NIMBA COUNTYHEALTH AND SOCIAL WELFARE PLAN

2011-2021

MINISTRY OF HEALTH & SOCIAL WELFARE

REPUBLIC OF LIBERIA

Date: APRIL 15, 2011

Executive Summary - Nimba County Health Plan (2011-2021)

With a population of 519,480 Nimba is Liberia’s most populous “rural” county. Its 61 health facilities include 5 hospitals; 5 health centers and 51 clinics. 58% of the population lives within 5km (one hour walk) of a health facility, and 35% of deliveries are facility-based with skilled assistance. OPV3/Penta3 vaccination coverage for children under one year is 85%.

The Nimba ten year health plan will further improve to the EPHS by adding 27 facility and 14 non-facility-based Service Delivery Points. The plan will also improve systemic components for services. Key objectives, baselines (2010) and targets (2021) will strive to: 1

Increase the population living within 5 km of a health facility from 58% to 90%;

Increase children under 1 year who received OPV3/Penta3 from 85% to 95%;

Increase facility-based deliveries with a skilled birth attendant from 35% to 80%;

Increase pregnant women provided with 2nd IPT malaria dose from 51% to 80%;

Increase public facilities with a two star accreditation from 2% to 90%;

Maintain timely, accurate and complete HIS reporting at more than 90%; and

Increase facilities with no stock-out of tracer drugs to 95%.

1 Baselines and targets will be refined and adjusted as more reliable data become available.

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Table of Contents

Executive Summary......................................................................................................................ii Table of Contents.........................................................................................................................iii List of Acronyms.........................................................................................................................iv1.0 Introduction and Context...........................................................................................................1

1.1 Potential for Foreign Investment.........................................................................................11.2 The County’s Risk Analysis................................................................................................11.3 Health Facilities...................................................................................................................11.4 Description of Current Health System.................................................................................11.5 Collaboration and Partnership..............................................................................................2

2.0 Implementation of Previous Plan...............................................................................................22.1 Achievements.......................................................................................................................2 2.1.1 Collaboration and Partnership......................................................................................2 2.1.2 Training........................................................................................................................3 2.1.3 Services Provision........................................................................................................3 2.1.4 Social Mobilization......................................................................................................3 2.1.5 Gaps.............................................................................................................................3

3.0 Vision and Mission....................................................................................................................34.0 Service Provision.......................................................................................................................4 4.1 Existing Services that were expanded..................................................................................4 4.2 New Services Included in EPHS..........................................................................................4 4.3 Operation level and Services to provided............................................................................4 4.3.1 Community Level.........................................................................................................5 4.3.2 District Level................................................................................................................6 4.3.3 County Level.................................................................................................................8 4.4 Service Delivery Points to be Established...........................................................................9 4.4.1 Intervention on Existing Health Facilities....................................................................9 4.4.2 New Service Delivery Points......................................................................................10 4.5 Brief Analysis of the Situation...........................................................................................10 4.6 Strategies............................................................................................................................115.0 System Components.................................................................................................................126.0 Sector Issues.............................................................................................................................137.0 Implementation and Monitoring..............................................................................................14

7.1 Phase Implementation........................................................................................................147.2 Capacity Building..............................................................................................................157.3 Monitoring and Supervision..............................................................................................15

Figures and Tables:

Map of Expansion of Service Delivery Points (Executive Summary)Figure 1: Organization Chart of the County Health and Social Welfare

Table 1: Interventions on Existing Health FacilitiesTable 2: Distribution for Mobile ClinicsTable 3: Nimba County Monitoring Framework

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List of Acronyms

EPHS Essential Package of Health ServicesNTDs Neglected Tropical DiseasesBPHS Basic Package of Health ServicesMIP Malaria in PregnancyMOHSW Ministry of Health and Social WelfareNCDs Non-Communicable DiseasePMTCT Prevention of Mother to Child Transmission of HIVPHC Primary Health CareGOL Government of LiberiaWCBA Women of Child Bearing AgeTB TuberculosisSGBV Sexual and Gender Base ViolenceANC Antenatal CareSDP Service Delivery PointsNCHSWT Nimba County Health and Social Welfare TeamMPW Ministry of Public WorksMYS Ministry of Youth and SportsMIA -Ministry of Internal AffairsM& E Monitoring & EvaluationMODG Ministry of Gender and DevelopmentBeMOC Basic emergency Management of Obstetric ComplicationREP Reaching Every Pregnant WomanTTM Trained Traditional MidwivesHMIS Health Management Information SystemNCHSWT Nimba County Health & Social Welfare Team IPT Intermittent Prevent TherapyHF -Health FacilityHC Health CenterACT Ateminsini Combined TherapyPBC Performance Based ContractNACP National AIDS Control ProgramHCT HIV Counseling & TestingTB TuberculosisDOTs Direct Observed Treatment Short courseGWHH George way Harley HospitalGUMH Ganta United Methodist HospitalCHDC Community Health Development CommitteeSCHC Saclepea Comprehensive Health CentregCHVs general Community Health VolunteersPHC Primary Health CentreARI Acute Respiratory InfectionDHTs District Health Teams

