The first and only comprehensive assessment of capacity of the health system in Liberia - finally!!

Capacity building seems to be the buzz term in Liberia. Everybody and their mother talks about building capacity! I am not even joking when I say everyone from the international donor community to local pen-pen drivers use the term capacity building. Sometimes it feels like people are just using the term because it makes them look "cool". Almost every NGO and donor agency has a line item for capacity building in their work plan. There is even a national capacity building strategy document for Liberia. If I had a nickel for every time someone used the term capacity building! Don't get me wrong! I strongly believe in building capacity. However, I get frustrated sometimes because the term is used very loosely. Many people who are in the business of building capacity in Liberia see it from a very narrow point - the point being training individuals to build workforce capacity. For someone like me who has spent a majority of his professional life strengthening systems, it is a bothersome view. Training workforce is one of the three components of capacity building; it should not be the only focus. An individual functions well in a system that enables her/ him to put their skills to good use. You cannot just train individuals and leave them to work in a system that is not conducive to working efficiently and effectively. Strengthening individual capacity and system has to happen simultaneously if we want to achieve maximum results. Allow me to give you an example. We often hear people being trained in Monitoring and Evaluation (also known as M&E for the geeks in international aid community). I personally know plenty of local workforce that has been trained in M&E as a part of building their capacity. However, the system under which an M&E professional works is not always enabling them to use their training. How can a trained M&E person be productive when s/he is lacking a data collection and reporting system? What kind of functions will a trained person perform when they do not even have a job description? What kind of data analysis can be performed and how is the data used towards decision making when there is no mechanism/ system to analyse data and distribute the findings to key stakeholders? The above example is just one of the numerous instances where a narrow focus on capacity building does not yield intended results. More often than not the NGO and donor community tends to focus narrowly and not see the big picture. While there are situations where a focus on individual capacity takes precedence, one must always keep the institutional and systems perspectives in mind. For example, immediately following conflict there was a great need for qualified workforce in Liberia. Majority of the resources were focused on building workforce capacity, which, at that time, was thoroughly justified. Now that foreign aid is dwindling and Liberia is moving in to a phase of planning for sustainability, the time is ripe for building comprehensive capacity, not just individual capacity. That is exactly why my/ our project's approach towards building capacity is comprehensive. The approach is comprehensive; I/we focus on three levels of building capacity - individual, organization, and system.

A notice pinned on the main notice board of Lofa County Health System announcing our assessment and  "mandating" participation

As mentioned in one of my previous posts, I am following the WHO six building blocks of a health system framework. There are two reasons for this: 1. The Liberian National Health and Social Welfare Policy and Plan (NHSWPP) is designed around the same framework 2. The framework is flexible enough to adapt to various situations and country systems and allows us to assess the health system in a comprehensive manner.

For anyone who has ever designed/ conducted/ participated in a health system assessment, I do not have to reiterate the fact that it is an extremely tedious process. As tedious - and sometimes frustrating - as it might be, it is immensely satisfying for geeks like me. It is very rare that an entire system comes together to assess performance, capacity, and functions. We finished the county level assessments two weeks ago and we just wrapped up our central assessments.

Key respondents and staff conducting the assessment in Lofa County

The county assessments were conducted in three counties - Lofa, Nimba, and Bong. They took place over a period of two weeks - two days for each county assessment + travel time in between. A team of us - from the ministry and our project - traveled to each county to conduct the assessments. I am not ready to share the results of all assessments yet, but I will say there is a lot of work to be done. No surprise there!

We are now moving in to the phase of analyzing our data and writing a report about our findings. I can already tell there are a few areas that we need to focus - performance management, pharmaceutical supply chain management, data use for evidence-based decision making, and organizational restructuring. The last one is going to be interesting to pull off, because people are usually resistant to change, especially when it comes to restructuring. There is vast disconnect between what the central ministry perceived the capacity to be at the county level and the actual capacity. We need to address this disconnect if we have to move forward with strengthening the health system.

