Which doctor?: Determinants of utilization of formal and informal health care in postconflict liberia.

BACKGROUND: Liberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care. OBJECTIVE: This study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This was a cross-sectional population-representative survey of 1435 adults living in rural Nimba County, Liberia. Participants were asked about past year visits to traditional and formal health care providers and demographics, health, and trauma indicators. The association between formal and informal visits and potential determinants was estimated in separate models using generalized estimating equations to adjust for village-level clustering. RESULTS: The median number of visits in the past year to formal and informal providers was 3 and 10, respectively. Clinic visits increased with younger age and female sex, past trauma exposure, the number of traditional healers, and the presence of a facility dispenser. Frequency of informal visits increased with poor self-reported mental and physical health, the presence of facility fees and decreased with literacy and wealth and satisfaction with the formal health system. CONCLUSIONS: Rural Liberians use both formal and informal health care extensively and as complements rather than substitutes. The reliance on traditional medicine to address health needs is of concern in a country with a high disease burden. Health system investments that build public confidence in the health system may help shift demand from informal to formal health care.

Rebuilding human resources for health: a case study from Liberia.

INTRODUCTION: Following twenty years of economic and social growth, Liberia's fourteen-year civil war destroyed its health system, with most of the health workforce leaving the country. Following the inauguration of the Sirleaf administration in 2006, the Ministry of Health & Social Welfare (MOHSW) has focused on rebuilding, with an emphasis on increasing the size and capacity of its human resources for health (HRH). Given resource constraints and the high maternal and neonatal mortality rates, MOHSW concentrated on its largest cadre of health workers: nurses. CASE DESCRIPTION: Based on results from a post-war rapid assessment of health workers, facilities and community access, MOHSW developed the Emergency Human Resources (HR) Plan for 2007-2011. MOHSW established a central HR Unit and county-level HR officers and prioritized nursing cadres in order to quickly increase workforce numbers, improve equitable distribution of workers and enhance performance. Strategies included increasing and standardizing salaries to attract workers and prevent outflow to the private sector; mobilizing donor funds to improve management capacity and fund incentive packages in order to retain staff in hard to reach areas; reopening training institutions and providing scholarships to increase the pool of available workers. DISCUSSION AND EVALUATION: MOHSW has increased the total number of clinical health workers from 1396 in 1998 to 4653 in 2010, 3394 of which are nurses and midwives. From 2006 to 2010, the number of nurses has more than doubled. Certified midwives and nurse aides also increased by 28% and 31% respectively. In 2010, the percentage of the clinical workforce made up by nurses and nurse aides increased to 73%. While the nursing cadre numbers are strong and demonstrate significant improvement since the creation of the Emergency HR Plan, equitable distribution, retention and performance management continue to be challenges. CONCLUSION: This paper illustrates the process, successes, ongoing challenges and current strategies Liberia has used to increase and improve HRH since 2006, particularly the nursing workforce. The methods used here and lessons learned might be applied in other similar settings.

Village characteristics associated with posttraumatic stress symptoms in postconflict Liberia.

BACKGROUND: Group-level factors may be associated with mental health. We assessed whether various village-level variables were associated with posttraumatic stress symptoms in a resettled postconflict population in Liberia. METHODS: Individual surveys were administered to a population-based sample (n = 1434). We used multilevel random intercept linear regression models to estimate associations between individual- and village-level variables and posttraumatic-stress-symptom score. RESULTS: In a multilevel model taking into account individual-level covariates, living in a village with higher mean number of traumatic experiences or greater history of displacement was associated with a higher symptom score. Conversely, living in a village with a more equal distribution of household wealth was associated with lower symptom score. CONCLUSIONS: Characteristics of communities, as well as of individuals, may be important determinants of posttraumatic stress in low-income countries, such as Liberia, that are recovering from conflict.

Availability of essential health services in post-conflict Liberia.

OBJECTIVE: To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war. METHODS: We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness. FINDINGS: Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county's 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively. CONCLUSION: Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.

Persistent psychopathology in the wake of civil war: long-term posttraumatic stress disorder in Nimba County, Liberia.

OBJECTIVES: We assessed the geographical distribution of posttraumatic stress disorder (PTSD) in postconflict Nimba County, Liberia, nearly 2 decades after the end of primary conflict in the area, and we related this pattern to the history of conflict. METHODS: We administered individual surveys to a population-based sample of 1376 adults aged 19 years or older. In addition, we conducted a historical analysis of conflict in Nimba County, Liberia, where the civil war started in 1989. RESULTS: The prevalence of PTSD in Nimba County was high at 48.3% (95% confidence interval=45.7, 50.9; n=664). The geographical patterns of traumatic event experiences and of PTSD were consistent with the best available information about the path of the intranational conflict that Nimba County experienced in 1989-1990. CONCLUSIONS: The demonstration of a "path of PTSD" coincident with the decades-old path of violence dramatically underscores the direct link between population burden of psychopathology and the experience of violent conflict. Persistent postconflict disruptions of social and physical context may explain some of the observed patterns.