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Comprehensive Analytical Profile: Liberia

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This analytical profile provides a health situation analysis of the Liberia and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to country context
2. Health status and trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context

Liberia contains 40% of West Africa’s rainforest. The climate is tropical with a wet season from mid-April to mid-October and a dry season from mid-October to mid-April.

The country is divided into 15 political subdivisions, called counties: Bomi, Bong, Gbarpolu, Grand Bassa, Grand Cape Mount, Grand Gedeh, Grand Kru, Lofa, Margibi, Maryland, Montserrado, Nimba, Rivercess, River Gee and Sinoe. Monrovia is Liberia’s largest city and serves as its administrative, commercial and financial capital.

Liberia’s population is estimated to be 3 476 608, with an annual growth rate of approximately 2.1%.[1] As a result of greater security in urban centres during war times and greater access to jobs, services and social gratification during peace time, 47% of the population lives in urban areas. According to the 2008 National population and housing census, the population is 50.1% male and 49.9% female.[1]

Health Status and Trends
Under-five mortality rate (LDHS, Liberia demographic and health survey; LMIS, Liberia malaria indicator survey 2009

While still high, under-five mortality rate in Liberia has declined from 220 per 1000 live births in 1986 to 110 per 1000 live births in 2007 (see figure). Concurrently, infant mortality rate has declined from 144 deaths per 1000 live births in 1986 to 71 deaths per 1000 live births in 2007.

If progress continues in reducing malaria prevalence, accelerated scale-up in prevention and treatment of pneumonia and diarrhoea, improvement in newborn care, and increase in birth spacing, Liberia will likely achieve Millennium Development Goal 4.

Progress
Progress on SDGs
The Health System
Health system outcomes

Immunization coverage in Liberia shows an overall gradual increase from 2010. Three doses of pentavalent vaccine (Penta-3) coverage increased from 73% in 2010 to 78% in 2011, while polio third dose coverage increased from 72% to 77% during the same period (see figure).[2]

The Comprehensive food security and nutrition survey 2010 found that 42% of Liberian children aged under 5 years are stunted, increasing their risk of dying from normal childhood illness and of developing chronic illnesses later in life. Rural areas have more cases of stunting than urban areas. Montserrado county has the lowest prevalence at 31%, while nine other counties exceed 40%.[3]

Leadership and governance

To provide clear policy direction and leadership within the health sector, the Ministry of Health and Social Welfare elaborated a medium-term National Health Policy and National Health Plan along with other subsector policies and strategies. The current health policy is based on the primary health care approach with a goal of achieving the Millennium Development Goals and improving health outcome.

The Health Sector Coordination Committee serves as the steering committee of the sector and makes critical programmatic and financial decisions. Representation on this committee includes:

  • the Minister of Health and Social Welfare with his four deputies and advisers;
  • heads of all donors and international development partners coordinators from international and local nongovernmental organizations and civil society organizations;
  • the private sector;
  • multilateral and bilateral missions with health development objectives.

The Health Sector Coordination Committee is chaired by the Minister of Health and Social Welfare.

Community ownership and participation

The involvement of the community is critical for health service delivery and ownership in Liberia. The National Health Plan elaboration process involves the community as a major stakeholder in the sector.

During the development of the National Health Plan, a series of county-level consultations was held in conjunction with various communities to identify health priorities and the causes of morbidity and mortality. It is envisaged that community involvement in the planning process will generate ownership and facilitate the implementation of the Plan.

Partnerships for health development

The Liberian health system has developed a foundation of public–private partnerships over the past two decades. Charities, faith-based organizations, nongovernmental organizations and private providers have been major contributors to the health delivery system. For example, the creation of the Christian Health Association of Liberia in 1975 recognized the key role that the faith-based community played at that time in the provision of health services, at the clinic, health centre and hospital levels.

Similarly, a number of private-for-profit clinics and hospitals, for example Firestone Rubber Company, not only operated health facilities for their employees but also provided services to the surrounding community. At that time it was estimated that approximately 25% of Liberia’s health facilities were owned and operated by private-sector partners with funding assistance from external sources (missions), company income, user fees, and/or Ministry of Health and Social Welfare funding.