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1.0 INTRODUCTION AND CONTEXT

Nimba is one of Liberia’s largest counties situated in the northeastern part of the country. It is bounded by La Cote d’Ivoire on the East, the Republic of Guinea on the North, Bong County on the West, Rivercess, Grand Bassa and Grand Gedeh on the South. Currently, there are six (6) health districts, seventeen (17) administrative districts, seventy-six (76) clans and five hundred and thirty-five (535) towns/villages.

It is the second most populous county in Liberia with the total population estimated at 519,480 people (2011).Of this population, 119,480 (23%), 20,779 (4%), 233,766 (45%) and 145,454 (28%) account for Women of Childbearing Age (WCBA), children under-one year, children one to fifteen years old and others respectively. Geographically, approximately 35% of the county population lives in the urban area while 65% resides in the rural setting. Majority of the people relies largely on subsistence farming, small scale trading/cash crops, small scale (localized) mining while the minority are absorbed in the private and public sectors.

1.1 Potential for Foreign Investment:

The county is blessed with abundant natural mineral resources such as gold, diamond, iron ores, timber, rubber, cacao, coffee, oil palm, etc. These have attracted lots of foreign investors into the county. Currently, three major concession ventures include the Multi Million Dollar Mining Company (BHP Billiton World Exploration), the Liberia Rubber Company and Arcelor Mittal Mining Company are operating in the county and gradually contributing to the health needs of our people.

1.2 The county’s Risk Analysis:

In 2007, Nimba was ranked as high risk county for the detection of Wild Polio Virus (WPV) and Lassa Fever due to its close geographical connections with neighboring Guinea and La Cote d’Ivoire that were reporting WPV cases and Bong and Grand Bassa Counties that were reported Lassa Fever cases.

The county also has some hard to reach communities among which Gbi & Doru, Kpablee, Kpaylehpula, Kpaykanwee, Teahzaygbayplay, Gbein- Bonla, Garr-Morgbain,Woloquoipea, Bentol, Tuolewin, Garr-Yehbo Nyanporyor, Vanyanpa, Sopa, Nyan Taylor,Gbien) are the most difficult and are not adequately covered with health care services.

Lucrative salaries paid by concessions operating in the county may post a challenge to the county health system in recruitment, placement and retention of skilled staffs, especially to the hard to reach areas.

1.3 Health Facilities

The county has sixty one (61) functional health facilities (Hospitals-5, Health centers-5, PHC clinics-51). Of the sixty one, 39 (64%) are supported by NGOs, 11 (18%) by Faith based and private and 11 (18%) by the Government of Liberia (GOL).

1.4 Description of current county health system:

The county health system consists of the County Health and Social Welfare team and partners Operational level of health delivery in the county is line with National Health Policy and Plan, and the then Basic Package of Health Services. The Nimba County Health and Social Welfare Team (NCHSWT) is headed by the County Health Officer (CHO) followed by the Community Health Department Director (CHDD), County Health Services Administrator (CHSA), Hospital Medical Director (HMD) and the County Pharmacist, and all other officers fall under these four. Figure 1 below shows organization of the NCHSWT.

CHO

CHDD

CSFP Clinical Supervisor

DHO

Clinic staff

RH officer EHTD

Surveillance officer

HIV/TB focal persons

Nutrition supervisor

CHSA

HR manager Accountant

Logistician

Drivers Maintenance/Janitors

Hospital administrators

CHP

Drugs Depot focal persons

M&E

Database Manger

County registrar

Death and Birth clerks

Figure 1: Organization Chart of the County Health and Social Welfare

1.5. Collaboration and Partnership:

The county has strong partnership collaboration with its implementing partners. In addition to the community, the county is blessed with the following partners.

NGOs: Equip-Liberia and IRC

Faith-based: Mid-Baptist, Catholic, Inland and Methodist Churches

Concessions: Arcelor Mittal & The Liberia Company (Cocopa)

Private Institutions: Newman, Power House, Agape, YMCA, KL- Foundation and Zoe-Geh Medical Centre(ZGMC), CHESS, LNRCS

2.0 IMPLEMENTATION OF PREVIOUS PLAN

In May 2009, the Community Health Department and Health implementing partners (IRC/EQUIP/RBHS) developed the Nimba Health Plan. The County Health Plan was developed based on the Basic Package of Health Services (BPHS) pillars of health services delivery in Liberia, and subsequently submitted to the MOHSW on May 29, 2009. Implementation of the plan by the NCHT and partners made significant gains.

