Ten years after the end of Liberia's civil war, the infrastructure is still in shambles, and there's a shortage of both health workers and money to pay them. But in spite of it all, the government recently rolled out an aggressive new plan to end preventable child deaths.
The country is one of the first to introduce a detailed plan of action to address child survival as part of a worldwide initiative launched in 2012 by the United States, India, Ethiopia and the United Nations Children’s Fund. More than 176 countries have joined the movement, called “Committing to Child Survival: A Promise Renewed,” pledging to redouble efforts to meet the 2015 deadline for the UN Millennium Development Goal to cut child mortality to two-thirds of the 1990 rate. By 2035, the countries have vowed to reduce the under-five death rate to 2 of 100 live births or fewer.
Liberia's optimism is rooted in a record of beating the odds: Liberia has improved child survival rates faster than any other African nation, cutting deaths by an average of 5.4 percent a year. In 1990, nearly a quarter of Liberian children never lived to see their fifth birthday, according to UNICEF. By 2010, that number had dropped 68 percent. It is one of just a handful of African countries to achieve the Millennium Development Goal ahead of deadline.
For a country that just 10 years ago was in the throes of a brutal war that killed nearly 300,000 and displaced 800,000, Liberia's progress is remarkable, said Laura O’Hara, who heads up UNICEF’s child survival and development program in Liberia.
After 14 years of fighting, Liberia's roads were destroyed. Water and power supplies were cut. Hospitals were looted and burned. By the time fighting ceased, almost 200 of the country’s 550 health facilities were out of commission and all but 168 physicians had fled. Now, the number of operational hospitals and clinics are back to pre-war levels. Government health spending, while still modest, increased from just $4.63 per person in 2003 to $54.90 in 2011. The number of children who get routine immunizations — a dismal 39 percent at war’s end — is now 75 percent.
“The government had to build the health system from basically nothing,” O’Hara said. “To see how the country has developed and how it is moving forward — even without the number of skilled health workers we should have — is a great testament to the Ministry of Health.”
But despite Liberia’s hard-won gains, roughly 8 of every 100 children still don’t survive to age five, and the leading causes of death — malaria, pneumonia and diarrhea — are treatable. Poor access to health care means about 6 of every 100 babies die within the first four weeks of life.
The country’s plan to meet the goals of A Promise Renewed includes increasing access to care by training community health workers and rolling out the rotavirus and pneumococcal vaccines (to fight diarrhea and pneumonia, respectively). To improve newborn survival rates, officials are developing national guidelines for sterilizing umbilical cords and launching a campaign promoting the practice of giving infants skin-to-skin contact to regulate body temperature after birth.
Education is a major part of the thrust. In many places, villagers could slow the spread of disease by simply designating “defecation-free” zones, O’Hara said. Only 4 percent of Liberians have access to improved sanitation facilities and 77 percent practice open defecation, according to UNICEF. Teaching mothers to breastfeed exclusively for the first six months — a practice that just 34 percent now embrace — would give babies a healthy jump on life, she said.
The government also has a lot of logistical problems to work out.
“The war impacted everything,” O’Hara said. “It’s difficult to train health workers because people didn’t go to high school — they didn’t even go to elementary school. How do you get medicine to people when the roads have all been destroyed?”
Liberia plans to build new clinics and upgrade olds ones. Officials are employing World Health Organization strategies to stretch immunization programs and pregnancy care to remote areas using community members.
All of this, though, requires money. And Liberia’s health system is strapped for cash, said Tolbert Nyenswah, Liberia’s assistant minister of health and social welfare. A vivid illustration of the problem: more than 20,000 of Liberia’s public health workers have been on strike since July 23 because the government can only afford to pay their $150 per month salaries sporadically.
By joining A Promise Renewed, Nyenswah said the country hoped to signal to international donors that the government is serious about saving children — and seriously in need of resources.
Foreign aid accounted for more than 62 percent of Liberia’s gross national income in 2010, according to the nonprofit data collection organization Global Humanitarian Assistance. Since the war ended and Liberia started rebuilding, monetary support has steadily declined. As of June of 2013, for example, UNICEF Liberia had received just 45 percent of the funds required to keep their programs running.
“Donors are very interested in countries that are in the middle of a severe emergency,” O’Hara said. “We are a country slowly moving towards an objective, and that’s not as exciting.”
O’Hara and Nyenswah both worry the resources will dry up before Liberia is ready to stand on its own.
“We are broken down,” Nyenswah said. “If we are to succeed in meeting these goals for reducing under-five mortality, we need strong partnerships. Liberia has recommitted. The partners now also need to make that same recommitment so Liberia can be a success story.”