Sector Scan The Medical Sector in Liberia

August 2018

Eline Terneusen Liberia Netherlands Business and Culture Council

Liberia Netherlands Business and Culture Council

The Liberia Netherlands Business and Culture Council (LNBCC) is an organization that represents

the business interests of both Liberian and Dutch companies. The LNBCC has been active in the

capital - Monrovia - since 2016, and is an extension of the Ghana Netherlands Business and Culture

Council (GNBCC). Both organizations work closely together with the Embassy of the Kingdom of

the Netherlands in Ghana.

The LNBCC’s core business is the promotion and fostering of trade relations between Liberia and

the Netherlands, under the mantra of ‘growing together’. Currently two employees - Theo Dennis

and Eline Terneusen - are working together in developing a membership base, producing sector

scans on subsections of the economy and organizing net- working events.

Besides those core activities, the LNBCC offers services to both members and non-members in the

following areas:

• Business development services: the LNBCC executes market studies for businesses wanting

to extend their services to Liberia. Company profiling and company visits can be set with

possible local partners. The LNBCC can also represent organizations locally. With

researchers on board with extensive experience in qualitative research methods, the LNBCC

can provide local and context specific information on a wide variety of topics.

• Business support services: The LNBCC provides advice on financial constructions,

accounting, bookkeeping, registering processes in Liberia, manners to get subsidies for

business models and trainings for accountants.

• Travel support services: LNBCC can negotiate prices for / provide car rentals, hotel

bookings, visa and immigration requirements.

• Trade mission & event services: Through our network we bring together authorities, experts

and entrepreneurs. The LNBCC organizes events such as plenary sessions, workshops,

trainings and meet & greets by taking on the event planning and management.

�1

Table of Contents

Ch.1 Executive Summary 3 Ch. 2 Acronyms 4Ch. 3 Liberian Context 6 Ch. 4 Country Overview 8 Ch. 5 The Medical Sector 9 Ch. 6 Opportunities 15 - E-Health and Information Systems 16 - Technological Developments 19 - Other Opportunities 20 Ch. 7 Sector Constraints 22 Ch. 8 Policy Framework 24 Ch. 9 Institutional Framework 26

Annex I WHO Liberia Health Statistics

�2

Chapter 1 | Executive summary

Liberia’s medical sector suffered greatly under the consecutive blows of a 14 year civil war and an

Ebola epidemic. Currently the sector has limited spending capability and lack of regulations. While

the government has committed to providing cheap primary health care, its services are hampered by

wide spread inefficiencies due to capacity limitations and corruption.

There is space for the private sector to play a greater and more effective role in meeting demand,

filling capacity gaps and supporting the relation of public sector health policies and goals.

This sector scan provides background information on the Medical Sector in Liberia, going into

detail on opportunities for private sector actors, drawing on examples of current interventions. These opportunities include:

This scan also outlines some of the constraints faced by private companies attempting to create

revenue in the sector. Finally the policy- and institutional frameworks are mentioned.

Sub Sector Opportunity

E-Health - E-Health- Logistics Management Systems- Inveneo- Electronic Payment Systems

Technological Developments - Technology in Hospitals- Technology in Maternal and Child Healthcare

Other - Supply Chain Management- Health Financing- Human Resources

�3

Chapter 2 | List of Acronyms

AfT Agenda for Transformation

AGOA African Growth and Opportunity Act (

BPHS Basic Package of Health Services

CCP Johns Hopkins Center for Communication Programs

CDC Centers for Disease Control and Prevention

CHO County Health Officers

CHSD Community Health Services Division

CHV Community Health Volunteers

CMC County Mobilization Coordinators

DMC District Mobilization Coordinators

EBA EU - Everything but Arms

ECOWAS Economic Community of West African States EPHS Essential Package of Health Services