2.1 Achievements:

2.1.1 Collaboration and Partnership

There was high level partners collaboration and all planned meeting was held and feedback given to all levels. About 80% of all facilities outreach sites were covered with integrated outreach activities. Functional health facilities increased from 59 to 61.

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2.1.2 Training

147skilled staff (Rn-104, CM-21, PA-17, MD-3, RNCM-2) benefited from in-service training for Malaria, Tuberculosis, HIV/STIs and Communicable Disease and Emergency case management, Rational use of drugs (RUD), integrated management of childhood illness (IMNCI), Comprehensive Condom Programming, Review of strategy for Family Planning commodity utilization, Essential Nutrition Action (ENA), Basic Life Saving Skills (BLSS) and New born Resuscitation. Training in Home Based Life Saving Skills (HBLSS) and Prevention of Malaria in pregnancy was conducted for 55 TTMs/TBAs from the six health districts. Additionally, 225 General Community Health Volunteers (gCHVs) benefited from training in Diarrhea, Malaria, STIs prevention and case detection of priority diseases, community cases management of Malaria, Acute Respiration Infection (ARI) and Diarrhea.

2.1.3 Service Provision

Vulnerable groups (Children <5 and pregnant women) benefited from Insecticide Treated Nets (ITNs) distributed via Maternal and Child Health (MCH) services. Though poor road network is a challenge to health services delivery in the county, the CHSWT ensured the distribution to all functioning facilities of contraceptives and IEC/BCC materials to promote RH service utilization, other drugs and medical supplies. Cold chain was adequately maintained at all health facilities. About 80% of all functional health facilities have solar fridges while the remaining 20% has kerosene fridges.

2.1.4 Social Mobilization

Community mobilization to promote health services utilization and full community participation was conducted through print and electronic media, and by town criers. This increased utilization of facilities, e.g., 1st ANC visits increased from 29,411 in 2009 to 41,736 in 2010, facility deliveries increased from 3,862 to 7,708 and Penta 3 from 12,332 to 17,875.

2.1.5 Gaps

Though implementation of the plan experienced significant gains, there are gaps to be addressed. Skilled staff retention especially in isolated and hard-to-reach terrains remains a huge challenge. Poor road network, insufficient accommodation, lack of attractive incentives and slow pace in placing non-employ staff on government payroll are contributing factors. Inadequate logistics and poor roads hamper the distribution of supplies and interrupt supervision, especially in hard-to-reach areas. While 80% of fridges are Solar, the limited knowledge on preventive maintenance threatens the breakdown in cold chain. Though the plan included conducting a baseline survey on adolescent sexual and reproductive health, this was not done due to lack of support.

3.0 VISION AND MISSION

Vision:

A county with healthy population with social protection for all by the year 2021.

Mission:

Nimba County Health Care Delivery System adheres to the mission of the Ministry of Health and Social welfare: To reform the health sector to effectively deliver quality health and social welfare services to the people of Nimba County. The NCHSWT is dedicated to the provision of a comprehensive, equitable, accessible, sustainable health care, health promotion and social welfare services.

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4.0 SERVICE PROVISION

Consistent with the Essential Package of Health Services (EPHS) of the MOHSW, the county ten-year plan will identify and address critical issues needed to improve the health status of the county population, especially the most vulnerable groups. The intention is to provide services as described in the EPHS at all levels of the county health care delivery system.

This plan strives for the community and district levels to progressively provide health and social welfare services to its target population within ten years. Programs and activities included in the plan are relevant to address the infrastructure, human resources, equipment and supplies, and management needs for the system. The EPHS includes additional services that were not considered in the then Basic Package of Health Services (BPHS) while other existing services were expanded.

4.1 Existing services that were expanded in the EPHS include:

1. MATERNAL AND NEWBORN HEALTHa. Family Planning b. Malaria in Pregnancy (MIP) c. Prevention of Mother to Child Transmission (PMTCT) of HIVd. Maternal and Newborn Nutrition

2. CHILD HEALTHa. Growth Monitoring b. Micronutrient supplementation

3. Mental Healtha. Stigma reductionb. Client reintegration into communityc. Psychiatric and non - Psychiatric cared. Psychological support and caree. Physiotherapyf. Occupational therapyg. Prosthetics

4.2 New services included in the EPHS are:

Environmental and occupational health Neglected tropical diseases (NTDs) Non-communicable diseases (NCDs) Social welfare School health package

4.3 Operational levels and services to be provided at each service delivery point

Health care services in the county will be provided in line with the operational levels described in the EPHS at the community, district and county levels. Cross-cutting health education and promotion will be addressed at all service delivery points.

