More than a year ago, I was in Liberia as part of a team looking into its health system and health financing reforms. The country was still recovering from long years of civil strife. But Liberia was eager to be one of a growing number of countries which were aspiring to and pursuing universal health coverage (UHC).
As we went around the country meeting with different groups concerned with the health system, we saw commendable attempts to expand access to health care services—starting with a basic package of services that was being provided in over 80% of government health facilities. For example, there were attempts to improve the quality of hospital services with a government-managed hospital accreditation system, which requires compliance with safety, quality, and clinical standards.
Yet, it was evident that Liberia’s health system remained fragile. Maternal mortality continued to be persistently high at 994 per 100,000. Per capita health expenditure remained low at $32, with bilateral and multilateral development agencies and other donors funding nearly half of government health spending.
Household out-of-pocket (OOP) spending was high with 85% of OOP paid to private providers. More than 80% of hospitals and health facilities were in the capital city of Monrovia with about half being private sector health facilities. And even with the private health sector included, there was only one doctor and 2.7 nurses per 1,000 people.
Liberia needed to improve all aspects of its health system—financing, service delivery, human resources, and information management—since weakness in any of these separate parts will weaken the rest and derail any effort to aspire to UHC.
But I left Liberia optimistic as I saw the country was seriously investing in health and beginning to strengthen its health system. Unfortunately, less than a year later, Ebola slowly began to creep into the country and then hit Monrovia hard—really hard. Sadly, Liberia’s health system was not yet strong enough to withstand Ebola.
Ebola is a severe disease which kills up to 70% of all those who are infected. It spreads through direct contact with the blood, secretions, organs or other bodily fluids of infected people, and materials (i.e. bedding, clothing) contaminated by blood and other bodily fluids. There is no treatment beyond supportive measures and experimental medicines.
Ebola patients become infectious when they develop symptoms and remain infectious as long as their blood and body fluids contain the virus. This puts health care workers at the highest risk of being infected, as suspected and known Ebola cases are most infectious when they are being treated.
By the end of October, more than 450 health workers had been infected and more than 240 of these workers had died. Suffering the highest toll among them have been the health workers of Liberia including two wonderful people I met. These illnesses and deaths have further reduced the already dangerously low number of health workers in the country. And the gains from the basic package of health services and hospital accreditation scheme are rapidly being reversed as enters are closed and hospital services curtailed because of the decreasing number of workers and the re-allocation of resources to focus on Ebola.
An already weak health system is becoming weaker and increasingly burdened in trying to successfully control the broader spread of Ebola within and outside the country. Hopefully, the global actions to support it will strengthen the system enough to contain this dreaded virus.
The case of Liberia illustrates the importance of pursuing UHC more close to home here in Asia and Pacific. The world has become so much more interconnected, with hundreds of millions of people moving easily across borders. So a country with a weak health system now has regional and global implications.
In the case of Liberia, the shortcomings in its health systems have put other countries—whether neighbouring or distant—at risk from Ebola and other similar viruses and illnesses. Indeed, even if Liberia restrains Ebola and the world keeps in check a further spread, other similar outbreaks would be difficult to contain unless the weakest country health systems are strengthened.
With more people moving from their home countries to work abroad, the more we must bolster country health systems all over Asia and the Pacific to ensure UHC for everyone, whether citizens or migrant workers. Otherwise, the weakest links in national health care systems will continue to jeopardize not only themselves, but the rest of the world.