DESK REVIEW LIBERIA HEALTH and WASH SECTOR September 2017

SOCIAL IMPACT LIBERIA, 2017

DESK REVIEW LIBERIA HEALTH AND WASH SECTOR September 2017

This publication was produced for review by the United States Agency for International Development / Liberia. It was prepared independently by Social Impact, Inc.

DISCLAIMER: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

CONTENTS I. Executive summary ...... 5 Methods ...... 5 Key Findings ...... 5 Recommendations ...... 7 II. Introduction ...... 11 Background ...... 11 Objective of this Study ...... 11 III. Desk Review Approach ...... 11 Research Questions ...... 11 Methodology ...... 12 IV. Desk Review Findings ...... 13 Question 1: What does existing information identify as major priority areas of intervention in Liberia’s Health and WASH Sectors? ...... 13 WASH ...... 13 Maternal and Child Health (and nutrition) ...... 14 Family Planning ...... 15 Infectious Diseases ...... 16 Non-Communicable Diseases ...... 18 Mental Health ...... 19 Animal and Veterinary Health ...... 19 Health Systems Strengthening ...... 20 Question 2: What do relevant Government institutions identify as their priorities and has there been any progress in accomplishing their goals in the Health & WASH Sectors? ...... 21 WASH ...... 22 Maternal and Child Health (and nutrition) ...... 24 Family Planning ...... 25 Infectious Disease ...... 26 Non-Communicable Diseases ...... 27 Mental Health ...... 27 Animal and Veterinary Health ...... 28 Health Systems Strengthening ...... 29 Question 3: Where are the gaps in the Health & WASH sectors and what are key opportunities for USAID investment? ...... 31 WASH ...... 31 1

Maternal and Child Health (and nutrition) ...... 32 Family Planning ...... 33 Infectious Disease ...... 33 Non-Communicable Diseases ...... 34 Mental Health ...... 35 Animal and Veterinary Health ...... 35 Health Systems Strengthening ...... 36 V. Recommendations ...... 37 Annex I – Statement of Work ...... 40 Annex II – Table of Existing Assessments, Reports and Surveys Post-2014 ...... 42 Annex I1I – Annotated Bibliography ...... 44 General Health ...... 44 WASH ...... 44 Maternal and Child Health ...... 46 Family Planning ...... 47 Infectious Disease ...... 48 Noncommunicable Disease ...... 49 Mental Health ...... 50 Animal and Veterinary Health ...... 51 Health System Strengthening ...... 51

ACRONYMS

Acronym Explanation ALMA African Leaders Malaria Alliance ACTs Artemisinin-based Combination Therapy ANC Ante Natal Check-up ARI Acute Respiratory Infection CDC Center for Disease Control CSW Commercial Sex Workers CHAI Clinton HIV/AIDS Initiative CHC Community Health Centers C-HMIS Community Health Management Information System CHDC Community Health Development Committee CHSD Community Health Services Department, Ministry of Health CHV Community Health Volunteer CLTS Community-Led Total Sanitation CRVS Civil Registration and Vital Statistics DHS Demographic and Health Survey DOTS Directly Observed Short-Course Treatment EmONC Emergency Obstetric and Newborn Care ENA Essential Nutrition Actions EPI Expanded Program on Immunization EVD Ebola Viral Disease FP Family Planning GOL Government of Liberia HBB Helping Babies Breath HIS/HMIS Health Information Systems/Health Management Information Systems HIV Human Immunodeficiency Virus HSPF Health Sector Pool Fund HPV Human Papillomavirus ICCM Integrated Community Case Management IDSR Integrated Disease Surveillance and Response IDU Injectable Drug Users IEC Information, Education and Communication IMNCI Integrated Management of Neonatal and Childhood Illnesses IPC Infection Prevention and Control IPTP Intermittent Preventive Treatment in Pregnancy ITN/LLIN Insecticide Treated Nets/Long Lasting Insecticide Treated Nets IRS Indoor Residual Spraying IWRM Integrated Water Resources Management LiCORMH Liberia Center for Outcomes Research in Mental Health LSS Life Saving Skills

MCH Maternal and Child Health MDR-TB Multi-drug Resistant TB MOH Ministry of Health MSM Men Having Sex with Men NACP National AIDS Commission NCD Non-Communicable Disease NGO Nongovernmental Organization NHSWFPP The National Health and Social Welfare Financing Policy and Plan NLTCP National TB Control Program NPHIL National Public Health Institute of Liberia NRWASH National Rural Water Sanitation and Hygiene Program ODF Open Defecation Free PMI President Malaria Initiative PMTCT Prevention of Mother-to-Child Transmission PTSD Post-traumatic Stress Disorder RMNCAH Reproductive, Maternal, Neonatal, Child and Adolescent Health SCM Supply Chain Management SDGs Sustainable Development Goals SO Strategic Objective TB Tuberculosis TRIPS Treaty on Trade Related Aspects of Intellectual Property UNICEF United Nations Children’s Fund VCT Voluntary Counseling and Testing WASH Water, Sanitation and Hygiene WHO World Health Organization WSS Water Supply and Sanitation WSSC Water Supply and Sanitation Committee

I. EXECUTIVE SUMMARY The USAID/Liberia Mission is currently preparing its five-year Country Development Cooperation Strategy (CDCS) for 2019-2023. In preparation for the new strategy, the Mission will assess existing literature and policies around the health, water, sanitation and hygiene (WASH) sector developed post- Ebola in Liberia. The objective of this desk review is to identify existing documentation on the health and WASH sector in Liberia to provide USAID/Liberia with an informed assessment of key health areas for attention and future investment. It is anticipated that the utilization of the results from this review may assist in the formulation of the subsequent USAID/Liberia CDCS and fully informs USAID’s decision making. The desk review provides an overview of the information available electronically, key findings to consider in designing the future CDCS and recommendations for future health sector investment by USAID and public and private sector stakeholders.

The questions addressed through the desk review are: 1. What does existing information identify as major priority areas of intervention in Liberia’s Health and WASH sectors? 2. What do relevant Government institutions identify as their priorities and has there been any progress in accomplishing their goals in the Health & WASH sectors? 3. Where are the gaps in the Health & WASH sectors and what are key opportunities for USAID investment? METHODS The desk review was completed using sources from the USAID/Liberia Knowledge Portal, the USAID Development Experience Clearinghouse (DEC), World Bank (WB) data, studies undertaken by other donors, such as the United Nations Children’s Fund (UNICEF), academic studies and to a limited extent, newspaper articles. The study focuses primarily on documents published post-2014 as this was a critical year in the Government’s increased focus on population health after the effects of the Ebola Virus Disease (EVD) outbreak. Few of the reports are representative of all counties, however, the national level documents are shared in a table in Annex 2 for ease of reading. Additionally, many documents utilize data collected prior to 2014. Where possible the author included studies done prior to 2014 if applicable to long term policy goals (i.e. 2011-2020), however the author sought the most updated information on health statistics from 2014 and beyond. There were a total of 113 original documents sourced, with a total of 89 being used in the writing of this report (Annex 3). Those documents unused were irrelevant sources or contained outdated information. KEY FINDINGS What Does Existing Information Identify as Major Priority Areas of Intervention in Liberia’s Health and WASH Sectors? The desk review found that there are several priority areas that will require intervention in order to reach long term health goals. WASH priorities include: Waste management, WASH in schools and health facilities, hygiene to prevent communicable disease and broader community health investments, such as community-led total sanitation. Maternal and Child Health (MCH) priorities include: Reducing maternal mortality (Liberia has one of the highest rates worldwide), especially preventable and treatable birth complications, improving distance to health facilities, nutrition outcomes and reversing the effects of Ebola on health seeking behaviors. Family planning (FP) priorities include: The unmet need for contraception and sexual education, especially for adolescents and the lack of supply and advocacy for long-term pregnancy prevention methods.

Infectious disease priorities include: A dearth of skilled personnel to treat patients post-Ebola, persistent rates of TB, HIV and Malaria, information sharing and surveillance on disease transmission and individual behavior change. Non-communicable disease priorities include: Cardiovascular disease reduction as the cause of 1/3 of all deaths and highest cause of disability and investing in prevention rather than treatment. Mental health priorities include: Depression, post-traumatic stress disorder (PTSD), the lack of mental health facilities and the lack of trained health professionals in psychosocial and mental health. Animal and veterinary health priorities include: Disease vector burdens and threats of animal to human disease transmission, lack of a veterinary school or degree program, lack of veterinarians in the country, need for technical knowledge of livestock screening. Health system strengthening priorities include: Supply chain management, human resource shortfalls, uneven health financing, poor health information systems and need for quality standards. What Do Relevant Government Institutions Identify as Their Priorities and Has There Been Any Progress in Accomplishing Their Goals in The Health & WASH Sectors? WASH priorities within the Government of Liberia (GoL) include: Waste management, WASH in schools (“Liberia’s first step to recovery from Ebola”) and health facilities and repair of WASH infrastructure. The GoL will continue to support Community-Led Total Sanitation’s (CLTS) early successes and restart after Ebola. Additionally, the GoL aims to address the budget constraints and inefficiencies and ramp up their M&E capacity for the sector. MCH is apparently “the number one priority of the GoL,” and priority areas of concern include: Increasing budget allocations for MCH, involvement of community level volunteers and development committees and improved oversight and management of MCH activities. There are 18 guiding policy documents regarding MCH for the period 2016-2030 with a focus on improved quality of emergency obstetric care, adolescent health, emergency preparedness and improving civil registration and vital statistics. Family planning priorities include: The inclusion of a budget line item dedicated to family planning, sex education in schools, wider information sharing and stigma reduction for pregnant adolescents. Infectious disease priorities include: A clear focus on information, education and communication to reduce myths around disease prevention and transmission. Community level surveillance and CHV involvement are key areas and individual behavior change is strongly highlighted in the National HIV, Malaria and TB strategies. Non-communicable diseases take less of a priority than communicable ones, however priorities include: Cancer prevention, community health awareness raising and information sharing. Mental health priorities include: Enforcement of Mental Health Policy and Plan, health worker capacity development to better cope personally (especially after the effects of Ebola) and to treat patients. Animal and Veterinary Health priorities include: Exploration of diseases that can easily jump from animals to humans to prevent another epidemic. However, no strategy or guiding document has been created to date. Health system strengthening priorities include: Focusing on a ‘resilient’ health system, rebuilding trust in the workforce and the facilities, enforcing accountability, management and leadership and scaling up the influence and responsibility of the CHVs.

Where Are the Gaps in The Health & WASH Sectors and What Are Key Opportunities for USAID Investment? 6

The desk review found that among all the health areas, there are challenges that will require future investment and that may be strategic opportunities for USAID. The lack of a clear strategy, accountability to international standards and lack of proper coordination among the institutions responsible for governance and implementation of WASH activities is a major concern, underlined by the lack of dedicated Government funding for sanitation, especially in rural areas. Community Health Volunteers (CHVs) are volunteers but do perform critical and often lifesaving tasks. However, there is currently no standardized incentives package to motivate the CHVs and the expectations of them steadily grows. Family planning funds are expended to cover expatriate staff costs rather than project costs and long-term methods are not widely distributed, creating an unmet need for family planning. Additionally, data on contraceptive use, especially for adolescents is not regularly collected and is necessary to inform decision making. MCH challenges include an unreliable supply chain, which is often necessary to provide lifesaving medications to mothers during or after childbirth, as well as a workforce that is often under-skilled to handle birth complications. Mothers still must travel far distances to health facilities and rely on CHVs in lieu of trained doctors or midwives. Improved health education around infectious disease and health messaging and communications is needed to share positive and well-informed behavioral messages; many people simply associate infection prevention and control (IPC) with Ebola and not with general hygienic practices. Additionally, while the GoL has prioritized reaching out to vulnerable populations, it has not yet addressed the stigma and discrimination on behalf of health workers serving those populations. The health system is lacking in consistent and standardized training for both CHVs and health workers. The medical schools need to increase enrollment if the GoL intends to replace health workers. Additionally, major guiding documents like the Supply Chain Strategy are outdated and in need of a revision taking into context the post-Ebola environment. RECOMMENDATIONS GENERAL • There is a recognized focus from the Government on the responsibility of the CHVs, however they must be provided with a formalized incentives structure, accompanied by thorough (and refresher) trainings to be consistently effective. The Ministry of Health must also invest in a more effective recruitment process that assesses the capacity, competency and commitment of CHVs and focuses on more intensive training, especially while the country regains trust in health facilities.

• A greater focus on M&E has been echoed in a number of policy reports, however, there is no concrete strategy for data monitoring, reporting and accountability in any of the health sectors. In order to move forward with improved data management, surveillance and responsive health sector initiative implementation, the GoL should emphasize the creation of M&E frameworks with standardized reporting schedules to all implementers, national and international.

• Overall investment in health should reach the minimum international standards set under the Abuja Declaration at 15%. Further, the GoL’s budget allocations for WASH are currently disjointed across several sectors. In order to ensure a minimum line item for health at 15% of the annual budget, the GoL should revise their health financing strategy to include family planning (5-15%) reproductive health (10%) and WASH (.5%) per the international frameworks the GoL has signed on to.

• Investing time in the development of a new robust supply chain management strategy (as the former only went through 2015) would be a strategic opportunity for USAID to work with the GoL to address what has been highlighted throughout this report as a bottleneck for maternal health, family planning and infectious and noncommunicable disease prevention. Supply chain management is a critical cross-cutting issue across all health sectors, which rely on a strong management system to effectively deliver services. WASH • The Government and implementing partners can support Open Defecation Free (ODF) communities through regulated monitoring and improve both monitoring and evaluation of ODF and CLTS initiatives, including accurate data disaggregation. Follow up and documentation of strengths and challenges will ensure that this important initiative receives the necessary attention and resources to uphold the early successes of community participation prior to the EVD Outbreak.

• A clear governmental mandate and increased responsibility is necessary for rural and peri-urban communities and small towns. Keeping Water Supply and Sanitation Committee (WSSC) as a regulatory body at the center of WASH policy is ideal for standardization of practices and accountability. The plethora of existing data on inequities between rural and urban piped water access (currently limited to towns of 5000+) should be used by the WSSC to advocate for such infrastructure improvements.

• More effort is required to strengthen WASH coordination and committees at the county-level and initiate coordination at the district level. This includes both national and international implementing partners, who should be held responsible to coordinate closely with local government bodies in the counties where they are operating, to reduce overlapping of programmatic resources and inaccuracy of data.

• The Ministry of Health (MOH) should establish a link with education and training institutions to enhance staffing requirements for the WASH sector and provide students with real-world and timely experience. This will ensure the health workforce is up to date with medical knowledge and international standards and will improve their quality of care.

• The GoL should be applauded for addressing the pressing needs of WASH in schools. The MOH should draft a national strategic framework to address WASH in health facilities. The WASH in health facilities baseline study was completed two years ago, hence such a framework would be well informed and serve as a guiding policy to which all health facilities should be held accountable, while keeping with international regulations and standards of quality of service.

Maternal Child Health and Family Planning • A skilled health workforce in midwifery and emergency obstetrics is key to reducing maternal and newborn morbidity and mortality. The GoL should invest in increased midwifery training especially in rural areas, with an incentive to prevent attrition. Task shifting, shown to be a positive solution to reducing health worker gaps, should be enforced as maternal health is a key area that can benefit from this strategy to increase the numbers of health workers with the necessary skills to prevent treatable deaths and encourage Ante Natal Check-ups (ANC) and Intermittent Preventive Treatment in Pregnancy (IPTP).

• The GoL should work closely with implementing partners to source necessary equipment to detect and treat complications in order to improve health facilities servicing expectant mothers and children. Improved capacity to treat maternal and child health problems may improve the health seeking behaviors of mothers who have lost confidence in the health system. Furthermore, an investment in lifesaving equipment should be geared towards rural facilities, as they are most in need.

• Family planning initiatives should be rolled out more rigorously in rural areas, not only in county capitals and cities. Community information, education and communication (IEC) campaigns should target adolescents and community-level engagement in discussions around family planning should include parents and teachers. Infectious Disease • IEC for infectious diseases should emphasize prevention, with a focus on behavior change and prevention of myths, stigmatization and discrimination. Broader Government disease prevention messaging should be targeted to improving quality of life and adopting healthy and hygienic practices, regardless of the presence of EVD, HIV, TB or Malaria.

• Liberia must build surveillance systems that monitor cases of infectious diseases, improve the safety and quality of national laboratory systems and establish emergency operations centers that can launch a quick, coordinated response to a public health threat. The Ministry of Health has already begun work in this arena but consistent follow-up will be required, namely in the creation of a structured system for community-based disease surveillance. Noncommunicable Disease • The MoH should adopt a formalized strategic framework to address non-communicable diseases. Cancer is an important priority, the Government should also seek to provide information at the community and national level regarding lifestyle disease, including cardiovascular disease and provide information regarding nutrition and exercise in schools. Mental Health • The Government should engage in a more targeted focus on mental health diseases and support systems, including designation of appropriate facilities and referrals. Health worker’s facility-level training should include mental health awareness and stigma reduction. The Government should also engage with international bodies to import necessary psychotropic drugs. Additionally, the Government could benefit from a population-level survey on prevalence of mental illness and depression. Animal and Veterinary Health • Liberia must identify priority zoonotic diseases of domestic and wild animals, raise awareness of disease control and good animal husbandry practices and prioritize resources to ensure the reduction of potential spillover of zoonotic diseases into the human population. Liberia can benefit from investment into continuous training of veterinary personnel and development of a multi-sectoral approach to zoonotic diseases at the national, county and local levels. This should include increased coordination between animal and human health systems. There’s a need for increased access to animal drugs, particularly for livestock and poultry farmers, accompanied by a minimum level of training in their use. Health Systems Strengthening

• A national Community Health Management Information System (C-HMIS) that collects data from the community level and is collated with health data from other levels of the health system, will allow for a comprehensive national community disease prevalence and surveillance dataset, as well as a way to track neonatal and maternal deaths in the community. This Information System should be part of the broader Health Information Management System (HMIS) and initiated at the county level.