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4.3.1 Community Level

Community health service providers such as general Community Health Volunteers (gCHVs), and TTMs/TBAs will be integrated to provide health education on all health care services. They will also carry out community mobilization, referrals, escorts of clients to health facilities, PMTCT follow up for mother and child, routine immunization follow up for child, growth monitoring, surveillance and reporting of immunizable diseases, community cases based management and referral, infant and young child feeding, community DOTs and defaulters tracing, mass drugs distribution for NTDs, early detection and referral of non-communicable diseases and health emergencies. The Environmental Health Technicians (EHTs) will supervise the activities of these service providers.

MCH Level 1 clinic: In each MCH Level 1 clinic, service provision will include: Maternal and new born care

o ANC careo Labor and delivery o Postpartum careo Maternal and child nutrition o Family planning o Refer for PMTCT to the next levelo Malaria in pregnancyo Immunization for mother and childo Refer complicated delivery and high risk pregnancy

Child healtho Routine Immunization for childo Growth monitoringo Integrated Management of Neonatal and Childhood Illnesses (IMNCI)o Child Nutrition

Family Planningo Promotion o Services

PHC Clinic: At the PHC clinic, services to be provided include: Maternal and newborn care

o ANC careo Labor and delivery careo BEMoCo Post partum careo Newborn careo Maternal and newborn nutritiono Family planning counseling and serviceso PMTCTo Malaria in pregnancy

Child healtho Expanded Program on Immunizationo Integrated Management of Childhood Illnesseso Growth monitoringo Micronutrient supplementationo Infant and young child feedingo Identify and refer cases of acute malnutrition to next level

Family Planning

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o Counseling and serviceso Refer to County hospital for surgical options

Sexual and Gender Based Violenceo Psycho-counselingo Management of caseso Referral services

Reproductive cancero Health educationo Refer to next level for management

Communicable diseaseso Health educationo Management and control of STIs/HIV/AIDSo Management and control of TBo Management and control of Malariao Management and control of other diseases with epidemic potentialo Refer complicated cases to next level

Mental healtho Counseling serviceso IEC/BCCo Management of depression and post traumatic stresso Crises intervention and referral

Emergency healtho First aide and Emergency resuscitationo Management and control of epileptic seizureso Refer to next level

Non-communicable diseaseso Health educationo Routine screening for risk factor identificationo Refer to hospital for managemento Follow-up cases

Neglected Tropical Diseaseso Community sensitizationo Early detection and timely treatment of caseso Refer to next level

Environmental healtho Health educationo Waste managemento Vector control

4.3.2 District Level

Health Center/District Hospital: The health center will serve as the point of referral for MCH level-1 and PHC facilities while the district hospital serve as referral point for the health center. Services to be provided at this hospital shall include:

General Internal Medicine services including epileptic disorders Communicable Disease Management and Control of:

o STIso HIV/AIDSo Tuberculosis o Malariao Respiratory tract infection

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o Diseases with epidemic potential Cholera (Treat and Refer) Measles Yellow fever (Refer) Lassa fever (Refer) Rabies Shigellosis Meningitis (Refer) Poliomyelitis Tetanus Hemorrhagic fever (Refer)

o Intestinal wormso Gastritiso Peptic ulcers

Non Communicable Diseaseso Cardiovascular diseases

Medical Emergency Deep vein thrombosis (Refer) Heart failure (Refer) Hypertension

Surgical Emergency Pulmonary edema (Refer to next level)

o Rheumatic fever (Refer)o Diabetes (Refer): Diagnosis and treatmento Sickle cell (Refer)o Cancers (Refer): Screening & refer

Neglected tropical diseaseso Leprosyo Lymphatic filariasiso Onchocerciasiso Schistosomiasis

Mental Health serviceso Anxiety, Depression and post traumatic disorderso Psychosomatic disorderso Psychosocial counselingo Substance abuse detoxification (Refer

Dermatology Eye conditions

o Treatment of common eye problemso Removal of cataracts (Refer)o Injuries and complicated cases- refer

Musculoskeletal conditionso Unspecific arthritiso Gouto Osteomyelitis (Refer)o Rheumatoid arthritiso Septic arthritis (Refer)

General surgeryo Surgical emergencies

Anaphylaxis Resuscitation of cardiac arrest Abdominal trauma (Refer) Simple burns

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Shock (Initiate management and refer) Poisoning (Initiate management and refer) Simple & multiple injuries

o General surgical conditions Acute abdomen (Refer) Thyrodectomy – refer Mastectomy – refer Hiatus hernia – refer Biliary tract – refer Colon operations – refer Hernioraphy (Refer) Rectal prolapsed (Refer) Superficial surgical abscess Cystostomy – refer Kidney stones – refer Prostectomy (Refer) Burns (3rd degree) (Refer)

o Gynecological disorders Fibroids (Refer) Pelvic masses (Refer) Sexual assault Abscesses Pelvic inflammatory disease

