Authors : John Solunta Smith Jr, Lucas Sempe, Sally Theobald
Site of publication: International Journal for Equity in Health
Type of publication: Article
Date of publication: November 2022
The SSSD situation in Liberia
Liberia is one of many African countries where SSSDs are endemic; across all counties, the burden of SSSDs, namely yaws, onchocerciasis, leprosy and LF (and resulting hydrocele and lymphoedema) is high among the general population. In Liberia, a 2012 nationwide SSSD assessment found that 258 cases of lymphedema and 268 cases of hydrocele were reported across 6 counties. By 2015, new confirmed BU cases increased to 105, with 59 cases treated through routine health services.
In recognition of need for effective case management, maintaining the gains of campaigns, and building a system capable of sustaining access to treatment and the achievement of the Sustainable Development Goal of universal health coverage, the Integrated Case Management Program (ICMP) set a goal “to reduce the burden of targeted NTDs to a level that is no longer a public health problem through an integrated control programme, contributing to the socio-economic development of Liberia”
We recruited and trained four local data collectors in the Lofa and Grand Gedeh counties, who worked with four research fellows to collect data at county, district, health facility and community levels. Data collectors were trained for 2 days inclusive of 1 day for piloting the KII topic guide with the research fellows. Meetings were also held with authorities of county and district health stakeholders, where we provided information on the study objectives and activities, prior to deployment of data collectors from October to December 2020.
The results have been reported using themes which are structured into five main sections, with section one presenting evidence from the literature highlighting the research gaps which this paper addresses and the remaining sections exploring findings from the KIIs. Section two explores the views of participants on financial decision-making processes at the national and county levels in Liberia. While section three explores the roles within financial decision making at different levels.
Section four present challenges with financial processes and planning at each level, whilst section four discusses out-of-pocket (OOP) costs. Section six details opportunities and recommendations for NTDs financing in Liberia and finally, section seven colligates findings from the evidence summary of the literature in LMICs and Liberia specifically.
To the best of our knowledge, there have been no comprehensive costing studies conducted for SSSDs or NTDs in Liberia except for one study done by Popovic, et al. (2017) that reviewed Marginal Budgeting for Bottleneck (MBB), Core+ and the One Health tool as costing tools that have been used in Liberia for core services, such as basic health packages.
Seven participants explained that financial decisions are made through the different programs supervisors who usually participate in fiscal planning and forecasting meeting on a yearly basis at the county level. However, whist these forecasts are sent to the national level, they are not binding, and may not be used by the national office. Rather, other program financing instructions are sent from the national level to the county with an approved budget and direction for the usage of the approved budget. Four county level participants expressed that the county authorities have no power to alter the financial decision made at the national level, even when it does not align with priorities. A similar situation was described in both ICMP and non-ICMP counties.
Opportunities and recommendations for NTD financing
Our findings also shows that partners’ funding decisions were made in partnership meetings, committee meetings and based on the MoH policies and financing needs. For example, the NTD program’s supporting partners depend on the ICMP in deciding what component of the program they will direct their support consistent with the finding of Kollie, K, Siakeh, A. et al., 2021.
Decisions are further communicated with the Ministry through partnership meetings, specialized meeting or specially arranged meetings for endorsement, acceptance, or approval by the ministry through the department compared to non ICMP counties, where these opportunities do not exist. The implications of this strategy for county and district level implementers are that local priorities are not influencing the budget during the implementation at the county and district levels.
Recommendations for further work
Building on the literature review findings, the authors recommend the following areas be addressed in future research. Firstly, the knowledge gap in the costing of SSSDs care in Liberia from societal and patients’ perspective must be addressed. Cost-effectiveness analyses of SSSD interventions in Liberia should also be conducted to identify cost drivers and incremental cost differences, to help guide SSSD policy and programs. Tis preparatory study for the wider REDRESS research project will contribute towards filling some of these critical evidence gaps.