• Data and information management is a critical area for investment. This desk review was plagued by outdated reports, websites and vital data/statistics on key health indicators. There are numerous documents of similar name, type and thematic focus, often within the same year, which is a questionable use of resources and time. MOH could benefit from a more coordinated, cohesive response to health reporting, especially with the formation of WASH Liberia and the Public Health Institute. Both institutions can also take responsibility of ensuring consistency in the way Liberian health information and policy documentation is presented and stored.

• Supply chain management and logistics should be included within the curriculum of training for all members of the health workforce to improve their understanding of commodity and stock management.

• Task-shifting has proven to be an effective means of compensating for the lack of trained personnel. Investing in health workers with the potential to learn new skills and play a critical role at the facility and community level will ensure that shortages in trained personnel no longer retards a health system in the face of an emergency and can also assist in reducing attrition and increasing job satisfaction.

• Health financing is currently donor driven. The GoL could benefit from diversification of funding sources to create greater opportunity for financial support to mitigate the out of pocket expenses that may prevent citizens from seeking care. One potential solution could be the utilization of public private partnerships to provide high quality services for citizens without additional undue cost burden.

II. INTRODUCTION BACKGROUND The USAID/Liberia Mission is currently preparing its five-year Country Development Cooperation Strategy (CDCS) for 2019-2023. In preparation for the new strategy, the Mission will assess existing literature and policies around the health, water, sanitation and hygiene (WASH) sector developed post- Ebola in Liberia. The objective of this desk review is to identify existing documentation on the health and WASH sector in Liberia to provide USAID/Liberia with an informed assessment of key health areas for attention and future investment. It is anticipated that the utilization of the results from this review may assist in the formulation of the subsequent USAID/Liberia CDCS and fully informs USAID’s decision making. The desk review provides an overview of the information available electronically, key findings to consider in designing the future CDCS and recommendations for future health sector investment by USAID and public and private sector stakeholders.

Several years of destruction caused by civil war, the EVD outbreak and neglect and lack of investment in the health system, has left the Liberian health infrastructure in poor condition, with severe shortages of skilled health workers and dysfunctional early warning systems. The Government began a health sector reform process aimed at rebuilding the health system to improve coverage and access to basic health services for the Liberian population. The first post-war National Health Policy and Plan, 2007-2011 introduced the Basic Package of Health Services (BPHS) that specified the minimum package of services that should be provided at every level of care, as well as, the minimum resources in terms of equipment and supplies, infrastructure and workforce that are required to deliver the services. This package was expanded as the Essential Package of Health Services (EHPS) that was later introduced under the current ten-year National Health Policy and Plan (2011-2021). The outbreak of EVD in 2014 halted much of the progress made towards reaching goals of improving nationwide health services. EVD also exposed the existing weaknesses of the health system whose revitalization had yet to come to fruition. OBJECTIVE OF THIS STUDY This desk review serves to review and synthesize existing research in the Health and WASH Sectors in Liberia by various stakeholders and to synthesize this information into one cohesive document. The desk review provides a detailed and annotated reference list of all resources reviewed, organized by technical area. It also identifies information gaps and synthesizes opportunities for investment and partnership regarding the design and implementation of future activities. Specifically, this document will inform the Mission in preparing for the next iteration of the 2018-2023 Country Development Cooperation Strategy (CDCS) and design of the future USAID/Liberia health project.

III. DESK REVIEW APPROACH RESEARCH QUESTIONS The desk review intends to address the following questions: 1. What does existing information identify as major priority areas of intervention in Liberia’s Health and WASH sectors? 2. What do relevant Government institutions identify as their priorities and has there been any progress in accomplishing their goals in the Health & WASH sectors? 3. Where are the gaps in the Health & WASH sectors and what are key opportunities for USAID investment?

Using the above questions as a guide, the desk review focuses on the following technical areas: • WASH • Maternal and Child Health (and nutrition) • Family Planning • Infectious Diseases

o HIV o Malaria o Tuberculosis o Any others • Non-communicable Diseases • Animal and Veterinary Health • Health Systems Strengthening

o Supply Chain Management o Health Financing o Capacity building of Liberia Ministry of Health/Government of Liberia o Health Quality Assurance o Human Resources for Health METHODOLOGY This report is based on a review of the documents listed in Annex II. The desk review collected, organized, reviewed and synthesized the available information across 89 documents and datasets related to Health and WASH in Liberia, with greater emphasis on documents published post-2014. The desk review was completed using sources from the USAID/Liberia Knowledge Portal, the USAID Development Experience Clearinghouse (DEC), World Bank (WB) data, studies undertaken by other donors, such as the United Nations Children’s Fund (UNICEF), academic studies and to a limited extent, newspaper articles. The desk review provides an overview of the information available and key information to consider in designing the next iteration of the CDCS. The findings contain numerous references where the topics can be explored in greater depth. The aim is not to summarize all the information on each of the topics but rather to draw out the most important and up-to-date information for USAID’s consideration and identify areas that need further exploration. As the health landscape was drastically affected by the EVD outbreak in 2014, the desk review relies on reports published after 2014 to ensure that the findings present a more accurate representation of health sector priorities after that time. However, there are some limitations to consider when reviewing this report. First, though most reports were published after 2014, many of the documents utilize data from 2012 or earlier, with a few nationwide surveys and statistical health analyses occurring post-2014. There is very limited nationally representative data available post-2014 and these gaps will be explored further in the response to research Question 3.

IV. DESK REVIEW FINDINGS QUESTION 1: WHAT DOES EXISTING INFORMATION IDENTIFY AS MAJOR PRIORITY AREAS OF INTERVENTION IN LIBERIA’S HEALTH AND WASH SECTORS?

WASH From 2012 to 2014, there were 10 separate assessments, sector reviews, performance reports, planning documents and studies done on the WASH sector in Liberia1, including most recently a WASH desk review funded by USAID in 2014. Post-EVD, strategy and national policy documents began to emerge, using EVD as a basis for renewed energy to address WASH issues. Liberia’s Third Annual Water, Sanitation and Hygiene Joint Sector Review in 2015 found that before the EVD outbreak, Liberia was plagued by limited access to water and sanitation facilities in both rural and urban areas, including at clinics and schools. Water and sanitation services were limited to one-fourth of the urban population across the country and solid waste management was only available in Monrovia. Water quality and hygiene issues are caused by poor or non-functioning pipes and sewage infrastructure.2 In general, the health implications of WASH deficits are exacerbated by the country’s lengthy rainy season (May–October) which contributes to the endemic waterborne and diarrheal diseases (e.g. cholera).3 During the EVD outbreak, increased awareness raising for behavior change around personal hygiene and waste management became more urgent and deemed a necessity in ensuring population health. A 2015 WASH and Environmental Health report by the GoL summarized that there are two components that are identifiable focal points for WASH: ‘Hardware’ components that include construction and rehabilitation of facilities, water points like wells and disposal systems; and ‘software’ components that include hygiene and behavior change, housekeeping and waste management.4 Several Government and private sector reports have documented that the experience with Ebola increased the understanding of the importance of water-borne diseases and the adoption of good hygiene practices, especially as it relates to water supply, sanitation and handwashing facilities in communities, in schools and in health facilities.567 A 2016 Nationwide Assessment of WASH Facilities in Schools in Liberia, had the following data for 2014: • 55% of 4,460 schools in Liberia did not have access to a functional water supply system; • 56.2% had functional latrines; • 43% were without basic sanitation facilities; • Almost half of schools burned their waste; • Only 18% had a permanent hand-washing facility. Schools are plagued by diarrheal diseases and malaria, which are exacerbated in areas of poor sanitation and waste management.8 The Liberia WinS: Water, Sanitation and Hygiene in Schools report of 2016 noted that WASH in schools can have a significant impact on school enrollment, gender ratios, absenteeism and performance and there are correlations between availability of facilities and safety, especially for girls. There are also critical hygiene and disease prevention aspects of providing hand

1 Liberia WASH Sector Assessment Desk Review. TetraTech/USAID. 2014. 2 Liberia’s Third Annual Water, Sanitation and Hygiene Joint Sector Reviews: Event Report. UNICEF. July 2015. 3 WASH Sector Investment Plan 2012-2017. Government of Liberia. 4 WASH and Environmental Health Package in Health Facilities. Liberia Ministry of Health. October 2015. 5 Liberia Wins: Water, Sanitation and Hygiene in Schools. Government of Liberia. 2016. 6 Nationwide Assessment of WASH Facilities in Schools in Liberia. UNICEF. March 2016. 7 Abrampah, N. et al. (2017). Improving water, sanitation and hygiene in health-care facilities, Liberia. World Health Organization 8 Nationwide Assessment, UNICEF. 13

washing materials and facilities for waste management. Improvements in these areas for schools will reduce illness and increase retention rates in schools.9 In health facilities, particularly in clinics and health centers in rural areas, sanitation conditions are not up to acceptable standards. A Liberia WASH in Health Facilities Baseline Report completed in 2015 showed that while 91% had at least one functioning toilet, only 42% of facilities had handwashing stations at or near toilets or latrines. The report also found that 95% of facilities did not meet MoH standards in terms of water quantity and only 63% had a functioning incinerator.10 In the same year, the Government of Liberia’s Health Sector Assessment noted that many facilities lack latrines, electricity and sanitation workers to clear and dispose of waste. Some have leaking roofs and lack hand pumps to provide water; many lack proper waste storage and disposal facilities, burial pits and wastewater systems and are badly in need of reconstruction and rehabilitation.11 According to the public health law of Liberia, water quality in health facilities is to be tested twice yearly. However, 65% of health facilities test their water once yearly.12 The lack of proper water and sanitation infrastructure and poor hygiene practices in healthcare facilities reduces facilities’ preparedness and response to disease outbreaks. This decreases the communities’ trust in the health services provided, especially with the threat of nosocomial (hospital- borne) infections. For example, an independent study published in the World Health Organization (WHO) Bulletin estimated that outpatient visits dropped by over 40% during the EVD outbreak due to the fear of contracting the virus in a health facility or from a health worker.13 At the community level, CLTS activities that depend on community engagement in promoting positive WASH behavior have shown to be effective. This includes using hand dug wells and pumps and reinforcing defecation-free environments. Unfortunately, these activities were affected by restriction on movement during the EVD outbreak, limiting monitoring visits to communities when CLTS initiatives were needed the most.14 The National Rural Water Sanitation and Hygiene Program (NRWASHP) has noted that community-level WASH is a priority but is constrained by inadequate and unreliable access to potable water, non-functioning hand pumps and poor groundwater. Community WASH teams are often under- resourced and dependent on NGO funding, lacking community management, systematic monitoring and evaluation and staffing. A UNICEF Analysis of Accountability for WASH Services’ Sustainability within Health Systems in Liberia stated that tackling accountability in governance and management of the WASH sector is a critical aspect to making long term, sustainable improvements, especially involving the use of public funds to improve service quality and the importance in receiving user feedback.15

MATERNAL AND CHILD HEALTH (AND NUTRITION) In 2012, Liberia was one of the first countries in sub-Saharan Africa to achieve its millennium development goal target of reducing the mortality rate of children under the age of five to one-third of its 1990 level. Contributing to this success were programs to prevent and treat malaria among children and progress in extending vaccine coverage. By 2015 however, Liberia’s maternal mortality ranked among the highest in the world at 1,072 deaths/100,000 live births, with maternal and newborn deaths attributed mainly to preventable, treatable complications.16 The Liberia Investment Case for Reproductive, Maternal, Neonatal and Child Health states that maternal death in Liberia is caused by hemorrhage (25%), hypertension (16%),

9 Liberia Wins, Government of Liberia, 2016 10 Liberia WASH in Health Facilities: Baseline Report. USAID/MOH/WASH Liberia. 2015. 11 Liberia Health Sector Assessment Report. Government of Liberia. 2015. 12 WASH in Health Facilities Baseline, 2015 13 Abrampah, N. et al. 2017. 14 Third Annual WASH Joint Sector Review, 2015 15 Analysis of Accountability for WASH services Sustainability within Health Systems in Liberia. UNICEF, Division of Environmental and Occupation Health. April 2016. 16 Liberia Investment Case for RMNCAH 2016-2020. Liberia Ministry of Health. 14

unsafe abortion (10%) and sepsis (10%). Neonatal deaths are 35% of the under 5 deaths, with prematurity as the leading cause of neonatal death.17 Further, major rural-urban health services face inequalities when it comes to accessibility and facilities lack access to both knowledge and equipment to address complications. In 2015, a population based survey using 2012 data found that for women living in the farthest quintile from the nearest health facilities, the distance lowers their odds of attending ANC checkups, delivering in a facility and receiving postnatal care. Children are less likely to receive care for fever, receive deworming and seek acute respiratory infection or diarrheal care from a formal health worker.18 Malnutrition is also an issue in the country, especially for young mothers and their children. A 2016 USAID Food Security Desk Review for Liberia highlighted that nearly 40% of Liberian adolescents have already begun childbearing before age 18, which puts them and their children at a higher risk of malnutrition and adverse pregnancy outcomes in addition to HIV, which has a higher incidence in pregnant women.19 Stunting, which indicates chronic malnutrition over a long period, affects 1/3 of Liberian children under 5. Stunting places the country in the WHO ‘high’ classification with a prevalence over 30%, most notably in River Gee county (43%). Wasting, which indicates acute malnutrition, is 6% nationally, falling into WHO’s ‘medium’ category, especially in food insecure counties such as Bomi, Grand Bassa and River Cess.20 During the EVD outbreak, services for women and children were particularly affected, with estimated declines of 43% for antenatal care, 38% for facility births, 45% for measles vaccinations and 53% for diphtheria-tetanus-pertussis vaccinations between August and December 2014, as compared to the previous year.21 Government HMIS data, highlighted in the Investment Plan for Building a Resilient Health System in Liberia, shows reversals in the gains made in maternal and child health interventions, ANC, skilled deliveries and immunizations since the EVD outbreak. During the EVD Outbreak, total health facility deliveries dropped. The Government estimates that facility-based deliveries decreased by 38% and first ANC visits decreased by 43%.22 County facilities that closed during the EVD outbreak resulted in a decline in utilization of antenatal visits and pregnant women receiving IPTp for malaria. The decline in care-seeking is likely due to both supply and demand factors modified by the outbreak, including the fear of contracting Ebola at health facilities, mistrust of health workers and clinic closures.2324 This damaged confidence in health systems caused grave repercussions for maternal and child mortality rates, due to disruptions in health services. An independent research report published by the World Bank Group estimates that higher mortality rates in the future will likely be due to the loss of health workers who died from EVD. Assuming healthcare workers lost to EVD are not replaced, it is estimated that the reduction in health personnel may increase maternal mortality by up to 111% in Liberia. Further, under-five mortality may increase by up to 28% in Liberia and infant mortality increase 20%.25

FAMILY PLANNING Early childbearing is a significant challenge for women in Liberia, given 38% of 15-19 year old girls are currently pregnant or have at least one child and 69.3% of all unmarried, sexually active 15-19 year old

17 Ibid 18 Remoteness and maternal and child health service utilization in rural Liberia: A population–based survey. Journal of Global Health. December 2015 19 Food Security Desk Review for Liberia 2016-2020. USAID Office of Food for Peace. February 2016. 20 LISGIS, MoH and Social Welfare, National AIDS Control Program and ICF International. 2014. Liberia Demographic and Health Survey 2013. Monrovia, Liberia: Liberia Institute of Statistics and Geo-Information Services. 21 Food Security Desk Review 2016-2020. 22 Investment Plan for Building a Resilient Health System in Liberia. Liberia Ministry of Health. May 2015 23 How did Ebola Impact Maternal and Child Health in Liberia and Sierra Leone? October 2015. CSIS. 24 Dahn, B. et al. Services for Mothers and Newborns During the Ebola Outbreak in Liberia: The Need for Improvement in Emergencies. April 2015. 25 Evans, D The next wave of deaths from Ebola? The Impact of Healthcare Worker Mortality. World Bank Group. July 2015 15

girls are not using a method of contraception.2627 The last Liberia Demographic and Health Survey (DHS) in 2013, showed that while there are married adolescents, among those 15-19, 75% don’t want a child in the next two years, yet only 17.8% are using a contraceptive method.28 This demonstrates the existing unmet need for FP services. FP is critical in light of burgeoning maternal and neonatal mortality. Babies born to adolescent mothers are at greatest risk of infant and under-5 mortality in Liberia.29 The question of knowledge and accessibility is critical. There is a lack of sex education in schools and at home. There is an unwillingness or inability of some health workers to discuss contraceptive options with youth, which restricts the information that adolescents receive about contraceptive options.30 There are widespread and frequent stock-outs and limited storage capacity of FP commodities, limiting accessibility.31 Increasing access to knowledge and use of contraceptive methods can be emphasized through a multilayered social and behavioral change approach that targets audiences at multiple levels and in different, complementary spaces to provide men, women and youth with information on family planning methods and improve linkages to other health services. For example, results from a 2012 pilot showed success in integrating services like immunization along with family planning. Mothers bringing in children for routine immunization were targeted by vaccinators for FP, such as same day and on-site referrals. Over 80% of referred women completed the FP visit that day, with over 90% accepting a contraceptive method that day. Those referred women accounted for 44% and 34% of total new contraceptive users in Bong and Lofa counties.32

INFECTIOUS DISEASES In addition to drastically affecting maternal mortality and WASH systems, the presence of EVD in Liberia and the massive disruption of health service delivery had a severe impact on infectious disease transmission and treatment. According to Government reports, independent research bodies and news sources from 2014-2016, clinics were closed, health seeking behaviors were negatively influenced, essential medicines were out of stock, patient tracking for drug adherence dwindled and preventable or treatable diseases went undiagnosed and untreated as febrile patients or those with diarrhea were often avoided or stigmatized due to fears of Ebola.333435 Poor health seeking behavior and misinformation caused measles vaccination rates to drop from 77.8% in January 2014 to 44.8% in January 2015. The 2014 measles campaign was suspended and community confusion between a start-up EVD vaccine campaign and the measles campaign led to fear of vaccinators and rejection in many communities. The low vaccination rate resulted in Liberia recording over 850 measles cases in the first six months of 2015, the largest outbreak in years.36 Researchers from the Yale School of Public Health, estimate that during the year-long EVD outbreak, the estimated 50% reduction in access to necessary treatment services meant that an extra 600 Liberians died