Vaginitis Menstrual disorders

Antenatal care and complications Pregnancy with communicable diseases Abortions Antepartum hemorrhages Intra-partum care and complications Complicated deliveries

Postpartum care and complicationso Complications of puerperiumo Postpartum hemorrhageo Puerperal infectionso Deep vein thrombosis (Refer)

Neonatal conditionso Neonatal asphyxia & resuscitationo Care for normal newborno Respiratory distress

Child Healtho Expanded program on Immunization (EPI)o Integrated Management of neonatal and childhood illnesseso Essential nutrition actiono Basic pediatric care services

4.3.3 County Level

County Hospital: The county hospital will serve as referral points for health centers and district hospitals. Services to be provided at this service delivery point include those provided at Health Centers/Districts plus the following:

Dental and oral conditions

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Peripheral abscess Acute ulcerative gingivitis Cellulitis Gingivitis Peridonitis Pulpitis Orthopedic trauma cases: Closed fracture and dislocation Herniaraphy Rectal prolapse Superficial surgical abscess Prostectomy Acute otitis media

o Otitis externao Chronic otitis mediao Foreign body in the earo Mastoiditiso Wax in the ear

The following conditions when seen will be referred to the next level for management:

Thyroidectomy Mastectomy Hiatus hernia Biliary tract Colon operations Cystostomy

Kidney stones Soft tissue injuries Spinal injuries stabilize & refer Pelvic fracture stabilize & refer Femur fracture stabilize & refer Tendon injuries stabilize & refer

4.4 Service delivery points to be established

4.4.1 Interventions on Existing Health Facilities

Two existing PHC facilities (Duo-Tiayee and Ganta Community Clinics in Sanniquellie-Mah district) each serving an average population of 15,000 will be upgraded to health centers. One health center, Karnplay Health Center in Gbehlay-Geh District, serving the district population of 83,848 will also be upgraded to district hospital. Seven health facilities (two health centers and five clinics) will undergo heavy rehabilitation while nine health facilities (clinics) will undergo light rehabilitation.

The county envisages relocating two of the existing health facilities: the county referral hospital - G.W. Harley Hospital, in Sanniquellie-Mah and the Flumpa Community Clinic in Saclepea-Mah Districts. The G.W. Harley Hospital a Government Referral Hospital constructed in 1948. Currently, there is limited space in the hospital for adequate and quality service delivery proportioned to the existing population. Coupled with the limited space, the hospital is located near a major railway with heavy locomotives operated by Arcelor Mittal Company. The daily operations of the railway produce so much noise that upset and make the patients agitated. Similarly, the Flumpa Community Clinic, a major health facility serving the catchment population of 11,179, is located in the center of a rural community and members of the community have encroached on the facility so much that the space has become very small compromising client’s privacy.

Table 1: Interventions on Existing Health FacilitiesDistrict Facility Name Type Catchment

Pop. Intervention(s) proposed Priority

Zoe-Geh Bahn HC HC 29,908 Heavy Rehabilitation High

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District Facility Name Type Catchment Pop. Intervention(s) proposed Priority

Zoe-Geh Beadatuo Clinic 7,944 Light Rehabilitation MediumZoe-Geh Wehplay Clinic 8,686 Light Rehabilitation HighZoe-Geh Lepula Clinic 7,133 Light Rehabilitation MediumSanniquellie-Mah GCC Clinic 13,312 Upgrade to Health Center HighSanniquellie-Mah Duo-Taiyee Clinic 16,212 Upgrade to Health Center HighSanniquellie-Mah G. W. Harley Hosp. 22,931 Relocation HighTappita Zuolay Clinic 4,636 Light Rehabilitation MediumTappita Bonlay Clinic 3,293 Heavy Rehabilitation HighTappita Toweh Town Clinic 11,226 Light Rehabilitation HighSaclepea-Mah Karnwee Clinic 10,560 Heavy Rehabilitation HighSaclepea-Mah Duo Clinic 9,552 Light Rehabilitation MediumSaclepea-Mah Flumpa Clinic 11,179 Relocation HighSaclepea-Mah Bunadin Clinic 8,118 Heavy Rehabilitation HighGbehlay-Geh Karnplay HC HC 83,848 Upgrade to District Hospital HighGbehlay-Geh Garplay Clinic 5,383 Light Rehabilitation MediumGbehlay-Geh Youhnlay Clinic 4,594 Heavy Rehabilitation HighGbehlay-Geh Gbeivonwea Clinic 4,610 Heavy Rehabilitation HighGbehlay-Geh Goagortuo Clinic 3,713 Light Rehabilitation MediumGbehlay-Geh Beoyoola Clinic 13,845 Light Rehabilitation MediumYarwin- Zekepa Clinic 12,031 Heavy Rehabilitation High