I always seek feedback from respondents immediately following an assessment. One of the statements that gives me satisfaction and makes it all worth is when the respondents said (I am paraphrasing here) "many people have come and gone in the name of capacity building assessments...you are the first person who has approached it comprehensively and has a plan". I will share the results once we finalize the report with feedback from the ministry. Until then, I am going to be spending numerous late nights writing the results and a plan of action.

I promise I will write something fun in the next post...food or about animals :)

Service delivery in the bush

Two weeks ago I visited some of our health facilities in the Grand Cape Mount county to observe service delivery and organizational structure. Our project supports many health facilities across the country, I am trying to visit as many as I can. As part of this mission, I visited one health center and two clinics - Sinje health center,  Bo-Waterside Clinic, and Tieni Clinic. Terminology is important because a health center is different from a clinic - type of services, number of staff, catchment population, and other factors play a role in deciding if a particular facility is a health center vs. clinic.

Sinje is a health center. They have a maternal and child health ward, provide family planning and reproductive health services, and even have an in-patient section. Fairly well run. I found a few issues here and there, but what health facility does not have issues, especially in the developing world? Even though I am not their supervisor, I found some areas in health records maintenance that I advised. I noticed that the newly appointed child survival officer was not adequately trained on recording patient data, therefore I took it upon myself to show her what individual columns mean in the ledger and how to record patient data. She was more than happy to listen because she has been looking for someone to show her how to record some of the data. If you look at the size of the book (see pic below), you will realize why training is needed to fill in the data. Our County Coordinator was quick to capture Dr. V in action, resulting in this picture.

Me explaining data collection to the child survival officer. Look at the size of that book!

After visiting the children's ward and talking to various staff, I wanted to visit the maternal health section. Reproductive and family planning services are top priority when it comes to improving Liberian health system. As such, it is very important for us to understand and improve service delivery in these areas. I was greeted by the Certified Midwife, who just finished delivering twins. I had the privilege to visit the children and delivery room. Neatly maintained. I even spoke to a few pregnant women who were waiting for their antenatal care checkup. I inquired patients about their satisfaction with services and the type of services they are receiving. While services are delivered as planned, there is still a lot of room for improvement. That is why I am here, to strengthen service delivery as a part of strengthening the system.

Avoid sex?

One of the posters I noticed on the wall in the maternal section caught my eye. It is a message aimed towards youth. Teenage pregnancy is a big problem in Liberia and there are different campaigns - from USAID, EU, WHO, etc - aimed towards family planning of both youth and adults. This particular poster is not from our project. What particularly caught my attention on the poster is "avoid sex". Technically speaking, the poster is absolutely correct. Abstinence is part of comprehensive family planning. I appreciate the "protect yourself at all times" message.

Following Sinje, I visited Bo-Waterside clinic. Also known as Bo-H2O (waterside = H2O, get it?), the town borders Sierra Leone. We ate lunch at a restaurant situated right at the border. In fact, we waved at the border patrol while eating lunch. Bo-H2O delivers a limited range of services compared to Sinje health center. We talked for an hour with the Officer in charge (OIC), who is a young guy working there for about 6 months. I discovered a lot of issues with the way the system is currently set up and I plan to address them during our interventions. Tieni clinic was the same as Bo-H2O, with limited service delivery and an even smaller facility. 

Pink delivery table

Besides these facilities, I also visited the Gbanway clinic in Lofa County. One of the best clinics I've visited so far, very clean, neatly organized, and all staff were present and busy working on the day I went (I didn't inform them ahead of time of my visit). The major attraction at Gbanway clinic is the pink delivery table. It put a smile on my face. Child birth is a tedious process, a little color in the delivery room might add some pleasant visual. I am so tired of seeing the hospital green and grey delivery tables, pink is a welcome change. I think every clinic should get a pink delivery table.

I can write about each one of the clinics in great detail, but I do not want to bore my non-public health friends with additional details. I have more trips planned and I will post pictures of my visits. I am in the bush all week doing assessments, so I hope to come back with more stories and pictures.