Bureau of Curative Services
The Bureau of Curative Services is composed of the Ministry’s operational level, which is the county health teams and health facilities (e.g., clinics, health centers and hospitals). The Bureau deals with services provided at health facilities within Liberia.
Counties Reporting Coverage
Out-Patient Department (OPD) reporting is gradually improving since the integration and harmonization of data gathering and reporting tools. However, individual counties reporting continues to show fluctuation over the years and the emergence of the Ebola Virus Disease has derailed the gains made in 2013 and in the recent past. The current national out-patient department reporting coverage declined by 11% from 2013 (83%). In 2014, two counties (Bong and Grand Kru) reported 100% coverage. The lowest reporting county is Montserrado (39%).
Reporting from health centers and hospitals (In-patient Department) across the country has shown great improvement in recent years. It increased from 40% in 2011 to 80% in 2013. However, in 2014, reporting coverage from IPD services declined by 7%. Montserrado (27%) and Margibi (75%) were the lowest reporting counties.
Health facility reporting coverage and data quality continue to improve as a result of trainings in data management and reporting, data use for decision making, quarterly data verification and quality checks exercisesand the initiation of the performance based financing program.
Health Facility Utilization
Utilization of health services in Liberia is measure by Primary Health Care (PHC) and curative consultations1 visits across the country. In 2014, 72% of the functional health facilities(682) in the country reported on health services provided. Utilization records show 3,325,076visits across the country with 32% (1,015,796) of these visits made by patients’ under-5 years old. Curative consultations account for76% of all visits.
The utilization rate for 2014 is 0.8per inhabitant with variations across counties, ranging from 0.4 in Gbarpolu to 1.3 in Bomi County. Utilizationof health services reduced by 39% in 2014 from previous year. The major contributor to this decline in health services utilization is the Ebola outbreak that devastated the entire health system. Poor access and the quality of health care delivery in Liberia impede utilization of services.Twenty-nine percent (1.5 million people)of the population has to walk over 5 kilometers or over one hour to reach the nearest health facility.
Examination of patients’ utilization records across Liberia in 2014 shows an average of 19visits/day/facility (22working days/month)2. However, this varies greatly between and within counties. The highest utilization of health facility on average per day was reported in Bong (32 visits/day/facility), Nimba (28visits/day/facility), and Grand Bassa (26 visits/day/facility). The lowest average patientvisits to health facility per day were seen in Grand Cape Mount (10 visits/day/facility), Sinoe (10 visits/day/facility), and Gbarpolu (11 visits/day/facility). This indicates 39% declined in services utilization across the country from 2013. The low utilization of health services is merely attributed to the Ebola crisis coupled with by poor health seeking behavior (cultural practices and beliefs), difficult access to health care (an estimated 29% or 1.5 million population living more than one hour walk from a health facility), poor road network, health workers attitudes to patients, long waiting time, and the erratic stock out of essential drugs.
Out-Patient Department Consultations
In recent years, patients’ visits to health facilities across Liberia for different ailment appear to be increasing. The number of patients’attendance increased from 3,935,901 in 2009 to 5,455,431 in 2013. In2014, attendance at health facilities decreased by 39% from 2013 (5.5 million visits in 2013 to 3.3 visits in 2014). This huge decline is attributed to the EVD geographic spread that obstructed normal service delivery and created fear in patients to seek medical services for illnesses and health workers to attend to patients presenting EVD like symptoms. Curative consultations also ballooned from 2,854,920visits in 2009 to 3,304,919 in 2013 but declined by 23.2% in 2014 (2,536,868 visits). Curative consultative visits at health facilities constitute 76% of all attendance visits.
In-Patient Department Consultations
Hospitals records from across Liberia documented 91,126patients admission for various medical conditions. One –fourth of the admission occurred in Montserrado, followed by Nimba with 20% of the total admission. However, admission analysis by inhabitant shows that Bomi and Margibi had the highest admission per 1,000 population. The data indicates that for every 1,000 population in Bomi and Margibi, 41 and 39 patients were admitted while in Rivercess only 4 and nationally 23. One –third of the patients were admitted for malaria in 2014.
Hospital admission declined by 36% from 2013 to 2014 (133,910 patients in 2013 and 86,027 in 2014). This dropped in admission is attributed the Ebola Virus Disease outbreak that led to the closure and abandonment of many public health facilities particularly in Montserrado, Grand Cape Mount, Bong and Lofa Counties.