26 At a glance, Liberia 2014. UNICEF. 27 Food Security Desk Review 2016-2020 28 Adolescent contraceptive use. Data from the Liberia Demographic and Health Survey (LDHS) 2013. WHO. 29 At a glance, Liberia 2014 30 UNFPA Launches Programme to Reduce Teenage Pregnancy in Southeastern Liberia. Front Page Africa Online. 31 Family Planning 2020- Country Action: Opportunities, Challenges and Priorities (Liberia). 32 Cooper et al. Successful Proof of Concept of Family Planning and Immunization Integration in Liberia. Global Health: Science and Practice March 2015, 3(1):71-84; 33 Joint Annual Health Sector Review, 2016 34 IRIN. "Ebola hampers HIV/AIDS care in Liberia." IRIN News, November 21, 2014. Accessed June 27, 2017 35 Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research. International Journal of TB and Lung Disease. 2015 36 CDC Liberia Fact Sheet. July 2017. 16

from Tuberculosis (TB) and another 1,000 died from HIV and malaria. That’s on top of the 4,800 killed at the hands of EVD itself.3738 It has proven difficult to conduct a definitive study of the exact burden of TB. Estimates place Liberia as one of the countries with the highest TB burdens in the world, with one in every 300 people having the disease.39 Before Ebola, the cure rate for the deadly bacterium stood at 55%. Now, in some parts of the country, it’s closer to 28%.40 Rural counties have a higher smear positive proportion and lower smear negative cases than the capital due to a lack of other diagnostic equipment other than a microscope.41 Factors that favor TB like overcrowding are drivers in the capital and there are notable gaps in the surveillance system to capture data on possible detections, especially for those already infected with HIV. TB clinics often do not offer HIV testing and counseling or patient referrals for those co-infected.42 The disruption of treatment for many during the EVD outbreak, where TB treatment was offered in 21% of facilities and prescription and ARV treatment was available in just 12% of health facilities, not only negatively affected their health but also could have led to drug resistance for both TB and HIV drugs.43 Directly Observed Treatment, Short-course (DOTS) is the adopted global strategy to control TB and was introduced in Liberia in 1999.44 Noted as the key contributor to reducing incidence of TB, DOTS access and supervision needs to be increased to improve treatment success rates. Providing TB care and achieving favorable treatment outcomes requires a fully functioning health system, accurate patient tracking and high patient adherence to treatment.45 Malaria has long been deadly in Liberia, accounting for about 40% of outpatient department attendance and 33% of inpatient deaths.46 The full extent of the impact of the EVD outbreak on progress achieved in malaria control in Liberia is not yet known. Data suggesting significant setbacks in progress include the drop in coverage of IPTp for prevention of malaria in pregnant women, from 52% in April 2014 to 9.5% in November 2014. The average monthly number of malaria cases treated by the public sector with Artemisinin-based Combination Therapy (ACTs) dropped by more than 52% during the September- December 2014 period, compared with the seven months prior.47 Malaria prevention behaviors such as correct and consistent use of long lasting insecticide treated nets (LLINs) for both adults and children, are difficult to enforce48 and require additional support from community health volunteers (CHVs).49 Malaria surveillance systems require equipment, supplies, training and mentoring for entomologic technicians to best determine case prevalence, mosquito densities and species distribution. Such systems are part of a national laboratory system.5051 Community-based disease surveillance through CHVs plays a large role, especially in case detection. There is a recognized need to scale up malaria control and prevention, including directed funding to improve M&E systems and supply chain management for seamless commodity distribution, namely for LLIN distribution and prophylaxis,52

37 Effects of Response to 2014–2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS and Tuberculosis, West Africa 38 As Ebola wanes, a spike in infectious disease sweeps through Liberia. Stat news. March 2016. 39 As Ebola wanes, March 2016 40 Ibid 41 National Leprosy and Tuberculosis Strategic Plan 2014-2018. Liberia MoH. 42 Ibid 43 IRIN. "Ebola hampers HIV/AIDS care in Liberia." IRIN News, November 21, 2014. 44 National Leprosy and Tuberculosis Strategic Plan 45 Ebola, fragile health systems and tuberculosis care. 2015 46 PMI Liberia Malaria Operational Plan FY 2017 47 Ibid 48 National Malaria Communications Strategy. Liberia MoH, National Malaria Control Program. 49 Liberia Community Health Road Map, July 1, 2014-June 30, 2017. Liberia Ministry of Health. March 2014. 50 CDC 2017 51 Presidents Malaria Initiative (PMI). Malaria Operational Plan FY 2017. 52 Ibid 17

especially for pregnant women. In Liberia, these systems are underfunded, understaffed and underskilled, preventing them from coordinating a quick response to public health threats.53 HIV/AIDS has a relatively low prevalence in Liberia, with a 1.1% prevalence in 15-49 year-olds as of 2015.54 There is a need for interventions to address the inequity in urban versus rural areas, in females compared to men and in key populations compared to the general population.5556 Comprehensive knowledge on HIV risk and transmission (risks of breastfeeding, unprotected sex, multiple concurrent partnerships) is low. For example, only 37% of women and 34% of men know that use of condo and having just one uninfected partner can reduce the chance of getting HIV and that healthy-looking persons can be infected.57 Key populations including commercial sex workers (CSW), men who have sex with men (MSM) and injectable drug users (IDUs) are often targeted by law enforcement for engaging in illegal activities. Therefore, these persons are afraid to access services for fear of discrimination or even prosecution and imprisonment.58 Liberia is one of the few countries that have not attained the global target for leprosy elimination of less than 1 case per 10,000 population. Country data over the last three years show a trend of continuous transmission of the disease with high notification of new cases.59

NON-COMMUNICABLE DISEASES In 2016, according to the WHO, non-communicable diseases (NCDs) including cardiovascular disease (11%), cancer (5%), respiratory disease (6%), diabetes (2%) and other NCDs (10%) constituted 34% of all deaths in Liberia.60 The prevalence ranking of the most deadly of these diseases, cardiovascular disease, has remained unchanged over the last decade, staying steady as the seventh leading cause of death in Liberia.61 This shows there is room for improvement and investment, especially in prevention strategies, since they are less expensive than treatment. Investment in prevention strategies such as lifestyle changes, diet and physical exercise, public health campaigns, were highlighted by a medical study by Liberian nurses as a priority area for intervention to combat obesity and its closely related diseases (cardiovascular disease and diabetes).62 According to the WHO, some of the lifestyle related prevention strategies that have been shown to reduce the risk of cardiovascular disease and other NCDs include; eliminating tobacco use, reducing salt in the diet, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol.63 While NCDs account for roughly a third of all deaths in Liberia, they collectively cause the most disability in the country. In 2015, six of the top ten causes of disability were NCDs: (#2) lower back and neck pain, (#4) sense organ diseases (such as blindness), (#5) skin diseases, (#6) depressive disorders, (#9) migraines and (#10) anxiety disorders.64 While most of these conditions are not lethal, they do contribute to the burden of disease in Liberia and reduce the number of productive years in the population. Over time, this

53 CDC 2017 54 UNAIDS Liberia HIV & AIDS Estimates, 2015 55 National HIV & AIDS Strategic Plan 2015-2020. Liberia MoH 56 Liberia: HIV Epidemic Situation. National AIDS Commission. 57 Ibid 58 Ibid 59 National Leprosy and Tuberculosis Strategic Plan 2014-2018. MoH. 60 World Health Organization. Diabetes Country Profile Liberia. 2016. 61 Institute for Health Metrics and Evaluation. Liberia data page. 2015. Accessed August 7, 2017. 62 Donkor, Noble et. al. Cardiovascular and type 2 diabetes risk factors in Liberian nurses. International Journal of Africa Nursing Sciences Volume 4. 2016. 63 World Health Organization. “10 Facts on the State of Global Health.” May 2017. 64 Institute for Health Metrics and Evaluation. Liberia data page. 2015. 18

has a great impact on the country’s productivity. They therefore should be given more attention as priority intervention areas for health programming.

MENTAL HEALTH In the wake of Liberia’s civil war that ended in 2003 and the EVD outbreak that hit in 2013, the incidence of mental illness, including depression and post-traumatic stress syndrome (PTSD) has been on the rise. According to the World Bank, in 2008 (the latest statistics on record) 40% of Liberians had symptoms of major depression and 44% appeared to have PTSD.65 Furthermore, according to WHO estimates, as many as 1 in 5 Liberians now suffer mild to moderate mental disorders.66 However, this increased incidence has not been met with sufficient services to handle it. As of April 2016, there were only 160 health workers who had received any mental health training and only one mental health hospital with 71 beds and one psychiatrist.67 NGOs have identified this dearth of trained health professionals with experience in mental health training as a priority area for intervention. NGOs such as the Carter Center have stepped in to provide such training. Since 2010, the Carter Center has worked with partners to train mental health clinicians to establish new services in communities. Services include; opening clinical practices in prison systems, training midwives to screen for maternal depression and providing psychosocial support to those affected by the EVD crisis.68

ANIMAL AND VETERINARY HEALTH There is scanty data post-2014 on Animal and Veterinary Health. Information is not consistently, sufficiently or systematically shared between animal health and human public health systems.69 During the EVD outbreak, the population was concerned with animals, namely bats, as they related to carrying the virus or other harmful diseases. However, all animals can be vectors for disease. This intensifies the need to screen livestock entering border crossing points and inspect them at the point of entry to determine if animals carrying diseases can be quarantined prior to entering populated areas or before being sold for consumption.70Many farmers lack technical knowledge to treat their livestock and poultry and there is a scarcity of animal drugs in the country.71 This is exacerbated by the fact that there have been a limited number of veterinarians in the country since 2007.72 Additionally, the field of veterinary science and medicine has not been addressed, as the current educational system does not offer the option of a veterinary degree73. This intensifies the issue of prevention of diseases that are easily transmissible from animals to humans. Liberia currently does not have a field network or established procedures to conduct zoonotic disease surveillance due to inadequate staff and technical capacity.74 According to the Global Health Security Agenda (GHSA), countries must identify priority zoonotic diseases of domestic and wild animals, raise awareness of disease control and good animal husbandry practices and prioritize resources to ensure the reduction of potential spillover of zoonotic diseases into the human population.75

65 Mayhew, Melanie. As Liberia and Sierra Leone recover from civil wars and Ebola, demand for mental health services surge. World Bank. April 2016. 66 World Health Organization. Mental health services in Liberia; Building back better. March 2016 67 Mayhew, Melanie. World Bank, 2016 68 The Carter Center 69 World Health Organization/Outbreaks and Health Emergencies. Joint External Evaluation of the Republic of Liberia Mission Report. September 2016. 70 Ibid 71 Liberia Daily Observer. Veterinary Medicine is Scarce in Liberia. January 2014. 72 Ibid 73 Joint External Evaluation of the Republic of Liberia Mission Report. September 2016. 74 Ibid. 75 Ibid 19

HEALTH SYSTEMS STRENGTHENING The EVD outbreak exposed the fragility of the existing health system, while introducing new priorities for future management and systematization for improved health outcomes and infectious disease prevention. After the civil war, the country was focused on rebuilding to improve its ability to provide care and improve citizen’s quality of life. This included not only the concrete needs of health facility infrastructure and development but also organizational and human resource capacity development. The delivery of health services takes place at three levels in Liberia; the primary level consists of the health clinics and health centers; the secondary level comprises the county and regional hospitals; and the tertiary level is the John F. Kennedy Hospital located in Monrovia. At each level, the country faces a shortage of health workers, poor health information systems, limited medical supplies and an ailing health infrastructure. There are major challenges in adhering to quality of care standards (as well as WASH standards). Out-of-pocket expenditure, including payment of user fees in public health facilities, is the predominant method of health financing.76 There are inequities in access to facilities in urban compared to rural areas. Overwhelmingly, the number of written resources dedicated to health system strengthening in Liberia are the most numerous out of the other sectors identified for this review. In addition to destroying weak supply chain systems, the EVD outbreak saw a number of key organizations providing technical assistance in the supply chain leaving the country at a time when the country was most in need. The EVD outbreak also saw huge consignments of commodities being brought into the country as a response from the international community. This led to a major increase in logistical requirements for the country and supply chain management (SCM) staff. This placed a huge burden on a system that was already weak.77 The supply chain is hindered by poor roads, understaffed warehouses, interrupted power supply and an inadequate cold chain,78 not to mention poor management capacity of inventory and stocks that lead to nationwide stock-outs of essential commodities. Inadequate capacity to manage medicines and related health products can lead to increased costs and wastage. Financially, some medicines may cost a few cents but often new interventions, such as those for family planning, are much more expensive. Also, the absence of professional health supply chain managers means that pharmacists, nurses and other healthcare professionals often perform logistic functions, though they often have little specific training in logistics and are usually needed elsewhere in the health system.79 In 2001, African leaders agreed in Abuja, Nigeria to allocate a minimum 15% of GDP towards health sector strengthening. However, while Liberia’s total per capita health expenditure increased to $63 million in FY 2014/15, the share of the national budget for health only reached12.36%, according to Ministry of Finance & Development Planning.80 Liberia’s investment in health is low, lacks comprehensive health financing policies and strategic plans, requires extensive out of pocket payments, has weak financial management, inefficient resource use and weak mechanisms for coordinating partner support.81 The National Health and Social Welfare Financing Policy and Plan (NHSWFPP) 2011-2021 identifies health funding sources through a mix of donor support, user fees and mechanisms for risk pooling and taxes.82 However, independent studies show that most of the budget in Liberia for the health sector still comes from out- of-pocket expenditure, including payment of user fees in public health facilities and bilateral and multilateral

76 Zolia Y, Musa E, Wesseh CS, et al. Setting the Scene for Post-Ebola Health System Recovery and Resilience in Liberia: Lessons Learned and the Way Forward. Health Systems Policy Res. 2016. 77 Supply Chain Management Training-Road Map for Liberia: A Sustainable Solution for Supply Chain Capacity Development. August 2015. 78 Investment Plan, 2015 79 Supply Chain Management Training for Liberia, 2015 80 Investment Plan, 2015 81 Liberia Health Sector Scan, 2016. Africabio Enterprises, Inc 82 Investment Plan, 2015 20

donors.8384 Since 2008, the MoH has implemented a transitional Health Sector Pool Fund (HSPF), a negotiated initiative under which donors agree to jointly provide financial assistance to implement Liberia’s 2007 National Health Plan. The Health Sector Pool Fund focuses on payment of health workers salaries and incentives, availability of medicine and supplies, risk mitigation and administration.85 These are all recognized areas of weakness within the larger health system. Liberia has a need of facility-level quality improvement efforts, such as strengthening regulation of services and updating and increasing adherence to both national and international standards. The Liberian accreditation system was designed and implemented by the MoH in collaboration with the Clinton HIV/AIDS Initiative (CHAI) in 2009 to determine the degree to which all health facilities are meeting the required clinical standards, as well as management standards necessary to provide those services.86 The EVD outbreak in 2014 tested those standards, finding that many were less than sufficient for the population, especially in an emergency situation.87 The WHO stated that Liberia has one of the world’s smallest and least skilled health workforces. EVD created a heavy toll on health systems due to the noticeable loss of this workforce. In Liberia, 0.11% of the general population died from EVD but Liberia lost 7.16% of its health workers. Furthermore, due to university closures, the country lost a graduating class of skilled health workers.88 Critical issues to be addressed within the public sector health workforce include; ensuring health workers are on payroll, improving the performance management system to regulate production and practice, identifying ways to better retain and incentivize health workers (especially in rural areas) and regulating the pressing needs for specific cadres of health workers such as midwives.89 Training and improved health communications in infection, prevention and control, as well as general health education, are priorities. The ‘don’t touch’ guidance from the Government during the EVD outbreak led to a decrease in treatment of both adult and child patients with preventable diseases.90 Refresher trainings and accountability are needed, regardless of whether EVD is present. There are currently disparities in the health workforce coverage in rural areas and outside the capital, hence hiring more health workers is a major priority, especially in rural areas.9192 QUESTION 2: WHAT DO RELEVANT GOVERNMENT INSTITUTIONS IDENTIFY AS THEIR PRIORITIES AND HAS THERE BEEN ANY PROGRESS IN ACCOMPLISHING THEIR GOALS IN THE HEALTH & WASH SECTORS?

Overall Government Priorities and Progress Cross-cutting and Integrated Themes Health investment is a cross-cutting theme for both human and national progress. The guiding documents for economic development in Liberia including the Economic Stabilization and Recovery Plan (2015), Agenda for Transformation: Steps Towards Liberia Rising 2030 (2012) and Education Sector Strategy 2010-2020, all include health in their frameworks as a key priority for the future of the country’s development.

