 33501 Bielefeld,

Germany;

Email: ulrich.laaser@uni-bielefeld.de

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Abstract

Aim: Liberia, situated at the West African coast, is composed of 15 counties with an economic

gradient steeply decreasing from the Northwest to the Southeast. Health-related activities by

government action in the 15 counties concentrate on the areas of family planning, antenatal and

delivery care, as well as immunization, health workforce and infrastructure. The differences in

this regard between the 15 Liberian counties will be reviewed.

Methods: A narrative review is employed, making use of the recent international and national

documents, relevant literature and available information from the following primary and

secondary sources and databases.

Results: The results point to gross differences between the 15 counties of Liberia in terms of

health service provision. The overall readiness based on defined indicators for all 701 facilities

was 59% with a range between facilities at the level of counties of 50% to 65%; for family

planning services 88% (range 65% – 100%); for antenatal care 62% (range 55% – 100%); for

immunization coverage 76% (range 66% – 86%). The health workforce of Liberia comprises

11.8 health workers per 10.000 population, WHO target is 23, the counties range from 8.0 to

15.7. Similarly, according to WHO standards, there should be 2 health facilities per 10.000

inhabitants, Liberia comes up to 1.9 however the counties range from 1.1 – 3.0 per 10.000.

Conclusions: It is obvious that across almost all areas of women and child health and health

services in general there exist large differences between counties, which points to considerable

health inequities in this country. The government of Liberia should consider reallocating the

available resources per number of population instead of accepting historical developments,

however with a correction factor in favour of disadvantaged regions and population groups.

Keywords: Africa, health services, Liberia, narrative review.

Conflict of interest: None.

Acknowledgements: The authors are grateful to Richard Gargli and Roosevelt McCaco in

Monrovia, Liberia for their help in identifying the relevant publications.

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Introduction

Liberia is one of the smaller West African countries, situated at the Atlantic coast with a rainy

season of approximately 6 months from mid-March to mid-October. Together with the

neighbouring countries Sierra Leone and Guinea Liberia experienced in 2014/15 the devastating

effects of the Ebola epidemic. The 4.5 million inhabitants – descendants of liberated American

slaves with a majority indigenous tribal populations – are concentrated with more than 1 million

in the capital Monrovia in the central county of Montserrado. There are 15 more or less

populated counties with an economic gradient decreasing from the Northwest to the Southeast.

With this paper we refer to the 2005 Paris Declaration on Aid Effectiveness and the 2011 Busan

Partnership Agreement (1) as well as the International Health Partnership for Universal Health

Coverage (UHC) 2030 (2). Coverage of essential health services according to UHC relates to 4

categories: 1) reproductive, maternal, newborn and child health, 2) infectious diseases, 3) non-

communicable diseases, and 4) service capacity and access to services. The Index of UHC

presents an average coverage for 16 tracer indicators across the four categories, adjusted for

coverage of the most disadvantaged population (3).

During the first meeting of the UHC-2030 working group in March 2017 (4), the main focus was

on low and middle-income countries facing ―a number of critical pressures on their health

systems‖. Some of these are particularly salient for countries that are currently or will soon be

―transitioning to much lower levels of external financial support‖. In preparation of the

aforementioned situation, the Ministry of Health of Liberia has established a Health Sector

Coordinating Committee serving as a regulator to the already established Pool Fund with five

donors since 2008. Nevertheless, a significant amount of donor support which constitutes about

75% (5) remains off-budget with various parallel implementation arrangements.

In our review, we focus on the intra-country differences of health services between the 15

Liberian counties.