Health information, research, evidence and knowledge

In 2011, the national reporting coverage for outpatient services in Liberia was 77%, compared with 76% in 2010, with variations across counties. Counties with high reporting coverage included: River Gee (100%), River Cess (99%), Margibi (96%) and Grand Kru (96%); while Montserrado reported the lowest coverage (52%). The figure presents outpatient department reporting coverage by county in 2011.

Improving and increasing the reporting coverage of hospitals and health centres remains a challenge, especially for private health facilities in Montserrado County. In 2011, the national coverage for inpatient reporting was 40%. Despite this low rate, River Cess (100%), Bong (97%) and River Gee (94%) attained high inpatient reporting coverage, while Montserrado (83%), Nimba (35%) and Margibi (42%) recorded the lowest coverage1. The figure presents health facilities inpatient department reporting by county in 2011.

Health financing system

In 2008, the Government of Liberia's total health expenditure reached over US$ 100 million (or US$ 29 per person), i.e. 15% of gross domestic product. This was an unprecedented level of expenditure for Liberia and was in line with the West and Central African regional average of US$ 28 per person in 2006 (WHO figures).

External donors and households accounted for the largest part of health expenditure (47% and 35%, respectively), while Government spending accounted for 15%. Government spending has remained stable as a percentage of the national budget (between 7% and 8%), but it has nearly doubled in absolute terms. Donor funds are predominantly used to support service delivery at the primary care level, while referral hospitals consume the largest portion of Government expenditure.

Service delivery

In Liberia, health service delivery is fundamentally linked to geographic distribution of the population and population density. In 2007, the Ministry of Health and Social Welfare committed to establishing a consistent package of evidenced-based, essential health services to the entire population.

Thus, the Basic Package of Health Services was developed in order to ensure equitable access to health services by increasing the overall efficiency and effectiveness of the health systems at all levels. The Basic Package of Health Services prioritized services perceived at the time as the most critically needed to improve the health status of the Liberian population within the available resources.

This Basic Package of Health Services was modified in the current health plan (2011–2021) to include additional services such as noncommunicable diseases, prison health, neglected tropical diseases and is now referred to as the Essential Package of Health Services.

Health workforce

In 2009, a national human resources census recorded 8553 health and social welfare workers. Of those who reported their cadre, 62% (5346) were clinical and 38% (3207) were non-clinical, including security guards, registrars and cleaners.

However, only 48% (2568) of the clinical workers were skilled providers (e.g. physicians, physician assistants, nurses, midwives, pharmacists, laboratory technicians) and almost 70% of the total workforce was either non-clinical or unskilled (see figure).

Progress has been made in expanding the number and quality of preservice training institutions in order to increase their capacity to produce more skilled workers.

Medical products, vaccines, infrastructures and equipment

As is usual for postconflict countries, Liberia is affected by a multitude of problems related to the management and use of medicines at all levels of the health care delivery system. Since good heath, by extension, is crucial to the quality, availability, good management and rational use of medicines, it becomes imperative to design appropriate strategies that can address these issues.

The National Drug Policy of Liberia provides a comprehensive framework for the development of all components of the national pharmaceutical sector with a perspective for the coming 10 years, but with monitoring and periodic reviews. It is designed to address the problems relating to accessibility, affordability, availability, supply chain management, rational use of medicines and others and is an integral part of the National Health Policy, which is part of the national comprehensive socioeconomic development plan.

The Ministry of Health and Social Welfare is committed to the provision of accessible health services of good quality and to the fair distribution of these services to all citizens.

General country health policies

The Government of Liberia's 2011 National Health Policy builds on:

The 2011 National Health Policy draws upon the knowledge gained by implementing these policies as well as from numerous sources of new data on the health status of the Liberian population. Thus, the Ministry of Health and Social Welfare is confident that the 2011 National Health Policy’s orientation is evidence based and reflects the best information and guidance available at the time it was developed.

The mission of the Ministry is to reform and manage the sector to effectively and efficiently deliver comprehensive, quality health and social welfare services that are equitable, accessible and sustainable for all people in Liberia.