4.4.2 New Service Points

To ensure equitable distribution of health facilities for the underserved communities to have access to quality health care, the total of 27 new PHC clinics will be established (see map in Executive Summary): Sanniquellie- Mah-6: Gbarpa, Duo-Sopa, Mao, Zuluyee, Gblassonnoh and Kinnon; Saclepea-Mah-6: Tudin, Guawin, Tunukpuyee, Sokopa, Doumpa and Kpallah; Zoe-Geh-5: Beipea, Nyor-Butuo, Siaplay Old Town, Dinplay and Zontuo; Tappita-5: Glahn Town, Dubuzon, Dorbor, Gbarplay and Ziah #1; Gbehlay-Geh-3; Zualay, Tartuo and Kpeahplay; and Yarwin mehnsonnoh-2: Dahnpa and Guotoin). These communities are 13 to 47 kms from existing health facilities and movements of dwellers and outreach service delivery, especially during the rainy season very difficult.

Integrated outreach services will be provided through mobile clinics in 14 communities that are about 10 to 28 km from the nearest health facility. Some of these communities are sparsely populated while others densely populated.

Table 2: Distribution for Mobile ClinicsNumber District Communities Nearest HF

Gar-Mongbain Ganta HospitalBorsonnoh Duo-Tiayee ClinicBaintonwin Lugbehyee Clinic

2 Saclepea-mah

Loyee Kapytuo ClinicBueh Saclepea CHCZao Bunadin ClinicGialemon Duo ClinicGanwin Bunadin Clinic

3 Zoe-Geh Rhlekporlay Wehplay ClinicKorsein Payee Clinic

4 Gbehlay-Geh Tiahzegbeplay Beo-Yoolar ClinicDulay Goagortuo Clinic

5 Yarwin Mehnsonnoh Sahnpa Zekepa ClinicDorpa Kwendin Clinic

4.5 Brief Analysis of the Situation

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Access to health services in Nimba County during the BPHS implementation was high in communities close to existing facilities. However, given that the county also has 65% of its population residing in rural and hard to reach communities that are not adequately covered with health care services, utilization of certain health services such as Family Planning, delivery by skilled staffs, adolescent sexual and reproductive health, general health promotion activities, SGBV, follow-up treatments (TB & HIV/AIDS), disease surveillance and referrals are low in these areas. In addition to the geographical disadvantages, difficulty in recruitment and placement of skilled staffs and cultural practices contributed to the situation. This situation affected the overall health outcome of the county thereby making it difficult to achieve some of the targets.

The overall institutional delivery coverage of forty-two percent (42%) falls below the national targets of 80%. For example, in Yarwin Mehsonnoh and Zoe-Geh Districts where bulk of the catchment communities of the health facilities lies in isolated areas, institutional delivery coverage is at twenty-seven and twenty-eight percent respectively.

First Antenatal Care (ANC) consultation of the county is at One Hundred Sixty-Four percent coverage which is far above the national annual target of seventy-six percent (76%), this clearly shows that ANC attendance is relatively high while institutional delivery is low. Thus, a lot of work needs to be done to encourage pregnant to deliver at health facility.

The Consultation/Head for the county which can be translated as the number of curative consultation divided by the county population is measured at 91.5%. This coverage indicates that cumulative facility utilization is high. However, considering individual facility performance, facilities serving isolated communities performed poorly as compared to those serving urban-cluster communities. For example, Beoyoolar clinic in Gbelay-Geh District have coverage of 30% while Kpein in Saclepea Mah District is at 80%.

For Penta 3, which is the immunization coverage indicator for children -under-one year, the over coverage for the county was Eighty-six percent. Interestingly, of the 54 health facilities providing immunization service, 52% (28) achieved more than One Hundred Percent coverage. For example, Zoe-Geh Medical Center in Zoe-Geh District, Gorgoatuo clinic in Gbehlay-Geh District and Bonlay in Tappita District, achieved 308%, 300% and 217% respectively. Data quality, service provider knowledge, under estimation of denominator and movements across borders could have led to this situation.

Strategies will therefore be developed to address the above issues.

4.6 Strategies

In an effort to bridge the gaps and improve the health delivery system, the NCHSWT and its partners, have developed a 10-year plan that include strategies geared toward high impact, evident based interventions. Details of county targets are shown in the annex. The below strategies among others, shall be employed during the ten years period.