Methods

The authors employed a narrative review, making use of the recent international and national

documents, relevant literature and available information from the following primary and

secondary sources and databases:

a) Published Liberian documents including policies, strategies, plans, programs and reviews of

the Ministry of Health and Government of Liberia; The most recent situation analysis is

presented in the ―Liberia Service Availability and Readiness Assessment and Quality of Care

report (SARA and QOC) (6), while the most recent documents covering MNH policy

implementation are the ―Joint Annual Health Sector Review Report 2016‖(7) and the

―Consolidated Operational Plan (FY 2016/17)‖(8).

b) Publications in the area of routine health statistics including population census and household

surveys developed by the Liberia Institute of Statistics and Geo-Information Services with

partners (2008 Population and Housing Census, Liberia Demographic and Health Survey 2000,

2007, 2013), national e-databases with administrative data of Liberia Health Information

Management System (DHIS2) and international e-databases (WHO, UNICEF, UNFPA, World

Bank Group and the United Nations Population Division, UN Inter-agency Group for Child

Mortality Estimation) for purpose of comparison;

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

c) Published reviews, scientific and professional articles on Liberian maternal and new-born

health in international journals, national surveys and project reports of international

organizations (WHO, EU, World Bank, UNICEF, UNFPA) that deal with issues of women‘s and

new-born health in Liberia.

Results

Demonstration how resilience can be built after health crises like the Ebola epidemic has been

recently presented in several scientific papers (9-11). However, the purpose of the Liberian

actions in the field of health is to monitor progress throughout the implementation period of

defined activities and achievements, following expressions in the Investment Plan (12). The

purpose is described as building a resilient health system through: (a) improved access to safe

and quality health services, (b) health emergency risk management, and (c) enabling

environment and restoring trust.

General services availability and readiness in 2016, based on the WHO SARA report (6)

encompasses assessment of basic amenities, basic equipment, and standard precautions for

infectious disease prevention, diagnostics, and essential medicines by involving particular tracer

items. The overall readiness to provide general health services in 701 facilities was 59%, while

the best situation at the national level was found for basic equipment (77%), followed by

standard precautions for prevention of infections (73%), basic amenities (57%), essential

medicines (44%), and availability of diagnostics (42%).

However, Liberia‘s 15 counties differ significantly in their capacity to deliver basic health

services (Figure 1). The worst situation regarding general service readiness is found in Bassa,

Maryland and Sinoe (each county with only half of facilities ready to perform a comprehensive

basic health services). The best situation is found in Grand Cape (65% readiness for general

services), followed by Bomi (64%), Rivercess and Grand Kru (each 62%). Diagnostics, which

has included availability of 8 tracer items, (among them malaria and HIV diagnostic capacity,

urine test for pregnancy), was the worst in Maryland (only 24% of facilities were ready),

followed by Sinoe (27%) and Bassa (readiness was 29%). Nevertheless, it is worthwhile to

mention that tracer items for malaria diagnostics were mostly present – in average in 88% of

facilities with the least readiness interestingly in Montserrado (51%).

The UHC approach (13) embraces the following 4 core groups of indicators:

1. Reproductive and newborn health (indicators adopted in Liberia for family planning, four or
more visits for antenatal care, skilled birth attendance and coverage of pregnant women with

IPT). With regard to family planning, now in Liberia defined as ‗Number of Total Couple Year

Protection (all methods), the indicator should be redefined according to the UHC approach as:

‗Proportion of married or in union women of reproductive age who have their need for family

planning satisfied with modern methods‘.

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Figure 1. General service availability and readiness (as percentage) in Liberian counties

(in total 701 health facilities were assessed)

Source of data: Ministry of Health, Republic of Liberia. Liberia Service Availability and Readiness Assessment

(SARA) and Quality of Care Report, 2016: pages 137-138.

2. Child immunization (in Liberia: ‗fully immunized infants‘). The corresponding UHC indicator
is defined as: ‗DTP3 immunization coverage among 1-year olds‘.

3. Infectious disease (in Liberia: ‗antiretroviral therapy (ART) for HIV positive pregnant
women‘ and ‗tuberculosis (TB) detection rate‘. Instead more appropriate: ‗utilization of TB

treatment‘.

4. Major social determinants of the population‘s health status as e.g. improved water sources and
improved sanitary facilities.

Looking at these indicators planned to measure implementation throughout national health

policies, it is not possible to track all tracer indicators and to calculate the Index of UHC.

Nevertheless, international, as well as national databases contain values for the main indicators

of relevance.