A total of 8,035 in-patients deaths were recorded in hospitals in Liberia. This number is grossly under-stated due to the fact that many persons died in communities because of limited access to health services during the EVD outbreak. Table D in annex A presents admissions and deaths by county in 2014.
The health sector has prioritized cost effective child health interventions at the community and health facility levels to quickenthe achievement of MDG 4- under-five mortality reduction. These child survival activities include immunization, integrated management of neonatal and childhood illnesses (IMNCI), ITNs distribution, Vitamin A supplementation and nutrition. Achievements during the year are presented below.
Liberia face a herculean task in achieving universal immunization coverage.However, significant improvements were made in recent years (2010 – 2013). Liberia introduced pneumococcus conjugate vaccines (PCV) in 2014 in addition to the already five antigens available to children less than one year (BCG, Polio, Pentavalent, Measles and Yellow Fever). In 2015, the Expanded Program on Immunization (EPI) is expected to launch the Human Papolumus and Rubella Vaccines. Antigens administered to children age 0-11 months in 2014 coverage are as follows: BCG (73%), OPV3 (63%), Penta-3 (63%), Measles (58%), Yellow Fever (54%), PCV-3 (45%) and fully immunized (46%).
Whilst most counties were determined to vaccinate children during the EVD crisis to avoid the outbreak of childhood diseases such as Measles, Polio and Whooping cough, others counties were petrified. Counties with the lowest immunized coverage were; Rivercess (34%), River Gee (36%) and Grand Gedeh (39%). Overall, 4 out of 10 infants were fully immunized in 2014. This undesirable EPI Services and decline in coverage has increase children under -five vulnerability to vaccine preventable illnesses. Table E in annex A presents immunization coverage by county.
The variance between Penta1 and Penta 3 (dropout rate) is used as a performance indicator for the immunization program. In 2014, counties with the highest dropout rates were Grand Kru (25%), followed by Bomi (22%), and Nimba (16%). Also, counties with lower dropout rates were Sinoe, Grand Gedeh (4%), Lofa (6%) and Gbarpolu (6%).
Immunization data analysis shows declining trends since 2012. Pentavalent coverage declined from 92% in 2012 to 84% in 2013 and by 21% in 2014. Additionally, measles coverage dropped by 6% from 2012 to 2013 and by 12% in 2014 from 2013.This major reduction in immunization services was attributed the EVD situation in Liberia.
Integrated Management of Neonatal & Childhood Illness (IMNCI)
In Liberia, high childhood mortality is associated with diseases and health conditions such as malaria, diarrhea, pneumonia, acute respiratory infection and malnutrition. To accelerate the attainment of MDG 4, the Ministry has prioritized the Integrated Management of Neonatal and Childhood Illness (IMNCI) as critical child survival interventions. In 2014, Malaria accounted for the highest disease burden among children under-five years old, followed by Acute Respiratory Infection (ARI) and Pneumonia. The proportion of children under-five diagnosed of Malaria is 46%, ARIor Pneumonia accounts for 27% and diarrhea 3.4%.
Vitamin A Supplementation
Vitamin A supplement is administered to children under the age of five to reduce diarrhea episodes, shorter and lessen severe attacks of measles, pneumonia and reduce the overall childhood morbidity and mortality. In 2014, 32,369 infants were provided Vitamin A supplements, while44,381 postpartum mothers received Vitamin A. The proportion of infants that received Vitamin A is 21%, while postpartum mothers accounts for 25%. Though the routine Vitamin A supplementation data is reporting very low coverage,Vitamin A supplementation during integrated immunization campaigns conducted in 2014 for under-5s nationwide was high.
The 2014 health facilities records show that curative services (diagnosis and treatments) for children under –five years accounts for 31% (793,493) of the 2,536,868 curative consultations during the year. A total of 6,854 under five deaths were reported by health facilities nationwide in 2014. This is a 41% childhood mortality increased from 2013. Malaria accounts for 30%,ARI 10%, anemia 9.7% and injuries 6% of reported under-five deaths in health facilities.