Orientate all staff on all Standard Operational Procedure (SOP) provided in the EPHS Advocate and provide insurance scheme for health staff Create human resource information system to evaluate, support and manage the health

work force. Construct and equip 27 new service delivery points (SDPs) with staff accommodation Construct staff accommodation at existing SDPs Construct waiting homes at referral sites

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Recruit and deploy skilled staff to new SDPs Recruit and deploy additional skilled staffs in sixteen (16) existing SDPs Ensure that all skilled staffs are included on Government of Liberia (GOL) payroll Ensure that unskilled staffs, e.g., cleaners are separated from security guards Provide attractive incentives for skilled staffs in hard-to-reach isolated communities Provide motivational package for TTMs who escort pregnant women to the health

facilities for ANC and delivery Provide motivational package for gCHVs who make timely referrals of cases

including postpartum, follow-up on TB, HIV, NCDs and NTDs to the health facilities Provide integrated outreach services to fourteen (14) new sites in the county Liaise with other line Ministries, particularly Ministry of Public Work (MPW),

Internal Affairs (MIA), Youth & Sports (MYS) and Ministry of Gender and Development (MOGD) among others in aiding the successful delivery of health services to the communities

Conduct light renovations at 9 existing health facilities Conduct heavy renovations at 7 existing health facilities Purchase 6 new ambulances, one each, for the six health districts. Purchase 18 motorbikes, three each, for the six health districts.

5.0 SYSTEM COMPONENT

This plan strongly considers s the below six components that are essential for smooth operation of the health in the county:

Human resources management and development Drugs/medicines distribution and rational use Financing: local revenues and use of transfers Network of facilities and SDP (current condition, expansion, upgrading, renovation) Supervision Quality improvement

5.1. Human resources management and development:

The county shall endeavor to provide the optimal number of health work force with the appropriate skills to deliver the EPHS. Currently, the county has One Thousand-One (1001) health workers (419 skilled and 583 unskilled staffs). Skilled staffs working in 85% (52) of the existing 61 functional health facilities county are over utilized. Considering the present workload and the additional SDPs to be established, recruitment, deployment and retention of skilled staffs shall be among the county’s high priorities. Therefore, the current number of work force shall be augmented the recruitment and deployment of skilled staffs to new SDPs be done in line with the staffing pattern described by the EPHS.

5.2. Drugs/Medicines distribution and rational use:

The need to have and maintain optimal stock level in all health facilities cannot be over looked. The county shall ensure that drugs and medical supplies are available and equitably. The county shall work in line with the strategies of the national supply chain plan for the distribution and rational use drugs/medicine while work along with the drugs/ medicines

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regulatory authorities to ensure that regulatory policies and guidelines are adhered to throughout the health delivery system.

5.3. Financing: local revenues and use of transfers:

In line with the National Health financing policy, the county shall continue the free service for three years and shall gradually introduce user fee for certain services for those who can afford. Services to be paid for shall be determined by the central MOHSW.

Communities shall be sensitized in preparation for introduction of user fees. The NCHSWT shall work with CHDC and CHC to initiate community-based fund raising and saving schemes that they may be able to pay for health services when user fees are introduced.

The county health sector shall advocate for at least 15% share of social development funds paid by concession companies in the county for support to the health system. In addition to donor support and other program supports, user fees for service shall form a part of county revenue and shall contribute to running of the health system.

5.4. Network of facilities and Service Delivery Points (SDPs) (see also section 4.4.)

The county currently has 61 functional health facilities, including 51 PHC clinics, 5 health centers, and 5 hospitals. Currently, the functional health facilities are inadequate to meet the health needs of the huge and growing population of the county. Evident by the work load at about 85% of the existing health facilities, there huge population of the county that are denied easy access to health care due to both distance and under staffing. For example, Gbelay-Geh District with 82,124 population, has 9 PHC clinics with only one referral center (a health center) and Tappita Mah Distrial fm the peripheral very difficult with a population of 75681, has 10 PHC clinics with only one referral center (a hospital), making referral very difficulty. In most instances, cases referred reach the referral center almost irreversible. Some of the existing health facilities are too small to fully implement the EPHS. These facilities shall be expanded and other upgraded to be more efficient. Additional facilities are also needed to enhance access and effective implementation of the EPHS.

5.6. Quality assurance:To ensure that health services delivered to the people are of quality, the NCHSWT shall conduct assessments, meetings and operational research on the following and make improvements wherever necessary:

Insecticide Treated Nets (ITNs) ownership and utilization survey Patient satisfaction survey Health facility utilization survey Family Planning commodities utilization EPI coverage survey Morbidity and mortality review EmOC assessment Training need assessment Quarterly review meeting Community Case management impact assessment

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6.0. SECTOR ISSUES

The Nimba County Health sector currently consists of the CHSWT, NGOs, Faith-based Organization and UN agencies. Partnership plays an important role in the health delivery system of the county. The partners help in resources mobilization, secondment of professional staff, payment of incentives, provision of drugs/medicines and medical supplies, capacity building, infrastructure development and other logistics. Partnership and Coordination will continue to be encouraged in the county at all levels (community, district and county) with its current partners while encouraging emergence of others during the period.