EPI Expanded Program on Immunization

EVD Ebola Virus Disease

FHD Family Health Division

GNBCC Ghana Netherlands Business and Culture Council GoL Government of Liberia

HC-3 Health Communication, Capacity, and Collaborative

HPFP Health Promotion Focal Persons IDSR Integrated Disease Surveillance and Response IHR International Health Regulations

LDHS Liberia Demographic and Health Survey

LNBCC Liberia Netherlands Business and Culture Council MIGA Multilateral Guarantee Agency MoHSW Ministry of Health and Social Welfare

NAC National Aids Commission

NCD non-communicable diseases NDS National Drugs Services NEPAD New Partnership for Africa’s Development

�4

NGO Non-Governmental Organization NHP National Health Policy

NHPD National Health Promotion Division NHSWPP National Health and Social Welfare Policy

NPSPHP National Policy and Strategic Plan on Health Promotion

NTD neglected tropical diseases

PACS Partnership for Advancing Community Based Services PPP Public Private Partnership

PPU Policy and Planning Unit

UNFPA United National Population Fund

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

�5

Chapter 3 | The Liberian Context

Liberia is located in West Africa, and bordered by Sierra Leone, Guinea, Cote d’Ivoire and the

Atlantic Ocean. The country is geographically divided into 15 counties, Montserrado county being

the most densely populated. This is also the county where Monrovia, the capital city is located.

Liberia continues to rank low on the Human Development Index and is considered a low-income

county. However, Gross domestic product (GDP) growth in 2017 was estimated at 2.5% compared

to a deceleration of 1.6% in 2016 and zero percent growth in 2015 . 1

With 16 languages spoken across 15 counties, Liberia was declared a nation in 1847 by freed and

freeborn black Americans who had arrived at its shores 26 years earlier. Between the 50s and 70s

Liberia was a pillar of strength as many African nations were moving away from colonialism and in

1959 hosted the inception meeting of what is now called the African Union. With strong ties to the

United States, the biggest rubber plantation in the world, and an abundance of minerals Liberia was

wealthy and stable for decades.

Since peace ensued in Liberia in 2003, the Liberian economy has again been viewed with optimism

as aid-driven recovery and growth started shifting into private sector driven growth. In 2005,

Liberia had $82 million in Foreign Direct Investments, and by 2013 this figure had risen

significantly to $700m, peaking in 2011 to $1.3 billion. Most of these investments were from

mining, oil palm and forestry, where $16 billion worth of agreements were signed. Harnessing this

private sector potential has become a priority for the Liberian government, which was aiming to

narrow the gap of growth and revenue between large (foreign) corporations and small local

businesses.

The 2014 outbreak of the Ebola Virus Disease (EVD) slowed down the economic recovery

significantly. The World Bank estimated a decrease of 11.7% of the country’s GDP in 2014.

Research showed 10% of businesses closed in relation to the crisis and overall employment

decreased by 33%. However, the same research also showed businesses’ optimism that employment

and revenues would increase within the next 6 months.

World Bank. Liberia Overview (2017). Retrieved from: https://www.worldbank.org/en/country/liberia/1

overview

�6

EVD posed the most daunting threat to the momentum Liberia’s economic growth since the civil

wars. However, the growth of the marketplace in both diversity and capability in the preceding ten

years provides a solid ground for the economy to - with the right support - bounce back. Liberia’s

current Agenda for Transformation (AfT) strategy holds as priority broad-based economic growth

and employment creation.

�7

Chapter 4 | County Overview

Bordering countries: Sierra Leone, Guinea, Cote d’Ivoire Land size: 111,369 kmTotal population 4,614,0002

Literacy rate: 42.9% Life expectancy at birth (m/f) 62/64 3

Poverty rate: 96.9% Urban population: 48% GINI Index: 38.2 GDP: 2.1 billion US Dollars Probability of dying between 15 and 60 years (m/f) 249/212 4

Total expenditure on health per capita $985

Total expenditure on health as % of GDP 106

Inflation rate: 11.50% Unemployment rate: 3.8% Road Network: 6.2% Access to Electricity: 2% Mobile penetration: 75% Internet penetration: 21% Trade and Economic Memberships: ECOWAS

