New Directions In Public Policymaking In Liberia: Part II
By: Emmanuel Dolo, Ph. D.
The disparity between available resources and unattended needs, waste of resources through bureaucratic mismanagement, corruption, and cronyism only demand efficiency and effectiveness if equity is to be fostered. Another important value that informs public policy formulation and has been omitted from public policy practice in Liberia is “consensus.” Public participation is the crux of ownership and investment in national decisions. When the public feels marginalized, people reel and detach from the governance process. This creates a fertile ground for undemocratic insurgencies such as the ones that escalated into an epidemic in pre-war Liberia.
Part I also highlighted that dismayingly, “preventable infectious and parasitic diseases” are prominent causes of many deaths among Liberians. Also noted was that disparities in access to care among rural inhabitants and urban poor are major healthcare challenges. Underserved populations are on a rise. High rates of investments in military armaments and low expenditures on the healthcare sector were depicted as a skewed logic, which only produces continued insecurity.
Part II will serve two functions. First, it will make relatively in depth analysis of the issues presented in Part I. Second, it will formulate specific recommendations for systemic changes in the healthcare and social welfare sectors. Like Pick, (1999), this paper takes a broader view of national security and suggests that the restricted military conception of national security is not autonomous from the healthcare sector. Given the scarcity of resources devoted to healthcare expenditures, and the resulting poor health of citizens, coupled with the gloomy economic prospects, national security remains at enormous risk. The psychosocial tolls of a growing insurgency ethos and depletion of financial resources through fraudulent practices and bureaucratic inefficiencies only exacerbate the problem.
Post-Conflict Healthcare and Social Policies
The remaking or reorientation of healthcare and social policies in post-conflict Liberia would have to consider the traumatic effects of the 14 years of war. The war has left numerous policy challenges and I have named them metaphorically as “dark valleys.” These “dark valleys” have been made ominous by the fact that they present multifaceted challenges in the arenas of politics, social well being, economics, and national security. Moreover, these problems have not been examined sufficiently in the past for varied reasons such as lack of interest or knowledge. Left unattended, each challenge reinforces the other and degenerates the crisis, and plunges the nation to new depths of despair. The public policy interventions that we create in response to these problems can no longer be outmoded as the previous fragmented sectoral strategy. Our solutions have to be multi-pronged, employed concurrently on a continuum, and with allowances for evaluating progress continuously to close silos, and prevent and/or repair reversals.
Post-conflict public policies cannot be simplistic political slogans, because as history has taught us, slogans tend to die with the political lives of those who make such utterances: Presidents William V. S. Tubman, William R. Tolbert, Samuel K. Doe, and Charles G. Taylor, just to name a few. For policy agendas to make needed impacts on ingrained problems such as unremitting poverty, unemployment, widespread illiteracy, various medical epidemics, poor infrastructure, high death rates, etc, the basis of policy has to be rooted in tested knowledge, which is consciously and continually being improved. Answers reside in “demythologizing” some deeply-held beliefs about individuals and social groups (whether it is based on ethnic identity, gender, age cohort, etc). Post-conflict public policies must also be based on realistic scientific or applied assessments of the capacity of the country in variety of interconnected spheres: workforce capacity, the capacity of the labor market to satisfy demands, specific sectoral needs and their overlapping connections. As a part of such a reorganization scheme, government must provide the public clear and concise results of the assessment of its capacity and build valid benchmarks for measuring the success of public policy responses established in the form of programs. It is by showing evidence that government is capable of making visible progress that it would garner legitimacy and leverage the goodwill of citizens and foreign donors or interlockers.
Robust Economic Policy
A robust economy is the backdrop for healthy social welfare and healthcare policies and programs. Indeed, it is in integrating these sectors into a holistic and functioning institution that government would make its greatest contributions to stability and security. Relating healthcare and social policy to economic policy is not new, but being intentional and purposeful in making the connection and monitoring it for progress on an ongoing and consistent basis is probably new in the Liberian public policy arena.
The inability of rural sector inhabitants to be integrated into the formal economy has been another “dark valley” with a significant implication for moving forward in Liberia. This has come about due in part to discriminatory policies that have paid little or no attention to decaying physical infrastructure such as roads, schools, housing, and the lack of telecommunications and other important sources of modernity. This disintegration in physical infrastructure corresponds with decay in human capital of the rural communities. The vulnerability of young rural inhabitants to the rebel or insurgency movements and the scourge of drug and alcohol use/abuse among these youth, the mounting rates of teen pregnancy in these communities, coupled with under age marriages, and the chronic unemployment problem only deepen the social dissatisfaction.
