Is There Hope in the Provision of Acceptable Health and Better Sanitation for Liberians in the New Liberia?

By Francis Nah Kateh, MD, MHA
Health Director, Anson County, North Carolina
At the
All Liberian National Conference
Columbia, Maryland
April 15, 2005


The Perspective
Atlanta, Georgia
April 25, 2005

The present Health Care System in Liberia is of major concern, and if nothing is done to remedy the situation, will lead to a serious and costly health system disaster. With this opening statement, let me take this moment to extend my thanks and appreciation to the Organizing Committee and those that brought my name forth to address this prestigious body on the issue of Health and Sanitation in Liberia. I wish to express my appreciation to the Ministry of Health and Social Welfare for the work they are doing in polio eradication, immunization, etc, during these difficult years of our nation. The timing is excellent because our beloved Country needs all the assistance it can get in order to help transform the course it has taken over the past decade, and the course it continues to take today. I hope we can all learn from this presentation, which may serve as a baseline for further discussion on this issue.


The Health Care System and sanitation of Liberia began at the inception of the Country. It only began taking shape in the late fifties when the late Dr. J. N. Togba Sr. became the first indigenous Secretary of Public Health, now the Ministry of Health and Social Welfare. Of concern, in the Togba age, was the philosophy developed by Dr. Togba that “medical practitioners are humanitarians therefore do not require adequate salaries for their services”. This statement still hunts healthcare providers today. As a result, healthcare providers for a long time have been among the lowest paid professionals in the Country. This salary structure has seriously impacted the provision of efficient and effective health care, since these providers have to work several hours in a paid period, at various hospitals, clinics, etc in order to make a decent living. The major consequences of the overworked healthcare providers are their ineffectiveness and misdiagnoses, which often leads to morbidity and mortality. While it is true that the civil crisis have had a grievous impact on all aspects of our Country, previous governments should have done more to change the mentality of many that could have led to a better understanding about the importance of Health and Sanitation and its consequences when not fully implemented.

The Old Trend, Does It Still Exist?

When I began my internship at the John F. Kennedy Memorial Medical Center in December of 1995, I was amazed by the fact that there were students of the Tubman Institute of Medical Arts, including medical students of the A. M. Dogliotti School of Medicine who carried bags containing essential medicines that were directly sold to patients and/or their relatives. Furthermore, I remembered on numerous occasions when criminal abortions performed by quacks resulted into complications, for which the victims were brought to the hospital for radical surgeries. What amazed me was the fact that those patients strongly protected the identity of the perpetrators, even to their death; thereby, permitting the perpetrators to continue such destructions of useful citizens’ lives with impunity. This is the Liberian way… said a dear friend and colleague. Who should be blamed, when the hotels, motels and/ or restaurants are unhygienic or even lack clean drinking water? A glaring example is the present environmental pollution in communities around the capital, Monrovia.

To divert for a moment, as a child, I heard a lot of stories about one “Doctor Borllic” a German “physician” who lived in Pleebo, Maryland County in the 50s and 60s. As the story goes, Doctor Borllic was an excellent physician. However, when patients came complaining about pain and medical ailments, he had the propensity to administer injections to those designated areas. For example, if you complain of headache, he will give you an injection on your head. As I grew-up and went through Medical School, I got to realize and subsequently know that this man did not understand the basic medical concepts regarding human anatomy, physiology and pharmacology, or even pharmacodynamics. Those acts, of the late Mr. Borllic, are still practice at some levels in Liberia today, where “doctors” practice as apprentice. The worst case scenario is the fact that in apprenticeship, one learns to perform with the hope that “all conditions are the same”, hence the ‘one strategy fits all concept” is embedded in the minds of many of our citizens”. These concepts need to be critically reevaluated in the New Liberia with public awareness and educational programs through the various health departments. I will try to go back to the bases of quality healthcare and what is needed to attain “Good Health and Sanitation in the New Liberia...

What Has Been Done?