Since 1990, the global under-five mortality rate has dropped by 41 percent from 87 deaths per 1,000 in 1990 to 51 in 2011. The 2012 Atlas for MDGs 4 indicates that Liberia is among eight countries that have made significant progress in achieving reduction of under-5 mortality. Liberia attained the fastest rate of annual reduction of under-5 mortality among these eight countries at a rate of 5.4%. In 2014, the Liberia Demographic and Health Survey report released, revealed thatinfant mortality rate decline from 72 deaths per 1,000 live births in 2007 to 54 deaths per 1,000 live births in 2013, while under five mortality decline from 111 deaths per 1,000 live births in 2007 to 94 deaths per 1,000 live births.This has placed Liberia among countries on track of achieving MDG 4. However, the EVD outbreak has derailed progression and has compromised our attainment of this goal.
Improving maternal health (MDG 5) is a staggering task for the Ministry of Health. The health sector has formulated an Essential Package of Health Services (EPHS) with well-defined maternal health interventions at both the community and health facility levels to accelerate attainment of health related MDGs and other development agenda. The EPHS is an assortment of health services that the Ministry is committed to providing in every health facility. Maternal health interventions describe in this report include, antenatal care, delivery, postnatal services, Intermittent Preventive Treatment, Family Planning and Tetanus Toxoid immunization services.
Antenatal services are a cost effective maternal health intervention that is globally encouraged to ensure that pregnant women are assessed periodically and prepared for labor and delivery. ANC coverage3 data is used to derive the proportion of pregnant women who received care during pregnancy. With an estimated 5% of the general population expected to be pregnant women, the 1st ANC visit that documents new pregnancies reported 62% in 2014 and for 4th visit 46%. The current ANC coverage declined by 14% for first visit and 9% for fourth visits from 2013.
There arehugeANC coverage disparities across counties. Four counties (Gbarpolu, Grand Cape Mount, River Gee and Montserrado) recorded 3 out of every 10 pregnant women that received four and more antenatal care in 2014 while another set of counties (Bong, Grand Bassa, Grand Gedeh and Nimba) documented 6 out of 10 pregnant women that received similar antenatal care.
ANC Dropped Out Rate
ANC drop-out rate is determined by the difference between those attending ANC first and 4th visits. In 2014, the national drop-out rate is 15% with variations across counties. Bomi (38%) and Nimba (24%) reported the highest drop-out rates while Maryland (9%), Rivercess (10%) and Gbarpolu(10%) reported lowest ANC drop-out rate in 2014.Three counties (Grand Bassa, Grand Gedeh and Sinoe) had negative drop-out rate which is unusual. This abnormal presentation of ANC stats could be attributed to either huge migration of pregnant women to these counties for many reasons or due to poor data quality.
The expected number of deliveries4 for 2014 was projected to be 174,244. However, only 42% of these deliveries were reported (77,864). Institutional deliveries account for 40% of the expected deliveries while reported home deliveries represent 4% of the expected deliveries. The proportion of deliveries attended by skilled personnel is 39%. Deliveries by skilled birth attendants declined by 7% from 2013 to 2014.The declined in reported and institutional deliveries is attributed partly to the EVD outbreak and largely to the inadequate access to skilled birth attendants across Liberia coupled with the fact that most rural pregnant women prefer being assisted by a tradition midwife than a professional health worker.
A critical maternal and neonatal health intervention to reduce postpartum hemorrhage and other complications is postnatal care. It is where both the mother and the newborn are assess for complications and provided early preventive treatment. Regardless of where the delivery occurs, newborns and their mothers must attend postnatal care to be examined by trained health worker within 42 days after delivery. In 2014, only 28% (48,922) of expected postpartum mothers received postnatal care services. On average, only 3 out of 10 newborn mothers received postnatal care.
Intermitted Preventive Treatment (IPTp)
The administration of Intermitted Preventive Treatment (IPTp) to pregnant women is an effective strategy endorsed by WHO and Rollback Malaria to reduce severe malaria in pregnancy and the associated complications. Pregnant women are encouraged to take at least two doses of IPTp to prevent severe malaria whilst pregnant. Over the past seven years, Intermitted Preventive Treatment (IPT-2) second dose coverage has been increasing, though still unsatisfactory. Analysis of IPT-2 coverage shows progressive trend from 2008 to 2013. However, coverage dropped by 1% from 2013 to 2014.
