Put another way, to take good governance seriously is to carry out three important tasks concurrently. First, society must restructure existing institutions. Second, society must simultaneously reorient the fundamental thinking of the people responsible to implement the new systems. Third, and concurrently, such a systemic change or transformational process must involve the conscious and purposeful linking of the various institutions or sectors of governance on a continuum. These changes would ensure that where systems overlap and are interwoven, if gaps exist, they would be deciphered and repaired.
The primary aim of the discussion conducted here is to produce basic understanding of the socioeconomic contexts of public policy formulation. Since public policy is the dominant theme, it is necessary to define it as used in this context. Public policy is defined here as the government’s role in effecting conditions that influence the standards of living of its citizens. Furthermore, public policy involves interventions, strategies, and/or programs that are mandated by legislation and administered by government or its surrogates to address national problems.
This paper is intended to broadly discuss public policy formulation in Liberia, describing its impact on two key sectors: healthcare and social welfare. I should note that social welfare policy can mean basic life needs such as employment, unemployment assistance, healthcare, food, housing, and many more. Also inextricably linked to social policy is the welfare of children, referred to as child welfare policy (Karger & Stoesz, 1998).
The secondary aim is to allow the first section to shed light on the past with an intention to suggest strategies for radically overhauling and/or providing new policy directions that should be pursued in the post-conflict era. It is fair to characterize this paper as descriptive and exploratory, and less so analytical, since there is very little background literature and data to draw from in this exercise. Essentially, the question of why certain things happened will be examined, although not thoroughly, especially since one lacks access to some of the primary and secondary data sources that could directly answer this question.
The various sources of social statistics have deteriorated over the years. Current government statistics are not readily available, including census and other population-specific data. Providers, practitioners, professionals, and academics do not regularly collect information on population growth, health, housing, education, unemployment, crime, and other vital statistics. Social indicators (summative or merged gauges), which are different from government statistics, but are “standardized measures” involving such things as infant mortality rates, school enrollment or literacy rates, doctors to population comparisons, etc; which, when studied closely, reflect more pervasive and persistent social conditions, are also not current and readily available. These factors have culminated into a dearth of necessary data to inform policymaking and/or research.
To restate my intentions, the question that I wish to address directly and perhaps most exhaustively is how healthcare and social policymaking came about prior to and during the civil war. This does not mean that I am less interested in the larger question of “why?” The paper is divided into two parts. Part one will very broadly extrapolate patterns from the very limited knowledge base on healthcare and social policymaking in Liberia and begin the task of establishing a model for social protection that will guide policymaking in the post-conflict years.
Part II will begin to evolve some specific recommendations
for how healthcare and social policymaking should
take course during the post-conflict era. This latter
section would be centered on interdisciplinary and
participative approaches to building and sustaining
a modernized healthcare system. It would also devise
strategies to overcome persistent inefficiencies in
order to establish a continuum of care rather than
a sectoral approach. The definition of reform utilized
in this is paper is the following: “sustained,
purposeful change to improve efficiency, equity, and
the effectiveness” of the social protection
sectors (Berman, 1995, p.15). The social protection
sectors constitute all the policies, procedures, interventions,
personnel, and infrastructure that cumulatively constitute
structured efforts to either prevent and/or treat
illnesses or diseases as well as the delivery of adequate
human services. While Part II will contain concrete
proposals for restructuring the two sectors discussed
in this paper, it will not represent a finished product
or recipe, but foundations for national dialogues
on the future of healthcare and social welfare in
Organizing Social Protection Systems
Typically, there are three systems of organizing social protection or healthcare infrastructure. They are the state-administered paradigm, corporate-run paradigm, and the hybrid or segmented paradigm. The crux of such a distinction is the following: the first is state-supported, the second, insurance-based, and third is a balance between state support and market-driven arrangements (Heidenheimer et al., 1983). In Liberia, the dominant social protection or healthcare systems are nationalized or state-administered. However, there are minimal market-based social protection or healthcare systems, administered in large part by religious institutions (i.e., St. Joseph Catholic Hospital and Ganta United Methodist Hospital) and small pockets of private clinics (i.e., Cooper Clinic and Sirleaf Clinic). During the war, these and other hospitals as well as the clinics became the cornerstones of healthcare delivery to the Liberian people, with limited interventions by international healthcare non-governmental organizations. The Liberian Red Cross was also notably a healthcare provider, which made significant contributions to meeting the social service and emergent healthcare needs of the public.