Mano River Union African Growth and Opportunity Act (AGOA) EU - Everything but Arms (EBA) China Preferential Trade Agreement with Developing Counties Multilateral Guarantee Agency (MIGA) New Partnership for Africa’s Development (NEPAD)

In 2016. World Health Organization. Retrieved from: http://www.who.int/countries/lbr/en/2

In 2016. World Health Organization. Retrieved from: http://www.who.int/countries/lbr/en/3

per 1,000 population in 2016. World Health Organization. Retrieved from: http://www.who.int/4

countries/lbr/en/

In 2014. World Health Organization. Retrieved from: http://www.who.int/countries/sle/en/5

In 2014. World Health Organization. Retrieved from: http://www.who.int/countries/sle/en/6

�8

Chapter 5 | The Medical Sector

Before the outbreak of the civil war, Liberia has 550 health facilities, after the conflict only 354

remained functioning. The facilities and health workers were concentrated in the capital city. In an 7

effort to rebuild the health system, the Government of Liberia (GoL) created the National Health

Policy (NHP) 2007-2011 . 8

The Liberian government aims to enable individuals, families and communities to take control of

their health and improve and maintain health outcomes. This surpasses primary secondary

preventive programs. The GoL emphasized these targets when signing the Health Promotion

Strategy for the African Region in 2013. This policy included a public-private partnership (PPP)

model that formalized the Ministry of Health and Social Welfare (MoHSW) to contract NGOs

through a pool fund to deliver a Basic Package of Health Services (BPHS) while at the same time

allowing the MoHSW to take ownership of, oversee and align funding to the health sector. This

would aid the transition from reliance on humanitarian aid to development.

Gains in improving the health status of people, specifically maternal and child health were

registered since cessation of the civil conflict.

In its recovery from 14 years on civil conflict, Liberia was making health gains, showing

improvements in a number of indicators in the 2013 Liberia Demographic and Health Survey

(LDHS), compared to the results of 2005. The Basic Package of Health Services (BPHS) defined

health services to be delivered at all levels.

The current National Health and Social Welfare Policy (NHSWPP) 2011-2021 builds on the BPHS 9

through the Essential Package of Health Services (EPHS), which expands service to secondary and

Lee PT, Kruse GR, Chan BT, Massaquoi MBF, Panjabi RR, Dahn BT, et al. An analysis of Liberia’s 2007 7

national health policy: lessons for health systems strengthening and chronic disease care in poor, post–conflict countries. Global Health. 2011.

Ministry of Health: National Health Policy and Health Plan 2007-2011. Retrieved from: http://moh.gov.lr/8

national-health-policy-and-health-plan-2007-2011/

National Planning Cycles. National Health and Social Welfare Policy 2011-2021. Retrieved from: http://9

www.nationalplanningcycles.org/sites/default/files/country_docs/Liberia/ndp_liberia.pdf�9

tertiary care. The pool funding mechanism was also extended under this policy. Even as health

objectives are achieved, reliance on foreign aid is persistent and enshrined in policy language.

Significant gains were dismantled due to the outbreak of Ebola in 2014/2015.

The Ebola Virus Disease (EVD) outbreak in 2014 grossly affected the social and economic lives of

the people of Liberia. The effects directly affected people through illness (over 9,000 cases) or

death (4,408 deaths). Of the deceased, 184 persons were health workers. Many experienced an

inability to access health services, while at the same time seeing their incomes drop due to a

slowdown of the economy.

The EVD outbreak laid bare the weakness of the health system in Liberia, a system which was

already strained - and had failed to effectively intervene in - other communicable and neglected

tropical diseases. Tropical diseases and conditions that stem from the social determinants of health.