In 1998, based on a request from the Ministry of Health and Social Welfare, the World Health Organization contracted Dr. Wilfred Boayue to write the National Health Plan of Liberia, looking at short- and long-range plans. Dr. Boayue, a son of Liberia with enormous experience in health care provision, did an excellent job based on the circumstances under which he had performed. Based on Dr. Boayue’s work, the following were the short-term priority areas for prevention-related activities by the Ministry of Health:

· Malaria
· Cholera
· Yellow Fever
· Polio Eradication
· Epilepsy Control
· Leprosy
· Expanded Program on Immunization (EPI)
· Meningitis
· Onchocerciasis
· Trypanosomiasis

The long-term priorities were as follows:

· Decentralization of Health Services
· Family Health
· HRD (Human Resource Development)
· Communicable Disease Control
· Water and Sanitation

While they are very necessary, the need to strategically prioritize the above in order to bring about effective changes can not be over-emphasized. Therefore, let us take a brief moment and peruse the ideas of Dr. Donabedian and see how his model can help us attain an acceptable healthcare standard in Liberia.

Dr. Avis Donabedian described the bases for quality healthcare by his model: Structure, Process and Outcome. Structure is described as the environment in which health care is provided; process as the method by which health care is provided; and outcome as the consequences of the health care provided. This model is very essential for the revitalization of the Liberian Health Care System.

The Role of the Government through the Ministry of Health and Social Welfare As I Perceive It

The Ministry of Health and Social Welfare has an important role, not as an implementer of programs, but as a conduit for setting up, monitoring and evaluating policies that are necessary for the implementation of quality health care system in the country. For instance, at the Ministry of Health and Social Welfare, there is an Assistant Minister for Planning- The role of the Planning Department is the most vital and pivotal aspect of the overall administration of the Ministry. This department should be responsible for major activities in the areas of policy coordination, legislation development, strategic planning, policy research and evaluation, and economic analysis. Furthermore, the Deputy Minister of Health / Chief Medical Officer of the Republic needs to set the pace for the Deputy Minister for Curative Services and that of Preventive Services. This core team has a critical role to play in changing the course of the nation’s health and sanitation policies. They have direct linkages to the county’s health officers by guiding, monitoring and evaluating their efforts to ensure that the health and sanitation needs of the public are maintained, and remain continue to be vital toward to the sustenance of the nation. During my five years plus of practice, I did not see or hear of any legislature put in place base on the prevailing health issues, for example, HIV/AIDS, Diarrhea, Malaria, etc. I feel that the honorable members of the legislature should become proactive in the formulation of health and sanitation laws by inviting expert and highly qualify witnesses to provide medical directions prior to enacting of those laws.

The Way Forward

To function effectively, the Ministry of Health and Social Welfare needs to go back to the drawing table and take a critical look at the Nation’s Health and Sanitation policies and redirect them to fit into the Donabedian Model. According to the World Health Organization’s Statistics for 2002, the life expectancy at birth 42.4 (per 1000), child mortality 232 (per 1000) M/F, adult mortality 582/471 (per 1000), M/F as compare to Gambia: Life expectancy 53.4 (per 1000), child mortality 91.0 (per 1000). This placed Liberia on the lowest scale as compare to the rest of the world. How do we medically resolve such poor health indicators? This leads me to the Donabedian Model.

Structure: Is there a structure in place that individuals interested in healthcare can follow? Are there various health and sanitation policies, as they relate to the role of a consultant, general practitioner, physician extenders (physician assistant, nurse practitioners, etc), pharmacists, nurses, and nurse-aids; health facilities and pharmacies? How about lodgings (hotels, motels, etc) and restaurants? This is where the need for trained man-power in environmental science is really needed. What are the systems and policies in place to make sure that those professionals and the environment where services are provided meet an acceptable standard? When these factors are elucidated, then the issue of continuous education for the provision of those acceptable services needs to be evaluated and monitored. This portion of the structure will assure the public that it does not matter where they go for treatment; because the same standard of treatment (care) will be provided at all facilities. This structure will also help with data collection, limiting those quasi services, and bringing the perpetrators to justice.

Process: Is there uniformity in the way services are provided among clinics, healthcare centers, hospitals, and pharmacies, drug stores and medicine stores? Has there been a defined criterion such as minimum education for the provision of those services? Has there been a system put in place for continuous education? Whenever there is a lapse or failure in the provision of services, is there a system put in place for its enforcement and /or reinforcement?