Poor Healthcare and Social Policy Formulation Legacies
To understand the current social conditions in Liberia, it is useful to review the ways in which these conditions have evolved over time. This will foster a better understanding of healthcare and social policy making processes in the future. Healthcare and social policy formulation in Liberia were products of the public sphere, administered by the Ministry of Health and Social Welfare and the Social Security Agency (SSA). In simple terms, provision of healthcare and social welfare services are institutionalized under the auspices of the state. The SSA was established to provide income support and provide income security and other programs to promote well-being.
During the 133 years following independence, Liberia was ruled by an Americo-Liberian oligarchy. This hegemony utilized “patrimonial practices” to appropriate public goods, services, and privileges to members of the ruling elite at the “social exclusion” of the vast majority of indigenous population and the poor settlers, largely of darker complexion. This meant that rural inhabitants, the indigenous poor and poor settlers, who constituted the majority, benefited the least from the country’s healthcare and social policies. This phenomenon, labeled by Midgley (1997, p. 192) as “distorted development,” whereby economic development benefits a small segment of the population, leaving the larger populace in poverty persisted in Liberia.
During the pre-war era, (Tubman and Tolbert years), although economic development enhanced the well being of relatively larger segments of the population, it did not reduce disparities between urban and rural inhabitants. Poverty was widespread among rural inhabitants. Urban migration also persisted, overcrowding Monrovia and other urban centers. This put housing problems on the rise, mainly in Monrovia. Illegal and/or illicit life styles, including crimes, substance abuse, and other social problems were endemic in adjoining urban slums that were on the rise near Monrovia: Soniwehn, Bassa Community, Jallah Town (Down the Hole), etc. Pressures to improve social conditions increased immensely among people in different sectors of the citizenry. It was in this environment that student movements, worker’s union, market women, and other disenfranchised populations began to agitate and demand for changes in the social compact. Through the agitation of these groups, many members of the military, enlisted men specifically, were stimulated and some even rendered disgruntled, which culminated into a coup.
In 1980 when the People’s Redemption Council (PRC) launched the coup that overthrew the William R. Tolbert government, it brought an end to Americo-Liberian rule. However, much did not change in healthcare and social policy formulation, except that the new political elites were of a different ethnic hue – indigenous people. A new hegemony was formed to exacerbate the conditions. The urban communities, where most of the educated people or working classes resided enjoyed better access to healthcare and social protections as opposed to the rural inhabitants, many of whom were not employed by the government or in the formal sector. The military, which became the location of the new elites, compensated themselves with many of the resources it lacked in previous years, including social protections. Noteworthy also, in concession communities like Yekepa and Buchanan, administered by Liberia American Mining Company (LAMCO) as well as Firestone and Bong Mines, these entities operated their own hospitals and deliver social services in far superior quality than did the government.
Social coverage was linked tightly to being employed in the public or private sectors. Indeed, egalitarian notions of rights were negated in Liberian social policy. This contradicted our national concept of citizenship that is rooted in democratic notions of liberties and rights. Our social security system was essentially tied to contributions that were made from salaries, with taxes playing a meager secondary role. This meant that the working class, middle class professionals, and the political classes enjoyed social protections. As such, the larger public unhinged from employment in the formal sector remained unprotected and vulnerable. The latter classes had to either pay for their care from their pockets or their needs were left unattended. A startling statistic that demonstrates this point vividly is that the “out-of-pocket expenditure on health as a percentage of private expenditure on health in 2002 was 95.70%” (World Health Organization). It is not surprising then to note that according to the National Transitional Government of Liberia 2004 Joint Assessment quoted by USAID, “less than 10% of Liberians have access to quality healthcare.” With bulk of the healthcare at present available focused in Monrovia and counties with improved security and working conditions (USAID, 2005), it is only natural to assume that rural inhabitants are the hardest hit.