The WHO recognizes that major causes of health inequities arise from the conditions in which

people are born, grow, live, work and age. Liberia was ranked 177 out of 188 on the Human

Development Index in 2017 , which scores counties based on factors such as life expectancy, years 10

of schooling and income levels. Factors that prescribe the social determinants on which health is

hinged. These social determinants are therefore significant and must be addressed to promote good

health. For this reason developing the health sector asks for a multi-sectoral and multi-stakeholder

collaboration in Liberia.

In the aftermath of the health crisis the MoHSW and its partners developed a Post Ebola Investment

Plan prioritizing three investment areas:

1. Build a fit-for-purpose productive and motivated health workforce that equitable and optimally

delivers quality services

2. Reengineer the health infrastructure to conform to the population’s needs for health services

‘Human Development Index and its Components’ (2017), retrieved from: http://hdr.undp.org/en/10

composite/HDI

�10

3. Strengthen epidemic preparedness, surveillance and response, including the expansion of the

established surveillant and early warning response system to ensure it is comprehensive enough

to detect and respond to future threats.

The purpose of the plan was to regain the population’s trust in the health system, improve the

demand for health services and reduce the risk of epidemics. The government wants to progress

towards universal health coverage. Currently, the sector is facing some significant challenges:

- Liberia still struggles with communicable, non-communicable diseases (NCD), neglected tropical

diseases (NTD’s) and other emerging and re emerging diseases.

- These diseases perpetuate partially due to a lack of sufficient skilled and non-skilled health

professionals. Particularly in the areas of service delivery and health promotion.

- There has been a significant reliance on information dissemination to create awareness instead of

strategies, sociocultural and behavioral change interventions.

- Finally, there are inadequate resources for health promotion activities across the spectrum of

health interventions.

Health promotion played a crucial role through advocacy, public education, social mobilization,

community engagement and stakeholder coordination to fight the EVD outbreak . 11

Currently, the MoHSW fails to optimize its resources and the health system suffered from a lack of

institutional capacity and systemic weaknesses. For these reasons the system does not deliver

services in which the population has confidence . Prior distrust was only exacerbated by the EVD 12

outbreak. As a result, unregulated private sector healthcare provision dominates the sector, as they

respond more effectively.

Over 50% of health spending in Liberia is covered by household out-of-pocket expenditure . The 13

health sector is a marketplace. The government should ensure quality, but it is equally critical that

R. Gladstone (2015) ‘Liberian Leader Concedes Errors in Response to Ebola’, The New York Times, 11 11

March, http://www.nytimes.com/2015/03/12/world/africa/ liberian-leader-concedes-errors-inresponse-to-ebola.html?_r=0

Svornos Theodore, Rose Macauley and Margaret Kruk. Can the health system deliver? Determinants of 12

rural Liberians’ confidence in health care. Oxford University Press, 2014.

Ministry of Health. Health Sector Assessment Report, 2015.13

�11

health care satisfies demand. Although the GoL has increased spending on health from 11% of GDP

to 12.39%, it has yet to meet the Abuja target of allocating 15% of GDP to the health sector in order

to accelerate efforts towards improved health outcomes.

Table: % of Government of Liberia Expenditure on Health 14

The Role of the Private Sector

The private health sector consists of two main actors: the private non-profit subsection and the

private for-profit subsector. The non-profit sector is much larger and better organized then the for-

profit sector. Combined, the non-profit private sector provides 47% of the healthcare in the country,

while the private for-profit sector provides less than 30%.

Local and international businesses that seek to generate profit from providing health sector services

make up the for-profit health care sector in Liberia. These entities are currently limited to retail,

wholesale pharmaceuticals and basic diagnostics. There is a significant lack of survey data on

private health care.

Health Assessment Report, 2015.14

�12

Figure 1: Structure of the Private Health Sector in Liberia

Working through the MoHSW

80-85% of the medical sector is donor funded. Primarily by the US, who are slashing their budgets

at the end of 2019, meaning the funds of the Ministry are in jeopardy. The Ministry does have a

strong hand in donors coming in. No health donors can simply come in and work.

