Availability of Essential Health Services in Post-Conflict Liberia/ Disponibilite Des Services De Sante Essentiels Dans la Situation Post-Conflictuelle Que Vit le Liberia/Disponibilidad De Servicios De Salud Esenciales En Liberia Tras Los Conflictos

Introduction Large-scale armed conflict has both immediate and long-term effects on population health in low-income countries. (1) In addition to violence-related mortality, disruption in the delivery of basic services, including electricity, water and health care raises death rates among non-combatants during conflict and after it has ended. The collapse of health systems, which suffer from flight of health workers, looting and physical destruction of facilities, exacerbates this indirect mortality. Although humanitarian organizations can alleviate suffering in the short run, repairing the health system is a more daunting task. (2) Liberia emerged from 14 years of civil war in 2003. This conflict resulted in near-total destruction of the country's infrastructure. Today, six years after the end of the war, the electrical grid still operates solely in the capital city, Monrovia. Few roads have been repaired and schools have only recently reopened. The health system was also destroyed in the war: of the 293 public health facilities operating before the war, 242 were deemed nonfunctional at the end of the war due to destruction and looting. (3) Doctors, nurses and other health workers fled the country, leaving 30 physicians to serve a population of 3 million. (4) Outside Monrovia, where humanitarian agencies provided some services, most of the population has little or no access to health care. The government of Ellen Johnson-Sirleaf, elected in 2005 in the country's first post-war democratic election, faced a dire health situation. The under-five mortality rate was 110 per 1000 live births and the maternal mortality ratio was 994 deaths per 100 000 live births, with the latter figure representing a 71% increase from the 2000 estimate of 550. (5) Malaria, which is endemic in Liberia, is a major cause of morbidity and an important contributor to under-five mortality. In 2006, one-third of the population had at least one episode of the disease and an estimated 6000 children died from its complications. (6) Mental health problems related to war trauma and exacerbated by dislocation are also a pressing concern. A 2008 survey found that 40% of the population had self-reported symptoms indicative of major depression and 44% probably had post-traumatic stress disorder. (7) The prevalence of human immunodeficiency virus (HIV) infection in Liberia was estimated at 1.5% in 2007, a figure similar to that in the neighbouring countries of Guinea (1.5%) and Ghana (2.2%) but substantially lower than in eastern and southern Africa, where seven countries had an HIV infection prevalence higher than 15%. (5,8) In response to the post-war health challenges, the Ministry of Health and Social Welfare, with assistance from donors and international nongovernmental organizations (NGOs), embarked on rebuilding the health system. The ministry's first aim was to expand the provision of primary health care, particularly in rural areas that were underserved even before the war. The 2007 National Health Plan outlined a basic package of health services: essential health services that would be provided without charge at clinics and hospitals throughout the country, ranging from HIV testing to emergency obstetric care. (9) The preventive and curative interventions in the basic package of health services target the disease burden in the country, particularly infectious disease and the high maternal and child morbidity and mortality (Box 1). (10) The ministry partnered with a large group of international and national NGOs to deliver a basic package of health services. Basic packages of health services implemented with support from international and national NGOs have been used to jump-start the rebuilding of the health system in other post-conflict countries such as Afghanistan and Sierra Leone, where they have been credited with increasing the utilization of health services and reducing mortality and morbidity. (11,12) Box 1. …