83 Setting the Scene, 2016 84 Liberia Health Sector Scan, 2016. 85 Joint Financial Management Assessment Report. MOH. August 2016. 86 Cleveland, E. et al. Introducing health facility accreditation in Liberia. Global Public Health. 2011 Apr; 6(3): 271–282 87 The Liberian MoH and WHO launch Training on Safe and Quality Health Services. WHO Regional Office for Africa. August 2014. 88 How did Ebola Impact Maternal and Child Health in Liberia and Sierra Leone? October 2015. CSIS. 89 Investment Plan, 2015 90 Siekmans, K, et al. Community-based health care is an essential component of a resilient health system: evidence from Ebola outbreak in Liberia. January 2017. 91 Evans, D. The next wave of deaths from Ebola? The Impact of Healthcare Worker Mortality. World Bank Group. July 2015. 92 Government of Liberia Launches Historic National Health Worker Plan to Reach 1.2 Million. Last Mile Health. July 2016. 21

Several community health policies, NHSWPP for 2011–2021 and the WASH Sector Strategic Plan 2012– 2017 target a multi-sectoral response through integrating health and nutrition services with water and sanitation support, agriculture promotion and social services,93 building off of the success of integrated programs like HIV & TB and family planning and immunization.94 The MoH will implement an integrated approach to child survival and development, focusing on convergence and integration of health, nutrition and WASH activities to achieve greater positive outcomes. These efforts include expanded integrated management of childhood illnesses, including screening and treatment of infant tuberculosis and HIV infections in health facilities, increased coverage of immunizations, improved nutrition action (especially for breastfeeding,) interventions for improved behavior change and implementation of family health practice.95 Guiding Body for Public Health Improvements A major step towards progress was the founding of the National Public Health Institute of Liberia (NPHIL) in December 2016, a partnership of the GoL with the Center for Disease Control (CDC), National Institutes of Health (NIH) and WHO. The Institute focuses on the following areas: • The development of the public health workforce; • The expansion of surveillance and response activities; • Conducting health and medical research to inform Liberian health policies and infectious disease epidemiology; • Laboratory and public health diagnosis. Clinical diagnosis will still be the role of the MoH but infectious disease outbreak response and environmental and occupational health safety will be a key function of NPHIL, as well as public health and medical research and training and capacity building. NPHIL will also serve as the key advisor to MoH on evidenced-based policy decisions. NPHHIL’s focus is on prevention; chronic NCD disease, food safety, water, hygiene, sanitation and road traffic injuries. However, it will investigate deaths, do audits and make recommendations; before the EVD outbreak, these would not have been a Government priority.96

WASH Before the EVD outbreak, the Government released the WASH Sector Investment Plan to cover the years 2012-2017. Ongoing WASH reform is driven by national policies developed since 2007 (National Integrated Water Resources Management (IWRM) Policy, Lift Liberia Poverty Reduction Strategy I, Water Supply and Sanitation (WSS) Policy, Agenda for Transformation Poverty Reduction Strategy II and the Liberia WASH Compact: Sanitation and Water for All (2011)). Since 2014, there have been several strategies and documents developed to guide the WASH priorities in Liberia, using EVD as a catalyst for urgent change in revamping the sector.97 The 2014 desk review of the WASH Sector found that out of the six 2012 WASH commitments made by the GoL, four were making ‘slow progress’ or experienced ‘major barriers’ in 2014, including advocating for 0.5% minimum GDP for sanitation and hygiene, creating a clear budget line for WASH, improved M&E systems for WASH and the implementation of a Rural Water Supply and Sanitation Bureau mobilized at the community level.98

93 Food Security Desk Review 2016-2020 94 Successful Proof of Concept of Family Planning and Immunization Integration in Liberia. Cooper et al. 95 Investment case for RMNCAH 96 Rebuilding Liberian Public Health: A Q&A with Tolbert Nyenswah. Global Health Now. March 13, 2017. 97 Water, Sanitation & Hygiene Sector Performance Report 2015. August 2015. WASH Liberia. 98 Liberia WASH Sector Assessment Desk Review 2014. Tetratech/USAID. June 2014. 22

WASH is undoubtedly an area requiring investment, it is not currently a stand-alone budget sector and there is inconsistency around whether WASH has been prioritized financially by the Government or not. There are five policy areas within the national budget that have identifiable budgets for WASH: Table 1: GOL WASH Budget Allocations National Budget Sector Ministry & Agency Budget Policy Area That Includes WASH Municipal Government Monrovia City Corporation Urban Decentralized Services Education Ministry of Education Student Counseling, Health and Hygiene and Extra-Curricular Activities Infrastructure and Basic Services Ministry of Public Works Rural Infrastructure and Community Services Energy and Environment Liberia Water and Sewer Corp. Water and Sewer Services Public Administration General Services Agency Administration and Management Source: Water, Sanitation & Hygiene Sector Performance Report 2015. August 2015. WASH Liberia. The recognition that the WASH sector has specific and often cross-cutting needs outside of the different agencies calls for separate funding of this sector, with key Government priorities noted in coordination, behavior change, monitoring and evaluation, systematization and rehabilitation. Progress has been made in the initiation of a centralized WASH Sector Capacity Development Support Team to operate through the newly formed National Water Resources and Sanitation Board and the Water Supply and Sanitation Commission (WSSC). This will help ensure effectiveness and efficiency, develop country and district WASH plans and standardized regulations and guidelines. This includes WASH services sustainability frameworks, personnel training and oversight of improved CLTS activities (which prevent open defecation and improve community level waste management and accountability).99100101 At the country level, capacity development and decentralized decision making will aid in better facilitated emergency preparedness and response mechanisms. Rehabilitation will focus on sound construction and maintenance of sewage systems, water sources like hand pumps and wells, health facilities and school WASH infrastructure. The MoH’s 2014-2017 Community Health Road Map (2014), Joint Sector Review (2016) and Sector Performance Report (2015) all emphasize that monitoring and evaluation is key to effective service delivery, reporting and enforcing accountability measures, especially at health facilities and in rural areas. The Government will develop new advocacy strategies to increase Government funding for the sector, focusing on engagement of NGO and public-private partnerships and donors to support the Ministry and coordinating more closely with the health and education sectors. Finally, behavior change is a critical priority from the community level upwards to improve personal hygiene practices including enforcing hand washing, food safety and preventing open defecation.102103 WASH in schools, defined as “Liberia’s first step to recovery from Ebola” will focus on institutionalization of hygiene education as part of school activities, as well as ensuring toilets are gender separated, the toilet- student ratio is reduced and safe drinking water is available for all students.104 The Government of Liberia developed and launched a ‘WASH in schools’ policy complete with updated curriculum and reporting indicators.105 WASH activities will have participation from school, community, parent and teacher associations and children that will support behavior change. At the health facility level, in the Government’s WASH and Environmental Health Package in Health Facilities report, Liberia aims to reach the minimum standards that reflect WHO/UNICEF recommendations, namely measuring water demand by facility type

99 Liberia's Third Annual Water, Sanitation and Hygiene Joint Sector Reviews: Event report. July 2015. UNICEF. 100 Water, Sanitation & Hygiene Sector Performance Report 2015. August 2015. WASH Liberia. 101 Liberia Community Health Road Map, 2014. 102 Ibid 103 WASH Baseline 2015 104 Liberia Wins: Water, Sanitation and Hygiene in Schools. Government of Liberia. 2016. 105 Sector Performance Report 2015 23

(clinic, center, hospital) and creating the means to improve infection prevention and control through improvements in laundry facilities, storm water drainage systems, hand washing facilities, toilets, bathrooms and wastewater collection, mortuary and healthcare waste management facilities (i.e. burn pits, incinerators).106 The GoL is committed to promoting CLTS to reduce open defecation, as detailed in the Guidelines for CLTS Implementation in Liberia (2012).107 In the first year after Liberia adopted the Open Defecation Free approach in 15 counties, 48% of the targeted communities achieved Open Defecation Free (ODF) status. One year later the ODF rate was over 70% in the poorest rural districts in the Southeastern, Northwestern and Central Regions.108 After the EVD outbreak, the Government determined that EVD didn’t occur in any of the ODF communities and a report by the NGO Global Communities found that approximately half of the number of communities in Liberia that became ODF over the last five years reached this status in the last 21 months prior to the 2015 report.109 All of Liberia’s 15 counties have County WASH Teams in place to facilitate coordinated interventions at the subnational level.110 A decentralized and active CSO network was founded in 2015 to advocate for the sector. The involvement of health workers has enabled progress of WASH at the health-care facility level, especially for training, improved practices and infrastructure investments.111 A National Rural Water Sanitation and Hygiene Program (NRWASHP) Development Study found that NGOs played a significant role in the development of the rural WASH sector through policy research, advocacy and direct implementation of WASH projects, with funding from a variety of development partners. Improvements in water and sanitation infrastructure, hygiene and infection prevention and control practices helped re-establish trust between health-care providers and communities and increased the use of health-care services.112 Other progress includes the development of the National Rural WASH Monitoring and Evaluation Framework under the National Rural WASH Program Development in 2015, where additional hydrometric and meteorological stations were established to expand the water resources data collection network.113

MATERNAL AND CHILD HEALTH (AND NUTRITION) There is strong political commitment to ensure accelerated expansion of primary healthcare and creation of a favorable environment for expanding maternal, child and newborn health services. Liberia has signed its commitment to the Sustainable Development Goals 2030 (SDGs), Family Planning 2020, African Health Strategy, Paris Declaration, Maputo Call to Action and the UN Secretary General’s Global Strategy for RMNCH Accountability and Results. These political commitments also include a willingness to make financial commitments. As a signatory to the Every Woman, Every Child initiative from the UN, there is a commitment to achieving a 10% budgetary allocation for reproductive health by 2030.114115 In Liberia's Commitment for the Global Joint Action Plan for Women and Children's Health of September 2015, it is noted that there has been a gradual increase from 2013 in its national annual budgetary allocation to the

106 WASH and Environmental Health Package in Health Facilities. October 2015. MOH. 107 Food Security Desk Review 2016-2020 108 WASH Baseline 2015 109 Sector Performance Report 2015 110 Ibid 111 Abrampah, N. et al Improving water, sanitation and hygiene in health-care facilities, Liberia. Bull World Health Organization 2017; 95:526-530. 112 In Brief: National Rural Water Sanitation and Hygiene Programme (NRWASHP) Development Study: Inception Report. March 2014. 113 Joint Sector Review 2015. 114 Investment case for RMNCAH 2016-2020. 115 Liberia's commitment for the Global joint action plan for Women and Children's Health. MOH. September 2015. 24

health sector from 10% to12.36%. This includes a budget line for maternal and newborn health, however, the allocations are less than 1% of the total budget allocated for health.116 The Liberia Investment Case for Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH 2016-2020) states that RMNCAH service restoration and delivery is the “number one priority of the Government of Liberia.” The Government has enacted 18 policies that include language responding to reproductive, maternal and child health needs for the years 2016-2030.117 The Government has also taken coordinated steps to address pervasive nutrition and health problems through policies and strategies, such as the National Health and Social Welfare Financing Policy and Plan (NHSWFPP) for 2011– 2021.118 Under the service delivery umbrella, the Government’s priority areas for RMNCAH interventions are: 1. Quality emergency obstetric and neonatal care; 2. Strengthening the Civil Registration and Vital Statistics (CRVS) System; 3. Adolescent health; 4. Emergency preparedness, surveillance and response, especially maternal neonatal death surveillance and response; 5. Sustainable community engagement; 6. An enabling environment of leadership, governance and management at all levels.119 The Joint Annual Health Sector Review Report (2016) also highlights priorities for capacity building of health professionals working in remote and urban areas along with training of midwives and CHVs on clean and safe delivery. Due to the shortage of highly trained health staff with specific skills in obstetrics, some task-shifting has been employed to train nurse midwives on life-saving techniques, such as caesarean sections, which will help in areas struggling with workforce attrition. As mentioned under Question 1, maternal health outcomes are directly tied to child development outcomes including malnutrition. The 2013 DHS highlighted that the Government focuses on strategies to prevent growth faltering and chronic malnutrition during a child’s first two years of life, as well as the preconception and pregnancy period. However, this desk review did not find evidence of any nutrition priorities of the Government since 2013. The GoL’s strategies focus on available training and resources on CHVs and designate health staff to support community-level activities in maternal and child health.120 Oversight and management of the systems in place to improve MCH outcomes are critical. The Liberia Community Health Road Map states that the Community Health Services Department (CHSD) at the MoH has been tasked with defining a standard package of services and prioritizing maternal, newborn and child health interventions. This is to be done by ensuring immunization coverage through awareness of Expanded Program on Immunization (EPI) activities (including a systematic outreach campaign to restore vaccination rates, especially considering the measles outbreak discussed earlier) and ensuring quality antenatal and postnatal care. The CHSD is also tasked with enabling effective referral systems, increasing training of health personnel on recognition of maternal danger signs, malnutrition and dehydration, treating malaria in pregnancy and recording newborn and maternal deaths.

FAMILY PLANNING A lack of sustained donor funding is a key constraint for family planning funding in Liberia. Since 2014, guiding policy documents such as the Investment Case for RMNCAH, along with the GoL’s written and

116 Ibid 117 Ibid 118 Food Security Desk Review 2016-2020 119 Investment case for RMNCAH 2016-2020. 120 LISGIS, MoH and Social Welfare, National AIDS Control Program and ICF International. 2014. 25

verbal commitments to international frameworks such as Family Planning 2020 and the Global Joint Action Plan for Women and Children's Health, highlight the need for increased Government financial commitments to family planning and the need for diversified donor and partner commitments. FP 2020 emphasizes advocating for a budget line for family planning from 5-15% and advocating for a strong donor and partner commitment, namely in procuring family planning commodities.121 Liberia has made a financial commitment of increasing its budget for family planning by over $5M in 5 years. Liberia is also committed to keeping all family planning services free of charge. 122 Other policy documents such as the Joint Health Sector Review and Community Health Road Map include a focus on family planning. The Road Map’s Strategic Objective 2 states a priority ‘to ensure quality service delivery of a standardized package of community health and social welfare services’ by expanding health services to include family planning promotion and counseling, distribution and dispensing of commodities to adults, adolescents and also to pregnant women.123124 In 2015, the MoH launched ‘Family Planning Week” in various communities in Montserrado County to distribute family planning methods and provide counseling aimed at students, young mothers and teenage girls and encouraging them to “Have your baby by choice, not by chance.”125 It is unclear if this initiative is ongoing or if it was ever expanded outside of the capital area. The Case for RMNCAH and FP 2020 also prioritize targeting the youth population through improved and accessible services to adolescents by providing youth-friendly services within existing facilities and including sexual education in schools. The education law was also amended to include comprehensive sex education in primary and secondary school.126

INFECTIOUS DISEASE Liberia has ramped up its focus on infectious disease since the EVD outbreak. This includes a focus on strengthened emergency preparedness, response and notification through initiating Integrated Disease Surveillance and Response (IDSR) and institutionalizing the development of an e-tool for surveillance and early warning (software, hardware, manual, training, maintenance). The Liberia Community Road Map prioritizes a standard package of services centered around utilization and greater responsibility of county health teams and CHVs to deliver health and social welfare services at the community level. These services include: Information, education and communication (IEC) and behavior change communication for community health promotion and disease prevention, disease detection and control and referral. To address HIV & AIDS, TB and malaria, the GoL rolled out National Strategic Plans for HIV & AIDS (2015-2020), TB and Leprosy (2014-2018) and Malaria (2016-2020) and under the President’s Malaria Initiative (PMI), initiated a National Policy and Strategic Plan on Integrated Vector Management for 2012- 2017. These strategic plans all place significant emphasis on surveillance, lab system and human resource capacity strengthening; and the importance of nationwide M&E systems to accurately record prevalence data, follow up and reporting. The President of Liberia is the current Chair of the African Leaders Malaria Alliance (ALMA) and malaria is one of the top five causes of death in Liberia. Vector control strategies focus on strengthening case management, enforcing indoor residual spraying (IRS) and LLINs, implemented by the National Malaria Control Program.127 Behavior change and health education on prevention and treatment especially for HIV and malaria is a major priority. The PMI 2017 strategy calls for a focused Social and Behavioral Change Communications (SBCC) framework and the GoL has rolled out a National Malaria Communications Strategy. Behavioral change priorities for malaria promote the correct and

121 Family Planning 2020 Commitment 122 Liberia Community Health Road Map, 2014 123 Ibid 124 Adolescent contraceptive use. DHS 2013 125 MOH Launches 'Family Planning Week'. The New Dawn. October 2015. 126 Liberia's commitment for the Global Joint Action Plan for Women and Children's Health. Liberia Ministry of Health September 2015 127 National Policy and Strategic Plan on Integrated Vector Management. USAID/RTI International. August 2012. 26

consistent use of mosquito nets and acceptance of IRS.128129 For HIV/AIDS, behavioral change focuses on correct and consistent use of condoms, prophylaxis use in pregnancy, abstinence and reducing the number of sex partners.130 For TB, the priorities are to reduce prevalence by expanding access to DOTS and addressing the TB needs for children and other vulnerable populations. HIV/TB co-infection is not as prevalent in Liberia as other countries but collaboration has been established between the National TB Control Program (NLTCP) and the National HIV/AIDS Control Program (NACP) and most counties now have a dedicated TB/HIV Focal Point.131 The specific role of CHVs in delivering integrated community case management (iCCM) for diarrhea, malaria and acute respiratory infection (ARI) has been developed through the Ministry and piloted with in-country partners. The GoL has standardized modules for training CHVs in iCCM, Internal Classification of Diseases and Essential Nutrition Actions (ENA), which have been rolled out at a limited level in most counties. However, there has yet to be a structured system for community based disease surveillance.132

NON-COMMUNICABLE DISEASES With the EVD outbreak under control, the Government of Liberia has recommitted itself to the management of NCDs including cancer. At a conference on cervical, breast and prostate cancer in July 2016, President Sirleaf described the Government of Liberia’s approach to fighting these and other cancers saying, “We have planned an incremental response to cancer management, beginning with active screening for breast and cervical cancer, resource-appropriate treatment of these cancers and simultaneous collection of data regarding other cancers that affect Liberian citizens. We will build our infrastructure around breast and cervical cancers then expand to provide quality care to all Liberians affected by cancer over the course of the next five years.”133 This ambitious anti-cancer program led by the current Minister of Health is now underway. This program includes increased staffing and resources for the MoH, support for the Liberia National Cancer Registry, promotion of prevention strategies including; a demo Human Papillomavirus (HPV) vaccine program, awareness raising to encourage early detection, improved diagnosis and treatment and a focus on palliative care.134 Due to the relatively short amount of time spent on it thus far, there is no data the research team could find on the MoH’s progress in any of the program components. In the Community Health Road Map, one of the stated strategic objectives (SO) was related to the prevention of non-communicable diseases. SO 2 is “to ensure quality service delivery of a standardized package of community health and social welfare services.” The first sub-objective under that SO details that the identified priority areas for this package of services are maternal, newborn and child health, with inroads made into other areas such as NCDs, HIV and TB.135

MENTAL HEALTH The MoH clearly laid out its priorities for mental health for the next five years with the creation of the 2016-2021 Mental Health Policy and Strategy Plan, the primary SOs for the Plan include:136 1. Increasing the clinical capacity of mental health professionals;

128 Presidents Malaria Initiative (PMI). Malaria Operational Plan FY 2017 129 National Malaria Strategic Plan (NMSP) 2016-2020. Liberia MoH. 130 Liberia HIV & AIDS Response Progress Report. National AIDS Commission. April 2016. 131 National Leprosy and Tuberculosis Strategic Plan 2014-2018. Liberia MoH. 132 Liberia Community Health Road Map, 2014 133 Beddoe, Ann Marie. Challenges to development of cervical and breast cancer program development in post conflict Liberia: Presentation prepared for African First Ladies' Conference, 10th SCCA Conference, Addis Abba, Ethiopia. 2016. 134 Ibid 135 Liberia Community Health Road Map, 2014 136 Mental Health Policy and Strategic Plan for Liberia (2016 – 2021). Liberia Ministry of Health. 27

2. Increasing inpatient capacity through the establishment of wellness units at all county hospitals; 3. Training selected professionals at the primary level in identifying, managing and referring mental health cases; 4. Ensuring all facilities have the necessary psychotropic drugs to expand the availability and access of mental health services in primary care; 5. Training community-based workers to recognize signs of mental illness and make referrals to the appropriate health facilities. 6. Sensitizing communities on mental health and illness and modifying negative perceptions about the mentally ill, thereby minimizing stigmatization and negative behaviors toward them. Families will be encouraged to be involved in the care and management of their loved ones; 7. Building the new Catherine Mills Mental Health Center. The current Plan builds on the previous Strategic Plan for 2010-2015. The following actions were achieved under the Plan, which will serve as a strong foundation for future improvements under the current Plan.137 1. Established the National Technical Coordinating Committee; 2. Formed a Mental Health Unit at MoH; 3. Agreement that all counties should have a Wellness Unit; 4. Drafted a comprehensive mental health law (passed in May 2017); 5. Established the Liberia Center for Outcomes Research in Mental Health (LiCORMH) to coordinate all research; 6. Provided of mental health services in prisons; 7. Created of a cadre of specialists in mental health. One hundred and sixty-six mental health clinicians were trained. In addition, some healthcare workers have been trained in mental health. In addition, social workers and some CHVs were trained in the non-clinical components. Many psychosocial support workers have been trained in psychosocial responses especially psychological first aid; 8. Curriculum development for clinical social workers; 9. Advocacy and education around mental health disorders that led to the establishment of a national consumer organization and a national anti-stigma organization; 10. Strengthened training on mental health in primary care.