It is also important for private actors coming in to the country to link with present national

institutions, instead of attempting to do things entirely separately. This helps to strengthen the

system through instead of just implementing separately. This will benefit the costumer but also

benefit the companies as the government can take actions to facilitate them. The government

institutions also have all the health data, which are valuable to companies wanting to enter the

sector.

�13

Definition of Medical Sector

The title of this sector scan is ‘Medical Sector’ and has been chosen instead of health sector or

healthcare sector.

According to the United Nations Standard Industrial Classification the healthcare sector is defined

as the following:

1. Hospital activities

2. Medical and dental practice activities

3. “Other human health activities”

Allied health professions including yoga, homeotherapy, acupuncture and others fall under the third

class. This sector scan will not include these activities. Some activities within this class however,

such as scientific research or diagnostic laboratories, are relevant. Hence, the term Medical Sector

now loosely refers to the first two classes with an addition of medical research. The terms medical

sector and health sector will be used interchangeably, as many policies refer to the health sector.

�14

Chapter 6 | Opportunities

Since the government controls primary health care delivery in Liberia along with subsidized NGO

services, private enterprises have a more strategic opportunity tot enter the market for ancillary

health activities. There is opportunity for investment in telemedicine, social marketing, diagnostics

services, clinical laboratory and the sale of medical technology and supplies.

The challenge for private sector entry into this market is two-fold: there is a significant barrier to

affordable financing for private investors, and there is a high cost of operation in Liberia. Large

donors such as USAID, IFC and World Bank have expressed interest in supporting private

investment in the medical sector to increase accessibility.

There is significant demand for ancillary and specialized health care services. Urban consumers in

particular are demanding specialized health care. consumers at the moment are traveling to the US,

Ghana and Cote d’Ivoire to access these services. The private sector could meet this demand in

Liberia.

Opportunities in ancillary health care that provide technological advances and/or use digital

solutions were identified as being high-potential opportunities.

�15

E-Health and Information Systems

Before the EVD crisis, the GoL was in the process of strengthening health information systems. The

decentralization of the ministry led to parallel and unconnected systems for managing health data,

meaning data is not properly shared across government bodies to ensure effective, meaningful and

targeted decision making.

In addition, the government does not have the capacity to analyze data at the county level between

hospitals and tiers that make up the structure of the health system . Patient information and registry 15

systems were all paper based, which contributed to the collapse of the healthcare system when put

under pressure during the EVD crisis.

E-Health E-Health in an NGO which was present in Liberia up until June 2018. It was the biggest player in

the e-health sector and was funded by post-Ebola donor money. When they first entered Liberia

post-Ebola, they searched for other institutions working in computer based solutions for the health

sector, and found none. It is an undersaturated sector while the need is extremely high . Most of the 16

health related NGOs were supported by EVD response money, most of these programs have now

shut down. The Ministry depends heavily on the support of the US Government, which has become

an unreliable donor recently and will be slashing its budgets after 2019. This is the time for e-health

solutions and the necessity is high and ever growing.

During its time in Liberia E-Health set up a Health Facility Registry which was linked on to the

MoHSW website. If a persons needs to find a health facility, the registry would allow them to find

the closest clinic, which services they provide and their contact information. Besides supporting

patients, this allows the Ministry to track where the health facilities are located. Post-Ebola clinics

and facilities opened throughout the country without the knowledge of the Ministry, who are tasked

with facilitating their access to medication.

Building Markets. ‘Liberia Health’ (2016). Retrieved from: http://aeiglobal.com/PDFs/15Health_Sector_Scan_Building_Markets_v4.pdf

Information gathered from a former E-Health employee.16

�16

Logistics Management Systems The MoHSW has, since 2015, been pushing to digitalize patient records. They have also been

looking to build a logistics management system to deliver medication and track the dispensation of

medication. The ultimate goal was to set up a Logistics Management System that could link to the

Health Facility Registry which was developed by E-Health. This was facilities would be able to

alert the Ministry when medication was running low.