Universal coverage

Physical access to primary health care has improved dramatically across Liberia, from one health facility serving an average of 8000 population in 2006 to one health facility per 5500 population in 2009. In several counties, namely Bomi, Grand Cape Mount, Grand Kru, River Cess and Sinoe, this ratio is below one per 4000 population. The national average ratio of facilities to served population is already lower than the norm established by the Basic Package of Health Services.

In light of the registered expansion of physical access to health care facilities (see figure), the inadequate coverage of immunization services is a matter of concern. It improved from 39% of fully immunized children in 2007 to 52% in 2010, but remains low. Most south-eastern counties present a lower than average coverage.

Specific Programmes and Services
HIV/AIDS

The first case of HIV/AIDS in Liberia – a female trader – was diagnosed in 1986, in Zorzor, Lofa county in the north-west of Liberia. This event prompted the Government of Liberia to establish the National AIDS and STI Control Programme as an umbrella organization within the Ministry of Health and Social Welfare with the mandate to prevent and control the spread of HIV/AIDS in Liberia. Barely 2 years after its formation, the Liberian civil crisis unfolded. Little was achieved up to 2004, because the database was destroyed during the civil hostilities.

The National AIDS and STI Control Programme is responsible for coordinating and monitoring the provision of quality care and treatment and support services for people affected and infected with HIV and AIDS in Liberia. The major objectives of the programme include:

  • preventing new infection in the general population and preventing mother-to-child transmission
  • providing quality care to those affected and infected by HIV/AIDS
  • mitigating the impact caused by HIV/AIDS.
Tuberculosis

In Liberia, the notification of tuberculosis (TB) trend has shown a steady rise over the years, increasing from 1771 cases of all forms of TB being reported in 2001 to 5402 cases in 2011 (see Table 1). The increased detection rate can be attributed to the expansion of TB services to all parts of the country and an improvement in the capacity of the health system to diagnose and report cases.

The TB new case detection rate is gradually increasing, although there have been fluctuations between 2006 and 2008 (see Figure 1). The case detection rate for 2008 was 61%, compared with 71% in 2010. This figure is above the WHO recommended target of 70%. However, sustaining and increasing access is still a great challenge.

The TB treatment success rate (total number of patients who completed TB treatment and were declared cured) has shown remarkable improvement, increasing from 67% in 2008 to 82% in 2010 (see Figure 2). Factors associated with the increased treatment success rate include encouraging patients to continue treatment and dismissing myths associated with the disease.

Malaria

Malaria remains the leading cause of morbidity and mortality in Liberia, with 38% of outpatient attendance and 42% of inpatient deaths attributable to malaria.[4] However, malaria prevalence in children aged under 5 years has been significantly reduced from 66% to 32% since 2005.[5]

In 2010, out of a total curative consultation of 3 132 073, malaria contributed 1 265 268 cases. It also accounted for 40.4% of total outpatient consultations (Table 1), which is an increase from 38% in 2009.[6]

Immunization and vaccines development

Since its inception, the Expanded Programme on Immunization in Liberia has led to a gradual increase in annual diphtheria–tetanus–pertussis (DPT) immunization coverage from a woeful 6% in 1997 to 42% in 2000. In 2000 and 2001, an attempt was made to improve the immunization coverage and Liberia received an award as best performing country in the WHO African Region, despite operational difficulties from the Task Force on Immunization in Africa.

However, the gains could not be consolidated in the country and coverage dropped by 50% to 31% in 2004 from 61% in 2001. The period from 2001 to 2005 saw fluctuations in DPT coverage from a low of 34% in 2003 to a peak of 87% in 2005.

The decline in coverage values was due to insecurity and consequently limited access to communities following the intermittent conflicts during this period, especially from 2002 to 2004. Higher coverage figures from 2005 to 2008 were achieved partly through intense supplementary immunization activities (county and nationwide outreaches).

Child and adolescent health

By the age of 15 years, approximately 11% of Liberian girls become pregnant and by the age of 19 years, 62% are pregnant.[5] A total of 26% of adolescent pregnancies are unintended, while 30% of pregnancies among adolescents end in unsafe abortions.[7]

Adolescents are more likely to engage in unprotected sex, which can result in pregnancy or sexually transmitted infections, including HIV. School attendance by girls is still lower than for boys and dropout rates are higher for girls. This directly affects their reproductive health decision-making, such as the use of various family planning methods and ability to negotiate safe sex.[5]

Maternal and newborn health

Contraceptive prevalence in Liberia is low with an 11% utilization rate for any method of contraception (including modern and traditional methods) and an unmet need of 36%.[8] Factors contributing to low utilization include cultural beliefs, poor access to health services and low male involvement in family planning.

