A global public health expert and an academic weigh-in on A Crisis in Care

By Dr. Tolbert G. Nyenswah and Dr. Samuel Wai Johnson, Jr,

Introduction:

The healthcare delivery system in Liberia is in dire straits, as evidenced by staggering statistics revealing that around 1,100 women—equivalent to about three women dying every 24 hours— and 8,100 newborns die each year. The 2019/2020 Liberia Demographic and Health Survey (LDHS) shows that among a population of 5 million people, there were approximately 1.3 million women of childbearing age, between 15 and 49 years. In May of this year, an assessment report by the United Nations H6 Joint Mission to Liberia sounded the alarm. The H6 partnership (formerly H4+) harnesses the collective strengths of UNFPA, UNICEF, UN Women, WHO, UNAIDS, and the World Bank Group to advance the “Every Woman” “Every Child” global strategy and support a country’s leadership and action for women’s, children’s, and adolescents’ health. A “Crisis in Care” denotes a situation where the healthcare system is failing to provide adequate and equitable care to the population, leading to negative health outcomes and widespread suffering.

Dr. Anshu Banerjee, Director of the Department of Maternal, Newborn, Child, and Adolescent

Health and Ageing in Geneva and head of the delegation, emphasized in a high-stakes meeting in Monrovia that “the gravity of the situation—1,100  women die every year in Liberia while giving birth, and of course, no woman should be dying while giving birth” — a moment that should bring joy to the family— should be a wake-up call to health authorities and the government of Liberia.

This situation signals a collapsing health system that requires immediate attention and action from the government of Liberia and its partners. The alarming statistics of maternal and newborn deaths are often referred to as composite and proxy indicators of health outcomes and system weaknesses. These deaths encapsulate multiple dimensions of health systems failures and reflect poor health outcomes, that are not only link to direct healthcare provision, but also broader socio-economic determinants of health, such as education, safe drinking water, sanitation, housing, extreme poverty, and food insecurity.

Monitoring these indicators allows policymakers, including the Ministry of Health, legislators, the Ministry of Finance, and health organizations, to identify weaknesses in health systems and implement targeted interventions to improve overall health outcomes. This article delves into the key drivers of maternal and newborn deaths in Liberia, examines the health financing landscape, draws lessons from other resource-poor settings, and offers recommendations to address this alarming crisis.

Recent Statistics and Context

According to the 2019/2020 LDHS, Liberia’s maternal mortality ratio (MMR) is estimated at 742 deaths per 100,000 live births, significantly higher than the sub-Saharan Africa (SSA) average of approximately 542 deaths per 100,000 live births. WHO defines maternal mortality to include “deaths of women during pregnancy, delivery, and within 42 days of delivery excluding deaths that were due to accidents or violence.” The newborn mortality rate stands at 36 deaths per 1,000 live births, which is alarmingly close to the SSA average of 27 deaths per 1,000 live births. If the 1,100 MMR figure mentioned by the UN H6 Joint Mission report is accurate, it indicates a significant increase, highlighting Liberia’s deficiencies in healthcare infrastructure, including inadequate access to skilled birth attendants and essential medical supplies. Many health facilities are either non-functional or severely under-resourced, which further exacerbates the crisis. The designation of Liberia’s First Lady as a champion for reducing maternal and newborn morbidity and mortality is commendable. However, the government, in collaboration with international partners and civil society, must prioritize actions to tackle this alarming situation.

Trend analyses conducted by a team of researchers at the National Public Health Institute of Liberia on maternal and other major causes of death in Liberia from 2018 to 2022 revealed that the leading cause of maternal mortality in the country is post-partum hemorrhage (PPH), accounting for 38% of all maternal deaths. Eclampsia/pre-eclampsia follows at 14%, with other significant causes including sepsis, obstructed labor, and abortion, the fifth most common cause of maternal death. PPH is characterized by heavy bleeding after childbirth. Typically, after delivery, the mother’s body stops the bleeding by contracting the uterus and clotting the blood. However, in cases of PPH, the bleeding is excessive and fails to stop on its own, posing serious risks and requiring immediate medical intervention.