The push in government for creating more data systems is part of a 5 year roadmap (which goes

until 2020). Logistics management and supply chain management are at its core. MoHSW does not

actively seek out companies. For urgent needs they look at what current partners can offer them.

Also, businesses can approach them with ideas. These ideas are then moved along to a technical

working group facilitated by the Ministry. These technical working groups then figure out how

these ideas can interplay with the current healthcare system.

A private company came in and built a logistics management system, but it was poorly done. The

main problem being that they had developed a closed source technology, meaning it could not be

integrated with the Health Facility Registry system. The solution was not effective, not what the

Ministry needed and did not play well with other systems. There is an urgent need for a company to

come in and redo this. The MoHSW is not actively looking for a company to do so, but they are

always open to proposals from private sector actors.

Inveneo The sector is heavily dominated by NGOs, but there are some revenue creating private sector

companies active. One of them is Inveneo. The initially came into the country on a USAID grant,

and have now moved on to setting up a revenue generating model.

They are working together with the MoHSW, the Ministry of Education as well as Lonestar and

Orange; both network providers and two of the largest corporations in Liberia. The project is

focussed on rural connectivity. With some leftover government funds from the Ebola crisis, they are

upgrading labs and health facilities out in the counties. Inveneo invests in the sites themselves and

involves the cellular phone companies to provide the connectivity. The solutions need at least 3G

connectivity.

�17

One of the major focusses is to develop disease surveillance systems. When cases of certain

infectious diseases come in in the counties, notifications are immediately sent to the Ministries. If

people are tested positive for these diseases the system can be used to send out warnings to other

health facilities. These facilities can then engage community health workers to mitigate the spread

and be prepared to treat more cases.

Electronic payment systems

When patients have health insurance, it is often difficult for them to claim back money as receipts,

faxes and emails get lost in the shuffle. Persons may also not have access to computers to fill in

claims. There was as idea circulating to pilot the use of mobile money to pay for scans. Setting up a

method to charge and pay for health services between insurance companies and clinics / hospitals

would greatly improve patients abilities to pay for health services.

Cellular providers are already working together with Inveneo on developing digital healthcare

solutions. Orange Liberia also has set up a scheme with the government to make paying taxes with

mobile money possible. Relations are there and similar structures are in place. To apply these

solutions to the health sector as well would be a great need fulfilled. As mentioned before, the

government is looking to shift towards tech systems.

�18

Technological Developments

Technology in Hospitals

There is no technology present in hospitals. There are no electronic records available. There is a

high need for:

- Imaging technology

- Modernization of health records

- Blood tracking systems

- X rays

- Labs

- MRI’s

If a company could provide cheap reliable labs they would be able to make a profit. Currently

hospitals, or the adjoining labs charge anywhere from $10-50 for a single lab, so patients and

families do not get them done. If they charges a more reasonable $5 then more people would make

use of the services. EKGs also charge around $50, which should be more around $5.

Technology in Maternal and Child Health:

The same issues of high prices surround pregnancy ultrasounds. Every women should get one at 20

weeks, but they are too expensive so hardly anybody does. These medical tests could be profitable

if companies focussed on volume rather than simply setting high initial prices.

The maternal mortality ratio continues to be one of the highest in the world. Some gains have been

made in decreasing maternal deaths. In the LDHS 2013, it was indicated that Liberia’s maternal

mortality ratio decreased from 1,100/100,000 in 2005 to 994/100,000 in 2012. After the outbreak of

ebola it bounced back to 1,072/100,000.

Electronic record keeping is extremely important for maternal health services. There are currently

no digital records kept of patients, while many women of child bearing age return to the same

clinics and hospitals. This reduces the opportunity for medical professionals to take a patients

medical history into account when treating them, especially if women have had complicated births

in the past. �19

Other Opportunities

Supply Chain Management

A broad range of investment opportunities exist across al components of the medical sector in

Liberia, and medical supply chain management is one of the most pressing needs. There are often

drug shortages. Outsourcing medical supply chain management on private firms can help bolster the

availability of drugs, medical equipment and other medical supplies.

