Maternal and New-Born Health Policy Indicators for Low-Resourced Countries: the Example of Liberia (Review Article)

Bjegovic-Mikanovic V, Broniatowski R, Byepu S, Laaser U. Maternal and new-born health policy indicators for low-resourced countries: the example of Liberia (Review article). SEEJPH 2019, posted: 19 August 2019. DOI 10.4119/UNIBI/SEEJPH-2019-221

REVIEW ARTICLE

Maternal and new-born health policy indicators for low-resourced countries: The example of Liberia

Vesna Bjegovic-Mikanovic1, Raphael Broniatowski2, Stephen Byepu3, Ulrich Laaser4

1 Belgrade University, Faculty of Medicine, Centre School of Public Health and Management, Serbia;

2 EPOS Health Management, Bad Homburg, Germany;

3 INHA University, Incheon, Korea and Monrovia, Liberia;

4 Faculty of Health Sciences, University of Bielefeld, Germany.

Corresponding author: Prof. Vesna Bjegovic-Mikanovic, MD, MSc, PhD; Address: University of Belgrade, Faculty of Medicine, Centre School of Public Health and Management, Dr Subotica 15, 11000 Belgrade, Serbia; Telephone: +381112643830; E-mail: [email protected]

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Abstract

Aim: Over the past two decades, two catastrophic events caused a steep decline in health services in Liberia: the long-lasting civil war (1989-2003) and the weak response of the health system to the Ebola Viral Disease (EVD) outbreak (2013-2015). In early 2015 The Liberian Government reacted and developed a strategic health policy framework. This paper reviews that framework with a focus on maternal and newborn health. Methods: The study is designed as a narrative review executed during the second half of 2017 in Monrovia. It takes advantage of triangulation, derived from recent international and national documents, relevant literature, and available information from primary and secondary sources and databases. Results: In 2015 the severely compromised health system infrastructure included lack of functional refrigerators, low availability of vaccines and child immunization guidelines, high stock-out rates, and an absence of the cold chain minimum requirements in 46% of health facilities. The public health workforce on payroll during 2014/15 included only 117 physicians. Skilled birth attendance as an indicator of maternal health services performance was 61%. Presently, approximately 4.5 women die each day in Liberia due to complications of pregnancy, delivery, and during the post-partum period, equalling about 1,100 women per 100,000 live births. Of particular note is the adolescent birth rate of 147 per 1000 women aged 15-19 years, three times higher than the world average of 44. Additionally, with a neonatal mortality rate of 19.2 neonatal deaths per 1,000 live births, Liberia stands higher than the world average as well. The high mortality rates are caused by multiple factors, including a delay in recognition of complications and the need for medical care, the time it takes to reach a health facility due to a lack of suitable roads and transportation, and a delay in receiving competent care in the health facilities. Conclusions: The fact that performance is above average for some indicators and far below for other points to unexplained discrepancies and a mismatch of international and national definitions or validity of data. Therefore, it is recommended to concentrate on the core of tracer indicators adopted at the global level for Universal Health Coverage and the Sustainable Development Goals to enable a permanent update of relevant information for policymaking and adjustment. At present all health policy documents miss a thorough application of the SMART objectives (Specific, Measurable, Attainable, Relevant and Timely), notably missing in most documents are realistic and detailed budgeting and obligatory timelines for set targets.

Keywords: health system, Liberia, maternal and newborn health, maternal mortality, policies, strategies.