ANIMAL AND VETERINARY HEALTH The Ministry of Agriculture, in its 2015 Annual Report, detailed the achievements and challenges of its various bureaus and divisions, which offer a tangential look at some of the areas most in need of improvement. The divisions related to animal health include the Animal Quarantine Division and the Bureau of National Livestock. The challenges listed by these two divisions had some overlaps including; lack of sufficient support logistics for their activities, lack of sufficient staff skills and lack of appropriate equipment. Both divisions registered some progress toward addressing the lack of sufficient staff skills in 2015 through the attendance of several staff members at regional and international workshops, seminars and conferences, as well as the training of ten quarantine technicians in surveillance and identification of symptoms of animal diseases.138 Another challenge highlighted by the Bureau of National Livestock corresponds with a priority intervention listed by other actors, namely the lack of essential animal drugs.139 As discussed in Question 1, Liberia has an acute lack of essential animal drugs with only one store in the country providing them.

137 Ibid 138 Liberian Ministry of Agriculture. Annual Report. 2015. 139 Ibid 28

This forces many animal farmers to go to neighboring countries to purchase them.140 The need for essential animal drugs relates to human health as there are many animal diseases that can infect humans. For example, in Liberia, the most common diseases among cattle are trypanosomiasis, parasites, brucellosis, cattle contagious peri-pneumonia, foot-and-mouth disease, anthrax (bacterial and symptomatic), pastoralosis hemorrhagic septicemia, piroplasmosis, anaplasmosis, babesiosis and theileriosis.141 Many of these diseases have the potential to be transmitted to humans.142 The Ministry of Agriculture has highlighted the lack of animal drugs as a challenge and presumably as an area for priority intervention. However, it is unclear whether any progress has been made on this. Within the Ministry of Agriculture, in 2015, the Department of Regional Development, Research and Extension provided extension and advisory services to 64,847 smallholder livestock farmers on improved technology. However, it is not clear whether animal disease control information or essential animal drugs were included as part of those services.143

HEALTH SYSTEMS STRENGTHENING The GoL is prioritizing a system that is responsive, effective, efficient and capable of dealing with future shocks and health emergencies.144 In many documents, the key word used by the GoL was ‘resilience’. The EVD outbreak revealed the stark weaknesses and gaps in the health system. The Government turned its focus toward avoiding the same experience in the future. The Government defines a resilient health system as one that “has the ability to absorb disturbances or shocks, to adapt and respond with the provision of needed services.”145 In the Investment Plan for Building a Resilient Health System in Liberia 2015-2021, the Government’s health system strengthening priorities fall under an overall goal of ‘achieving universal health coverage.’ This is ambitious and includes ensuring universal access to safe and quality services through improved health worker capacity. It includes ensuring a robust health emergency risk management system, through building public health capacity for prevention and response for health threats. It also includes ensuring an enabling environment by restoring trust in the health authorities’ ability to provide services (including community engagement, leadership and governance and an accountable management system). Capacity development for health and WASH personnel is key. The Liberia Water, Sanitation and Hygiene Sector Capacity Development Plan was developed in 2012 as a framework to guide the country’s steps over five years. The capacity development plan proposes a mix of strategies such as; educational upgrades, the development of sector-specific block training courses with on-going mentoring and practice, action research/pilots, scholarships and internships, support for improving teaching and learning materials, the development of a practical training center, secondments, the procurement of equipment and logistics and the development of processes, systems, guidelines and strategies.146 Performing regular capacity assessments of the workforce is a Government strategy to best place workers, ensure they are learning new skills and prevent attrition. A key aspect of improving health systems nationwide recognized by leading MoH strategy documents is to invest in robust information management systems to produce quality data and health statistics with a

140 Liberia Daily Observer. Veterinary Medicine is Scarce in Liberia. January 2014. 141 USAID Office of Food for Peace. Food Security Desk Review for Liberia 2016-2020. February 2016. 142 Centers for Disease Control and Prevention. Farm Animals Diseases. 143 Liberian Ministry of Agriculture, 2015 144 Joint Annual Health Sector Review, 2016 145 Setting the Scene for Post-Ebola Health System Recovery and Resilience in Liberia: Lessons Learned and the Way Forward. Health System Policy Res. 2016. 146 Liberia Water, Sanitation and Hygiene Sector Capacity Development Plan 2012-2017. Government of Liberia. 29

focus on data sources and indicators, management, dissemination, use and M&E.147148149150The GoL has prioritized the improvement of health Information systems over the past several years. The National Health Information System of Liberia’s strategy document was released in 2009,151 and the more recent MoH Investment Plan, Consolidated Operational Plan and Community Health Road Map built on the original strategy to include measures that account for a post-EVD environment. By improving the systematization of these processes, the health system will better manage the flow of essential medicines, supplies and commodity logistics; and sharing health information.152153 The Final HIS strategy includes 17 strategic objectives: • Five related to resources, focusing on policies and infrastructure; • Nine related to data sources and indicators, focusing on the functionality of various structures; • One related to data quality, management, dissemination and use; • Two related to the M&E of the strategic plan.154 An important priority for the Government post-EVD is to restore trust in the health system by engaging more with communities and increasing accountability of leadership and governance, as well as building referral systems from community to facility. The EVD outbreak undermined trust in the health system and the re-building process necessitates a response to these concerns to ensure future buy-in. The Community Health Road Map for 2014-2017 outlines four major strategic objectives for strengthening the national community health program, with a focus on the CHV program. Community health workers provide the most accessible (and therefore most visible) care for much of Liberia, making their performance vital to improving the perception of the health system. The Community Health Road Map consists of a detailed suite of improvements for the community health program in Liberia, including growing and tracking the population of CHVs and other community health workers, standardizing the quality of services provided by CHVs, as well as their incentives and supervisory structures, improving the referral and supply chain management systems for community health and expanding training of community health workers at all levels. By emphasizing the importance of improving community health, the GoL is working towards its key priority of achieving universal access to health services. The efforts of the Government in health systems strengthening have already seen improvement. Analysis of the 28 monitoring indicators of the National Investment Plan for Building a Resilient Health System found that progress was made in FY 2015/16, mostly in health support systems. For instance, core clinical health workers per population ratio increased from 8.6 core health workers (doctors, certified midwives, nurses and physician assistants) per 10,000 population in 2015 to 11.7 in 2016. The proportion of health facilities meeting the minimum IPC standard increased from 65% in 2015 to 73% in 2016. And the percentage of health facilities with basic utilities (i.e. water and electricity) improved from 55% in 2015 to 77%. Additionally, the health facility density ratio increased from 1.6 health facilities per 10,000 population in 2015 to 1.9 in 2016.155

147 Liberia Community Health Road Map, 2014 148 Investment Plan for Building a Resilient Health System, 2015 149 Building Capacity for Resilient Health Systems, 2017 150 Ministry of Health Consolidated Operational Plan FY 2016/2017. Liberia Ministry of Health 151 National Health Management Information Systems Strategy and Implementation Plan. Liberia Ministry of Health, 2009 152 Liberia Community Health Road Map, 2014 153 Investment Plan for Building a Resilient Health System, 2015 154 Hart, L. et al. Building Capacity for Resilient Health Systems- lessons Learned from Sierra Leone, Guinea and Liberia in the time of Ebola. USAID/ MEASURE Evaluation. 2017. 155 Joint Health Sector Review, 2016 30

QUESTION 3: WHERE ARE THE GAPS IN THE HEALTH & WASH SECTORS AND WHAT ARE KEY OPPORTUNITIES FOR USAID INVESTMENT? At this stage, the most updated wide-reaching statistical information gained from the DHS is almost 5 years-old. Liberia should be undertaking a new DHS in 2018 which will be critical for the analysis any concrete changes in the health & WASH sectors post-EVD. Community Participation Community level health investments such as community health behavior change, information sharing and governance, are critical to achieving improved health outcomes. CHVs and community members themselves play a large, cross-cutting role in disease surveillance, maternal and child health and health promotion. This is a key recommendation in the Community Health Road Map, however community level investment is not always easy to accomplish. A 2013 Community Mapping Report on community health program implementation across Liberia found that only 54% of communities had established Community Health Centers (CHCs) and only 48% of communities had an established Community Health Development Committee (CHDC). Furthermore, few local leaders were involved in community health services, leading to less community awareness and support of the CHDC.156 CHVs experience serious logistical challenges and there are many serving very remote populations who they are unable to reach regularly. It has been widely recognized that both performance-based financial and non-financial incentives are required to motivate CHVs to do their work both effectively and efficiently. NGOs provide CHVs with incentives varying from performance-based monetary incentives, to transportation reimbursements, to non- monetary incentives such as food or non-food items. There is currently a lack of standardized incentives for CHVs. These challenges can prevent CHVs from performing as effectively and efficiently as they are expected to. Unfortunately, there is no structured system for community-based disease surveillance and CHVs will require more intensive training on how to provide supportive supervision for prevention, treatment and reporting of communicable diseases, as well as making referrals.157

WASH While several areas of WASH policy have been identified and prioritized by GOL, there are still gaps and areas for continued research and future investment. At the school level, the Nationwide Assessment of WASH in Schools in 2016 noted that at current rates, over half a million students will need additional WASH facilities to meet the growing demand of enrollment in schools. Open defecation is still common in schools, which is due to the unavailability of toilet facilities, or when toilet facilities are not gender separated.158 This lack of appropriate waste management continues to be a public health and safety concern. There have been considerable gains in improving WASH within health facilities. However, the 2016 MoH WASH in Health Facilities baseline report determined that only 27% of health facilities had proper disposal for waste, 95% health facilities did not meet MoH standards in terms of water quantity and less than half had handwashing stations at latrines. Water quality remains a problem in urban and rural facilities because of the pollution of surface water, lack of sewage networks and shallow aquifers. There is a noticeable lack of dedicated and trained human resources and lack of Government funds for decentralized WASH institutions and for local Government oversight. Additionally, the peri-urban settings have not been targeted by sanitation programs by Government and there is no program targeting the urban poor.159

156 Liberia Community Health Road Map 2014 157 Ibid 158 Liberia Wins, GoL, 2016 159 WASH in Health Facilities Baseline 2015. 31

Liberia has benefited from the investment of several public and private stakeholders but the lack of coordination of WASH county-level partners for total WASH packages (hygiene, water and sanitation) remains a challenge.160 Lack of coordination often leads to underreporting, inefficiency in resource utilization, limited ownership and maintenance of facilities, inconsistent monitoring or regulation and duplication of efforts in one facility while ignoring another.161 This lack of coordination can also be seen in the inconsistent data available on the current levels of access to improved water and sanitation. In a presentation in June 2014, the National Rural WASH Program presented recent water coverage statistics variation by source. The data illustrated variations in rural water coverage from 35% to 56% and urban water coverage varying from 65% to 79%.162 Currently piped water is only accessible to towns with populations greater than 5,000 people and resources like solid waste management and sewage infrastructure are only available in Monrovia, most of which are dysfunctional.163164 Accountability measures for reporting have been lagging, including adherence to standards for reporting water quality at the community level.165 Overall, the lack of a clear strategy, accountability to international standards and lack of proper coordination among the institutions responsible for governance and implementation of WASH activities is a major concern. This is underlined by the lack of dedicated Government funding for sanitation, especially in rural areas.

MATERNAL AND CHILD HEALTH (AND NUTRITION) The Liberia Investment Case for RMNCAH, the current guiding document for MCH in Liberia, highlighted key areas in the MCH realm requiring attention and noted several distinct gaps in the current framework for addressing MCH. Liberia recognizes MCH as one of its utmost priorities and has made well-intentioned strides. However, the country is lagging in addressing many factors that contribute to poor outcomes for mothers and children, namely: 1. An insufficient supply chain management system that hampers quality of RMNCAH services. There are weaknesses in health service with limited availability of essential drugs, equipment and medical supplies. The supply challenges are due to product pilferage, improper drug storage, poor distribution mechanisms, procurement and stock management (especially the cold chain for oxytocin). 2. Inadequate number and limited skills of health workforce providing RMNCAH services. Skilled birth providers are in short supply and the country suffers from a lack of registered midwives (currently 1 for 23,000 people instead of WHO standard of 1 for 5,000). There is limited capacity in detecting pregnancy complications and inability to perform life-saving interventions (especially to stop postpartum hemorrhage, the leading cause of maternal death in Liberia). The Emergency Obstetric and Newborn Care (EmONC) curriculum needs revising to harmonize the four training programs necessary for skilled birth attendants: Life Saving Skills (LSS), Helping Babies Breath (HBB), Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and Family Planning. Additionally, students need practical training outside the classroom, which is not currently prioritized in the curriculum. 3. In line with the need for improved skills for RMNCAH workforce, the low availability/limited access to and demand for adequate health facilities for RMNCAH services is detrimental. While

160 Liberia's Third Annual Water, Sanitation and Hygiene Joint Sector Reviews: Event report. July 2015. UNICEF. 161 Water, Sanitation & Hygiene Sector Performance Report 2015. August 2015. WASH Liberia. 162 Liberia WASH Sector Assessment Desk Review. 2014. TetraTech, USAID. 163 WASH Sector Investment Plan 2012-2017 164 Development Partner response to Liberia Sector Performance Report (SPR). May 2014. WASH Liberia 165 Liberia's WASH Joint Sector Review, 2015 32

health workers lack skills, facilities are also consistently lacking equipment for lifesaving functions needed for birth and pregnancy complications. 4. Community health service delivery is a challenge due to the far distance between rural communities and health facilities. This results in less births attended by skilled personnel and fewer opportunities for mothers facing obstetric emergencies to receive timely care. This leads to maternal and infant deaths from preventable complications. A 2015 population-based study found that less than half of full-term pregnancies were delivered in a health facility and only 22.2% of mothers received the full cascade of maternal services.166 5. There is a lack of accountability among health workers and inadequate monitoring and supervision systems to ensures standards of international quality are met. 6. It is a necessity to improve birth and death registration but there is limited coordination between the Center for National Documents and Records and the Statistics Department at MoH. 7. Weak leadership, management and governance capacity at county and district level drives the need for an improved policy design process. 8. Adolescent’s face multiple issues including barriers in accessing healthcare, receiving appropriate care from properly trained providers and receiving sex education in all schools.

FAMILY PLANNING Family planning faces challenges when it comes to financing due to international funding fluctuations. However, a 2016 Cost Efficiency Analysis of FP material distribution showed that existing Liberian FP programs were cost-inefficient in terms of operational costs (those costs unrelated to direct health staff or facility management). This includes general support staff, finance managers, procurement coordinators and grant administrators. Among programs analyzed, in four other countries, Liberia’s proportion of costs dedicated to support was almost 50%; more than 40% of costs were for support costs of international staff. It is unclear why the FP sector relies so heavily on international staff. Additionally, costs of FP compared to the number of years of contraception coverage they created was $23 for Liberia (including support costs) and $12 (without support costs). More permanent or long-term methods reduce cost but Liberia had the lowest proportion of long-acting methods distributed (vasectomy, tubal ligation, IUC, IUD, 3/5yr implant) out of the other countries in the study. The fact that funds are expended to cover expatriate staff rather than project costs and that long-term methods are not widely distributed are definite gaps in addressing FP needs in the country.167168 The Family Planning 2020 Country Action Plan recognizes the gap in the need for adolescent services and outreach, including providers trained appropriately for work with adolescents, as well as the lack of disaggregation of data collected on family planning uptake for youth and adults. Improved data is necessary to better inform policy about directing resources towards youth and adult needs, especially when funding may be a challenge. The lack of data highlights additional needs for monitoring of key FP indicators to facilitate more focused programing efforts and documentation of results.