The following sections describe availability and readiness for selected health services with a

focus on the UHC priority of Mother and New-born Health (MNH):

7779

100

Bomi

Bong

Bassa

Grand
Cape

Mount

Grand
Gedeh

Grand
Kru

Lofa

MargibiMaryland

Montserr
ado

Nimba

Rivercess

Sinoe

River Gee

Gbarpolu

Basic amenities

Basic
equipment

Standard
precautions

Diagnostics

Essential
medicines

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

1) Family planning

Despite 88% of health facilities are offering family planning services, still there are significant

disparities in the availability between counties (Figure 2). Astonishingly, this service is more

available in rural than in urban areas (97% versus 70%) and significantly more in government/

public facilities (97%) in comparison to private (62%) and mission/faith based facilities (60%).

Family planning readiness, in general 73%, is less present measured by availability of particular

tracers: guidelines, check-lists, trained staff, and different modern methods of contraception. A

particularly small number of facilities, only 14%, indicated to have at least one trained staff in

the past two years for application of family planning counseling.

Figure 2. Family planning – availability and readiness of services in counties as percentage

(701 health facilities)

Source: Ministry of Health, Republic of Liberia. Liberia Service Availability and Readiness Assessment

(SARA)and Quality of Care Report, 2016: pages 143-144.

2) Antenatal care:

The next important UHC tracer indicator is antenatal and delivery care (14). Routine antenatal

care (ANC) is clearly important for the health of the mother and her baby, but it also provides an

important access point to the health-care system for pregnant women, and may include

vaccination against tetanus, screening and treatment for high blood pressure, diabetes, anaemia,

HIV, malaria and sexually transmitted diseases, dissemination of information on topics such as

postpartum contraception and breastfeeding, and ultimately linkage to care during delivery.

Based on the SARA assessment in 2016 Liberia, in average, is doing well with 90% of facilities

offering antenatal care, while 6 counties (Bassa, Grand Cape, Grand Kru, Rivercess, River Gee,

and Gbarpolu) reported that all facilities are performing antenatal services and almost all have

84
79

7876

100

Bomi

Bong

Grand Bassa

Grand Cape
Mount

Grand Gedeh

Grand Kru

Lofa

MargibiMaryland

Montserrado

Nimba

Rivercess

Sinoe

River Gee

Gbarpolu

Facilities offering family
planning

Family planning readiness

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

tracer items available: iron and folic acid supplementation, intermittent preventive therapy,

tetanus toxoid vaccination, and monitoring for hypertensive disorders of pregnancy (Figure3).

Figure 3. Availability and readiness of antenatal care services in counties as percentage

(701 health facilities)

Source: Ministry of Health, Republic of Liberia. Liberia Service Availability and Readiness Assessment (SARA)

and Quality of Care Report, 2016: pages 149-150.

Geographical location is also a factor with one third of world‘s countries having ANC4 coverage

at least 20% higher in urban than rural areas. In Liberia the situation is, according to the recent

assessment in 2016, opposite: 75% of urban facilities are offering antenatal care in contrast to

98% of rural facilities. Even more: the most urbanized environment in Liberia – Montserrado

County - has the least availability and readiness of antenatal services (70% and 55%

respectively).

In general, the readiness in other areas - expressed as availability of staff, guidelines, equipment,

diagnostics, and medicines and commodities - is considerably less. At the national level 62% of

facilities are not fully ready to deliver antenatal care, predominantly due to the lack of

diagnostics (only 27% of facilities are ready regarding diagnostics) followed by staff and

guidelines (40% answered positively) (6). Tracer items in diagnostics, which are the most

problematic and contribute to the low readiness, were: haemoglobin test (available only in 12%

of facilities) and urine dipstick protein test (availability of 42%). Similar to the family planning

services – low presence of Continuing Professional Development (CPD) of staff is contributing

to lower readiness of antenatal health services. Only 15% of facilities had at least one trained

staff in the two past years for antenatal care. So far, it seems that the availability of a well trained

workforce in this field is still insufficient.

