Health cooperation in post-conflict Liberia has focused on rebuilding the health system and improving health outcomes. The Basic Package of Health Services was introduced to deliver essential services through decentralized provision and performance-based contracting. International aid has supported health governance, financing, infrastructure and technical assistance. While maternal and child mortality have declined, challenges remain in strengthening all aspects of the health system and better coordinating stakeholders. Sustainable improvement requires both top-down and bottom-up capacity development with a rights-based approach that empowers local communities.

1. Health cooperation in
post-conflict setting
July 16, 2013
Hideaki NAKAJIMA
254th IDEC Asia Seminar

2. 254th IDEC Asia Seminar
Liberia - Data
http://wikitravel.org/en/File:LocationLiberia.png
Stats Figure Remarks
Surface area 111,369km2 -
Population 3,994,000 Estimated in 2010
GDP US$873,000,000 Current US$ in 2010
GDP growth rate 5.2% At constant 2005 prices in
2010
GDP per capita US$218.6 2010
Human Development
Index ranking
174 Out of 186 countries in 2012
- http://data.un.org/CountryProfile.aspx?crName=Liberia
- http://hdr.undp.org/en/statistics/

3.  1822: Freed American slave settlers arrived
 1847: Independence (first republic in Africa)
→ Only “Americo-Liberians” had civil rights and politically and
economically ruled Liberia
 1980: Coup d’etat by Samuel Doe (indigenous origin)
 1989: Rebel by Charles Taylor
→ Civil conflict
 2003: Accra Peace Accord
 2006: Inauguration of first democratically elected
female president in Africa (Ellen Johnson-
Sirleaf)
254th IDEC Asia Seminar
Liberia - History

4. No. of health facilities: 550 before conflict → 354
High maternal mortality rate: 770/100,000 (2010)
(7th highest in world) (*Japan: 6/100,000)
Infant & under 5 mortality rates are also still high:
58/1,000 (2011) (*Japan: 2/1,000) &
78/1,000 (2011) (*Japan: 3/1,000)
Infectious disease (malaria) prevalent
Neglected tropical disease (NTD: lymphatic filariasis, etc.)
Non-communicable diseases (diabetes, cardiovascular
disease, etc.)
Basic care such as eyes, nose & throat (ENT) is also still to
be improved
254th IDEC Asia Seminar
Situation in health in Liberia

5. BPHS:
Introduced into post-conflict setting (e.g. Afghanistan
other than Liberia)
Comprehensive health service package to “effectively
deliver quality health services to the people” (Liberia
National Health Policy 2007-2011)
Decentralization
Performance-based contract with NGOs & local authority
(even aiming at contract with health facilities)
254th IDEC Asia Seminar
Basic Package of Health Services (BPHS)

6. <2007 - 2011>
 Maternal & newborn care
 Reproductive & adolescent health
 Child health
 Communicable disease control
 Mental health
 Emergency care services
254th IDEC Asia Seminar
BPHS (cont.)

7. BPHS expanded to
Essential Package of Health Services (EPHS)
BPHS (2007-2011) EPHS (2011-2021)
(1) Maternal & newborn care
(2) Reproductive & adolescent health
(3) Child health
(4) Communicable disease control
(5) Mental health
(6) Emergency care services
- (7) Non-communicable diseases
- (8) NTD
- (9) Environmental & occupational health
-
(10) School health services (Oral hygiene/dental care,
Eye care, Immunizations, Personal hygiene, Family
planning counseling, etc. )
- (11) Prison health services
-
(12) Essential support services (Facility infection
prevention, control & health waste management,
pharmaceutical services, Health management
information systems, Laboratory services, Health
promotion/IEC/BCC)

8. 254th IDEC Asia Seminar
Cooperation in health in Liberia
MoHSW
NGO
GAVI
Global Fund Japan
China
Ireland
Switzerland UK
EU US
WHO
UNICEF
UNAIDS
UNFPA
Pool Fund
Aid coordination
Funding（PBC）
Support in
services provision
TA
Funding（PBC）
- Funding
- TA
cooperatio
Support in
service
provision- Funding
- TA
Funding
- Funding,
equipment
- Support in
service
provision
- TA
Funding
Funding
- Funding,
equipment
- Support in
service
provision
- TA
- Support
in service
provision
- TA
Funding
- Infrastructure
- Equipment
- Support in service
provision
- TA