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Introduction Our narrative review investigates maternal The Liberian population is comprised of and new-born health policies. Also, review the descendants of the immigration from addresses the basic components of the United States in the early 19th century reproductive health specific for Liberia as and of 17 major tribal affiliations. Half of an example for other low-resourced the population lives in urban areas (1), the countries especially in West-Africa: majority being Christians, a minority of fertility (actual bearing of live offspring), about one-tenth are Muslims. The civil war safe motherhood (pregnancy and delivery from 1989 to 2003 generated a death toll without risk for own life and child's life), of about 18% of the population of 4.5 family planning, prevention of unwanted million and nearly one million displaced pregnancies and abortions, as well as persons (2). Living standards dropped characteristic diseases for women in their considerably also as a consequence of the reproductive age. weak response of the health system to the subsequent outbreak of Ebola Viral Methods Disease (EVD) 2013-2015 (3). We make use of a combination of Accordingly resources for health services quantitative and qualitative methodologies. missed the so-called Abuja target of 15% A participatory process involving (4) by 2.6 percentage points. A restart and governmental stakeholders through several overhaul of the health system became interviews was particularly helpful and mandatory. supportive in ensuring that issues were Health system oriented towards women explored across sectors to provide a and children obtained particular attention holistic understanding of the situation. of the Liberian government (5). The Also, the paper takes advantage of “Global Strategy for Women’s, Children’s triangulation based on national and and Adolescents’ Health” (2016-2030) (6) international sources and publications as in the context of the Agenda for well as on data and documents of the Sustainable Development (7) identify 9 Government of Liberia predominantly the areas for ‘Reproductive, Maternal, New- Ministry of Health and the Liberia Institute born, Children, and Adolescent Health’ of Statistics and Geo-Information Services. (RMNCAH) policies, calling on We employ further the current governmental initiatives and country methodology proposed by the Maternal leadership, financing for health, health Mortality Estimation Inter-Agency Group system resilience, individual potential, (MMEIG) (10). community engagement, multi-sector The main framework of analysis is action, humanitarian and fragile settings, following steps of the policy cycle (11) as research and innovation, and necessary, moving towards universal accountability for results, resources and health coverage. All actual policy rights. Similarly, Universal Health documents are analyzed looking at 1) Coverage identifies availability, agenda-setting with problem definition and accessibility, acceptability, and quality of situation analysis, 2) policy formulation services (8). These target areas for with goals and objectives, 3) RMNCAH are of similar priority for implementation by government action and almost all countries in the Economic 4) monitoring/evaluation with revised Community of West African States agenda setting. (ECOWAS) as recently analyzed (9).

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Results born Health). We have retrieved in total 28 policy documents, which all involve 1) Review of health policy documents maternal and new-born health, either as a related to Maternal & New-born Health general or specific priority health problem (MNH) under concern and in need for accelerated

The key documents in this context are the action (Table 1), as maternal mortality in “Investment Plan for Building a Resilient Liberia is among the highest worldwide Health System 2015-2021” (12)in line being 1,072/100,000 live-births during the with the “National Health and Social seven years preceding the 2013 LDHS Welfare Policy and Plan 2011–2021” (13). (15). According to the 2007 LDHS, Also, recently the Ministry of Health maternal mortality was even slightly less (MoH) in cooperation with national and than today being 994/100,000 (16). international partners drafted and endorsed Approximately 4.5 women die each day in a document, the “Investment Case for Liberia due to complications of pregnancy, Reproductive, Maternal, Neonatal, Child delivery, and during the postpartum period and Adolescent Health 2016-2020” (14) (17), equalling about 11 women for every aiming to support high impact intervention 1,000 live births. for improving MNH (Maternal and New-

Table 1. Liberian policy documents embracing MNH

Time No Title of the Policy Document Source (Internet pages or references) Frame 1 National Health and Social Welfare Policy 2011-2021 http://moh.gov.lr/category/policies/ and Plan  National Health and Social Welfare Policy  National Health and Social Welfare Plan 2 National Health and Social Welfare Financing 2011-2021 http://moh.gov.lr/category/policies/ Policy and Plan 3 National Human Resources Policy and Plan 2011-2021 http://moh.gov.lr/category/policies/ for Health and Social Welfare 4 National Health and Social Welfare 2011-2021 Not online Decentralization Policy and Strategy 5 Investment Plan for Building a Resilient 2015-2021 http://moh.gov.lr/cabinet-endorses-investment- Health System plan-for-building-a-resilient-health-system/ 6 Investment Case for Reproductive, Maternal, 2016-2020 http://www.globalfinancingfacility.org/sites/gff New-Born, Child, and Adolescent Health _new/files/documents/Liberia%20RMNCAH% 20Investment%20Case%202016%20- %202020.pdf 7 Liberia community health road map 2014-2017 Not online 8 Revised National Community Health Services 2016-2021 Not online Strategic Plan 9 National Policy and Strategic Plan on Health 2016-2021 http://www.afro.who.int/en/liberia/liberia- Promotion publications.html 10 National HIV & AIDS Strategic Plan 2015-2020 http://www.nacliberia.org/doc/Liberia%20NSP %202015- 2020%20Final%20_Authorized_%20OK.pdf 11 National Malaria Control Program. Malaria 2016-2020 http://www.thehealthcompass.org/sites/default/f Communication Strategy iles/project_examples/Liberia%20NMCS%2020 16-2020.pdf 12 National Leprosy and Tuberculosis Strategic 2014-2018 http://www.lcm.org.lr/doc/TB%20and%20Lepr Page 4 of 17