Readers should also be reminded that in the latter
part of the 1980s and early 1990s, the pace of deindustrialization,
meaning the retrenchment or closure of their operations,
particularly, Bong Mines, LAMCO, and Firestone also
caused steep declines in employment and weakened the
Linkages between Economic and Social Policymaking
Economic stagnation, rising unemployment, inflation and an assortment of downward trends in the economic sector produced and intensified poverty and inequality. Structural problems such as minimal or no investments only deepened the risks of external shocks. The absence of an income distribution policy to shore off vulnerabilities due to distributive injustices and poverty only established the strongest links between economic, healthcare, and social policies. People’s purchasing power and disposable incomes were on a downward spiral, although the incomes of politicians who were stealing from government coiffeurs continued to rise, increasing wealth and quality of life disparities.
The inability of the economy to recover and the deepening
political crisis only furthered the pattern of unfair
income distribution. As stability and national security
grew tenuous, economic growth, which is a by-product
of private foreign investments, waned. The pattern
only became relentless as the political situation
worsened. This goes to say that the social and health
sectors are dependent on the labor market, and vice
versa. Therefore, the hardening of the labor market,
the resulting high unemployment, the high inflation,
the introduction of Liberian-owned currencies and
the consequent weakening of purchasing power among
wage earners, and the differential gaps between income
earners and the poor, only set the stage for the worse
of times in the years that followed.
In 1989, when Charles Taylor and the National Patriotic Front of Liberia (NPFL) launched its war on the Samuel K. Doe regime, inequality was already at a very high point. Between 1990 and 2002, hundred and thousands of Liberians fled their towns and villages because war-related violence, civil conflict, or ethnic hatred. Uprooted Liberians lived under decaying social conditions in the country (internally displaced) and in refugee camps in nearby countries. Poverty and suffering became prevalent and unrelenting. By 2002, total expenditure on health as a percentage of GDP was 2.1%. Social security expenditure on health as a percentage of general government expenditure on health in the same year was also zero, both according to the World Health Organization (WHO).
During the Taylor years, there were little or no sets of public policies geared toward investments in healthcare or social services. It has been established that economic growth is a precondition for repairing distributive injustices and mitigating poverty. And it became clear during the Taylor regime, that there were no prudent use of social expenditures, demonstrable by the dilapidated social conditions in the country. The Taylor government was unable to improve income distribution. It too, deepened the inequalities further by creating an environment even more conducive for siphoning wealth from the public sector through numerous illegal schemes. President Charles Taylor and a few henchmen became the biggest culprits: stealing maritime funds, and selling publicly owned raw materials and divesting the funds into their personal use. Public investments in education, water and sewage, child mortality rates, life expectancy at birth, and other social indicators were on swift declines, while Taylor and his corrupt cohorts enriched themselves, living by First World standards, as the rest of the citizens inhabited a world steep in backwardness and savagery.
The accelerated rates of violence and addictions of various kinds during the warring years altered social relations, and created a more visible class of troubled youth, who due to inactivity saw it, quite beneficial to attach to the insurgency groups either as a source of self-protection, protection for their families, and/or a means of livelihood. If one were to draw the health profile of the citizenry at the time, it would not be too far to form conjecture that Liberians were living in times where a mere fever or dysentery could kill you. Health indicators published by the World Health Organization (WHO) on Liberia indicated that life expectancy at birth in 2003 was 41 years old for the general population. Child mortality (probability of dying under age 5 years, per 1000) in 2003 was 246 for males and 224 for females. Adult mortality (probability of dying between 15 and 59, per 1000) in 2003 for males was 590 and females 484. This means that for every 1000 people in Liberia 590 men are expected to die between the ages of 15-59 and 484 women might die between the ages of 15-59. With the proportion of GDP spent on health as 2.1%, in 2002, it showed a penchant toward minimal investments of national expenditure in the healthcare sector. Add to this fact that health promotion, disease prevention, and other public health programs received very little attention. While the health sector was acutely short of resources, the government was investing a bulk of national resources in militarized armaments: arms and ammunitions. If education and income are critical indicators of good health (McDonough, 1999), then it is fair to surmise that the health of many Liberians, the rural poor in particular, many of whom are illiterate, can only be described as abysmal. This conclusion is borne out by the fact that available data on health and nutrition indicators of Liberia are situated among the “worst” in the world (USAID, 2005). In 2003, even by African standards, Liberia was world’s worst country in which to live, according to the Economist Magazine as quoted by Winsley Nanka in an article on the Perspective website, dated, December 18, 2002.