9. 254th IDEC Asia Seminar
Outcome?
260
578
994
890
770770
145
1986 2000 2007 2008 2010 MDG2015
Maternal mortality (out of 100,000 live births)

10. 254th IDEC Asia Seminar
Outcome? (cont.)
114
117
71
78
73
61
5858
31
1986 2000 2007 2008 2009 2010 2011 MDG2015
Infant mortality (out of 1,000)

11. 254th IDEC Asia Seminar
Outcome? (cont.)
220
194
110 112 114
83
7878 80
1986 2000 2007 2008 2009 2010 2011 MDG2015
Under 5 mortality (out of 1,000)

12. 254th IDEC Asia Seminar
Vertical vs Horizontal approaches
Health systems
Governance Finance Human
resource
Services Facility/
equipment
Information
Malaria
Morbidity specific
HIV/AIDS
TB
- Effectively tackling diseases
- Morbidity stakeholders are not interested in put in lower priority
- Lack of coordination among stakeholders >> High transaction cost
- Improving sustainable health services
- Takes time to show outcomes
- Lack of coordination among stakeholders >> Difficulty in strengthening
all components in balance
X
XX

13.  Policies/strategies made in the course of state
reconstruction (sometimes in donors’ interest?)
Essential, BUT…
 Gap between what is written and what is actually
implemented
254th IDEC Asia Seminar
Liberal peacebuilding/development?
Midwives & nurses
always scold me at
clinic. Drugs are
sometimes out of
stock and so I have to
buy ones myself. And,
clinic is far! I don’t
want to go to clinic…
So many people
come and I’m busy
and tired… No pay
increase, and
payment sometimes
delays! I want to get
new skills, to be
respected. I don’t
want to stay in rural
area…!

14.  Decentralization?
Wait a minute…
 Weak enforcement of systems, weak governance,
lack of authority…
- Government and donors/NGOs are working on
strengthening gov’t governance…
- But no good coordination among them…
254th IDEC Asia Seminar
Liberal peacekeeping/development? (cont.)

15. Humanitarianism
Human security
Equity/justice
National interests
Global public goods
254th IDEC Asia Seminar
Why aid?
?
?

16. Public goods:
Non-excludable & non-rivalrous in consumption
(e.g. lighthouse, peace & security, law & order)
In this rapidly globalizing world, health GPG
is…
- Health R&D
- Communicable disease control
(Smith R.D. & MacKellar L. (2007))
254th IDEC Asia Seminar
Global public goods (GPG)

17. WHO’s recent report:
“Global and regional estimates of violence against women:
Prevalence and health effects of intimate partner violence and non-
partner sexual violence”
254th IDEC Asia Seminar
GPG (cont.)
<Sexually transmitted infections (STIs)>
Women who experience physical/sexual partner
violence are 1.5 times more likely to acquire STIs
including HIV.

18. The politically/economically/socially disadvantaged
(women) are physically (and mentally) abused and
suffer from morbidity…
Society, whose structure keeps the vulnerable
(women as well as children) as they are, is
itself vulnerable in that it is prone to conflict,
isn’t it? And there is no peace, if those people
are still vulnerable, in post-conflict situation.
254th IDEC Asia Seminar
GPG (cont.)

19. 254th IDEC Asia Seminar
How health cooperation works in
post-conflict setting?
1. Evoking and extending altruism generates positive feelings
among parties
2. Identifying and replacing rumors with facts rebuilds mutual
confidence
3. Redefining the prevalent norms changes the terms of the
debate and opens new space for discussion
4. Regenerating a sense of shared identity
5. Personal solidarity actions by healthcare professionals,
especially respected doctors, can have a demonstrably powerful
effect
(Mukesh Kapila, Healing Broken Societies: Can Aid Buy Love and Peace?)

20.  Capacity development
 Synergy between the dual approaches: top-down (system/rule
making/strengthening) & bottom-up
 Stakeholder coordination/collaboration
 Rights approach (e.g. right to health; universal health coverage)
 Cross-cutting approaches (e.g. education & health; economic development that
gives people hope for future, which does not indulge people in desperate
health damaging abuse)
AND…
 Respect for people: think & try hard to help people get motivated, esteemed
and rewarded as we wanted if we were them!
254th IDEC Asia Seminar
How health cooperation works in
post-conflict setting? (cont.)
Takes time to achieve goals (sometimes three
steps forward & two steps back…), but we
can do it!

21. 254th IDEC Asia Seminar
Thank you!!