Contraceptive prevalence rate is gradually increasing in Liberia. It has increased by 8% over a six years period, from 11% in 2007 to 19% in 2013 (LDHS). However, unmet need (36%) for family planning services is still high and the inequity in access between rural and urban residents is unacceptable. Increased access to family planning services is an important component of fertility control, and the reduction of maternal and infant mortality. In 2014, 298,172women of reproductive age (15-49 years) were provided family planning services, excluding those that opted for condoms. Oral pills and injectables (Depo) were widely accepted. IUCD and implant were barely used by females partly due to limited service provision as well as inadequate access to information. Only 581 women opted for IUCD and 10,633 accepted implants. However, implant users double over the past two years (2013 & 2014).
There has been a gradual increase in family planning uptake since 2010. Couples years of protection (CYP) continue to increase with a number of new users. The number of couples that were protected from being pregnant in 2014 is 73,976.
Tetanus Toxoid (TT)
Tetanus Toxoid (TT) vaccines are administered to pregnant and non-pregnant women of childbearing age (15–49 yrs) to protect their unborn children from neonatal tetanus. In Liberia, TT vaccines are administered through routine immunization services. In 2014, 322,221doses of TTvaccines were administered to women of reproductive age, with pregnant women being the most beneficiaries (61%). However, 54% of pregnant women received TT2 doses.
Liberia is among countries with dire maternal mortality rates at 1,0725 deaths per 100,000 live births. To ensure that this undesired rate tumbles, the health sector has elaborated maternal and newborn mortality reduction road map with cost effective interventions. Factors affecting maternal health include, limited access to basic emergency obstetric services, low utilization of family planning services, low coverage of antenatal and postnatal services, insufficient number of skilled birth attendants, delays in referrals, and weak referral systems. Despite the under-reporting of maternal deaths by health facilities for fear of been investigated, criticized and punished and the lack of verbal autopsy, maternal deaths remains very high. Maternal deaths recorded for 2014 indicate that for every 1,000 live births there were 2 maternal deaths. Counties that reported high maternal deaths were Gbarpolu (12 deaths per 1,000 live births) and Maryland (5 deaths per 1,000 live births). It is worth noting that maternal deaths recorded(149) exclude those that occurred in communities. The majority of maternal deaths in Liberia are due to postpartum hemorrhage, obstructed or prolonged labor, complications from unsafe abortions, eclampsia, malaria and anemia.
Morbidity and Mortality
This section of the report discusses three major diseases (Malaria, Tuberculosis and HIV/AIDS) that have generated both national and international interest and are very relevant to Liberia’s MDGs accomplishments. These priority diseases account for a significant proportion of Liberia’s disease burden, mortality and are of major public health concern. However, other communicable and non-communicable diseases are equally of public health relevance and have been provided due attention.
Liberia has made efforts towards reducing the untold suffering and burden associated with malaria. However, it remains a major public health problem in Liberia, taking the greatest toll on young children and pregnant women. To address the malaria burden, the MOHSW introduced a policy and strategic plan for malaria control and prevention. Measures instituted are attempts to fulfill the Roll Back Malaria (RBM) objective for reducing malaria morbidity and mortality.
In 2014, malaria accounts for 41% of curative consultations (2,536,868) across Liberia. The number of children under-5 diagnosed of malaria represents40% of all malaria cases. Approximately, 83% of all diagnosed malaria cases were treated with ACT. It is worth noting that either Rapid Diagnostic Test (RDT) or microscopy confirms these malaria cases.
The overarching goal of the National Malaria Strategic Plan for 2010-2015 is to reach Millennium Development Goal 6: to have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. Liberia has adopted four major strategies to control malaria in the country. The first strategy is to improve treatment by scaling up the availability, accessibility and use of artemisinin-based combination therapy (ACT), the first-line treatment for malaria. The second strategy is an Integrated Vector Management (IVM) approach, and the third strategy addresses malaria in pregnancy. The fourth approach to malaria prevention is to increase support for advocacy, health education, and behavior change.
In fulfillment of these strategies, the MOHSW with support and collaboration from partners have made substantial gains. First, treatment with ACT has improved from 66% in 2011 to 83% in 2014. Second, mosquito net ownership increased from 18% in 2005 to 50% in 2012 and 58% in 2013 (2013 LDHS). Third, IPTp administration increased from 16% in 2008 to 49% in 2014(HMIS). Fourth, the use of mosquito net increased from 6% in 2005 to 32% in 2011 and 40% in 2013 (LDHS 2013). Also, the prevalence of malaria in children under the age of five reduced from 66% in 2005 to 49% in 2012.