6769

62
60

100

Bomi

Bong

Grand Bassa

Grand Cape
Mount

Grand Gedeh

Grand Kru

Lofa

MargibiMaryland

Montserrado

Nimba

Rivercess

Sinoe

River Gee

Gbarpolu

Availability

Readiness score

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

3) Immunization of children

Universal immunization is a core of one of UHC‘s objectives, and a key focus of global

initiatives. Notably, the Global Vaccine Action Plan (GVAP) 2011–2020, which aims to achieve

at least 90% national coverage by 2020 and at least 80% vaccination coverage in every district or

equivalent administrative unit for all vaccines in national immunization programs is yet to reach

the full target as planned. According to the SARA Report (6), Liberia still did not reach this

threshold with an average 82% of health facilities offering child immunization and an average

readiness score of 76% of facilities out of 701.

While in international statistics immunization coverage is at the level of 52% for Liberia in 2015,

the national figure for the same year is above 60%. Such discrepancies can be a consequence of

different definition of indicators or quality of the data. Nevertheless, MoH is reporting decrease

in immunization for the two years stricken with EVD (15). The Investment Plan has a target of

91% fully immunized infants and the real progress will be monitored during the population

survey DHS 2018. Only five counties (Bomi, Bong, Rivercess, Sinoe and Gbarpolu) have

readiness scores proposed as threshold in the UHC approach - above 80% - although all counties,

except one, have health facilities stated to offer child immunization in average above 80%.

Extreme outlier is the highly populated Montserrado County, where only 54% out of 261 health

facilities offer immunization services with a readiness score of 70%. Their readiness score

encompasses (1) staff and guidelines, (2) equipment, and (3) medicines and commodities. One of

the possible reasons could be the generally lower commitment to child immunization services in

urban counties (only 61% are offering this service with 71% readiness). The same is the case

regarding low immunization services offered by mission/ faith based health facilities, NGO/not-

for-profit and particularly private-for-profit health facilities – possibly because they are more

clinically oriented. While government/public facilities are offering immunization service in 95%

of cases, private-for-profit institutions are doing so only in 47% of 235 registered facilities.

Regarding readiness score counties are more equalized (reaching from 66% to 86%) (Figure 4).

Figure 4. Availability and readiness of child immunization services in counties as

percentage (701 health facilities)

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Source: Ministry of Health, Republic of Liberia. Liberia Service Availability and Readiness Assessment
(SARA) and Quality of Care Report, 2016. pages 147-148.

The infrastructure regarding workforce, facilities and equipment is analysed in the following

sections 5-7.

5) Health workforce

The Investment Plan 2015-2021 placed the health workforce as the first investment area: ―to

build a fit-for-purpose productive and motivated health workforce that equitably and optimally

delivers quality services‖ (16).

Despite, the pull of human resources for health was heavily hit by the Ebola crisis, when 372

health workers obtained the disease and even 184 died (as of April 08 2015)(17), following the

2015/2016 health workforce census, the total number of health workers of 16,064(18) have

exceeded the number projected in the National Health and Social Welfare Plan 2011-2021(19)

and the National Human Resources Policy and Plan for Health and Social Welfare 2011-

2021(20), which aimed at 15,626 in 2021 for the population projected to be 4,555,985 in the

same year.

However, the actual composition of workforce does not follow the same positive path. If we look

exclusively at the physician, physician assistants, registered nurses, certified midwifes and nurse-

midwifes, we would expect to see - following the cited plans – more than 6,294 health workers

and not as in reality only 4,756 of them placed on the Governments payroll.

That means, Liberia still has to cover a 24% deficit of the nationally projected number of the

core health workforce.

The biggest deficit is with physician assistants, Liberia is still missing 48% of the projected

number for 2021, followed by physicians with deficit of 44%. The least deficit is with registered

nurses, certified midwifes and nurse-midwifes – 20%.

81
80

79
75

100

Bomi

Bong

Grand Bassa

Grand Cape
Mount

Grand Gedeh

Grand Kru

Lofa

MargibiMaryland

Montserrado

Nimba

Rivercess

Sinoe

River Gee

Gbarpolu

Availability

Readiness score

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

If we look at the WHO‘s threshold of 23 health workers per 10,000 population, then Liberia

would need to speed up to reach the total number of 10,479 core health workforce. In other

words, still 55% of health workforce is missing in comparison to the WHO threshold.