It is hard to dispute that restoration of the hard hit communities, including rural areas and the poor urban areas will be inefficient, if an all-inclusive and systematic strategy that integrates these communities into the economic and social development milieu is lacking. Micro financing of agricultural projects, job readiness initiatives, the restoration of traditional social institutions, the incorporation of self-help projects and/or voluntary associations, non-governmental organizations, to establish the institutional base of these communities will go a long way in halting and reversing these disadvantages.
Building National Identity
One of the other major public policy “dark valleys” that Liberia faces in the post-conflict era is the question of national identity formulation in the midst of ethnic, class, religious, gender, and other sources of polarization. For example, gender, now used as a proxy for women’s needs is now a preoccupation of both researchers and practitioners working on policy issues. There is a greater recognition that men and women do not live in a “desexualized” context, and therefore, their needs cannot be viewed as seamless. Women’s worldviews, interests, and indicators of their well-being are all different than their male counterparts. Indeed, any viable public policy response that has to be developed must pay special attention to the social experiences of women. No longer can women’s experiences be extrapolated from that of men. The same can be said about children, youth, older adults, etc.
The principle of a cohesive political unit, namely, Liberia, where social groups recognize their interdependence and dependence on each other and the nation at large, manifested by patriotism has been recklessly harmed by past leaders and the undemocratic insurgency ethos made pervasive by the war. In effect, we have seen the growth of corruption and cronyism as cottage industries manufactured to further the interests of predators who only source of humanity is in being troughs that feed off of government. Such an exaggerated egotistical pursuit of self-interest at the expense of those in the weakest position to defend themselves and their loved ones has only created reasons for continued internal strife and a “loss” of policy direction to guide the society out of its macabre state of affairs (Dolo, 2006, forthcoming).
Marginality of Liberian Youth
Another “dark valley” that Liberia faces is the national security problem, rooted in large part because of the strong likelihood of large-scale violence by disenfranchised youth who see their prospects mired by lack of opportunities for self-advancement. Swindlers await an opportunity to mislead them into resorting to the use of violence. There still remains a commitment of some in Liberian society to link with and strengthen their ties among young and vulnerable Liberians to spur chaos, because they cannot thrive in civil and competitive environments (Dolo & Nanka, 2005). In order to ensure that this “dark valley” does not produce hazard, it is important that healthcare and social policy in the post-conflict era pay a special attention to enfranchising youth (see Dolo, 2005).
Liberian youth face despair, estrangement, and lack effective mechanisms to be integrated into the economic and social structures of society. Following their exploitation by the powerful in society, and their feelings of subordination and even inferiority and the possible lack of self-consciousness due to drug and alcohol use/dependence, many have resigned themselves to fatalism. Who would argue that they do not have enormous grounds for distrust and scorn of the status quo? The impact of marginality forces its victims to live a different reality, and thanks to the bigots and pillagers every youth in Liberia who faces difficulties in succeeding in society has a ready made excuse, perhaps an extenuating factor. How long can we allow such a condition to prevail?
To conceptualize a new public policy agenda in the post-conflict era is to increase social cohesion by expounding the idea that all Liberians have a social obligation to one another and between ethnic groups, social classes, especially those who have spent much of their lives stealing from societal coiffeurs. The latter group is indebted to their fellow Liberians to reinvest in rebuilding what they have been responsible for destroying. Egalitarianism or the notion of rights has to be embedded in our public policy formulation processes. Equally so, formulating strategies to work on skills to build trans-ethnic alliances between people with different ethnic and cultural backgrounds and evolving a process that leads toward national identity formation would be fundamental. Public policy will have to confront difficult and real issues related to ethnicity, gender, and other differences that are used as outlets for fostering oppression.
Reducing Government’s Control
Government’s control of a significant portion of the healthcare and social services delivery systems, particularly the creation of an environment that is not conducive for private capital investment in these systems has also been a “dark valley” that has erected barriers to efficiency and choice. If capitalism is to be the mode of economic governance and democracy the means of political governance, then, the paternalistic practices, which led to government control, have to be broken. Government would have to create strategies for promoting entrepreneurship and productivity in the private sector among its citizens and foreign investors. Government responsibility would be to create a climate that is attractive to investors and develop regulations within reason.
