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
All Liberian National Conference
April 15, 2005
April 25, 2005
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:
· Yellow Fever
· Polio Eradication
· Epilepsy Control
· Expanded Program on Immunization (EPI)
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.