Achieving the SDG threshold of 44.5 per 10.000 would be even more unlikely. The Global

strategy on human resources for health ―Workforce 2030‖ underlines the required progress

towards UHC by strengthening health workforce (21).

At the same time, inequitable distribution per 15 counties is remarkable and fluctuation of

workforce is significant from year to year (Figure 5).

Commitment to strengthen workforce for health in Liberia by increasing investment through

country resources is remarkable looking at the staff on payroll.

The percentage of health workers placed on the national budget payroll increased from 58% in

2015 to 68% (7,214 out of 10,672 employed in governmental/ public health facilities) in 2016.

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Figure 5. Density of health workforce by counties – health professionals per 10,000

population

Data sources merged:

1. Ministry of Health, Republic of Liberia. Investment Plan for Building a Resilient Health System 2015 to 2021.
Monrovia, Liberia: Ministry of Health, 2015. Pages 8-35.

2. Ministry of Health Republic of Liberia. Joint Annual Health Sector Review Report 2016. . Monrovia, Liberia:
Ministry of Health, 2016. Page 44. Available from:

http://www.seejph.com/public/books/Joint_Annual_Health_Sector_Review_Report_2016.pdf [cited 2017 July 30]

6) Construction of health facilities

While lack of access to health services continues to be of major concern and central tenet of

UHC, in many parts of the world, there are several forms of barriers, the most obvious being the

lack of quality health services; but there are also obstacles such as a deficit of numbers of health

facilities and distance to the nearest one (22). The WHO global threshold for health facilities is 2

per 10,000 population, while there is no set target for the indicator ―percentage of population

living within 5 kilometres from nearest health facility‖ (national target for 2021 in Liberia is

85%).

Figure 6 presents the density of public and private health facilities per 10,000 population.

Though, mal-distribution of health facilities by counties is still obvious, even six counties

exceeded WHO threshold of 2 per 10,000 already in 2015, and the same situation appeared in

2016: Sinoe, Grand Kru, Rivercess, River Gee, Bomi and Grand Cape. In comparison to 2015,

critical shortage of health facilities has decreased, however still three counties – Bong, Nimba

and Grand Bassa have extremely low health facilities‘ density being <1.5 per 10,000 population.

15.7
14.9

12.3
12.2

11.5 11.4 11.3 11.2
9.9 9.9 9.5 9.4 9.2

8.5 8

11.8

8.6

6.3

2016 2015 2010

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Figure 6. Health facilities’ density per 10,000 population by counties

Sources:
1. Ministry of Health, Republic of Liberia. Investment Plan for Building a Resilient Health System 2015 to 2021. Monrovia, Liberia:
Ministry of Health, 2015: page 7. Available from: http://moh.gov.lr/cabinet-endorses-investment-plan-for-building-a-resilient-health-

system/ [cited 2017 Mar 17]
2. Ministry of Health Republic of Liberia. Joint Annual Health Sector Review Report 2016. . Monrovia, Liberia: Ministry of Health,
2016. Page 54. Available from: http://www.seejph.com/public/books/Joint_Annual_Health_Sector_Review_Report_2016.pdf [cited

2017 July 30]

One example is county Nimba. The projected figure of 70 public health facilities is not enough to

reach a density of 2 per 10,000 population; in fact it would be necessary to have 121 facilities in

this county. As of 2016, Nimba has 68 public and private health facilities and therefore still 53

functional health institutions are missing in order to reach WHO‘s threshold.

In 2011, MoH reported 550 opened health facilities (378 public and 172 private) (23), while in

the 2016 health sector performance report 727 health facilities were listed (out of 701 directly

assessed: 437 public; 216 private-for-profit and 48 private-not-for-profit – together 264) (24).

Whereas in 2011, Liberian health policy set out a projection of 543 public health facilities to be

reached up to 2021- with reference to the WHO‘s threshold of 2 functional health facilities per

10,000 population - Liberia would need a total of 911 health facilities serving the projected

number of population being 4,555,985 in 2021. In conclusion Liberia needs in addition to the

543 public facilities projected by GoL and the 264 private ones, pre-existing in 2011 a number of

211 additional facilities, either public or private.

