Building a More Resilient Health System after Ebola in Liberia

Dreisbach, Tristan

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In 2014, an Ebola outbreak hit Liberia, a country with a health system that had been severely weakened by two civil wars, economic stagnation, and the loss of many skilled and educated health workers who left the country to escape violence. By the end of the outbreak in 2015, Liberia experienced a total of 10,685 Ebola cases, and 4,809 victims had died. Confidence in public health facilities dropped and demand for public sector health services declined. During the outbreak, many facilities had temporarily closed due to fear of contamination and spread of the disease. Collaboration between the Liberian government and its international partners eventually led to the end of the epidemic, but the health ministry’s leaders wanted to ensure that the health system would be better prepared for the next public health emergency.

There were several challenges to building up the Liberian health system. The country lacked skilled health workers, particularly specialist doctors and nurses, and those shortages were especially acute in rural areas. Health workers had clashed with the health ministry over complaints including low pay and poor working conditions, and had gone on strike shortly before Ebola arrived in the country. Those tensions were detrimental to the motivation of health workers. Liberia was very dependent on donor support for the functioning of its health system, but that support was often fragmented and it was difficult for the government to track exactly what was being funded and implemented throughout the country. There was also a basic problem of weak health infrastructure, including lack of proper equipment, few triage facilities, and a poorly functioning supply chain.

As Liberia began to bring the Ebola crisis under control in late 2014, health ministry leaders saw an opportunity to transition from the short-term emergency response to a longer-term plan for strengthening the health system. Through consultations with internal and external stakeholders, the ministry created an investment plan for building a resilient health system, to run until 2021. The three highest-priority areas were: building a productive and motivated health workforce that fit the needs of the country, reengineering the health infrastructure, and strengthening the epidemic preparedness, surveillance, and response system. Fully realizing the investments in the plan would cost an estimated total of $1.7 billion, but the ministry forecasted a $735 million gap based on existing donor commitments.

This study highlights several aspects of the investment plan. First, the plan provided for the creation of a new cadre of paid community health assistants, a model piloted in cooperation with a local NGO. Second, it included measures to improve the health workforce, such as an emergency hiring and management plan to transform lower-paid contractors into civil servants and academic partnerships to strengthen postgraduate medical education. Third, it provided for the creation of a public health institute to strengthen disease surveillance and response. Fourth, it guided investment in new health infrastructure. As of 2019, several positive results were apparent. Community health assistants across the country helped connect rural communities to the public health system and the National Public Health Institute of Liberia improved the health system’s emergency response capability. More health facilities had isolation units and triages than was the case in 2014, when the Ebola outbreak began. The country’s laboratory facilities greatly improved, allowing samples to be tested for at least seven priority infectious diseases within 24 hours. The density of health facilities increased from 1.6 per 10,000 population in 2015 to 1.9 per 10,000 in 2016. Despite progress made, however, the number of trained health workers remained far below the needs of the country and out of pocket health expenditures remained high, evidence that the public health system was still not meeting demands. Lessons learned from this case study include the importance of incorporating donors and external partners into long-term planning and policymaking after a crisis and the need for donors and implementing partners to invest in permanent infrastructure during a health crisis, not only temporary structures.

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KDI School of public policy and management, Global Delivery Initiative
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