Plan osy%20Strategic%20Plan%202014- 2018%20consolidated%20(1)%20(1).pdf 13 The National Traditional Medicine Policy and 2015-2019 http://moh.gov.lr/category/policies/ Strategy (2015-2019) 14 Strategic Plan for Integrated Case 2016-2020 Not online Management of Neglected Tropical Diseases (NTDs) 15 Consolidated Operational Plan (FY 2016/17) 2016-2017 http://moh.gov.lr/wp- content/uploads/2017/04/Operational-Plan_FY- 17_-martin.pdf and: http://www.seejph.com/public/books/Consolidat ed_Operational_Plan_2016-17.pdf 16 Joint Annual Health Sector Review Report 2016 http://www.seejph.com/public/books/Joint_Ann 2016. ual_Health_Sector_Review_Report_2016.pdf 17 Family Planning 2020 Commitment 2011-2020 http://ec2-54-210-230-186.compute- 1.amazonaws.com/wp- content/uploads/2016/10/Govt.-of-Liberia- FP2020-Commitment-2012.pdf 18 National Gender Policy 2010-2020 2010-2020 http://www.africanchildforum.org/clr/policy%2 0per%20country/liberia/liberia_gender_2009_e n.pdf 19 National Therapeutic Guidelines for Liberia 2011- https://www.medbox.org/countries/national- and Essential Medicine List ongoing therapeutic-guidelines-for-liberia-and-essential- medicines-list/preview?q= 20 Essential Package of Health Services (EPHS) 2011- http://apps.who.int/medicinedocs/documents/s1 ongoing 9420en/s19420en.pdf 21 Road Map for Accelerating the Reduction of 2011-2015 Ministry of Health and Social Welfare, Republic Maternal and New-born Morbidity and of Liberia. Roadmap for Accelerating the Mortality in Liberia (2011-2015)(18) Reduction of Maternal and New-born Mortality 2011-2015 (an updated version of the original publication in 2007). Monrovia, Liberia: Ministry of Health, 2011. 22 Accelerated Action Plan to Reduce Maternal 2012-2016 Ministry of Health and Social Welfare, Family and Neonatal Mortality 2012-2016 (19) Health Division. Accelerated Action Plan to Reduce Maternal and Neonatal Mortality. Monrovia, Liberia: Ministry of Health and Social Welfare, 2012 July. 23 The National Roadmap for maternal mortality 2007 http://apps.who.int/pmnch/media/events/2013/li reduction “the Reach Every Pregnant Woman beria_mnh_roadmap.pdf (REP) Strategy” 24 National Strategy for Child Survival in Liberia 2008-2011 http://liberiamohsw.org/Policies%20&%20Plans /National%20Strategy%20for%20Child%20Sur vival.pdf 25 National Sexual & Reproductive Health 2010 http://liberiamohsw.org/Policies%20&%20Plans Policy /National%20Sexual%20&%20Reproductive%2 0Health%20Policy.pdf 26 Poverty Reduction Strategy 2008 http://www.emansion.gov.lr/doc/Final%20PRS. pdf 27 National Policy and Strategic Plan on 2012-2017 http://pdf.usaid.gov/pdf_docs/PA00J21W.pdf Integrated Vector Management 28 Liberia Health System Assessment (20) 2015 Ministry of Health, Republic of Liberia. Liberia Health System Assessment. Monrovia, Liberia: Ministry of Health, 2015.