Reducing maternal and newborn mortality in low- and middle-income countries (LMICs) demands a comprehensive approach, as the issue extends beyond medical care to involve public health and societal factors. Effective interventions necessitate a holistic strategy that addresses healthcare access, education, socioeconomic conditions, referral networks/pathways, and cultural contexts. Collaboration among governments, healthcare providers, communities, and international organizations is crucial to developing sustainable solutions that enhance health outcomes for mothers and newborns.

Examples of successful interventions in Africa and elsewhere include:

1. Family Planning and Reproductive Health Services in Kenya: was initiated to expand access to family planning, it has empowered women to make informed choices about their reproductive health, reducing unintended pregnancies. Healthier timing and spacing of births have contributed to better maternal and newborn health outcomes.
2. Skilled Birth Attendance in Bangladesh: The government implemented programs that ensure skilled birth attendants are present at every birth, significantly improving maternal health outcomes. Skilled birth attendance reduces complications during childbirth and facilitates timely interventions.
3. Community Health Workers (CHWs) in Ethiopia: CHWs were trained to provide maternal and newborn care in rural communities, including prenatal visits, health education, and referrals to health facilities. This increased access to care and education in remote areas thus has improved health-seeking behavior and reduced mortality rates.
4. Access to Emergency Obstetric Care in Rwanda: The government invested in expanding emergency obstetric and newborn care (EmONC) services, including establishing referral hospitals. This improved access to timely and appropriate care for pregnancy and childbirth complications and has led to a decrease in maternal and neonatal deaths.

Liberia’s Health Financing Landscape

Liberia’s health financing landscape is a blend of domestic and external resources, comprising government budget allocations, international aid, and private sector contributions.

By the end of Liberia’s civil war in 2003, fourteen years of brutal conflict had devastated the nation’s economy, infrastructure, health system, and the health and education of our people. In response, President Ellen Johnson Sirleaf’s administration introduced bold new policies aimed at transforming Liberia into “an international model of post-conflict recovery.” This led to the launch of the Poverty Reduction Strategy (PRS) and the development of the first national health plan and policy for 2007-2011, which aimed to “improve health and social welfare status and equity in health.” A major policy decision was the suspension of user fees, essentially providing free health care at the primary (health clinics) and secondary healthcare (health centers and county hospitals) levels, although fees remained at the tertiary level (JFK, JFD and others). The removal of user fees was well-received, especially given that most Liberians lived on less than $1 per day at the time. However, there is no measurable effect of this policy on health index outcomes and the population’s wellbeing. The increasing maternal mortality rate (MMR) and newborn deaths, as proxy indicators, suggest a health system in decline.

Nearly two decades after the introduction of free health care, it remains unclear whether this policy will continue under President Joseph N. Boakai’s administration. Is health care truly free? It appears not. Despite the suspension of user fees, out-of-pocket expenditures in Liberia remain exceptionally high, and the quality of services is often compromised. Studies have shown that these expenditures are driven primarily by non-prescribed medicines and medical supplies (58%) and total outpatient care (35%), which includes consultations, prescribed medicines, and examination. Pregnant women, urban dwellers (in cities such as Monrovia, Gbarnga, Ganta, Kakata, Buchanan, etc.), and the elderly are most likely to incur out-of-pocket spending. Additionally, 15% of households face catastrophic health expenditures, highlighting a widespread issue across Sub-Saharan Africa. These high out-of-pocket costs often push families into poverty and reduce their demand for healthcare services.

For FY 2024 (January–December), Liberia’s national budget is $738.9 million USD, with $80.1 million allocated to the health sector—about 11% of the total budget. This allotment marks a significant increase of nearly 10% from the FY 2023 allotment of $76 million U.S dollars. However, this allocation still falls short of the Abuja Declaration, which calls on African governments to allot  at least 15% of their annual budgets to the health sector. The US $80 million allotted to the health sector in FY 2024 is insufficient to provide adequate and quality health services for the five million people of the country and to help Liberia meet the SDGs of reducing maternal and newborn deaths by half by 2030 leaving a significant funding gap. In the 2019-2021 Revised National Health Plan, expenditure per head was to increase from US$18 to US$29. Adjusted for inflation, Liberia would therefore need about $201 million U.S dollars per year to deliver just essential health services, not comprehensive health care, to its citizens. Delivering the government’s prioritized Universal Health Coverage (UHC) package, which includes primary and secondary care, will be challenging without sufficient funding thus making attaining the health for all target of the 2030 SDGs an illusion.

