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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.
Because the aim of the study was to measure availability of services for a “typical” rural population, we selected Nimba county as the study site on the basis of advice from the ministry and its partners. Nimba county has a primarily rural population, is distant from the capital Monrovia (and therefore unable to rely on health services available there) and like other parts of Liberia, experienced large-scale destruction of its infrastructure. The organization of the county’s health services is similar to that of other parts of Liberia and is consistent with the ministry’s central health strategy. Thus, we considered Nimba to be representative of rural, deprived areas of the country. Nimba county is located in northern Liberia, along the border with Guinea and Côte d’Ivoire. It is the country’s second most populated county, with 462 026 inhabitants.15 There are two major ethnic groups, the Mano and the Gio, and most communication is done in local languages and Liberian English – a modified form of English. The majority of the population lives in the northern half of the county, with lightly inhabited rainforest found throughout much of the southern half. Nimba county has a small network of primary roads connecting major towns, and dirt roads connect most small villages to this primary road network. Most dirt roads become impassable for four-wheeled vehicles during the rainy season from April to October. Data from the 2008 National Census15 were used to identify a three-stage population-representative sample from Nimba county. The sampling frame consisted of all rural villages in Nimba county; we defined these villages as settlements with a population less than 2000. In the first stage 50 rural enumeration areas were selected with probability proportional to size. Household listings, identified by the name of the head of household, were obtained and 30 households were randomly selected. A Kish table was used to select a respondent in each sampled household. Individuals over the age of 18 years who resided in the selected household were eligible to participate. The ministry and the Institutional Review Board at the University of Michigan provided ethical approval for the study. Written consent was obtained from all respondents. Study materials included a survey instrument, a village data form and a health facility data form. The survey instrument included domains related to demographics (including an asset index for wealth status assessment), health status, health care utilization (both formal and informal), trauma exposure and post-traumatic stress disorder. Personal digital assistant devices were used for data collection. The survey was written in English and translated into Liberian English by Liberian study personnel. Four focus groups and 75 pretests were conducted, and survey content and translations were refined based on information gathered during focus group discussions and the pretest results. After the survey instrument was revised, a team of 12 trained interviewers deployed in three teams administered the surveys in participating villages between October and December 2008. A list of geographic information system coordinates for all villages in Nimba county was obtained from the Liberia Institute of Statistics and Geo-Information Services. Health facilities (including health clinics, health centres and hospitals) closest to the study villages were selected for data collection. Health facility data were collected from 43 of Nimba county’s 49 health facilities by record review, supplemented by interviews with each facility’s officer-in-charge (typically the head nurse) in 2008. We collected data on personnel, infrastructure and equipment, service volumes and range of services provided. Study staff visually verified the functioning of equipment and presence of health personnel. Basic information was collected from county authorities about the remaining clinics in Nimba county to permit comparison with clinics included in the study. To assess the availability of clinic inputs we assessed five basic inputs for each facility. These were: presence of at least one skilled health worker (nurse, physician assistant or doctor), electricity, a water pump, at least two stethoscopes (e.g. one for the patient intake and one for consultations) and a refrigerator. Availability of the basic package of health services was assessed through interviews with the officer-in-charge using the question, “does this facility currently provide the following service?” As index services for the basic package of health services, we selected emergency obstetric care (EmOC) to treat labour and delivery complications (maternal health), the integrated management of childhood illness (IMCI) (child health), HIV counselling and testing (AIDS control), artemisinin combination therapy (malaria control) and mental health counselling and treatment (mental health). IMCI is the leading international strategy for tackling childhood diseases that account for most deaths from diarrhoea, pneumonia, measles, malaria and malnutrition in children aged less than five years. The approach includes: provider assessment and action-oriented classification of illness, identification and instruction of treatment or urgent referral when necessary, feeding assessment and counselling of mothers, and follow-up instruction during return visits.16 Emergency obstetric care, i.e. rapid treatment for complications of labour and delivery, is a key intervention required to reduce maternal mortality globally.17 Here we focused on the provision of basic EmOC, which consists of antibiotics, oxytoxics, anticonvulsants, manual removal of the placenta, assisted vaginal delivery and removal of retained products.18 Because of the low use of vacuum extractors in primary care settings, we categorized facilities as providing basic EmOC if they reported provision of all of the other components excluding assisted delivery. Testing for HIV is recommended to assess serostatus, to direct treatment and to prevent transmission of the virus through counselling on behaviour change.19 ACT is the recommended regimen for the treatment of malaria in the face of increasing resistance to chloroquine. Treatment consists of a two-drug cocktail and requires assessment at a health facility.20 Lastly, mental health counselling was included to obtain a baseline estimate of provision, because mental health services are not yet fully integrated in the basic package of health services. The question asked of each clinic’s officer-in-charge was whether the facility provided any services for patients who present with mental health problems. This could include any form of counselling, referral or treatment with medicines. The health facilities nearest to study villages and travel times on foot were assessed through interviews with village chiefs rather than by geographic estimates to account for variable road conditions that may make some geographically more proximal facilities less accessible than further ones. Actual straight-line distances between villages and facilities were calculated with geographic information system coordinates. Data for the types of facilities available and specific health service provided were reported as frequencies and percentages. Maps were created to display geographic distributions of service availability at health facilities. All locations were mapped according to the coordinates obtained, and maps were created with ArcGIS Explorer, build 1200 (ESRI, Redlands, USA).
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