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The most recent situation analysis is the International Health Partnership for presented in the “Liberia Service Universal Health Coverage (UHC) 2030, Availability and Readiness Assessment based on the 2005 Paris Declaration on and Quality of Care report (SARA and Aid Effectiveness and the 2011 Busan QOC)” (21), while the most recent Partnership Agreement(30).During the first documents covering MNH policy meeting of the UHC-2030 working group implementation are the “Joint Annual in March 2017 (31), the main focus was on Health Sector Review Report 2016” (22) low and middle-income countries facing and the “Consolidated Operational Plan many threats to their health systems (FY 2016/17)” (23). including decrease in the external financial The most important of the documents support. Liberia potentially faces similar listed in table 1 is the Investment Plan threats in the near future but joined IHP+ (number 5) for the period 2015-2021 only in March 2016, however, a significant making use of the more recent data of the amount of donor support (about 75%) (32) DHS 2013. The political decision-maker remains off-budget with various parallel drafting it employed the MDG targets and implementation arrangements. indicators (24) but not yet the more recent Nevertheless, progress is visible in spite of SDG indicators (25). The method of the recent Ebola crisis (2014/15), mainly stating targets is not explained, in spite of due to the efforts of the Liberian the recommendation to tailor targets government to implement an Essential towards local context and embrace a more Package of Health Services (EPHS) - since realistic approach. As an example, 2011 (33,34). Liberian policymakers envisioned a goal to reduce maternal mortality by three quarters 2) Analysis of Maternal and Neonatal between 1990 and 2015 as set in MDG-5. mortality

That would be equal to - looking at the Looking at time trends, from 1985 to 2015 upper bound level in 1990 (figure 1 below) (Figure 1), the period of the first civil war – 1,980 maternal deaths to be reduced to (1989-1996) was when maternal mortality 495 per 100,000 live-births in 2015, which experienced a peak. In 1994 mortality is at the same time close to the national ratios were 1,890 deaths per 100,000 live- target of 497 maternal deaths per 100,000 births (with the upper bound of 2,470 and live-births set as a desirable goal only for a lower bound of 1,320). After a 2021. Due to such weaknesses and significant recovery, the second civil war inconsistencies, it may be assumed that the (1999-2003) again caused a negligence to selection of Liberian objectives and targets MNH and retardation of improvement. in these documents often have been set at Today Liberian reproductive women have random. Such assumption is mirrored in a 3 times higher chance than the average the recent MGDs assessments (26) that global population of women to experience criticize too ambitious MDGs, which do premature death due to complications not take into account infrastructure and during pregnancy, delivery, and the health system capacity in general, which is postpartum period. Between 2000 and a strong request of the Global Strategy for 2015, the global maternal mortality ratio, Women’s, Children’s and Adolescents’ or a number of maternal deaths per Health (2016-2030) (27-29). 100,000 live births, declined by 37 percent To enhance increased investment into - to an estimated ratio of 216 per 100,000 health systems of resource-limited live births in 2015. In Liberia maternal countries, IHP+ has been transformed into Page 6 of 17

mortality in the same period declined by summarises: “The Liberian Public Health 43% from 1,270 to an estimated ratio of Law of 1976 mandates the MoH to register 725 per 100,000 live births in 2015, all deaths within 24 hours. As a result of indicating considerable improvement since inadequate access, the coverage of the civil wars ended, although still higher registration has always been below 5% than the global average. The national data annually. Death certificates are usually based on the DHSs published in 2008 and processed in Liberia with the intent to 2013 represent maternal mortality during obtain insurance benefits, to settle the 7 preceding years. The main reason for inheritance issues and not as a requirement differences is insufficient death statistics in for burial and documentation of the cause Liberia, with many failing to register the of death.” (35).As an example: in 2013, majority of causes of deaths in the only 659 deaths were registered according population. The Liberian MoH information to the rules.

Figure 1. Maternal Mortality Ratio in Liberia (9,15)

2500 Lower bound (80% UI) Point estimate 2000 Upper bound (50% UI) LDHS

1500

994 1072

1000

500

1994 1986 1987 1988 1989 1990 1991 1992 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 1985