7) Availability of equipment

2.8
2.5

2.2 2.2
2.5

2.2
1.9

1.7
1.4

1.2
1.5

1
1.2 1.1

1.6

3 2.9

2.3 2.3 2.2 2.2

1.9 1.8
1.6 1.6 1.6

1.2 1.2 1.1

1.9
2

0.5

1.5

2.5

3.5

2015 2016

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

At this stage of implementation, the envisioned inventory of equipment and a comprehensive

maintenance plan for facilities and equipment are still missing. With significant differences

between counties, basic equipment is ready in 77% of 701 health facilities, however only 19% of

facilities have all items (adult and child scale, thermometer, stethoscope, blood pressure

apparatus, light source). While Margibi and Montserrado have problems with child scales,

dramatic problems with light sources are reported in five counties which have less than 20% of

facilities with permanent electricity: Maryland, Sinoe, River Gee, Grand Kru and Grand Gedeh

(6).

Discussion

In spite of the described deficits Liberia‘s position with regard to the 15 West-African countries

is acceptable for a country after civil war and Ebola epidemic (25). The health related SDG

Index for Liberia is 33 i.e. the 9
th

position where Niger is the 15
th

with a value of 23 and

neighbouring Sierra Leone 13
th

with 27. Ghana takes the 2
nd

position with 43 and Capo Verde

islands the first with 53 (26).

Although the validity of the data used here may be questioned to some degree it is obvious that

across almost all areas of women and child health and health services in general considerable

differences between counties can be identified (even with regard to basic immunizations) which

points to considerable health inequities in this country. The most impressive ones are

demonstrated in figures 5 and 6 regarding the density of staff – ranging in 2016 from 8.0 to 15.7

- and facilities per population ranging the same year from 1.1 to 3.0 per 10.000 population.

Whereas the national average of the number of facilities is close to the WHO recommendation of

2.0 facilities per 10.000 population, the number of staff in average is far below i.e. 11.8 vs. 23.0

with an interim goal of 14 per 10.000 in 2021 (7).

Nevertheless, the recent health workforce census has identified once more the low motivation of

health workers and their deep frustration regarding financial incentives together with insufficient

possibilities for professional development (27). This demonstrates very clearly that investments

should go with priority into education and continuing training of qualified staff, paid regularly

and reliably, especially registered midwifes (28). Furthermore the poor infrastructure in Liberia

(lack of roads, electricity, water and sanitation) and the devastating economic situation appear to

be the main threats to the health system in general (personal communications).

In addition to the availability of sufficient health facilities, their staffing and quality of services,

also accessibility in terms of distances and road quality are of highest relevance. The Investment

Plan 2015-2021 set a percentage of population living within 5 km from the nearest health facility

(approximately within one hour of walking distance). In 2016 71% of all Liberian citizens have

access within 5 kilometers of their place of living. Nevertheless, Liberia is yet to reach the

nationally projected target of 85%. In addition, there are significant disparities across counties,

with Gbarpolu having only 32% of population with nearby access and Montserrado with 96%

respectively (29).

In order to obtain more reliable estimates of the main health indicators across the Liberian health

sector, the Government of Liberia is preparing - in collaboration with international partners -the

next generation of demographic and health surveys together with the Population Census for the

year 2018.

Kesselly RY, Kwenah NK, Gonyon E, Byepu S, Bawo L, Jacobs G, Korvayan J, Graeser MS, Galakpai MK, Wesseh

S, Laaser U. The status of health services in the 15 counties of Liberia (Original article). SEEJPH 2018, posted:

14June 2018. DOI 10.4119/UNIBI/SEEJPH-2018-190

Conclusions

The Ministry of Health has the responsibility to take care of effective extension of coverage of

health services to the entire population in Liberia. One key instrument is transparent investment,

i.e. timely and accurate reporting of local and international donor agencies including

implementing partners and correspondingly to reallocate the available resources per number of

population instead of accepting historical developments, however with a correction factor in

favour of disadvantaged regions and population groups.

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