Complexity of Policymaking
The process of policymaking and implementation is rather a complex feat. “Complex interrelated forces” tend to conspire to cause the issues that public policy seeks to address. Remedies cannot be ad hoc, but must be rigorous and systemic. Noteworthy though, public policy solutions are often based on probabilistic calculations. Thus, readers should never be fooled into believing that suggestions for improvement such as the array offered here are based on “exact science” and thus problem proof.
The recommendations that follow start out broadly and then graduate to more specific suggestions for systemic change.
1. There are four key characteristics that must be
the bedrock of public policy formulation in the new
era. They must be concurrently “transformative”
and preventive – change the nature of how we
respond to issues and ensure that policymakers are
not content with the status quo and endeavor to improve
the quality of life of the citizens. Second, our public
policy has to be practical and not just idealistic.
The enthusiasms of the leadership have to be tempered
by reality so that elaborate promises are not made,
which cannot be fulfilled. While transformative change
is the goal, such a process cannot be reckless in
radically destroying existing institutions. Changes
have to be incremental and preceded by careful examination
(formal and informal) of the problems at hand. Third,
and most importantly, the national interest must be
the key driver of all public policies so as to foster
a unified national identity (Walter Russell Mead,
2005). We should avoid practices of the past whereby
leaders used the instruments of governance to preserve
the peculiarities of their referent ethnic group or
the ruling elite, thus building hegemony. Fourth,
public policies in the post-conflict era must be steep
in the nation’s history, and thus pay special
attention to the traditions, values and beliefs of
constituents. History has to be the guide or signpost
that directs how public policies are formulated so
as to prevent making the same mistakes that led the
nation to retrogress for 14 years.
2. Having argued that there is an intricate or mutually reinforcing link between economic policy and health and social welfare policies, policymakers would have to develop an economic policy that creates a climate and pathway for sustained foreign investments. These pathways must include a new structure that enters the nation into the technological age and makes the nation globally competitive and also destroy the base of public corruption by restructuring the bureaucracy. In Liberia, national security and the stability of the nation is threatened by a variety of forces, but primary among these menaces is the increased number of youth and middle age people who are unemployable due to lack the capacity or war-induced trauma and mental illness. The solution to this situation has been proposed in earlier writing suggesting a concerted outreach and investment in mental health and job readiness programs for disadvantaged youth who suffer from leftover effects of the war. Government has to reverse its investments in military armaments and build more human capacity. It should also take a strong stance in defending people civil rights, and attack the anti-democratic insurgency ethos, which has made many to think that the most plausible response to their grievance is through the use of the barrel of a gun. Anything to the contrary, will be storing trouble for the future.
3. Legislatures should examine past policy directions in healthcare and social policy and develop Healthcare and Social Policy frameworks or Acts that would provide a comprehensive array of services and supports for citizens including health prevention and promotion, which has its roots in public health, acute care, rehabilitative services, community mental health and psychiatry, and income maintenance programs to serve those people whose sources of incomes have been adversely affected by unemployment, disabling illnesses, old age, etc.
4. An important feature of policymaking that has not been a popular tradition in Liberia is that we have not allowed the works of academics to filter into policy. Equally so, academics have not been innovative in contributing new ideas, rooted in tested and validated knowledge that can meet the optimal standard for being included in policy. Fostering a healthy medium between these two disparate sides would be essential in evolving systemic responses to national problems because proven interventions with greater efficacy would be integrated in programs.
5. Our markets have often been characterized by monopolies in a variety of sectors. In the case of healthcare and social service delivery, the government has controlled these sectors. An institutional change that would invite private providers to compete through Requests for Proposal (RFP) or public-private partnerships to deliver services would be critical in changing the monopolistic traditions of old and lead to optimal governance. This will essentially contract the size of government and restrain extravagant public spending.
6. We have lacked an adequate data gathering and management system on the pervasiveness of diseases, workforce needs, the number of individuals that get treated annually for different diseases, and the number of beds available in different hospital. Keeping an adequate count of people with various disorders: physical and mental would require in depth studies, both short-term and long-term using standardized measurement instruments. Building and sustaining a data base would be critical to moving forward.
