Working in many such post-crisis contexts, Médecins sans Frontières (MSF) witnesses the ongoing risks to the population’s health in the aftermath of emergencies. As transition and reconstruction phases begin and humanitarians give way to development actors, government and donor priorities shift. During this transition, healthcare is too often in danger of falling off global policy and donor priority lists, even as the lives and health of vulnerable populations remain in the balance.
Liberia is but one example of many. After fourteen years of civil war, the population remains in a precarious state. Three quarters of the population survive on less than $1 a day and 23% of children die before the age of five. Interviews with patients at MSF-supported clinics on Bushrod Island in Monrovia – which has a population of around half a million – revealed that over half of them had had only one meal the day before consultation. 36% had no direct source of income, while the average income of the remaining 64% was under $0.30 per person per day. With poor access to water, latrines and health services, communicable diseases are widespread – particularly respiratory infections, malaria, diarrhoea and skin infections. The two MSF clinics in the area handle 20,000 consultations per month, including deliveries. 77% of all medical care in Liberia is currently provided by international NGOs and faith-based organisations.
The government, international donors and other decision-makers confront enormous and competing needs during the reconstruction phase. Many questions remain open about which sectors should be supported, the amount and duration of aid and the policies connected with assistance. Yet health often risks being omitted from policy-making and donor agendas. The draft agenda of the long-awaited Washington Donor Conference on Liberia in February 2007 did not even include healthcare.
Healthcare becomes increasingly complicated once an emergency has passed and policies of free care and support for secondary healthcare facilities are no longer a given. In MSF’s experience, the introduction of the principle of cost recovery and the withdrawal of support from secondary healthcare structures in the name of government responsibility and ‘sustainability’ greatly impact the ability of vulnerable and conflict-affected populations to access medical care in the aftermath of a crisis. We saw first hand the disastrous effects of the introduction of user fees in Liberia in 2001-02, which resulted in an up to 40% drop in attendance at MSF-supported facilities in Monrovia. When fees were suspended in 2003, we saw a 60% increase in consultations. This cancellation of fees not only impacted on curative services but also on attendance rates for preventive services like vaccination. The people of Liberia simply do not have the means to pay for their own healthcare.
Redemption Hospital is one of Monrovia’s main public hospitals, with a 150-bed capacity. After six years of support and a final renovation and expansion, MSF completed a gradual hand-over of the facility to the Ministry of Health in June 2006. Since then, the situation at Redemption has deteriorated considerably. There are major staffing gaps as the management cannot afford to pay decent salaries. Patients have to purchase their own drugs outside the hospital, and fees for services and drugs have been re-introduced. As a result, the number of patients has dropped dramatically from 1,200 inpatient admissions per month in 2005 to currently negligible levels of bed occupancy. During the transition phase, if no alternatives could be found for Redemption, the only Ministry of Health secondary healthcare structure in Monrovia, Liberia’s capital, the situation could only be worse in other areas of the country.
Financial and other barriers must be lifted to ensure Liberia’s population can access medical care. The key will be to continue providing a package of essential medical services free of charge throughout the transition period. Asking the country’s vulnerable, violence-affected population to pay for urgently needed healthcare only erodes their still-fragile coping mechanisms. It also risks contributing to their impoverishment and blatantly contradicts international concerns for poverty reduction.
The Liberian government has demonstrated its commitment by increasing the allocation for health to $10m in its 2007 budget. The Ministry of Health has also expressed its willingness to work toward the provision of a basic healthcare package to the entire population, while maintaining free care for all, at least throughout the transition phase. As the transition phase advances, humanitarian funding for healthcare in Liberia will dry up. As an emergency organisation, MSF will now reduce its activities after 17 years of intervention in-country. Faced with the ongoing dire health conditions in the country, in an exceptional move MSF decided to remain engaged in Liberia at least until the end of 2008 to ensure the provision of decent and accessible basic healthcare through Ministry of Health structures.
External aid will be vital to ensure that the Ministry of Health has the capacity to match its ambition to continue to provide basic healthcare for the population. It remains to be seen if international support will materialise to address the undeniable medical needs in Liberia. After years of war, Liberia’s population deserve more than second-class assistance. Its 3.5 million people challenge international commitment to avoid the pitfalls of other transition countries and to choose to do better.
Katharine Derderian (email@example.com) is Humanitarian Advisor for Policy Issues, Helene Lorinquer (firstname.lastname@example.org) is Coordinator of the Analysis and Advocacy Unit and Stéphan Goetghebuer (email@example.com) is Operational Coordinator for West Africa at Médecins Sans Frontières Operational Centre, Brussels (www.msf.be).