INFECTIOUS DISEASE The Liberia HIV & AIDS Response Progress Report of 2016 identified that it is a challenge to ensure effective coverage of HIV treatment services. These services are seriously hampered by the limited

166 Remoteness and maternal and child health service utilization in rural Liberia: A population–based survey. December 2015, Journal of Global Health. 167 Cost Efficiency Analysis: Distributing Family Planning Materials. International Rescue Committee. 2016. 168 Liberia DHS Analysis of Trends in Use of Modern Contraception. 2014 33

capacity of the health system in terms of qualified staff, infrastructure, equipment and inadequate procurement, supply and management systems. Though Liberia has included a focus on vulnerable populations in its AIDS and TB Strategies, the country needs to improve in stigma and discrimination facing these populations, especially within the health system. Discrimination widely affects the utilization of voluntary counseling, testing services and prevention services such as Prevention of Mother-to-Child Transmission (PMTCT) or treatment of HIV/TB co-infection.169 Additionally, it is encouraged to address attrition of HIV or TB positive individuals who fail to return regularly for appointments or who are unable due to extenuating circumstances. This treatment failure is dangerous and can result in resistance to medication and to the virus, requiring costlier second-line drugs and putting others at risk of transmission.170 There is also a need to align some TB programing and materials with the WHO recommendations, especially regarding the approach to multi-drug resistant TB (MDR-TB) treatment,171 which is not currently addressed in Liberia. Addressing the health information and communications needs of the population as it relates to disease transmission is important. The HIV Response Progress Report states that one-third of adults and almost half of youth don’t know where to get a male condom, 55% are familiar with where the closest Voluntary Counseling and Testing (VCT) site is and 20% think AIDS can be cured. During the EVD outbreak, the ‘don’t touch’ message spread far and wide, making family members afraid to touch, washing their hands numerous times per day and distancing themselves from infection but old habits resumed once the fear of EVD dissipated. It is essential for health communications to be scientifically accurate and not only drive home the ‘prevention of EVD’ message but instead focus on the ‘prevention of disease’, so that the population associates practices with overall good health behaviors. The key is ensuring the population is learning from past mistakes including what the proper IPC protocol is and when it is used. Handwashing is a good practice that must be enforced, regardless of outbreak status. Reinforcement of good health behaviors, including health promotion and general disease prevention messaging is a potential area for investment.

NON-COMMUNICABLE DISEASES Many of Liberia’s gaps regarding NCDs relate to a lack of formal policies and strategies on combatting and preventing them. For example, Liberia currently has: • No operational NCD unit/branch or department within the MoH; • No operational multi-sectoral national policy, strategy or action plan that integrates several NCDs and shared risk factors; • No operational policy, strategy or action plan to reduce the burden of tobacco use; • No operational policy, strategy or action plan to reduce the harmful use of alcohol; • No operational policy, strategy or action plan to reduce physical inactivity and/or promote physical activity; • No operational policy, strategy or action plan to reduce unhealthy diet and/or promote healthy diets; • No evidence-based national guidelines/protocols/standards for the management of major NCDs through a primary care approach; • No NCD surveillance and monitoring system in place to enable reporting against the nine global NCD targets;

169 Liberia HIV & AIDS Response Progress Report, 2015 170 IRIN. "Ebola hampers HIV/AIDS care in Liberia." IRIN News, November 21, 2014. 171 National Leprosy and Tuberculosis Strategic Plan 2014-2018. 34

• No national, population-based cancer registry.172 Working with the MoH to develop such policies, strategies and action plans could be an opportunity for contributing to Liberia’s approach to combatting NCDs. Another gap in Liberia’s management of NCDs is related to the broader challenge in Liberia of gaining continuous access to pharmaceutical drugs. Since 1994 the Treaty on Trade Related Aspects of Intellectual Property (TRIPS) has set rules for protecting intellectual property rights of pharmaceutical companies. However, despite several declarations that focus on access to drugs being a fundamental right of all nations, affordability of cancer-related drugs remains a deterrent.173 Liberia currently has a short-term drug donation program but requires a long-term solution to drug procurement.

MENTAL HEALTH The gaps in treating mental health most cited by Liberian Government sources, international health organizations and NGOs working on mental health are: 1. Lack of psychotropic drugs; 2. Lack of trained mental health professionals. The lack of psychotropic drugs is part of a larger problem in getting access to pharmaceutical drugs as discussed in the previous section on NCDs. In addition, there has never been a functioning supply system for psychotropic medicines. On occasion, the country receives donated medicines but often these are close to their expiry date or have even expired.”174 An unwillingness to import drugs and a hesitation among health staff to prescribe psychotropic drugs are other contributing challenges. The lack of trained mental health professionals is a well-documented gap in Liberia, which is why organizations such as the Carter Center have made it their mission to train new cadres of mental health workers. Since 2010, they have trained over 200 mental health clinicians, many of whom specialize in child and adolescent mental health.175 Supporting efforts to include mental health treatment in nursing school curricula, as well as training current health workers,176 are key opportunities for addressing this priority gap in mental health.

ANIMAL AND VETERINARY HEALTH The lack of essential animal drugs is a major gap in animal health and should merit attention from USAID. It is more likely for work on animal health to happen under an agriculture or food chain related project, rather than a general health project. A 2016 USAID desk review on food security noted these same animal health gaps, noting that it is quite difficult to secure animal vaccines in rural areas and acknowledging that farmers receive practically no assistance from government extension officers to address animal disease.177 Partnering with local animal drug retailers to provide essential animal drugs and disease management information to livestock farmers could be considered as part of future agriculture programing. This type of assistance would fall within the dissemination of improved technologies, which is a common intervention area for agriculture related projects.

172 WHO Noncommunicable Disease Country Profiles 2014. 173 Beddoe, A. Challenges to development of cervical and breast cancer program development in post conflict Liberia: Presentation prepared for African First Ladies' Conference, 10th SCCA Conference, Addis Abba, Ethiopia. 2016 174 Mayhew, M. As Liberia and Sierra Leone recover from civil wars and Ebola, demand for mental health services surge. World Bank. April 2016. 175 The Carter Center. Mental Health in Liberia. 2015. 176 Ibid 177 Food Security Desk Review, 2016 35

HEALTH SYSTEMS STRENGTHENING There are many gaps that need to be addressed to rebuild a strong and resilient health system. In the realm of health workforce, one such gap is the training of community health workers. The outbreak and rapid spread of EVD laid bare the lack of universal understanding of effective infection prevention and control tactics amongst community health workers. Proper tactics for managing the outbreak were ultimately effectively spread to health workers but many did not continue to employ these best practices once the epidemic was under control. To adapt community health programs to a post-EVD context, CHVs and health workers need to receive more comprehensive training on infection prevention and control during a crisis. In addition to better training across levels of care, the number of healthcare professionals suffered a substantial loss due to EVD casualties.178 Some efforts are already underway to address this issue,179 yet the number of medical universities and training programs for doctors, nurses and midwives is not sufficient to produce trained health workers needed to sustain necessary growth. Among these already limited ranks, further gaps emerge in terms of geographic distribution of high-skilled professionals, with the level of training and skill varying greatly by location.180 This also ties into the need for expanded training of community health workers, as to elevate the standard of care across the country and decrease the geographic variance in care. The EVD outbreak exposed logistical system inadequacies in Liberia that caused a myriad of issues in coping with a health crisis. The lack of an emergency response framework to dictate the roles and responsibilities of different players led to chaos and inefficiency in supply chain management. The Liberia Supply Chain Management Policy has not been updated since 2010 and expired in 2015. The development of a broad-reaching operating procedure for supply during crisis scenarios would prevent this from occurring again. Training on such a framework and incorporating supply chain and logistics into health worker training, could also benefit those who would likely need to use it in the result of a crisis situation. The continued high costs to the average healthcare user necessitates a careful and purposeful use of resources. For this reason, the continued monitoring of health aid effectiveness is crucial to ensuring that resources are put to their best use. Even as policy has been instituted, improved health sector financing and dissemination of policy documents has lagged at the lower level, resulting in a bottleneck in implementation. The current investment in health, although significant at 12.39%, is still not compliant with the Abuja target of 15% of the annual budget. The Investment Case for RMNCAH noted that the Liberian out of pocket health expenditure is $64 per capita. The Health Sector Pool Fund remains an effective way to meet the gap in universal healthcare coverage but is not sustainable with a free care policy that still incurs “high under the table user fees” for citizens due to inefficiencies and corruption. The governance and accountability structures at national and county levels are currently insufficient for the inflow of substantial financial resources for the implementation of the investment plan.181

178 Evans, David K. et. al. World Bank Group 2015 179 Clinton Health Access Initiative, 2016 180 African Health Observatory, 2012 181 Zolia Y, Musa E, Wesseh CS, et al. Setting the Scene for Post-Ebola Health System Recovery and Resilience in Liberia: Lessons Learned and the Way Forward. Health System Policy Res. 2016 36

V. RECOMMENDATIONS

GENERAL • CHVs must be provided with a formalized incentives structure, accompanied by thorough (and refresher) trainings to be consistently effective. The Ministry of Health must also invest in a more effective recruitment process that assesses the capacity, competency and commitment of CHVs and focuses on more intensive training.

• There is no concrete strategy for data monitoring, reporting and accountability in the health sector. The GoL should emphasize the creation of M&E frameworks with standardized reporting schedules to all implementers, national and international.

• Overall investment in health should reach the minimum international standards set under the Abuja Declaration at 15%. Further, the GoL’s budget allocations for WASH are currently disjointed across several sectors. In order to ensure a minimum line item for health at 15% of the annual budget, the GoL should revise their health financing strategy to include family planning (5-15%), reproductive health (10%) and WASH (.5%) per the international frameworks that the GoL has signed on to.

• The Lack of adequate supply chain management is a bottleneck for maternal health, family planning and infectious and noncommunicable disease prevention. Supply chain management is a critical cross- cutting issue for all health sub-sectors, which rely on a strong management system to effectively deliver services. WASH • Improve monitoring and evaluation of ODF and CLTS initiatives including accurate data disaggregation, follow-up and documentation of strengths and challenges. This will ensure that this important initiative receives the necessary attention and resources to uphold the early successes of community participation prior to and during EVD outbreak.

• Strengthening WSSC as a regulatory body at the center of WASH Policy is ideal for standardization of practices and accountability. Existing data on inequality between urban piped water access and rural areas should be used by the WSSC to advocate for expanding infrastructure improvements to rural areas.

• Strengthen WASH coordination at the county and district levels. National and international implementing partners, should be held responsible to coordinate closely with local government bodies in the counties where they are operating to reduce overlapping of programmatic resources and inaccuracy of data.

• The MoH should establish linkages with education and training institutions to enhance staff capacity in the WASH sector.

• The Ministry of Health should draft a national strategic framework to address WASH in health facilities. The framework should serve as a guiding policy in keeping with international regulations and standards of quality of service to which all health facilities should be held accountable.

Maternal and Child Health and Family Planning 37

• A health workforce skilled in midwifery and emergency obstetrics is key to reducing maternal and newborn morbidity and mortality. The GoL should invest in increased midwifery training especially in rural areas, with an incentive to prevent attrition. Task shifting, shown to be a positive solution to reducing health worker gaps, should be enforced as maternal health is a key area that can benefit from this strategy to increase the numbers of health workers with the necessary skills to prevent treatable deaths and encourage ANC and IPTp.

• The GoL should improve the capacity of health facilities to treat maternal and child health problems, which may improve the health seeking behaviors of mothers who have lost confidence in the health system. Further investment in lifesaving equipment to rural facilities is also necessary.

• FP initiatives need to be rolled out more rigorously in the rural areas, not only in county capitals and cities. IEC campaigns should target adolescents and community-level engagement in discussions around FP should include parents and teachers.

• Given that longer birth intervals are linked to lower prevalence of chronic malnutrition, promotion of child spacing through improved access to family planning is also crucial to addressing child malnutrition. Infectious Disease • IEC for infectious diseases should emphasize prevention, with a focus on behavior change and prevention of myths, stigmatization and discrimination. Broader Government disease prevention messaging should be targeted to improving quality of life and adopting healthy and hygienic practices, regardless of the presence of EVD, HIV, TB or Malaria.

• Liberia must build surveillance systems that monitor cases of infectious diseases, improves the safety and quality of national laboratory systems and establish emergency operations centers that can launch a quick, coordinated response to a public health threat. While the Ministry of Health has already begun work in this arena, consistent follow-up will be required, namely in the creation of a structured system for community-based disease surveillance.

Non-communicable Disease • The Ministry of Health should adopt a formalized strategic framework to address non-communicable diseases, such as cancer, lifestyle diseases, including cardiovascular disease and provide information regarding nutrition and exercise in schools.

• NCD prevention is not the primary focus of community health programming. However, it is well suited to the medium of CHV-run programing due to the non-technical nature of activities like awareness raising and information sharing which would be a key component of such programs.

• According to the WHO, some of the lifestyle related prevention strategies that have been shown to reduce the risk of cardiovascular disease and other NCDs include; eliminating tobacco use, reducing salt in the diet, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol.182 All of these measures should be encouraged as part of a comprehensive public health campaign aimed at preventing the top mortality causing NCDs in Liberia.

182 World Health Organization. “10 Facts on the State of Global Health.” May 2017. 38

Mental Health • The Government should have a targeted focus on mental health diseases and support systems, including designation of appropriate facilities and referrals. Health worker training should include mental health awareness and stigma reduction. The Government should also engage with international bodies to import necessary psychotropic drugs. The Government could benefit from a population-level survey on prevalence of mental illness and depression. Animal and Veterinary Health • Liberia must identify priority zoonotic diseases of domestic and wild animals, raise awareness of disease control and good animal husbandry practices and prioritize resources to ensure the reduction of potential spillover of zoonotic diseases into the human population. Liberia can benefit from investment in training of veterinary personnel and development of a multi-sectoral approach to zoonotic diseases at the national, county and local levels. This should include increased coordination between animal and human health systems. There’s a need for increased access to animal drugs, particularly for livestock and poultry farmers, accompanied by a minimum level of training in their use.

Health Systems Strengthening • A national C-HMIS that collects data from the community level and is collated with health data from other levels of the health system, will allow for a comprehensive national community disease prevalence and surveillance dataset, as well as, a way to track neonatal and maternal deaths in the community. The C-HMIS should be part of a broader MoH information management system and initiated at the county level.

• Data and information management is a critical area for investment, as this desk review was plagued by outdated reports, websites and vital data/statistics on key health indicators. There are numerous documents of similar name, type and thematic focus, often within the same year. It is a questionable use of resources and time. The Ministry of Health could benefit from a more coordinated, cohesive response to health reporting, especially with the formation of WASH Liberia and the Public Health Institute. Both institutions can also take responsibility of ensuring consistency in the way Liberian health information and policy documentation is presented and stored.

• Coming back strong post-EVD means focusing on building a productive and motivated health workforce to deliver quality services by reducing attrition, improving payroll, redistributing CHVs and re-engineering the health infrastructure by reusing facilities, remodeling and improving construction. This resilient health system would also be adequately prepared for epidemics through an advanced early warning system (EWS), labs with proper capacity and improved surveillance.

• Health financing is currently donor driven. The GoL could benefit from diversification of funding sources to create greater opportunity for financial support to mitigate the out of pocket expenses that may prevent citizens from seeking care. One potential solution is the utilization of public-private partnerships to provide high quality services for citizens without additional undue cost burden.

ANNEX I – STATEMENT OF WORK Liberia Strategic Analysis SOW – Health & WASH Sector Desk Review Overview Liberia Strategic Analysis (LSA) will conduct a desk review of documents pertaining to the Health Sector in Liberia since the end of the 2014 Ebola Virus Disease Outbreak in the region. This desk review is an exercise meant to collect, organize, review and synthesize current information available on Liberia’s Health Sector. This document will inform the Mission in preparing for the next iteration of the 2018-2023 Country Development Cooperation Strategy and design of the future USAID/Liberia health project. This desk review coincides with a Donor Mapping recently conducted by LSA, which details the donors active in the Health Sector and their current and future strategies in Liberia. This review will also be followed by a meta-analysis of all assessments and evaluations conducted on USAID/Liberia’s activities during the current CDCS period, 2013-2018. In order to avoid duplication of effort, this review will instead focus on the following technical areas, which have been identified as important areas with existing knowledge gaps. Technical Areas: ● WASH ● Maternal and Child Health (and nutrition) ● Family Planning ● Infectious Diseases ○ HIV ○ Malaria ○ Tuberculosis ○ Any others ● Non-communicable Diseases ● Animal and Veterinary Health ● Health Systems Strengthening ○ Supply Chain Management ○ Health Financing ○ Capacity building of MoH/GOL ○ Health Quality Assurance ○ Human Resources for Health

The desk review will be based primarily on the resources available on USAID/Liberia’s Knowledge Management (KM) Portal (http://usaidliberiakmportal.com/). In addition, LSA will work with the Health Team to gather additional relevant strategy documents and reports that may not be publicly available on the KM Portal, particularly from the following sources: ● GOL and MoH ● Donors: WHO, UNICEF, UNFPA, World Bank, CDC and EU ● Other special studies of interest

Objective The objective of the desk review is to synthesize existing research in the Health Sector in Liberia by various stakeholders and to synthesize this information into one cohesive document. This document will serve to inform the design of the health strategy. The desk review will synthesize opportunities for investment regarding the design of future activities, identify information gaps and where possible, provide infographics and maps. It will also produce a detailed and annotated reference list of all resources reviewed, organized by the technical areas listed above. Review Questions Using relevant assessments, reports and data on the Liberian Health & WASH Sector since 2014 in the key technical areas identified above, this desk review seeks to answer the following questions: 1. What does existing information identify as major priority areas of intervention in Liberia’s Health and WASH sectors? 2. What do relevant Government institutions identify as their priorities and has there been any progress in accomplishing their goals in the Health & WASH sectors? 3. Where the gaps in the Health & WASH sectors and what are key opportunities for USAID investment? Necessary Level of USAID Support The Health Team will gather additional documents that are relevant to the review in a Google Drive folder and share access with LSA’s Gmail account: [email protected]. LSA will upload publicly available documents to the KM Portal. Deliverables and Level of Effort One Program Manager and one Program Associate internal to Social Impact with technical skills in the health sector will be identified to perform the desk review. LSA staff will assist the consultant in gathering documents and identifying and preparing possible infographics and/or maps. No. Deliverable Description LOE Proposed Completion Date 1 Reference List of Documents ● List will be the first draft of the Annotated Bibliography and will ensure that the documents to be reviewed 5 days July 20, 2017 match the interest of the Health Team. ● Documents will be sourced from the KM Portal and other relevant information provided by USAID ● Estimated number of documents: 150 2 Complete Desk Review, including: ● Synthesized purpose, findings and recommendations ● Identified information gaps, if any 25 days August 31, 2017 ● Where applicable, infographics and/or maps ● Recommendations ● Annotated reference list