Data on maternal mortality presented in number of skilled human resources for Figure 1 are obtained from databases health in general and of maintained by the WHO, UNDP, experienced,skilled birth attendants UNICEF, and World Bank Group. specifically also inadequate emergency Some of the earlier policy documents obstetric and new-born care services, stated several reasons for high maternal inadequate referral mechanisms, mortality rates mainly related to the inadequate essential drugs, equipment, and insufficient quantity and quality of the supplies were cited. The major non health Liberian human resources for health and factors include a lack of clearly defined health facilities’ performance (36). Some community referral, lack of health of the problems cited were an inadequate financing mechanisms, and socio-cultural Page 7 of 17

inequities. There are significant delays The next important indicator of MNH in which also contribute to maternal and new- the SDG framework is neonatal mortality. born mortality: delays in recognition of With 24.1 neonates’ deaths up to 28 days danger signs and making the decision to per 1,000 live-births, Liberia is still above seek health care, delays in reaching a the world average (19.2 per 1,000 live- health facility via an insufficient road births). However, the historical decrease in system (37), and delays in receiving care at neonatal mortality is significant (Figure 2). the health facility. Consequentially, the The main causes of neonatal deaths are leading causes of maternal deaths are preterm birth complications (10%) and haemorrhage (25%) and hypertension intrapartum related events: asphyxia (9%), (16%) followed by sepsis and abortion and sepsis (8%). (each 10%).

Figure 2. Neonatal Mortality Rate in Liberia (15,38)

80 per 1,000 live-births

70 66.9 65.4 63.8 62.4 61 59.7 58.6 60 57 57 55.1 55.5 52.9 54.3 52.9 50.8 52 51.1 50 50.3 48.4 49.1 46.3 47.4 44.2 48.3 45.6 47 46.1 43.7 42.2 45 40.4 43.8 41.7 43.3 42.5 38.7 40 41.9 39.7 37.1 40.7 37.9 35.7 34.8 34.8 39.1 36.2 34.2 34.1 34.1 34.4 34.5 37.3 34.5 35.5 32.9 33.8 31.3 30 32.1 29.9 30.6 28.6 29.1 27.6 26.8 27.5 26 25.3 26.2 24.7 24.1 24.8 23.4 20 22.1 20.8 19.5 18.6 17.6 16.7 Lower 10 Median

Upper years 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Legend: Lower, Median and Upper refer to the lower, median and upper bound of a 90% uncertainty interval.

Despite these results, policymakers should insufficient Liberian deaths registration carefully consider whether the relatively (potential entrap of under-registration). low neonatal mortality could be due to the The framework for SDG monitoring includes 27 indicators for monitoring of

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SDG-3 (“Ensure healthy lives and promote physician assistants, 2,137 nurses well-being for all at all ages”), out of (RN/LPN), and 659 midwives (1.2 per which a group of 16 indicatorsis directly 10,000 population). Also 2,856 Trained related to health status (39). Though all Traditional Midwives (TTM) are listed. indirectly are relevant for MNH, a TTMs belong to the corpus of 8,052 particularly important indicator, within community health volunteers (based on the SDG-3, is the adolescent birth rate per 2013 mapping exercise). Today, health 1,000 women aged 15-19 years. The main workers’ density varies significantly rationale for the recognition of this between counties in Liberia, the lowest indicator is: “Preventing unintended being in Nimba and the highest in Bomi. pregnancy and reducing adolescent Though improvement in quantity is visible childbearing through universal access to from 2010 to 2015, still numbers are far sexual and reproductive health-care below the levels proposed by WHO to services are critical to further advances in avoid critical shortage: 23 health workers the health of women, children, and per 10,000 are considered as necessary to adolescents. Childbearing in adolescence secure essential maternal and child health has steadily declined in almost all regions, services to the entire population (42).The but wide disparities persist: in 2015, the Roadmap for scaling up human resources birth rate among adolescent girls aged 15 for improved health service delivery in the to 19 ranged from 7 births per 1,000 girls African region 2012-2025 has determined in Eastern Asia to 102 births per 1,000 the same threshold (43). girls in sub-Saharan Africa” (40). In Skilled health professionals’ density is 25 Liberia, this rate was even higher in 2015 per 10,000 globally, but in Liberia almost and also higher than in ECOWAS and the nine times less (2.9 per 10,000). The African region. With 147 adolescent girls difference stems partly from different per 1,000 aged 15-19 years who gave birth definitions of a skilled health professional, to a baby, Liberian female population is at and consequently, different counting in 3 times higher risk in this regard than the WHO and national statistics. For world average (44.1 per 1,000) (41). international comparison, WHO includes as skilled health professionals only the 3) Status of health services following: nurses, midwives and