Liberia is amongst countries with the highest prevalence and burden of tuberculosis in sub–Saharan Africa. Though few cases of TB were detected between 2005 and 2007, an increase in notification was observed from 2008 to 2014. This huge notification was largely due to the expansion of the program through funding from the Global Fund. The estimated number of all forms of TB cases in 2014 was expected to be 10,712 while the smear positive cases were projected to be 4,647. However, the actual cases of all forms of TB notified were 3,206, which is 34% of the expected cases. The reported number of new smear positive cases detected during the year was 1,422,which is 37% of the projected smear positive cases.
TB notification trend over the years have shown uneven pattern. Cases increased from 6,668 in 2010 to 7,899 in 2011 and decline to 3,643 cases in 2014.On the other hand,TB smear positive cases detected in 2014decreased by 8756 over the one-year period. This dropped in TB positive case detection could be attributed to the low level of public awareness and education on TB and access to services. TB positive case detection rate declined from 98 cases per 100,000 inhabitants in 2011 to 77 in 2012 and further decline by 20 cases per 100,000 inhabitants in 2013. The current new smear positive detection rate is 347cases per 100,000 inhabitants. This current figure is far below the WHO recommended target of 70 new cases per 100,000 inhabitants. Therefore, all efforts must be mustered to meet and sustain the recommended target by expanding services and by creating greater access.
Treatment Success Rate: TB treatment success rate (total number of patients who completed TB treatment and were declared cured) has mesa over the past five years. There has been no significant change, since 2009. However, TB successful rate declined by 15% from 2013 to 2014.
Treatment Outcome: Cured, completion, defaulters, deaths and treatment failure rates reported from 2008 to 2014 indicate that the program has made gains in maintaining low death, and failure rates. On the other hand, TB cured rates continue to fluctuate with an increase of 3% from 2012 to 2013, and a decrease of 7% from 2013 to 2014. The number of patients that defaulted treatment reduced from 13% in 2008 to 5% in 2013 and further increased by 10% from 2013 to 2014.Death rates continuous to show a stable pattern since 2011, however, it increased by 3% from 2013 to 2014. The program targets for defaulter and death rates are less than 5%, and 4% for failure respectively. The program did not achieve its targets for defaulter rate (5%) and failure rate (4%) in 2014.The program needs to assess the situation that led to failure in 2014 that are not EVD crisis related and plan for improvement in 2015 and beyond.
Liberia has a generalized epidemic with a national prevalence rate of 1.9%. As the country accelerates efforts towards attainment of the Millennium Development Goals (MDGs), active surveillance must be guaranteed. HIV and AIDS remains one of the leading causes of death among women and children and the second leading cause of mortality among young people. Despite being a post conflict country with many challenges, Liberia has significantly reduced the HIV prevalence among pregnant women from 5.7% in 2006 to 2.5% in 2013 and has initiated strategies to reduce the chances of mother to child transmission (MTCT) of the disease.
HIV Counseling and Testing: HIV counseling and testing services remains a key component of prevention and treatment. Voluntary and providers’ initiative counseling and testing remains vital program strategies to scale up counseling and testing services. During the year under review, there was a huge declined in HIV counseling and testing services. This was due to EVD outbreak.
A total of 106,108 persons were tested in all fifteen counties during the period and 99.8% of them received their results compared to 98% in the previous (2013) year. This is a significant improvement because most people tested are now receiving their results. In the past, huge portion of people tested for HIV were not going through post-test counseling. There was a reduction in the rate of positivity from 3.7% in 2013 to 2.7% in 2014. Maryland, Montserrado, and Grand Gedeh counties recorded the highest positive rate of 5.5%, 4.6% and 3.8% respectively while Gbarpolu recorded the lowest 1.8%. Nimba and Grand Kru counties both recorded the lowest testing opt in rate of 93.5% while River Gee recorded a 100% testing opt in rate.
into HIV care and treatment, receiving cotrimoxazole Preventive Therapy as treatment for Opportunistic Infections. Higher percentage (13.4%) of children are enrolled into care compare to those initiated on ART. With the implementation of the new WHO recommendations of initiating ART, a greater proportion of people tested HIV positive will start early ART.