ANNEX II – TABLE OF EXISTING ASSESSMENTS, REPORTS AND SURVEYS POST-2014

Title Summary Liberia Community Health Road Map, The Road Map provides guidance to the MoH to coordinate and July 1, 2014-June 30, 2017 activate existing community health structures and support systems at all levels, as well as accelerating the implementation of a standardized package of community health services. Liberia Water, Sanitation and Hygiene This first-of-its-kind report in Liberia documents progress toward (WASH) Sector Performance Report WASH sector goals and was authored by staff from Government and (SPR) (2014). donors. The SPR represents a concerted effort to bring actors in the fragmented Liberia WASH sector together under a common reporting umbrella. The Investment Plan provides an overall framework for restoring the National Investment Plan for Building a gains lost to EVD and provides health security for the people of Resilient Health System (2015-2021). Liberia. The consolidated operational plan provides a roadmap to address Ministry of Health Consolidated Work major health issues identified in the National Investment Plan. Plan (2016/2017) The National Plan provides a result-based framework for driving the National HIV and AIDS Strategic Plan decentralized, multi-sectoral national HIV/AIDS response within (2015-2020) which all HIV/AIDS evidence based interventions are guided. The National Plan is designed to put Liberia on the road towards National Leprosy and Tuberculosis achieving international TB control targets, to increase access to TB Strategic Plan (2014-2018). Ministry of diagnosis and provision of comprehensive high-quality treatment Health. services. The National Plan highlights malaria control and prevention strategies National Malaria Strategic Plan (NMSP) to reduce malaria mortality and morbidity in Liberia. (2016-2020) The Malaria Communication Strategy contributes to targets laid out Malaria Communications Strategy (2016- in the NMSP 2016–2020 by intensifying social and behavior change 2020) activities at all levels of society. The program identifies targeted interventions to strengthen the Liberia Health Workforce Program public-sector health workforce at all levels of service delivery. (2015-2021) The Investment Case is an integral part of Liberia’s policies and plans Liberia Investment Case for to achieve the SDGs related to RMNCAH by 2030. It further outlines Reproductive, Maternal, Newborn, Liberia’s efforts to end maternal and newborn mortality from Child and Adolescent Health preventable causes as highlighted in the country’s policy and regulatory (RMNCAH) (2016-2020) framework. WinS provides a guide for schools in the implementation of school Liberia WinS (Water, Sanitation and initiated or NGO supported Wash in schools to ensure that program Hygiene in Schools) Guide. (2016). objectives are met. The report was produced as part of a two-day stakeholder forum to Liberia's Third Annual Water, Sanitation discuss progress and decide the best way forward for the sector and and Hygiene Joint Sector Reviews: Event identify and agree on the priorities for the WASH sector for FY Report. (November, 2015) 2015/16. This report highlights progress on three strategic objectives (improve Joint Annual Health Sector Review access to health services, improve quality of health services and Report. (November, 2016) improve health infrastructure) in relation to the implementation of maternal and child health initiatives and targets, utilizing a document review and interviews.

Title Summary The assessment provides information on key WASH indicators in Nationwide Assessment of WASH schools. It serves as a baseline and informs coordination of district, Facilities in Schools in Liberia. (March, county and national levels. 2016). UNICEF The baseline serves as a starting point for the Liberia National WASH Liberia WASH in Health Facilities- Strategy in 2015. Baseline Report (2015) The report contains minimum requirements for WASHEH in WASH and Environmental Health healthcare facilities as part of the program for Early Recovery and Package in Health Facilities (October Resilience Building from the EVD outbreak in Liberia. 2015) The Assessment generates evidence for the formulation of the post- Liberia Health Sector Assessment (2015) Ebola health sector investment plan that will be used as the instrument for building a resilient health system. The desk review summarizes data on the causes and distribution of USAID Office of Food for Peace- Food chronic food insecurity in Liberia; identifies at-risk population groups; Security Desk Review for Liberia (2016- and describes existing policies, strategies and programs that aim to 2020) reduce food insecurity and strengthen resilience in Liberia.

ANNEX III – ANNOTATED BIBLIOGRAPHY General Health 1. Joint Annual Health Sector Review Report 2016. Liberia Ministry of Health http://www.seejph.com/public/books/Joint_Annual_Health_Sector_Review_Report_2016.pdf This report highlights progress on three strategic objectives (improve access to health services, improve quality of health services and improve health infrastructure) in relation to the implementation of maternal and child health initiatives and targets, utilizing a document review and interviews. 2. Liberia Health Sector Assessment 2015. Liberia Ministry of Health. The overall objective of the assessment is to generate evidence for the formulation of the post- Ebola health sector investment plan that will be used as the instrument for building a resilient health system. 3. Liberia Community Health Road Map, July 1, 2014 – June 30, 2017. Ministry of Health and Social Welfare March 2014. http://pdf.usaid.gov/pdf_docs/PA00KBFN.pdf. The Road Map provides guidance to the MoH to coordinate and activate the existing community health structures and support systems at all levels, as well as accelerate the implementation of a standardized package of community health services. 4. Ministry of Health Consolidated Operational Plan FY 2016/2017. http://moh.gov.lr/wp-content/uploads/2017/01/Operational-Plan_2016.pdf The consolidated operational plan provides a roadmap to address major health issues identified in the National Investment Plan via an overall systematized management and operational approach to meeting short and long-term goals and objectives. 5. Rebuilding Liberian Public Health: A Q&A with Tolbert Nyenswah. Global Health Now. March 13, 2017. https://www.globalhealthnow.org/2017-03/rebuilding-liberian-public-health-qa-tolbert- nyenswah Interview with the Director-General of the Public Health Institute of Liberia. 6. Public Health Institute of Liberia. www.nationalphil.org The official website of the newly launched Public Health Institute of Liberia. 7. National Investment Plan for Building a Resilient Health System in Liberia 2015- 2021. Liberia Ministry of Health. May 2015. http://usaidliberiakmportal.com/resource_library/investment-plan-for-building-a-resilient- health-system-in-liberia-2015-2021/ The Investment Plan provides an overall framework for restoring the gains lost to EVD and provides health security for the people of Liberia, including; reducing risks due to epidemics and other health threats, accelerates progress towards universal health coverage by improving access to safe and quality health services and narrows the equity gap for the most vulnerable populations. WASH 1. Liberia's Third Annual Water, Sanitation and Hygiene Joint Sector Reviews: Event report. July 2015. UNICEF. http://usaidliberiakmportal.com/resource_library/liberia-third-annual-water-sanitation-and- hygiene-joint-sector-review-event-report/ The report was produced as part of a two-day stakeholder forum to discuss progress and decide the best way forward for the sector and identify and agree on the priorities for the WASH sector for Financial Year (FY) 2015/16, discuss challenges faced by the sector and reviews progress against key sector policies and plans. 2. Liberia Wins: Water, Sanitation and Hygiene in Schools. 2016.

http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2016/07/Liberia-WINS-Protocol- FINAL-SIGNED.pdf The report provides a guide for the country, district, county and schools in the implementation of school initiated or NGO supported WASH in schools to ensure that program objectives are met. 3. Nationwide Assessment of WASH Facilities in Schools in Liberia. March 2016. UNICEF. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2016/07/WASH-in- Schools-Assessment-Report-Version-10-FINAL-1.pdf The assessment provides information on key WASH in schools indicators to serve as a baseline and inform coordination mechanisms at district, county and national levels. 4. Liberia WASH in Health Facilities- Baseline Report. 2015. USAID/MOH/WASH Liberia. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2016/06/Liberia-WASH-in- Health-Facilities-Baseline-Report.pdf The baseline serves as a starting point for the Liberia National WASH Strategy in 2015 and includes an assessment of the status of WASH facilities in 647 health facilities. 5. Water, Sanitation & Hygiene Sector Performance Report 2015. August 2015. WASH Liberia. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2013/01/SPR- 2014-MASTER.2014-pdf.pdf This first-of-its-kind report in Liberia documents progress toward WASH sector goals and was authored by staff from government and donor entities. The SPR represent a concerted effort to bring actors in the fragmented Liberia WASH sector together under a common reporting umbrella. 6. WASH Sector Investment Plan 2012-2017. Liberia Ministry of Health. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2013/06/SIP_Vol_I_final _22jan20131.pdf The plan provides information on the WASH sector with information for institutions, the Government and development partners. 7. National Rural Water, Sanitation & Hygiene Program Development Study - Workshop to Review Draft Situational Analysis and Concept Note: Event Report. May 2014. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2014/06/NRWASHP-SA-CN- Workshop_Event-Report-v1.pdf This workshop report discusses the development of a comprehensive, country-led NRWASHP to guide the Government of Liberia to make decisions on possible investments in partnership with Development Partners. 9. In Brief: National Rural Water Sanitation and Hygiene Program(NRWASHP) Development Study: Inception Report. March 2014. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2014/06/Egis.-In-Brief-NRWASHP- Development-Study-IR-v2.pdf The inception report highlights results from coordination, consultation with stakeholders and desk review on NRWASHP progress. 10. Development Partner Response to Liberia Sector Performance Report (SPR). May 2014. WASH Liberia. http://wash-liberia.org/wp-content/blogs.dir/6/files/sites/6/2014/05/JSR-II.-Development- Partner-Response-Document-to-SPR-for-JSR-2014.pdf. The report is the response from development partners and feedback towards the first draft sector report. 11. Improving Water, Sanitation and Hygiene in Health-Care Facilities, Liberia. Abrampah, N. et al. Bull World Health Organization 2017; 95:526-530. https://www.washinhcf.org/documents/Bulletin-Libiera.pdf. This article identifies challenges and lessons learned in addressing the lack of proper water and sanitation infrastructure and poor hygiene practices in health-care facilities. 11. Analysis of Accountability for WASH Services Sustainability Within Health Systems in Liberia. UNICEF, Division of Environmental and Occupation Health. April 2016 https://www.washinhcf.org/documents/Accountability-for- Sustainability_Report_2016_ Liberia.pdf. Highlights the operational and financial challenges 45

that need to be addressed for the health system to become resilient to shocks and improve population health status. 13. WASH and Environmental Health Package in Health Facilities. October 2015. Liberia Ministry of Health. https://www.washinhcf.org/documents/Final-WASH-EH- Package-for-Health-Facilities-003.pdf. Contains minimum requirements for Water, Sanitation and Hygiene (WASH) and Environmental Health (EH) in healthcare facilities as part of the program for Early Recovery and Resilience Building from the EVD outbreak in Liberia. 14. Liberia WASH Sector Assessment Desk Review. 2014. TetraTech/USAID. http://pdf.usaid.gov/pdf_docs/PA00KMCM.pdf. Documents current conditions in the Liberia WASH sector to inform future USAID programming decisions. The Desk Review presents the findings of a broad landscape analysis of the WASH sector based primarily on secondary sources and addresses key aspects of the sector, including a review of the financial, institutional, environmental, technical and social considerations. 15. Liberia Water, Sanitation and Hygiene Sector Capacity Development Plan 2012- 2017. Liberia Ministry of Health. http://wash-liberia.org/wp- content/blogs.dir/6/files/sites/6/2013/01/Capacity_Development _Plan.pdf. Considers the interventions required which will contribute to short, medium and longer-term impact. The main focus is on building capacity for service delivery against the WASH Sector Strategic Plan, 2012-17. Maternal and Child Health 1. USAID Office Food for Peace Food Security Desk Review for Liberia 2016-2020. February 2016. USAID/Liberia. https://www.usaid.gov/sites/default/files/documents/1866/FFP-Desk-Review-Liberia- Feb2016v2.pdf Provides an overview of the current food security and nutrition situation including the impact of the EVD outbreak in 2014-15 and summarizes data on the causes and distribution of chronic food insecurity in Liberia. Identifies at-risk population groups; and describes existing policies, strategies and programs to reduce food insecurity. 2. Liberia's Commitment for The Global Joint Action Plan for Women and Children's Health. Liberia Ministry of Health. September 2015. https://www.everywomaneverychild.org/images/Liberia_Commitment_Letter2015.pdf Liberia’s affirmation of support for the Global Joint Action Plan for Women’s Health as underlined by the UN Secretary General. 3. How Did Ebola Impact Maternal and Child Health in Liberia and Sierra Leone? October 2015. CSIS. https://csis-prod.s3.amazonaws.com/s3fs- public/legacy_files/files/publication/151019_Streifel_EbolaLiberiaSierraLeone_Web.pdf Report examines the specific adverse health outcomes for mothers and children during the EVD outbreak due to changes in health seeking behavior, infrastructure shortfalls and loss of skilled health workers. 4. Services for Mothers and Newborns During the EVD Outbreak in Liberia: The Need for Improvement in Emergencies. Dahn, B. et al. April 2015. http://currents.plos.org/outbreaks/article/services-for-mothers-and-newborns-during-the-ebola- outbreak-in-liberia-the-need-for-improvement-in-emergencies/ Article examines the specific adverse health outcomes for mothers and children during the EVD outbreak due to changes in health seeking behavior, infrastructure shortfalls and loss of skilled health workers. 5. LISGIS, Ministry of Health and Social Welfare, National AIDS Control Program and ICF International. 2014. Liberia Demographic and Health Survey 2013. Monrovia, Liberia: Liberia Institute of Statistics and Geo-Information Services and ICF International. Data from the DHS of Liberia from 2013, the last year in which a DHS was completed. Vital statistics on all health outcomes and indicators are included in the DHS.

6. Liberia Investment Case for RMNCAH 2016-2020. Liberia Ministry of Health. http://www.globalfinancingfacility.org/sites/gff_new/files/documents/Liberia%20RMNCAH%20Inv estment%20Case%202016%20-%202020.pdf The Investment Case is an integral part of Liberia’s policies and plans to achieve the SDGs related to RMNCAH by 2030. It further outlines Liberia’s efforts to end maternal and newborn mortality from preventable causes as highlighted in the country’s policy and regulatory framework. 7. Remoteness and Maternal and Child Health Service Utilization in Rural Liberia: A Population–Based Survey. December 2015, Journal of Global Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512264/ Study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Family Planning 1. Successful Proof of Concept of Family Planning and Immunization Integration in Liberia. Cooper et al. http://www.ghspjournal.org/content/3/1/71.abstract Research done to mobilize vaccinators to provide mothers key family planning information and referrals to co- located, same-day family planning services in resource-limited areas of Liberia, leading to substantial increases in contraceptive use. 2. Cost Efficiency Analysis: Distributing Family Planning Materials. International Rescue Committee. 2016. https://www.rescue.org/sites/default/files/document/1415/fpdesignedbrief20170227.pdf Analysis of four family planning programs in the Democratic Republic of the Congo (DRC), Kenya, Liberia and Myanmar. Analysis considers cost efficiency of delivering family planning services in each case focusing on the cost per couple-year of protection (CYP) and differences across countries. 3. Family Planning 2020- Country Action: Opportunities, Challenges and Priorities (Liberia). http://ec2-54-210-230-186.compute-1.amazonaws.com/wp- content/uploads/2016/11/Country_Action_Opportunities-Challenges-and- Priorities_LIBERIA_FINAL.pdf Country context, opportunities, challenges and priorities developed by FP2020 focal points for Liberia in collaboration with the FP2020 Secretariat and other partners during the Anglophone Africa Focal Point Workshop in Kampala, Uganda in April 2016. 4. Family Planning 2020 Commitment: Government of Liberia. http://ec2-54-210-230- 186.compute-1.amazonaws.com/wp-content/uploads/2016/10/Govt.-of-Liberia-FP2020- Commitment-2012.pdf Written commitment from the President of Liberia to the Family Planning 2020 Framework. 5. Liberia DHS Analysis of Trends in Use of Modern Contraception. 2014. http://ec2-54- 210-230-186.compute-1.amazonaws.com/wp-content/uploads/2015/07/Liberia-DHS- Summary.pdf Analysis of contraceptive use for Liberia, disaggregated by rural, gender, wealth, marital status and education. 6. Adolescent Contraceptive Use. Data from the Liberia Demographic and Health Survey (LDHS) 2013. WHO. http://apps.who.int/iris/bitstream/10665/252332/1/WHO- RHR-16.31-eng.pdf?ua=1 DHS data exploring the contraceptive use among married and unmarried Liberian adolescents. 7. MOH Launches 'Family Planning Week'. The New Dawn. October 2015. http://allafrica.com/stories/201510161103.html News article highlighting inaugural Family Planning Week by the Ministry of Health. 8. UNFPA Launch Program to Reduce Teenage Pregnancy in Southeastern Liberia. http://www.frontpageafricaonline.com/index.php/health/3499-unfpa-launch-programme-to-