It is expected that integrating the private sector in medical supply chain management will improve

delivery efficiency and ease the burden of public provision of drugs and equipment . Particularly in 17

the rural areas of the country. Several key informants indicated that the government is now

considering contracting out its procurement of medicine and medical supplies to private firms.

Health Financing

It is not possible for the GoL to fund all, or even the majority of, health expenditure. Private sector

investment in health infrastructure and service delivery can create a more efficient and innovative

health system. If private businesses are simultaneously given space to make profitable investments

and are effectively monitored by the GoL to meet contractual obligations, there is an opportunity to

provide regulated and more affordable heath care.

Human Resources The public health sector faces a shortage of qualified health workers throughout the county. Low

pay causes an absence of staff motivation, an unequal distribution of the health workforce, poor

performance, ambiguity of functions and lack of accountability.

The country lacks specialists. In the rural areas here is a general lack of trained health professionals.

Doctors often shift to the more lucrative private sector, it is a challenge for many to find alternative

employment as health practitioners since the government is the only employer. This leads to a cycle

of low performance and negative attitudes. A government monopoly on potential hires only deepens

the cycle and encourages people to sometimes seek employment while remaining on government

Building Markets. Liberia Health (2016). Retrieved from: http://aeiglobal.com/PDFs/17

Health_Sector_Scan_Building_Markets_v4.pdf�20

payroll. The existence of a robust private sector may lead to better job satisfaction as the

government begins to compete for human resources.

There is a high need for work force development and capacity building. Internships and transfer of

skills programs are much needed.

�21

Chapter 7 | Sector Constraints

Limited spending capability, lack of regulations and monitoring, competition from subsidized

INGO and government services and a lack of local capacity are some of the challenge that are entry

barriers to private firms in Liberia’s medical sector.

Health Promotion Constraints

- Institutional: promotion has not been fully integrated into all divisions and programs that are

providing services within MoH. There is limited knowledge and appreciation of the value of

health promotion.

- Capacity: capacity gaps exist in advocacy, risk communication, knowledge management,

formative research and data analysis.

Drug and medical supply procurement

The National Drugs Services (NDS) is at this point in time not able to maintain an efficient drug

management system and experiences frequent stock outs, counterfeit drugs and offers only a narrow

supply of medical options. The NDS is wholly responsible for the procurement of medical supplies

for the public sector. There are numerous non-profits supporting the public sector, they are all

required to use the government procurement system to purchase medical supplies and drugs.

Bureaucracy and corruption can severely delay the process of receiving supplies.

The for-profit sector faces challenges in increasing and improving the services that it is able to

provide. Absence of cooperation and coordination with the GoL hinders expansion plans. The

government’s mismanaged free primary health care services drives out professional private actors,

even as citizens end op paying for unregulated private services. The manager of a for-profit health

outlet explained the challenges that hinder the company’s ability to provide high-quality health care:

“We currently face constraints with the importation of equipment and supplies. Right now, our CT

scan machine, in addition to other medical equipment, is held up at the airport because of custom

regulations, and that has limited us to the use of just one…Also, there is a lack of willingness from

the GoL to subsidize private health providers. I mean, not financial subsidy, but at least some kind

�22

of break would be welcome. If we have breaks on the importation of medical equipment, for

example, it would boost our plan to expand in other parts of the country. ” 18

Dutch companies working in the medial sector in Liberia emphasized the following points:

- The importance of connecting and working with the MoHSW for information and access

- Do not assume different branches of government you work with are fully informed about each

others’ activities

- Complex collaborative structures in which the government is involved financially can be difficult

to carry out due to the government’s budget constraints

- Interventions should be practical, simple and small scale

Building Markets. Liberia Health (2016). Retrieved from: http://aeiglobal.com/PDFs/18

