Financing Common Goods for Health in Liberia post-Ebola: Interview with Honorable Cllr. Tolbert Nyenswah

About this Commentary

Honorable Cllr. Tolbert Nyenswah was interviewed as part of the Financing Common Goods for Health (CGH) special issue based on his first-hand experience in managing Liberia’s Ebola virus disease (EVD) outbreak in 2014. Through this interview insights are gained into how a national government and its citizens collectively responded to such a public health crisis and what actions have been taken since in the call for more investments in CGH.

About the Interviewee

Honorable Cllr. Tolbert Nyenswah was the Incident Manager of Liberia’s National Ebola Response from 2014-2016. In this role, he coordinated the multinational complex EVD response for the Government of Liberia and coordinated related national and international actors. Before this position, he was an Assistant Minister of Health heading the Bureau of Disease Prevention and control as well as the Deputy Chief Medical Officer of Liberia in 2012. After leaving the position of the Ebola Incident Manager in 2015, Mr. Nyenswah became the Deputy Minister of Health for Disease Surveillance and Epidemic Control, a new department created in the Ministry of Health. In this capacity, he established and became the first Director General of the National Public Health Institute of Liberia in 2017, which was modeled after the US Center for Disease Control and Prevention. In collaboration with the Ministry of Health, the Institute works to strengthen existing infection prevention and control efforts, laboratories and surveillance systems, environmental health efforts, and monitoring of diseases with epidemic potential. It also coordinates the National Emergency Operation Center (EOC) in Monrovia and 15 additional EOCs in all counties of Liberia.

What were the main challenges or constraints to investing in Common Goods for Health (CGH) in Liberia before the 2014 Ebola virus disease (EVD) crisis? Are there areas where the country did well in terms of these investments?

Mr. Nyenswah: The Government has to manage a lot of competing priorities, which has made overall health financing in Liberia an on-going challenge. Instead of supporting CGH across the health sector, most resources were, and still are, fragmented to support disease-specific programs, with 38% of health expenditure coming from external aid in Liberia in 2014.¹ For example, UNICEF funds immunizations, while HIV, tuberculosis, and malaria are funded by The Global Fund and PEPFAR. This is due to the fact that donors have their specific areas of concern so they choose to support these programs independently of one another. Thus, resources would come into the sector with little management or coordination between the programs or broader Ministry of Health (MoH) plans.

Additionally, social determinants and non-traditional health functions, like housing and water, access, sanitation and hygiene (WASH), were not a primary focus of our government. However, it is important to note that Liberia did well in investing in other CGH, such as functions related to child health. Since 2004, immunization services for basic childhood vaccines in Liberia have more than doubled from 30% to 80%.² Furthermore, we were the first sub-Saharan country to achieve Millennium Development Goal 4 (reducing child-mortality by two-thirds from 1990 levels). Clean water is another area we had invested in, which helped to reduced water-borne diseases like diarrhea and cholera.

Has coordination in the health sector, either across government and/or donors, changed in the post-EVD era? If no, why not?

Mr. Nyenswah: Concerted efforts have been made to improve coordination within the government since the EVD crisis. One area in particular is the development of the National One Health approach, which brings together all of the sectors relevant to infectious disease control under a common platform to enable better coordination in the case of future public health events.

The overarching objective of the One Health Coordination Platform is to collaborate and facilitate discussions and actions on issues concerning the health of humans, animals, and the environment that cut across multiple sectors. Across the world, One Health efforts are being undertaken to manage and mitigate the emergence of infectious diseases that have local and global implications.

The Government of Liberia and partnering organizations recognize the critical importance of this type of multidisciplinary collaboration and coordination in order to effectively prevent, detect, and respond to health threats. This approach in Liberia involves steering committees, comprised of various ministries and agencies that promote coordination and discussion on issues related to global health security and service provision. Furthermore, technical working groups have been established to enhance collaboration on issues related to human, animal, and environmental health both across the health sector and across ministries. These include the epidemiology surveillance, laboratory, preparedness and response, antimicrobial resistance (AMR), and human resources working groups.

However, the coordination of these sectors through this approach has not had an impact yet on budgets and financial flows in terms of consolidating and mainstreaming shared functions. While it is a positive step forward in terms of facilitating discussions, there is still work to be done to change incentives and budgets. Additionally, Liberia has not recovered economically since the EVD crisis, so the revenue base remains small, which has further exacerbated inter-ministerial competition for resources.

What has changed after the EVD crisis, if anything, in terms of the focus of political leaders and how donors are providing health aid to Liberia?

Mr. Nyenswah: Before the 2017 Presidential election, there was a lot of discussion and initial efforts behind a sector-wide approach, including an agreement across donors to pool funding at a systems level. Liberia is a signatory to the International Health Partnership (IHP+) for Universal Health Coverage (UHC) 2030. The IHP+ for UHC 2030 is an effort to revitalize and realign multi-stakeholder partnerships for health to work towards the Sustainable Development Agenda 2030. It is a platform that Liberia believes will increase the coordination efforts of health systems strengthening and will promote accountability for UHC.

The Sustainable Development Goals (SDGs), and notably target 3.8 on UHC, provide the opportunity for a more coherent and integrated approach to health, beyond the treatment of specific diseases. UHC is the target that underpins the overall health goal and is the ultimate expression of equity that can operationalize the ambition to leave no one behind. It also has the best chance of meetings people’s expectations for comprehensive care that does not drive them below the poverty line. Attaining SDG 3 will require a new commitment to reduce fragmentation in health, with more efficient and coordinated investment in the health system.