An antenatal sentinel surveillance survey conducted in 2008 showed an HIV prevalence rate of 4% among pregnant women attending antenatal care in Liberia. As of 2011, the Ministry of Health and Social Welfare has scaled-up HIV and AIDS service delivery points to 194 HIV counselling and testing sites, 230 prevention of mother-to-child transmission sites and 34 HIV care and treatment sites. Antiretroviral therapy coverage among HIV-positive persons eligible for antiretroviral therapy increased to 41% as of December 2010.[2]

Gender and women's health

The health care that a mother receives during pregnancy, at the time of delivery and soon after delivery is important for the survival and well-being of both the mother and her child. Maternal and childhood mortality are critical development and health indicators that determine a country’s progress towards the achievement of Millennium Development Goal 4 and Millennium Development Goal 5.

Young girls in the age group 10–18 years and single women are especially vulnerable and live uncertain lives. They have little access to and control of economic resources, have a poor sexual and reproductive health status, and their interests and opinions are rarely represented at the local level.

Epidemic and pandemic-prone diseases

Disease epidemics are fuelled by factors common to developing countries such as displacement, environment mismanagement and frequent exposure to risk factors. Epidemic diseases have a significant impact on an already weak health system and, if not controlled, can spread quickly across borders.

Liberia has established a mechanism for early detection, confirmation, characterization and prompt information exchange through:

The Ministry of Health and Social Welfare has established a weekly and monthly surveillance reporting system on diseases of epidemic potential to provide prompt early warning, investigation, preparedness and response. These diseases include acute flaccid paralysis, measles, acute watery diarrhoea (possibly cholera), bloody diarrhoea, meningitis, neonatal tetanus, H1N1 virus, rabies, yellow fever, haemorrhagic fever (Lassa fever), severe acute respiratory distress syndrome and guinea-worm disease.

Neglected tropical diseases

Onchocerciasis
Onchocerciasis is prevalent in 14 out of 15 counties in Liberia, with more than 1.1 million Liberians at risk. The Essential Package of Health Services will utilize the existing community-directed treatment with ivermectin approach for annual mass drug administration by community health volunteers.[1]

Lymphatic filariasis
Lymphatic filariasis is prevalent in 13 out of 15 counties (Immuno-Chromatic Test Survey, 2010).[1] The community-directed treatment with ivermectin strategy will be utilized to administer annual mass drug administration of albendazole and ivermectin to the target population in 13 counties. Elimination is targeted for 2020.[1]

Schistosomiasis
Schistosomiasis has a prevalence of 20% or greater in Bong, Lofa and Nimba. In endemic communities, with prevalence rates above 50%, mass drug administration with praziquantel will target all resident children ≥5 years old.[1]

Non-communicable diseases and conditions

The prevalence of blindness in Liberia is estimated at 1%, with an estimated total of 35 000 blind people. Cataract is the major cause of blindness in Liberia, with an estimated backlog of 17 500 people or 50% of the total blind population. An additionally 3% of the total population (10 500 people) suffers from visual impairment (WHO 2002 figures).

Owing to the high burden of morbidity caused by blindness and its bidirectional link to poverty, the Ministry of Health and Social Welfare is committed to working with new and existing partners to ensure that eye health services are integrated into all county health systems, including school health services.