7.0 IMPLEMENTATION AND MONITORING

The plan will be implemented in three phases involving all relevant sectors, the community and other implementing partners.

7.1 Phase implementation

Phase 1 (Year 1-3):

During this phase, existing services including social services will be strengthened while assessment is conducted to gather baseline information that will assist the NCHSWT and its partners to plan for introduction of Mental Health and Neglected Tropical Diseases (NTDs) services. Continue identification of social issues in the community will be conducted.

The NCHSWT will collaborate with the Ministry of Youth and Sports and other partners to provide adolescent sexual and reproductive health services at Youth Friendly Centers. In collaboration with the Ministry of Education, plan will be made for the reintroduction of school health services in the county health care delivery system.

Assessment and planning will be conducted for upgrading two (2), establishing twenty-seven (27) new ones and to provide staff accommodation at each health facility, including fifty six (56) existing ones, especially in hard to reach areas. Recruitment and deployment of staffs for each upgraded and new SDPs will be planned as provided for in the EPHS.

The referral system will be strengthened and plan made for the provision of at least one Land Cruiser ambulance for each district.

Phase 2 (Years 4-6):

The Zekepa PHC facilities will be upgraded to Health Centers, Karnplay Health Center upgraded to district hospital, ten new SDPs (PHC clinics) established, with accommodations and the service provision will begin at the fourteen integrated outreach sites. Accommodation will also be provided for fifteen existing health facilities. The provision of adolescent sexual and reproductive health services at established and existing YFCs will begin in other districts School health services will be reintroduced in four districts and be rolled out to other.. Mental health and NTDs services will be provided at all levels of care provision. Regular monitoring and supervision will be continued and joint mid-term evaluation be conducted during the fifth year.

Phase 3 (Years 7-10)

Lessons learnt and gaps identified in implementation of the plan, by the mid-term evaluation, will be addressed during this phase. The REMAINING SDPs will be established and equipped and accommodations will be provided for these and the remaining existing SDPs.

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School health services and the provision of adolescent sexual and reproductive health services will be provided in other districts. Other services provision and regular monitoring and supervision will be continued and an end of term evaluation be conducted at year nine.

7.2 Capacity Building

Ensuring improved staff performance is crucial to the provision of quality health and social services to the people of Nimba and is highly considered in the plan. Training opportunities will be sort for staffs at central as well as the peripheral levels. At the second and third phase of the plan, efforts will be exalted to have staff benefit from short and long term trainings, with preference given to service providers in the hard to reach areas, as a means of motivating them. Training gaps identified during monitoring and supervision will be addressed through on-the-spot and in services trainings.

The NCHSWT will be provided the necessary equipment and tools both at the central and peripheral levels to facilitate their job.

7.3 Monitoring and Supervision

Regular monitoring and supervision will be conducted with partners, encouraging high level community participation as much as possible, .at all phases of the implementation.. Continuous coordination and collaboration with all stakeholders will be encouraged. Monitoring and supervision will be highly supportive and conducted on a monthly and quarterly basis from the central county level to the peripheral (district-health facilities and communities) and weekly by district health teams. The MOHSW supervisory checklist will be used, reports prepared and feedback given to all levels.

Table 3: Nimba County Monitoring Framework

Objective Indicator Base-line

Target 2021

Increased access and utilization of health services % population living within 5 km from the nearest health facility 58% 90%

Service Provision

Maternal Health

[# and] % of deliveries that are facility-based with a skilled birth attendant 35% 80%

Family Planning Couple-years protection with Family Planning Methods N/A 50%

Child Health/EPI

[# and] % of children under 1 year who received DPT3/pentavalent-3 vaccination 85% 95%

Service Consumption OPD consultations per inhabitant per year

Malaria [# and] % of pregnant women provided with 2nd dose of IPT for malaria 51% 80%

HIV/AIDS Number of pregnant women testing HIV+ and receiving a complete course of ARV prophylaxis to reduce the risk of MTCT 35% 85%

Tuberculosis Number of smear positive TB cases notified per 100,000 population 35% 90%

Systemic components

Human Resources

Number of skilled birth attendants (physicians, nurses, midwives & physician assistants)/10,000 population

Drugs[# and] % of facilities with no stock-out of tracer drugs during the period (amoxicillin, cotrimoxazole, paracetamol, ORS, iron folate, ACT, FP commodity)

NA 95%

HMIS [# and] % of timely, accurate and complete HIS reports submitted to the MOH during the year 91% >90%

Financing % of execution of annual allocation of GoL budget for health 100%

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Quality # and % of facilities reaching two star level in accreditation survey including clinical standards (public network facilities) 2% 90%

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