Liberia’s signing of the IHP+ represents this move towards coordination; however, the new government that came into power in January 2018 has not implemented the provisions of the agreement and this larger effort has been greatly derailed. New people came into ministerial and agency positions with different priorities.

Our current political leaders do not recognize the importance of investing in CGH and more work needs to be done to impress upon them the importance of these investments. The current government priorities are focused on roads, energy, bridges, and infrastructure. While health care and education are critical to human development, they are not recognized as such. However, the government's new 5-year National Development Plans (NDP) includes their Pro-Poor Agenda for Prosperity and Development 2018 to 2023 (PAPD), the core of which is to address the basic needs of Liberians such as income security, access to basic services, and education. It will be interesting to see what comes out of this PAPD.

In short, nothing has changed in terms of how donors are providing aid in Liberia since the EVD crisis. Support continues to go through individual organizations or agencies and a sector- and a system-wide approach has not been adopted. There is a need to reorient both the government and donors alike towards the importance of financing these core CGH.

Do you think that it is more politically salient for governments to invest in personal, curative services, as compared to these more preventive, population-based functions. Is this true in Liberia?

Mr. Nyenswah: Yes, the government definitely invests more in these types of personal services, as well as buildings and infrastructure. One of the things that I tell people is that investing in health care is not the same as seeing a bridge being built. In a year or two, the bridge is finished and you can see the highway. Investing in preventative health, however, promotes health outcomes that will not be visible in the short run, such as increased life expectancy, reduced child deaths, improved immunization coverage, increased survival rates of mothers and newborns, improved child nutrition, greater gender equity in primary education, increased access to clean and safe drinking water and sanitation services, and a healthier working population. A lot of the reason behind this comes from the 14-year civil war in Liberia. Infrastructure like hydro-dams, bridges, and other aspects of the Liberian society were destroyed by its citizens so there has been increased efforts towards rebuilding and restoring the country.

One way to shift this mentality in the government would be to use widely respected champions to take the time to explain the importance of and advocate for financing these core health functions. Additionally, this could generate citizen demand, which would help put stress and urgency to their overall importance on political leaders.

Some of these champions could come from within the government, but sometimes external individuals have more influence. One option could be someone from the National Public Health Institute who could give anecdotes on what was seen during the EVD crisis and how Liberia’s GDP was affected by one single disease. Civil society organizations and the media would be another sound way to target political leadership. Other options could be technically respected international bodies, such as USAID or WHO.

What was the polio-related investments in Liberia as compared with Nigeria? Did this disease-specific investment provide any support during the EVD crisis in Liberia?

Mr. Nyenswah: The EVD situation in Nigeria was not the same as in Liberia. First, EVD did not hit the same populations in Nigeria as it did in Liberia. Nigeria had improved surveillance systems because of the polio investment, which was helpful to contain the spread of diseases. Their polio field epidemiologists and polio surveillance systems were mobilized to track and combat EVD, while Liberia did not even have an institutionalized system for disease tracking. Many of the initial efforts of the National Public Health Institute focused on establishing this function. We are now building a surveillance system in the country based on the WHO integrated disease for surveillance and response system and we are training field epidemiologist.

Surveillance systems and field epidemiologists are areas that, after the EVD crisis, the government has worked hard to implement and improve with the help from the US CDC. For instance, the US CDC is currently supporting Liberia through the Africa field epidemiology network and capacity building of surveillance officers. In the last two years, we have achieved over 95% completeness and timeliness of disease reporting due to the active surveillance system at the district and community level. We have also established functional Emergency Operation Centers and an electronic records system.

Has there been any dialog with neighboring countries regarding the shared provision of CGH that have regional impacts beyond national borders?

Mr. Nyenswah: There has been a significant increase in collaboration between the countries neighboring Liberia in terms of cross boarder health coordination and meetings. We share important aspects with each other such as capacity trainings, scientific information and data related to health, and scientific conferences with the Africa CDC, the Regional CDC, and the west Africa CDC in Nigeria. Now, for example, if there is an outbreak of yellow fever in Nigeria, neighboring countries like Liberia, can support them by sharing epidemiological data or sequencing information they need to help stop the spread of disease and vice versa.

What changes would you recommend in terms of financing CGH in Liberia moving forward?

Mr. Nyenswah: Financing CGH will require pooled funding of resources, and donors need to respect this commitment in the interest of resources being used more effectively and efficiently in Liberia. For CGH specifically, it is necessary to look beyond specific programs and instead invest in cross-cutting functions like, for instance, human resources, how well health facilities are stocked, essential medication, and information technology systems. Pooled donor funding will help the government to redirect resources by making health, and CGH more broadly, a priority in budgetary allocation. This is not a one size fits all strategy but requires strong advocacy to meet the Abuja declaration of 15% of government GDP to the health sector.³ However, for the system to function well, it requires a health systems approach like the WHO health systems building block framework and not a disease driven approach like we have now.⁴ As it currently stands, the bulk of our domestic health budget is allocated towards salaries, while the rest of the activity-related funding is still segmented by program.

We need to establish and support a one health planning board that can coordinate across the health system to set the necessary priorities for investment in areas like CGH, and have budgets follow these plans and priorities. Additionally, if we want to achieve this change towards a more health-systems oriented approach, it will be necessary to have the government lead this charge.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Additional information

Funding

This article was supported by the World Health Organization. Funding from Finland’s Ministry of Social Affairs and Health, the UK Department for International Development, and the European Commission is gratefully acknowledged.