Key Determinants
Risk factors for health

Alcohol consumption
Alcohol use has health and social consequences for those who drink, for those around them, and for the nation as a whole. Alcohol-related deaths occur from cancer, cirrhosis of the liver, pancreatitis, motor vehicle accidents, falls, drowning, suicide and homicide. The Liberia STEPS survey 2011 recorded 24% of current consumers of alcohol among respondents and 63.2% lifetime abstainers.[1]

Tobacco use
Tobacco use and smoking are dangerous addictions that commonly cause a wide variety of diseases, cancer and death. The Liberia demographic and health survey, 2007 revealed that only 2% of women said they use tobacco of any kind and only 1% said they smoke cigarettes. Twenty per cent of men use tobacco products, with 15% saying that they smoke cigarettes.[9] Also, results from the 2011 STEPS survey showed that 9.9% of sampled adults are current smokers, of which 17.2% are men and 2.8% are women.[1]

The physical environment

Liberia encompasses 43% of the Upper Guinea Forest. The annual consumption of woody biomass is estimated to be 10.8 million tonnes for fire wood and 36 500 tonnes for charcoal. The current rate of deforestation is 0.6%, which has resulted in 42.7% loss of forest cover. Shifting cultivation, timber exploitation, poverty, population pressures, coastal erosion, monoculture plantation, poaching and hunting, and lack of land use planning are threatening forest resources. United Nations' experts predict that, without appropriate regulation and deterrents, achievement of 41.2% forest cover will be unattainable in 2015.

Generally, a good environment offers an opportunity for economic growth, development and better health conditions, while a poor environment exposes household members, especially children, to infectious diseases that cause illnesses such as diarrhoea and cholera and leads to mortality.

Food safety and nutrition

In Liberia, agriculture, including fisheries and forestry, represents 61.5% of gross domestic product and provides the primary source of income and employment for many people. Food insecurity was heightened during the civil conflicts, reducing nutritional levels in children and resulting in low weight-to-height ratios.

Food insecurity’s lingering effects are reflected in the sampling of opinions in the country. In 2006, more than 40% of the population was highly vulnerable to food insecurity.[10] According to the Ministry of Agriculture, imported rice accounted for 42% of consumption in 2007–2008. Since rice is the nation’s staple, its exposure to the volatility of international commodity markets is undesirable.

Social determinants

According to the National population and housing census, 2008 Liberia’s population is estimated at 3 476 608 persons, with an annual growth rate of 2.1%. The overall sex ratio (males per 100 females) in the population is 100.2, which means an almost even distribution of the population between males (1 739 945) and females (1 736 663). Average household size is around 5.1 persons. There are indications of increasing urbanization, which is a challenging environmental health issue.[1]

In 2008, the national population density was 93 persons per square mile, ranging from as high as 1540 for Montserrado to as low 22 for Gbarpolu. There were 17 major ethnic affiliations. Most Liberians (86%) identified themselves as Christian, while Muslims made up 12.2% and “Other” made up 2.2%. Nationally, 47% of the population lives in urban areas.[1]



References
  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2008 National population and housing census: preliminary results (pdf 680.08kb). Monrovia, Liberia Institute of Statistics and Geo-Information Services (LISGIS), 2008
  2. 2.0 2.1 Annual report. Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2011
  3. The state of food and nutrition insecurity in Liberia. Comprehensive food security and nutrition survey 2010 (2.93Mb). Monrovia, Government of Liberia, Ministry of Agriculture, and World Food Programme, 2010
  4. Liberia health facility survey, 2009. Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2009
  5. 5.0 5.1 5.2 Liberia malaria indicator survey, 2009 (pdf 1.04Mb). Monrovia, Government of Liberia, Ministry of Health and Social Welfare and Liberia Institute of Statistics and Geo-Information Services; and ICF Macro, Calverton, Maryland, 2009
  6. Annual report. Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2010]
  7. The essential package of health services. Primary care: the community health system. Phase one (pdf 394.62kb). Monrovia, Government of Liberia, Ministry of health and Social welfare, 2011
  8. Liberia demographic and health survey 2007 (pdf 2.5Mb). Monrovia, Liberia Institute of Statistics and Geo-Information Services, Ministry of Health and Social Welfare National AIDS Control Program and Macro International, 2008
  9. Liberia demographic and health survey, 2007 (pdf 2.5Mb). Monrovia, Liberia Institute of Statistics and Geo-Information Services, Ministry of Health and Social Welfare and National AIDS Control Program, and Macro International, 2008
  10. Comprehensive food security and nutrition survey. Strengthening emergency needs assessment capacity (pdf 1.54Mb). Monrovia, Government of Liberia, Ministry of Agriculture, and World Food Programme, 2006