reduce-teenage-pregnancy-in-southeastern-liberia Article highlighting inauguration of UNFPA funded teen pregnancy prevention program in Liberia, date unknown. Infectious Disease 1. Liberia HIV & AIDS Response Progress Report. April 2016. National AIDS Commission. http://usaidliberiakmportal.com/resource_library/liberia-hiv-and-aids-response- progress-report/ Compilation report of updated annual statistics around HIV diagnosis care and treatment programing and capacity in Liberia. 2. National HIV & AIDS Strategic Plan 2015-2020. Republic of Liberia. http://www.nacliberia.org/doc/Liberia%20NSP%202015-2020%20Final%20_Authorized_%20OK.pdf Provides a result-based framework for driving the decentralized, multi-sectoral national HIV/AIDS response within which all HIV/AIDS evidence based interventions are guided. 3. IRIN. "Ebola Hampers HIV/AIDS Care in Liberia." IRIN News, November 21, 2014. http://www.irinnews.org/news/2014/11/21/ebola-hampers-hivaids-care-liberia. News article highlighting the challenges facing HIV positive patients and their specific vulnerabilities during Ebola that were exacerbated by the stressed and underperforming health system. 4. National Leprosy and Tuberculosis Strategic Plan 2014-2018. Ministry of Health. https://www.medbox.org/liberia-national-leprosy-and-tuberculosis-strategic-plan-2014- 2018/download.pdf. Designed to put Liberia on the road towards achieving international TB control targets. It aims at increasing access to TB diagnosis and provision of comprehensive high-quality treatment services for TB patients across the country. 5. As Ebola Wanes, A Spike in Infectious Disease Sweeps Through Liberia. Stat news. March 2016. https://www.statnews.com/2016/03/16/liberia-tuberculosis-after-ebola/ News article highlighting the disease vulnerabilities existing in Liberia post-Ebola that have been exacerbated by the stressed and underperforming health system. 6. Effects of Response to 2014–2015 EVD Outbreak on Deaths from Malaria, HIV/AIDS and Tuberculosis, West Africa. https://wwwnc.cdc.gov/eid/article/22/3/15-0977_article . Research article to estimate the repercussions of the EVD outbreak on the populations vulnerable from these diseases using a computational model for disease transmission and infection progression. 7. Presidents Malaria Initiative (PMI) Fact Sheet for Liberia. May 2017. Accessed August 21, 2017. https://www.usaid.gov/sites/default/files/documents/1860/PMI_Fact_Sheet_May_2017.pdf Factsheet providing information on PMI activities in Liberia, including planned investments and the consortium of partners implementing the initiative. 8. Malaria Operational Plan FY 2017. Presidents Malaria Initiative (PMI). https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational- plans/fy17/fy-2017-liberia-malaria-operational-plan.pdf?sfvrsn=6 Annual guiding document detailed implementation plan for Liberia based on the strategies of PMI and the National Malaria Control Program (NMCP). 9. National Malaria Strategic Plan NMSP 2016-2020. Liberia Ministry of Health. The National Plan highlights malaria control and prevention strategies to reduce malaria mortality and morbidity in Liberia. 10. National Malaria Communications Strategy. Liberia Ministry of Health. http://www.thehealthcompass.org/sites/default/files/project_examples/Liberia%20NMCS%202016 -2020.pdf The Malaria Communication Strategy contributes to targets laid out in the NMSP 2016–2020 by intensifying social and behavior change activities at all levels of society. 11. CDC Liberia Fact Sheet. July 2017. https://www.cdc.gov/globalhealth/countries/liberia/pdf/CDC_Liberia_FactSheet.pdf. Factsheet

detailing the work of the CDC in Liberia including population statistics and top causes of mortality. 12. National Policy and Strategic Plan on Integrated Vector Management 2012-2017. August 2012. Liberia Ministry of Health/Centers for Disease Control (CDC)/National Institutes of Health (NIH) and USAID. This policy and strategic plan will enable more cost-effective, ecologically sound and sustainable vector control interventions to speed up control of malaria and other vector-borne diseases. 13. UNAIDS Liberia HIV & AIDS Estimates 2015. http://www.unaids.org/en/regionscountries/countries/liberia. This site provides the most up to date statistics on HIV & AIDS for Liberia from UNAIDS. Noncommunicable Disease 1. Non-Communicable Diseases (NCD) Country Profile Liberia. 2014. World Health Organization. Accessed August 7, 2017. http://www.who.int/nmh/countries/lbr_en.pdf. This is a one-page fact sheet on NCD statistics in Liberia in 2014 and includes a table of national systems response to NCDs. 2. Institute for Health Metrics and Evaluation. Liberia Data Page. 2015. Accessed August 7, 2017. http://www.healthdata.org/liberia. This is a webpage with an overview of causes of mortality in Liberia in 2015. 3. Donkor, Noble et. al. Cardiovascular and Type 2 Diabetes Risk Factors in Liberian Nurses. International Journal of Africa Nursing Sciences Volume 4. 2016. Accessed August 7, 2017. http://www.sciencedirect.com/science/article/pii/S221413911500027X. Medical study taking a random sample of Liberian nurses and screened them for risk factors related to diabetes and cardiovascular disease. They found a positive relationship between BMI, blood pressure and glucose levels. 4. Beddoe, Ann Marie. Challenges to Development of Cervical and Breast Cancer Program Development in Post Conflict Liberia: Presentation Prepared for African First Ladies' Conference, 10th SCCA Conference, Addis Abba, Ethiopia. 2016. Accessed August 7, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310111/. Conference presentation on the challenges of developing a robust cancer program in Liberia. It includes discussion of the priorities of the Government vis a vis cancer treatment, as well as key gaps in cancer treatment and prevention. 5. Diabetes Country Profile Liberia. 2016. World Health Organization. Accessed August 7, 2017. http://www.who.int/diabetes/country-profiles/lbr_en.pdf?ua=1. One-page fact sheet on diabetes statistics in Liberia in 2016 and includes a table of national policy responses to diabetes. 6. Analytical Summary Non-Communicable Diseases and Conditions. World Health Organization. Accessed August 10, 2017. http://www.aho.afro.who.int/profiles_information/index.php/Liberia:Analytical_summary_-_Non- communicable_diseases_and_conditions. One-page summary of major NCD conditions in Liberia. Includes links to other reports and sources, though all of them are pre-2014. 7. Atlas of African Health Statistics. 2016. Accessed World Health Organization. August 10, 2017. http://www.aho.afro.who.int/sites/default/files/publications/5266/Atlas-2016- en.pdf. Comprehensive report on the current health status of the populations of all African countries that includes discussion of health trends, health systems and key determinants of health. On Liberia specifically, this report includes mostly summary data on mortality rates due to various disease and the data sources were primarily from 2008 and 2012.

Mental Health 1. Action Against Hunger/German Cooperation. Mental Health and PSS Needs and Resources Assessment. - Bomi County. May 2016. Accessed August 10, 2017. http://usaidliberiakmportal.com/resource_library/mental-health-and-psychosocial-support-needs- and-resources-assessment-bomi-county/. This report details a needs and resource assessment done by ACF International in Bomi County related to psychological health. It detailed individuals’ main distress factors, coping mechanisms and access to services. 2. Mayhew, Melanie. As Liberia and Sierra Leone Recover from Civil Wars and Ebola, Demand for Mental Health Services Surge. World Bank. April 2016. Accessed August 31, 2017. http://www.worldbank.org/en/news/feature/2016/04/11/as-liberia-sierra- leone-recover-from-civil-wars-and-ebola-demand-for-mental-health-services-surges. This article details the gaps in mental health treatment in Liberia and Sierra Leone and the increased need for mental health services following their civil wars and experiences with Ebola. It also highlights some current programs that are ongoing in both countries to bridge the gap in government provided services. 3. Sonpon, Leroy. House Passes Law to Protect Persons with ‘Mental Disorders’. Liberia Daily Observer. May 2017. Accessed August 31, 2017. https://www.liberianobserver.com/news/house-passes-law-to-protect-persons-with-mental- disorders/. An overview of the new mental health act passed in May 2017. It includes some of its provisions and intended outcomes. 4. Press Release. The Carter Center Congratulates Liberians on Passage of the Landmark Mental Health Act to Improve Health and Protect Citizens Living with Mental Health Disorders. May 2017. Accessed August 31, 2017. https://www.cartercenter.org/news/pr/liberia-052617.html. This press release gives an overview of the mental health act provisions and provides background and updates on the Carter Center’s work on mental health in Liberia. 5. Mental Health in Liberia. The Carter Center. 2015. Accessed August 31, 2017. https://www.cartercenter.org/health/mental_health/mh-liberia.html. This article gives an overview of Carter Center programing on mental health in Liberia. It also includes progress of the program to date. 6. Mental Health Services in Liberia; Building Back Better. World Health Organization. March 2016. http://www.who.int/features/2016/mental-health-liberia/en/. This article provides an overview of WHO and other training programs on mental health treatment, support and stigma reduction. It also details the existing gaps in Liberia’s response to mental health and some of the Government’s planned improvements in dealing with mental health. 7. Bornemann, Thomas. Presentation on the Liberia Mental Health Program. August, 2014. http://symposium.phscof.org/docs/2015Symposium/2015Presentations/Tuesday/Physician/Borne mannLiberiaMentalHealth.pdf. This presentation gives details on the Carter Center’s Liberia Mental Health Program, including background, accomplishments to date and next steps. 8. MoH of Liberia. Mental Health Policy and Strategic Plan for Liberia (2016 – 2021). https://www.mindbank.info/item/6397. This is the Mental Health Policy and Strategic Plan developed by the MoH and details the strategic objectives Liberia will focus on regarding mental health over the next 5 years.

Animal and Veterinary Health 1. World Health Organization/Outbreaks and Health Emergencies. Joint External Evaluation of the Republic of Liberia Mission Report. September, 2016. https://www.ghsagenda.org/docs/default-source/jee-reports/liberia-jee-report.pdf This WHO report details Liberia’s ability to prevent, detect and respond to outbreaks and health emergencies. Of relevance is the discussion on zoonotic diseases. 2. Veterinary Medicine is Scarce in Liberia. January 2014. Liberia Daily Observer. https://www.liberianobserver.com/columns/health/veterinary-medicine-is-scarce-in-liberia/. This article details the dearth of veterinarians and veterinary drugs in Liberia. 3. The Urgent need for Vets in Liberia. January 2014. Liberia Daily Observer. https://www.liberianobserver.com/opinion/editorials/the-urgent-need-for-vets-in-liberia/. This article discusses the bios of the handful of vets who have worked in Liberia since the 1950s and the lack of attention the Ministry of Agriculture has for promoting more vets. 4. Liberian Ministry of Agriculture. Annual Report. 2015. http://moa.gov.lr/doc/2015%20Annual%20Report-%20Ministry%20of%20Agriculture.pdf. This government sponsored annual report details the successes and challenges of various bureaus within the Ministry of Agriculture in 2015. Of interest are the updates on the Division of Quarantine and the Bureau of National Livestock.

Health System Strengthening 1. The Liberian MoH and WHO Launch Training on Safe and Quality Health Services. WHO Regional Office for Africa. August 2014. http://afro.who.int/news/liberian-ministry-health-and-who-launch-training-safe-and-quality-health- services. An article from the World Health Organization that discusses the Liberian MoH’s training efforts on the new Safe Quality Services. The SQS focuses on infection prevention and control, psychosocial support, disease surveillance and clinical emergency management. 2. Zolia, Yah et. al. Setting the Scene for Post-Ebola Health System Recovery and Resilience in Liberia: Lessons Learned and the Way Forward. January 2017. http://www.hsprj.com/health-maintanance/setting-the-scene-for-postebola-health-system- recovery-and-resilience-in-liberia-lessons-learned-and-the-way-forward.php?aid=18326. This study examines the development of the Investment Plan from the Liberian MoH in the aftermath of the EVD outbreak. Includes lessons learned and paths forward from this process. The detailed account of the process undertaken in developing this plan informs the outline of potential implementation difficulties. 3. Hart, Lauren et. al. Building Capacity for Resilient Health Systems - Lessons Learned from Sierra Leone, Guinea and Liberia in the Time of Ebola. 2017. https://www.measureevaluation.org/resources/publications/tr-17-158. This report looks at the MEASURE Evaluation’s capacity building efforts in the health systems of Liberia, Guinea and Sierra Leone in the wake of the EVD outbreak. It compares and contrasts the effect of capacity building and strategic planning interventions on the health systems across the three countries in order to elicit over-arching takeaways. 4. Health Workforce Program FY 2015-2021. Implementation Plan. Liberia Ministry of Health. http://liberia.resiliencesystem.org/sites/default/files/Health%20Workforce%20Program%20Imple mentation%20Plan_20150502%20(1).pdf. This document is a draft of the Liberia Health Workforce Program for 2015-2021. It outlines the strategy and objectives of the Liberia Ministry of Health with regards to the improvement of the health workforce in Liberia.

5. Siekmans, Kendra et. al. Community-Based HealthCare is an Essential Component of a Resilient Health System: Evidence from EVD Outbreak in Liberia. January 2017. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-4012-y. This study examines the role of community health workers in the continuation of childhood illness- prevention efforts during the EVD outbreak. It provides evidence to support the efficacy of community health workers in creating a resilient health system by continuing to provide treatment for other serious medical risks during a crisis. 6. Evans, David K. et. al. World Bank Group. The Next Wave of Deaths from Ebola? The Impact of Healthcare Worker Mortality. July 2015. http://documents.worldbank.org/curated/en/408701468189853698/pdf/WPS7344.pdf. This working paper considers the impact of health worker mortality on the strength of health systems in countries affected by the EVD outbreak. It uses these statistics to point to further reaching health outcome consequences if substantial investment in building up the health workforce does not materialize. 7. Government of Liberia Launches Historic National Health Worker Plan to Reach 1.2 Million. Last Mile Health. July 2016. http://lastmilehealth.org/government-liberia-launches-historic-plan/. This article discusses the launch of the National Community Health Assistant Program by Liberia’s president in 2016. It discusses the importance of the impact the program could have on Liberian health systems 8. Cost of Scaling up the Health Workforce in Liberia, Sierra Leone and Guinea Amid the EVD outbreak. Frontline Health Workers Coalition Analysis. March 2015. https://www.frontlinehealthworkers.org/wp-content/uploads/2015/04/WAfricaCosting.pdf. This analysis estimates the investments needed to double the combined health workforce of Liberia, Guinea and Sierra Leone over a five-year period. 9. Supporting Recovery, Rebuilding and a National Health Workforce in Liberia- World Health Day 2016. Clinton Health Access Initiative. April 2016. http://www.clintonhealthaccess.org/world-health-day-2016-liberia/. This article discusses the Clinton Health Access Initiative’s work to assist the GoL in increasing the training and production of healthcare professionals. Begun before the EVD outbreak, this plan was folded into the Post-Ebola Recovery and Resiliency Plan. 10. Analytical Summary-Health Workforce. African Health Observatory. 2012. http://www.aho.afro.who.int/profiles_information/index.php/Liberia:Analytical_sum mary_-_Health_workforce. This webpage provides a summary of the health workforce in Liberia, including distribution of skilled providers vs. non-clinical/unskilled providers and the gender distribution across positions. 11. Quarterly Report of the Health Sector Pool Fund. October 1-2014- December 31, 2014. Liberia Ministry of Health. http://reliefweb.int/sites/reliefweb.int/files/resources /HSPF_AR_2015_Q2_final_lr.pdf. This report utilizes HMIS data, among other sources, to discuss the status of the Health Sector Pool Fund in Liberia. In addition to financial updates, it discusses the activities undertaken using the funds and presents data on key health indicators. 12. Government of Liberia. The Government of Liberia and Development Partner's Contributions in Response to the Ebola Crisis. November 2014. http://usaidliberiakmportal.com/resource_library/the-government-of-liberia-and-development- partners-contribution-in-response-to-the-ebola-crisis/. This paper discusses the effort of the GoL in conjunction with development partners to allocate resources towards fighting the EVD outbreak. It outlines specific financial allocations and the objectives of the funds. 13. Joint Financial Management Assessment Report. Liberia Ministry of Health. August 9, 2016. https://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Key_Issues/Fin ancial_Management/Liberia_Heatlh_Sector_JFMA_Report11_08092016.pdf. This assessment 52

reviews the health sector financial management practices in Liberia. It also recommends solutions for strengthening these practices to improve health outcomes for the funding available. 14. Africabio Enterprises, Inc. Liberia Health Sector Scan, 2016. 2016. http://aeiglobal.com/PDFs/Health_Sector_Scan_Building_Markets_v4.pdf. This document provides an overview of the health sector in Liberia, including financing, human resources, infrastructure and information systems and supply chain management. It also considers the role of the private healthcare sector and how the health sector can be improved and become more efficient. 15. Health Sector Pool Fund. 2017. Liberia Ministry of Health. Accessed August 30, 2017. http://MoH.gov.lr/health-sector-pool-fund/. This page provides the GoL overview of the Health Sector Pool Fund, including the objectives, achievements, administration and contributors. 16. USAID Global Health Supply Chain Program- Liberia Profile. USAID. 2016. http://www.ghsupplychain.org/country-profile/liberia. This page provides the “country snapshot” for Liberia under the USAID Global Health Supply Chain Program. 17. Supply Chain Management Training-Road Map for Liberia: A Sustainable Solution for Supply Chain Capacity Development. People that Deliver. August 2015. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved= 0ahUKEwii5Lj_taPWAhUG4IMKHTt4DlIQFggoMAA&url=https%3A%2F%2Fpeoplethatdeliver.or g%2Fptd%2Fdownload%2Ffile%2Ffid%2F465&usg=AFQjCNHhDLp6jpN8IChKUGGtpIs-Y9rcOQ This outlines the supply chain management training roadmap designed by Pharmaceutical Systems Africa. It responds to the personnel issues that were often at the root of supply chain issues in Liberia. 18. Supply Chain Strategy 2015- Liberia. Liberia Ministry of Health. 2010. http://liberiaMoH.org/Policies%20&%20Plans/SCMP%20Strategy%20Plan%20final%20draft%20070 910.docx. This document outlines the GoL supply chain strategy through the year 2015. 19. Paterson, D. Offering a Lifeline: Delivering Critical Supplies to Ebola Affected Communities in Liberia 2014-2015. 2017. https://successfulsocieties.princeton.edu/sites/successfulsocieties/files/DP_Supplies_Final_April% 202017_0.pdf. This document provides a case study account of the EVD outbreak and the delivery of supplies to critical areas. The researchers conducted interviews with those involved in the logistics and procurement of supplies to these critical areas and provided insight for preventing the failures and difficulties that arose during the EVD outbreak. 20. National Health Management Information Systems Strategy and Implementation Plan. Liberia Ministry of Health. June 2009. http://liberiaMoH.org/Policies%20&%20Plans/Final.HMIS.Strategy.07.07.09.doc. This plan outlines the initial strategy for the implementation of the HMIS in Liberia. It takes into account system structure, technology usage, strategy for integrating the system and lays out an implementation plan.