Factors influencing rapid progress in child health in post-conflict Liberia: a mixed methods country case study on progress in child survival, 2000–2013

Abstract

ObjectivesOnly 12 countries in the WHO’s African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia’s success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality.DesignA case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country’s civil war.SettingThe interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region).ParticipantsKey informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services.ResultsThree prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals.ConclusionsAlthough Liberia experiences continued challenges related to limited resources, Liberia’s effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.

Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

“…Case studies from other post-conflict settings, such as Rwanda, Liberia, and Afghanistan, have shown that MoH leadership and the implementation of governance and accountability mechanisms are key determinants to strengthen health systems, increase the coverage of utilization of health services, and improve maternal and child health outcomes [66][67][68].…”

Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health

“…Four SSA countries (Liberia, Zambia, Kenya and Zimbabwe) were chosen based on their U5M ARR between 1990 and 2011 (data available when the study was designed, Figure 1) and their national governments’ willingness to participate. Detailed study methods for each country case study have been published (Kipp et al ., 2016; Brault et al ., 2017, 2018; Haley et al ., 2017).…”

“…We previously conducted country-specific case studies of four SSA nations with different annual rates of reduction (ARR) in U5M to identify specific barriers and facilitators that influenced their progress towards MDG#4 (Figure 1) (Kipp et al ., 2016; Brault et al ., 2017, 2018; Haley et al ., 2017). Liberia and Zambia were on track for MDG#4 when the study began (and have now met MDG#4) while Kenya and Zimbabwe were not on track (and did not meet MDG#4) (Figure 1).…”

Measuring child survival for the Millennium Development Goals in Africa: what have we learned and what more is needed to evaluate the Sustainable Development Goals?

“…Due to the limitations of health information systems in these countries [8] and quantitative indicator data to provide more nuanced understanding [9], we triangulated data from a policy review, qualitative key informant interviews with stakeholders working at multiple levels of the health system, and focus groups with women accessing services for their children (see supplemental file for interview and focus group discussion guides). Countries were chosen based on their U5M ARR between 1990 and 2011 (data available at the study's onset) and their health ministries' willingness to participate [10][11][12][13][14]. Two nations, Liberia and Zambia, were selected by our team because they were on track to achieve MDG4 in 2013 when the study was initiated (both countries did, ultimately, meet MDG4).…”

“…Two nations, Liberia and Zambia, were selected by our team because they were on track to achieve MDG4 in 2013 when the study was initiated (both countries did, ultimately, meet MDG4). In Liberia, we found the following factors to be critical to their reduction of U5M: national prioritization of MNCH after the civil war combined with continuous review and updates to key strategies; implementation of integrated services in facilities that expanded intervention access and promoted intersectoral collaboration; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals [15]. In Zambia, we found qualitative evidence of the benefits of Zambia's ongoing and long-term national health reform focused on ensuring universal access to MNCH care, specifically through strong community health strategies and service delivery approaches as well as positive and well-coordinated relationships with external partners [14].…”