7. In the health care and mental health arenas, concerns about the quality of life of patients placed in institutional settings wrought deinstitutionalization in US and other parts of the world in the 1940s (Ward, 1946; Bachrach, 1976; Kiesler & Sibulkin, 1987). The trend has been toward devising alternatives to institutionalization. Community placement (in close proximity to the client’s home) has been the preferred option for the aged, children, people with developmental disabilities and others needing out-of-home placement. Issues of patient-to-staff ratios have also been salient to prevent overcrowding; coupled with efforts to demonstrate the effectiveness of treatment outcomes.
8. Skyrocketing healthcare costs and social spending have constituted immense public policy challenges. Healthcare and social spending often constitute large segments of government expenditures at county and national levels. Chronic poverty and the accompanying inability of many to pay for healthcare and to address other social needs would have to be addressed by the new government. Perhaps, the government can design a payment system comparable to Medicare and Medicaid in the US, which are public health care programs mandated by statute. Medicare is designed to provide prepaid hospital insurance for the aged. It also serves as a voluntary medical insurance while Medicaid is a public means-tested assistance program (Tracy & Ozawa, 1993; Karger & Stoesz, 1998). Federal guidelines are used to determine client eligibility. However, any transfer of social technology to Liberia such as these, would need to be customized to address cultural peculiarities as well as social and political realities.
9. Advancements in medical technology are occurring at a rapid pace. These innovations have improved diagnostic capacities and made treatment available for some of the most difficult diseases. Public policy would have to motivate change in the intellectual culture and generate an economic climate that rewards innovation.
10. Considering the rapid increase in HIV/AIDS infections, treatment of this disease and the associated costs would take a toll on healthcare and social spending. Tracking the pervasiveness of the disease and creating an infrastructure to systematically respond to its spread through preventive education and outreach would be necessary.
11. The population of elderly people is also growing, yet we lack an institutional response to the increased nature of chronic diseases that they face, particularly those wrought by the war and neglect that ensued due to breakdown in the communal family structure that served as a traditional source of “social security” for the aged. Would out-of-home placements for elderly, especially those diagnosed with chronic illnesses be necessary? Would such a shift be culturally appropriate?
12. Build a national healthcare agenda that limits the role of the public sector in healthcare and social service delivery. Provide clear balance between the two sectors in order to achieve synergy in their interventions.
13. Provide a climate that is suitable for more citizens to make them employable and increase employment opportunities.
14. Due to severe healthcare workforce shortages due to brain drain, it will be critical to conduct situational and workforce capacity analyses to determine both the size and scope of needs (build an analytic framework for adequacy levels) relative to existing workforce.
15. Develop a national action plan to bridge identified service needs and workforce needs so as to ultimately improve the performance of the current and future healthcare and social service delivery systems.
16. Develop more robust short-term and long-term training programs for healthcare and social service professionals at post-high school, university, and graduate levels so as to enhance the quality of human resources needs. This should include undergraduate and graduate programs in Psychology, Social Work, Public Health, and Healthcare Policy.
17. Integrate mental health into the national healthcare system to address the massive problems related to the war trauma and substance abuse that have gone unattended over the years.
18. Build a system for a national healthcare research center that invests in applied research to study the complex ongoing healthcare and social services needs of the public. Shift the orientation from curative to a more preventive system of care.
19. The strategy for reform should not be implemented in a piecemeal fashion, but comprehensively so as to affect vital components of the social sector sequentially as well as concurrently.
20. Learning from the experiences of the West, healthcare policy should be regulated against financially debilitating citizens, mainly the poor.
21. Establish rigorous standards for licensing child serving agencies to guide against abuse and neglect.
22. Establish laws against recruiting children below 18 from participating in any warring or insurgency activity.
23. Establish statutes that promote “gender justice” especially the protection of girls from sexual abuse by predatory males and females, and enforce such statutes vigorously where they already exist.
24. Mandate a social justice education curriculum that age-appropriately teaches inclusiveness and tolerance from elementary school to college and in the workplace based in the Liberian historical context.
25. Prioritize mental health and ensure that mental health services are integrated in all hospitals and clinics and newer licenses for establishing hospitals and clinics should specify how mental health services would be provided.
26. Policymaking should involve the participation of all stakeholders through public hearings and other outreach activities.
27. While the healthcare system is decentralized, its administration is centralized, thus posing a management dilemma. It would be important to decentralize the administration of healthcare practice within the public sector and furthermore embrace the private sector more fully.
28. Reduce military spending and increase spending on healthcare sector.