Throughout the life of the nation, with the state being the primary provider and/or providing public assistance to supplement the care given by private healthcare entities, we established a largely politicized social protection system. In this kind of environment, it was the poor and the most vulnerable that did not have access to care and services. In a politicized system, it was the constituencies with power or close proximity to power that possessed leverage to acquire their interests.
Essentially, the healthcare and social service delivery
systems were stratified. Those citizens that were
employed in the formal market received social security,
while the larger citizenry received services from
John F. Kennedy Hospital or other government-run healthcare
providers. Government providers notably provided mediocre
substandard quality care. For that reason, it is not
hard to see while a majority of the citizens felt
disaffected. When the social demands of the larger
populace were unmet, it strengthened the hands of
the political opposition, who themselves proved to
be only interested in their personal gains from the
government. The political opposition in the form of
insurgent groups argued that the bureaucratic structures
were inefficient and distributed national wealth unequally
among the constituents. They too gained access to
government through the barrel of a gun and eventually
set notorious records of pillage and treachery.
The industrialized world: the United States, Japan, Australia and Western European nations have transformed their agrarian subsistent economies into modern economies. They have made marked improvements in their social conditions. All these changes have occurred because of concerted investments in economic development and constructive government interventions in social development. Consequently, these industrialized nations have created environments conducive for soaring levels of production and made large-scale wage employments natural parts of their economies. This, in turn, has caused considerable improvements in the quality of life of their citizens (Midgley, 1997). With an accompanying democratic political system, where checks and balance exist between different branches of government to maintain balance of powers, and established avenues for litigating the interests of aggrieved parties, they have managed to minimize, if not, contain the kinds of national security challenges that emanate from having severe persistent economic and social malaise.
From their experience, we have come to learn that no other indicators are critical than those that depict the level of social protections that the government provides to its citizens. Hence, the criteria by which one can distinguish between good and spurious leaderships is its ability to provide the basic needs of the people: employment, improved mortality rates, availability of and access to nutritious food, healthcare, service delivery systems, and safeguards to foster safety and security. A society where citizens have equal access to opportunities diminishes the degree to which groups seek to preserve narrow group interests: ethnic or otherwise, in response to feelings of disenfranchisement and inequality.
To the contrary, throughout the life of our country and more so during the warring era, hundreds of Liberians have died from curable illnesses including malaria, dehydration, diarrhea, etc. There are complex and complicated web of reasons for why our healthcare and social protection systems have deteriorated over the years. Perpetrators have included massive failure of leadership as well as economic, political, and cultural factors. The network of institutions responsible to finance, organize, and deliver healthcare and social services have been plagued by the same societal ills that have prioritized the militarized sectors over the basic needs of the citizens. The state has served as the key provider of healthcare and social services. As the state’s capacity has eroded due to excessive bureaucracy, public corruption, and political struggles between different social actors (political and ethnic groups), the ability to create the social consensus needed to mount robust policy and intervention responses to societal needs, including healthcare and social welfare have weakened and declined.
To close, it is hoped that this paper has begun the process of promoting a level of “policy consciousness” where such has been lacking. In the second part, attempts will be made to provide new vistas into how we can restructure our healthcare and social welfare systems and change the basic thinking of citizens. Finally, the emergence of Ellen Johnson Sirleaf to the presidency should not be viewed simply as one single “earth-shattering” event in the life of our country, merely the “first woman President.” Rather it should reflect fundamental changes in how we create and conduct public policy so that it is inclusive of all citizens, especially women, youth, and the poor who have often been excluded from this process. Hopefully, there will be equitable distribution of resources necessary for good health and improved social welfare.
The Author: Emmanuel Dolo is the Director of Educational Equity and Integration at South Washington County Schools in Cottage Grove, Minnesota. He lives with his wife and two children in Coon Rapids, Minnesota.