The second group of relevant indicators for physicians (44). There Liberia with the situation analysis of MNH in relation 2.9/1.000 is the fourth to last place in the to SDG-3 is related to health system ECOWAS community and much below its strengthening. These indicators refer to nationally calculated average of 6.4/1.000 health system structure, quality, and of skilled health professionals. effectiveness of performance, which holds Maternal health services performance a prominent place in the situation analyses assessed by the proportion of births of many Liberian health policy documents. attended by skilled health personnel in The Investment Plan for Building a Liberia at 61% is better than the ECOWAS Resilient Health System (2015-2021) has average of 57% and the average of the been marked already as one of the best African region. According to these health policy documents in Liberia. statistics, Liberia still performs at a lower Following this report (3), the public health level than the global average where 3 out workforce on payroll, during 2014/15, of 4 births (73%) were assisted by skilled included only 117 physicians, 436 health-care personnel in 2015. Performance is above average for some Page 9 of 17

indicators and far below for others (e.g., rates, and absence of the cold chain maternal vs. neo-natal mortality), the minimum requirements in even 46% health disparity points to unexplained facilities. 13% are also without direct discrepancies and mismatch of access to water, 43% without incinerator, international and national definitions or and 45% without regular electricity. validity of data. For example a comparison of maternal and neonatal mortality Discussion throughout historical periods in Liberia is A main observation with regard to this misleading: researchers and authors of policy analysis is that significant LDHS-2013 (page 285) (45) have weaknesses of the national policy rightfully warned that comparison is documents derive from missing links possible only with LDHS-2007, due to the between objectives, realistic and fact that methods of estimates were measurable targets, activities with a significantly changed in 2007 and cannot quantifiable input, precise and controlled serve for comparison with previous timelines for their implementation, and surveys – LSDH-1999/2000. Furthermore, appropriate reliable budgetary allocation the interpretation of indicators does not (49). An example of necessary links is account for the fact that LDHS provides given in figure 3. direct estimates of maternal mortality for Furthermore, Liberia (in spite of the the seven years preceding each survey. country’s low capacity) could use Finally, a tracer indicator, relevant for available opportunities to improve the MNH and SDG-3, may serve to describe insufficient registration of birth and death the status of the Liberian health system events. An immediate option is provided and its infrastructure best: “Infants by the Multiple Indicator Cluster Survey receiving three doses of hepatitis B (MICS), organized and funded by vaccine”. In Liberia, only 50% of children UNICEF. Preparation for the MICS 6 is received the vaccination in 2014 (46) ongoing in many countries (50), while (ECOWAS average 78%). Such situation Liberia implemented only the first round in is well explained in a national situation 1995, with only three counties at the time analysis (47) as a consequence of the EVD (Montserrado, parts of Margibi and Bassa) crisis (with declines not only of though with 60% of the total Liberian immunizations but also all other MNH population living in the same areas) (51). services). The recent SARA report (48) MICS is a valuable data source covering clarifies the situation by severely the reproductive health of women, health compromised health system infrastructure: outcomes for children and adolescents, lack of functional refrigerators, low child mortality, education, water, and availability of vaccines and child sanitation. immunization guidelines, high stock-out

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Figure 3. The complex linkage between a health problem, its determinants, areas of intervention, the regulatory framework and SMART activities

Health Potential intervention SMART Determinants Regulatory changes Problem areas Activities

Curriculum update Developing Planning Workforce for Workforce for Maternal Health Increasing study Maternal Health places

Accreditation of Supervised field- Colleges/ work Staff quantity Motivation of Schools and midwifery staff Define CE courses qualification Obligatory CE for Guaranty 24/7 midwifery Low Availability of Secure High connectivity, reimbursement maternal staff at point of lack of (solar) access Employing mortality electricity and sufficient Reliable salaries tape water midwifery staff and incentives

Reconsider TTM Insufficient Secure EmONC role and reduce transport services at all waiting time capacity & lack levels of maternal Organise all donor waiting homes conference/ Compact

Health Problem: Upgrade facilities and replace The maternal mortality rate outdated in Liberia was 1072/100,000 equipment life-births in 2013.

Based on the model Healthy Plan-itTM of CDC Atlanta.