Since 2006, Liberia has not been able to fully finance the cost of healthcare for its citizens. Over this period, the United States Government (USG), through USAID, provided nearly 35% of the US $201 million US dollars of health expenditure for Liberia through direct budget support under the Fixed Amount Reimbursable Agreement (FARA). The USG also provides support through the UN systems such as WHO and the Centers for Disease Control and Prevention, global health security agenda initiative, the National Institutes of Health (NIH) PREVAIL, and through the Global Fund for AIDS, TB, and Malaria. The remaining 25% of finance needed to supply healthcare in Liberia is contributed by other bilateral donors, EU, Chinese Aid, Irish Aid, JICA, and multilateral organizations such as the World Bank, GFATM, Gavi, The Vaccines Alliance, WHO, other UN agencies and private providers.

Globally, providing healthcare services is a multifaceted and complex process, especially in a resource-poor, low-income country such as Liberia. Overall, to strengthen the healthcare delivery system—particularly in reducing high maternal mortality ratio and mitigating the impact of infectious diseases—government and partner resources must prioritize investments across all components of the health system building blocks. This includes ensuring quality and efficient health sector governance, enhancing health infrastructure, improving access to pharmaceuticals, and supporting healthcare workers. A one-size-fits-all approach will not suffice. Below are recommendations:

Practical Actions and recommendations

1. Revamp the Health Sector Coordinating Platform: Establish a unified platform that pools resources and aligns all donors and partners with one Government of Liberia health plan, one policy, and one strategic direction in the context of Universal Health Coverage and the SDGs 2030. Building donors’ confidence and fostering strategic thinking are critical to bringing all stakeholders together.
2. Engage New Players and Donors for Healthcare Innovations and R&D: Seek out new players and donors willing to invest in healthcare innovations and research and development (R&D) in Liberia. Prioritize the design of an insurance scheme that involves Liberians and private providers in healthcare financing decisions. This scheme should aim to reduce catastrophic health expenditures by minimizing substantial out-of-pocket payments for services in clinics, medicine stores, pharmacies, hospitals, ambulance services, and emergency rooms. Gradually impose user fees based on evidence-based findings.
3. Increase Health Sector Funding: The Liberian government must allocate a larger portion of its budget to the health sector, aiming to meet or surpass the 15% target set by the Abuja Declaration, with a specific focus on maternal and newborn health initiatives. This includes pursuing international aid and partnerships to enhance funding for health programs.
4. Strengthen Human Resources for Health: Implement comprehensive training programs to enhance the skills of healthcare workers, particularly in maternal and neonatal care. Strategies to retain healthcare professionals in rural areas, such as competitive salaries and incentives, are essential.
5. Upgrade Health Infrastructure: Invest in the development and renovation of health facilities, especially in rural communities. All health centers should be adequately equipped with medical supplies, safe delivery rooms, and emergency care capabilities.
6. Enhance Community Health Programs: Foster community health initiatives that promote awareness of maternal and newborn health. Educational campaigns should inform women about the importance of prenatal and postnatal care, supported by local civil society organizations.
7. Establish Robust Monitoring and Evaluation Systems: Create effective data collection and monitoring systems to track maternal and newborn health outcomes using infographics and real-times reporting. This data will inform policy adjustments and highlight areas needing urgent intervention. 

Conclusion:

The crisis of maternal and newborn mortality in Liberia is a clarion call for the government, international partners, and civil society to take decisive action. By implementing these practical measures, we can begin to rebuild the healthcare delivery system and ensure that every woman and child has access to the care they deserve.

The future of millions depends on our response today.