Health_Sector_Scan_Building_Markets_v4.pdf�23

Chapter 8 | Policy Framework

In 2011 the government developed the National Health Promotion Policy , which supports the 19

goals set forth in the National Health and Social Welfare Policy and Plan (2011-2021) as well 20

as the Investment Investment Plan for Building a Resilient Health System in Liberia 21

(2015-2021)

Other policies include:

MOH Recovery Plan (2014-2015)

Ministry of Health Consolidated Work Plan (2016/2017)

Read: http://moh.gov.lr/wp-content/uploads/2017/04/Operational-Plan_FY-17_-martin.pdf

Mental health Policy and Strategic Plan for Liberia (2016/2021)

Read: https://www.mindbank.info/item/6397

WHO Health Promotion Strategy for the African Region (2013)

Government of Liberia is a signatory and has demonstrated commitment to the promotion of health.

Read: https://www.afro.who.int/publications/health-promotion-strategy-african-region

Integrated Disease Surveillance and Response (IDSR)/ International Health Regulations

(IHR) Strategic Plan (2016-2020)

Read: http://www.wahooas.org/IMG/pdf/VERSION_ANGLAISE_CORRIGEE.pdf

National Policy and Strategic Plan on Health Promotion (NPSPHP) 2016-2021

Read: https://www.afro.who.int/publications/national-policy-and-strategic-plan-health-promotion-

liberia-2016-2021

Read full document: http://liberiamohsw.org/Policies%20&%20Plans/19

National%20Health%20Promotion%20Policy.pdf

Read full document: http://moh.gov.lr/wp-content/uploads/2017/03/2011-2021-National-20Health-Policy-Plan_MOH.pdf

Read full document: https://au.int/sites/default/files/newsevents/workingdocuments/27027-wd-21

liberia-_investment_plan_for_building_a_resilient_health_system.pdf�24

Post Ebola Investment Plan 2015-2021

Developed by the MoHSW and its partners. Aims to build a resilient health system which endeavors

to restore the gains lost due to the EVD crisis and provide health and security for the people of

Liberia.

�25

Chapter 9 | Institutional Framework

The Government of Liberia is responsible for the primary healthcare of the county’s citizens. The

Ministry of Health and Social Welfare is a large governmental body containing the following

subdivisions:

Policy and Planning Unit (PPU)

Community Health Services Division (CHSD)

Family Health Division (FHD)

Expanded Program on Immunization (EPI)

County Health Officers (CHOs)

National Aids Commission (NAC)

National Health Promotion Division (NHPD) coordinates the implementation of health promotion

in collaboration with partners in Liberia. It is headed by a Director and supported by an Assistant

Director. At the county level there is no dedicated staff to lead health promotion interventions.

There are County Health Teams in each of the 15 counties and those interested in health promotion

were provided with extra training and became Health Promotion Focal Persons (HPFPs) in those

counties.

County Mobilization Coordinators (CMCs) and District Mobilization Coordinators (DMCs) were

deployed by UNICEF during the ebola outbreak. They have remained playing a key role in

undertaking social mobilization activities in their assigned counties.

At the community level volunteers are selected to become Community Health Volunteers (CHVs),

they are trained by MoHSW, CHTs and Partners to be the frontline workers of health promotion.

National Drug Services (NDS):The National Drug Services is the agency the government agency wholly responsible for

procurement of medical supplies for the public sector.

Non-Governmental Actors:

- WHO-AFRO �26

- WHO Liberia :provides technical and financial support to facilitate the development process.

- Partnership for Advancing Community based Services (PACS)

- Health Communication, Capacity, and Collaborative (HC-3)

- Johns Hopkins Center for Communication Programs (CCP)

- United Nations Children’s Fund (UNICEF)

- Centers for Disease Control and Prevention (CDC)

- Mercy Corps

- United National Population Fund (UNFPA)

- United States Agency for International Development (USAID)

�27