A final evaluation will only be possible relevant for Liberia is the SDG index, with upon completion of all planned activities tracer indicators that serve both for health in 2021. Liberian MoH policymakers workforce and health services’ monitoring. should consider more closely (during The index comprises only 12 indicators monitoring activities) the international and serves for both national and developments, which received a final international comparisons. The latest endorsement in 2017. The Universal examples of such utilization can be found Health Coverage (UHC) Indicators for the in the Global strategy on human resources Sustainable Development Goals (SDGs) for health – Workforce 2030 and the Monitoring Framework have been agreed Global Strategy for Women’s, Children’s on March 13, 2017 (52). The global and Adolescents’ Health (2016-2030). indicator framework has been formally adopted by the United Nations General Conclusions and recommendations Assembly through the United Nations There are well-developed strategies in Economic and Social Council and will be almost all health areas,but most of them instrumental for the national and are missing defined action plans with international monitoring, evaluation,and publicized targets following SMART comparison of achievements. Particularly principles, therefore correspondingly there Page 11 of 17

is a severe gap in implementation. Also, counties) is one of the immediate tasks data used should be referenced, cross- for the Liberian MoH. checked, and critically evaluated regarding  Strengthening of policy planning at the reliability and validity. It is recommended county level is also a priority in policy to go beyond simple presentation and formulation, preferably by using one of analyze differences in outcomes for the proven models for programme statistical significance, including multiple planning, such as Healthy Plan-itTM by regressions to identify significant CDC (Atlanta). determinants of health outcomes. Analyses  Invited international expertise should and the discussion of their results should be given full access to data, and always be compared to West African, Technical Assistance should have African, and global parameters, not access (observer status) to policy restricted to the national perspective. For meetings like the Health Sector intra-national comparisons, the same data Coordination Committee (HSCC) and sources have to be used as otherwise the Pool-Fund meetings (as otherwise a comparability and conclusions are lateral and vertical information jeopardized. exchange within the MoH is severely It is further recommended to initiate as inhibited). soon as possible a process of developing new health policy documents in Liberia - Derived from Liberian health policy for implementation after 2021 - by MoH documents, the situation analysis, and the stakeholders, involving inter-sectoral literature review, the following areas may representation and independent expertise. be prioritized regarding MNH services A multidisciplinary team of health (54): policymakers should analyze opportunities  Ensure timely, equitable, respectful, and strengths, based on existing National evidence-based, and safe maternal– Development Plans (especially the Liberia perinatal health care, delivered through Agenda for Transformation: Steps towards context-appropriate implementation Liberia Rising 2030 (53)). The main strategies; intention is to have health policy  Build linkages within and between documents fitting the local context and the maternal–perinatal and other health- new movement towards SDGs, strictly care services to address the increasing applying SMART principles, especially diversity of the burden of poor obligatory timelines and budgetary maternal health; allocation as a key element of the SMART  Increase the resilience and strength of principle in realistic planning. health systems by optimizing the Acknowledging the local context, already health workforce and improving now a first step could be the revision of the facility capability; national health and social welfare  Guarantee sustainable financing for decentralization policy and strategy: maternal–perinatal health; and  Development of a roadmap 2030 for the  Accelerate progress through evidence, SDGs, which will allow for advocacy, and accountability by: implementation and monitoring after - developing improved metrics, and 2021 (providing transparency of support implementation research to fragmented implementation and a promote accountable, evidence- database of ongoing projects in based maternal health care and Page 12 of 17

- translating evidence into action Conflict of interest: None declared. through effective advocacy and accountability for maternal health. Ethical approval: Not required as this paper does not contain any studies with Finally, there is a significant opportunity human participants or animals performed for Liberia and all African countries to by any of the authors. make use of the new WHO leadership and Dr. Tedros Adhanom Ghebreyesus, WHO Funding: This work has been done in the Director-General, who recently pointed out framework of project funding by the (55): European Commission: Technical “Universal health coverage is ultimately a Assistance to support the implementation political choice. It is the responsibility of of the national health plan and the every country and national government to roadmap for the reduction of maternal pursue it. Countries have unique needs, mortality in Liberia (FED/2014/351/044). and tailored political negotiations will determine domestic resource mobilisation. Acknowledgments: The authors are WHO will catalyse proactive engagement grateful to the Ministry of Health of the and advocacy with global, regional, and Republic of Liberia, to Richard Gargli and national political structures and leaders Roosevelt McCaco in Monrovia for their including heads of state and national help in identifying the relevant parliaments”. publications, and to Nelson Chase for English editing.

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