Outcome: When the structure and process are adequately in place, the outcome is plausible. One would see quality control in action which could lead to acceptable healthcare delivery system

According to Public Health and Related Laws of North Carolina, 2nd Edition, the role of the Ministry/Department of Health and Social welfare/Services in any country should be the provision of healthcare services to its people by:

· Preventing health risks and disease
· Identifying and reducing health risks in the community
· Detecting, investigating, and preventing the spread of disease
· Promoting healthy lifestyles
· Promoting a safe and healthful environment
· Promoting the availability and accessibility of quality health care services
· Lodging and institutional sanitation
· On-site domestic sewage disposal
· And water and food safety and sanitation

These basic provisions are the essential requirements for the health sector viability of a country. A country that does not provide and monitor these basic services to its people is definitely going to fail because “healthy people make a viable, sustainable and vibrant nation”.

In other to enhance its provision of a standardize health and sanitation services, we recommend the following strategic directions for Liberia:
· The government through the Ministry of Health and Social Welfare needs to clearly define her role;
· A role that will not compromise the basic health services which has to be standardized for personal aggrandizement; and
· A role that will entail monitoring, evaluating and promoting of continuous education. It is through continuous education that professionals learn new techniques, or bring to perfection what they have already learned.

Another major aspect of effective monitoring and evaluation is the decentralization of the Ministry of Health and Social Welfare. This issue has been mentioned in many publications regarding the provision of healthcare to the people of Liberia. In the December 2, 1997 Action Plan- “Revitalizing the Health Sector, Challenges and Opportunities 1998-1999, the issue of decentralization was clearly elucidated in the document. Decentralization will enhance the ability and capability of the Ministry to focus on essential aspects for continuous provisions of standardized health care; providing the necessary and appropriate resources to legislators to enact laws base on the prevailing health issues; strategizing man-power development; monitoring, evaluating and empowering county health officers and stimulating regional and national dialogues in order to share best practices. All of these will enhance health and sanitation care in the New Liberia.

But all of these may not come to fruition if remunerations for healthcare and sanitation providers are not adequately met. It doesn’t make sense for a doctor, after four years of undergraduate and five years of post-graduate studies to begin his or medical practice with a salary of less than fifty United States dollars or one thousand Liberians dollars. Appropriate salary compensation should also be considered for other civil servants in order to curtail the high rate of “GORBACHOP” (corruption) at its highest peak. One cannot preach for good services when the providers of those services are not happy.

In conclusion, the provision of quality health and acceptable sanitation care is the hallmark of any viable government. In order to implement quality health and acceptable sanitation care, we make the following recommendations to the government for considerations:
· Redefine and Redesign the role of the Ministry of Health and Social Welfare
o By placing the right mix of professionals at the pyramid of the ministry,
o By reinforcing various policies if there are any, or formulating the right health and sanitation policies that would address the present situations, yet providing the flexibility to accommodate future problems,
o By enforcing the policies and not just coming-up with policies with out an enforcement clause,
o By evaluating the present health care man-power needs of the population and at the same time forecasting the future demands,
o By forecasting future demands, decentralization of paramedical and professional institutions becomes important for the purpose of equitable distribution i.e., Physician Assistants/Nursing Schools, Midwifery Schools, Environmental Health Programs, Certified Nurse Assistant programs and most importantly, the expansion, strengthening and financially supporting the A.M. Dogliotti School of Medicine in continuing its provision of the Country’s physicians,
o By empowering the Liberian Medical and Dental Association, Physician Assistants, Nurses and other paramedical associations,
o By providing the bases for an acceptable remuneration system for health professionals,
o By placing emphasis on continuous education at all levels of the health profession,
o By formulating acceptable baseline criteria for the provision of an acceptable standard of medical care at all levels, and
o By encouraging the establishment of an autonomous accrediting body comprising of health care professionals that will give accreditation to hospitals, health centers, clinics, pharmacies, etc.

· With a qualified and competent manager/leader, the timetable for the implementation of these plans, in order to see a positive trend, would be two years with all of the appropriate man-power and necessary financial support from the government and other compatriots.

With such an implementation strategy, fellow Liberians, brothers and sisters, the issue of health and sanitation care will not only meet the international quality regarding the standard of care, but will improve the health and sanitation need of all Liberians now and generations to come. Accordingly, this will transcend Liberia into a strong, vibrant and viable NATION.

May God Bless Our Country.