Introduction
Fourteen years of war caused or exacerbated significant problems in the workforce, infrastructural, and systems needs of the healthcare sector in Liberia. This experience is analogous to a train wreck and rebuilding reflects the intimidating challenge of placing the train back on track. That is the unenviable position of the Sirleaf administration as the Non-Governmental Organizations (NGOs) and religious organizations that have provided bulk of the healthcare services during and after the war complete their rehabilitation missions and are verging on departure. The Ministry of Health (MOH) has yet not provided a plan to the public regarding how it will administer the transition and build a sustainable healthcare system. The health transition workshop which United States Agency for International Development (USAID) and the Academy for Educational Development (ADE) launched in early 2005 addressed some of these concerns, but MOH still has to provide a comprehensive policy response on healthcare reform. Nearly two years into the government, the healthcare sector faces a looming crisis in attracting qualified workforce.

It goes without saying that healthcare reform in post-conflict Liberia presents one of the key opportunities for fundamental improvements in quality of life and in varying other socioeconomic indicators. Healthcare is a crucial institution because it lays the foundation for survival in all arenas of life. A coherent healthcare reform policy will help to overcome some of the nation’s most pressing challenges: in education, social welfare, the economy, and national security. Healthcare cuts across an array of important nation building portfolios because healthy citizens are the backbone of a strong and competitive society. Nothing in my view is connected to improved labor market performance and substantial redistribution of income than broad-based access to healthcare and education.

But I should warn that a short essay on healthcare reform cannot tackle all manifold issues that are locked into the topic. Considering the complexity of the issue, one has to arbitrarily pick a slice of this mammoth subject to enable a reasonable analysis. For this reason, I chose allied and auxiliary healthcare workforce shortage as the subject of this paper. The focus on allied and auxiliary healthcare workers is not aimed at highlighting the disciplinary boundaries used to establish a hierarchy of healthcare workers, but to show their indispensable interrelationships. Workforce shortage in this context applies to the fact that the supply of allied and auxiliary healthcare workers does not equate to the demand for these specific professional skills. The notion of income redistribution is offered here because allied and auxiliary healthcare workers largely constitute middle and lower middle class people or even the working poor in some instances. Investment in this tier of the workforce could raise living standards for a sizeable segment of the society and produce growth and equity benefits.

It is merely an assumption that workforce shortages exist rooted in anecdotal evidence surmised from USAID and MSF reports as well as informal conversations with healthcare professionals in Liberia. Currently, Liberia has no definitive data source from which analysts can forecast the future number of healthcare workers that are required to match specific population ratios. We have limited or no ways of determining service needs and targets nor do we have adequate resources to determine the workforce needs of defined geographic locations. We do not have immediate access to data that distinguishes between healthcare professionals working in the private and public sectors. We still are unable to determine the healthcare workforce distribution based on areas of specialty and/or gender imbalances in these professions. These identified shortcomings alongside many others make it difficult to adequately capture the scope of the problem at hand.

Perhaps, these factors explain the reason why healthcare challenges have not featured heavily in our national discourse on rebuilding. But then, why the silence when our political leaders have continued to vow to close quality of life gaps that persistently stand in the way of fostering “equality and justice for all.” In the absence of a publicly announced systematic plan for healthcare reform from the executive branch and/or the legislature, I have chosen to draw some attention to components of the problem. In this paper, I present a rationale and suggestions for transforming our workforce shortages in allied and auxiliary healthcare professionals. The solutions that I have suggested are “first tier/macro-level” policy interventions given that pervasiveness and population-specific (demographic) data are rare or missing completely in certain instances.

The Existing Healthcare Environment
When one looks closely at the political economy and healthcare sector more specifically, it is clear that Liberian society has changed. All of our industries experienced decline for 14 years or more and the healthcare sector was not spared. Faith-based healthcare providers and NGOs are among the leaders in healthcare services in Liberia. In Monrovia, there are the Island, Benson, Catholic, and Redemption hospitals providing care of varied kinds, including “pediatric and obstetrics inpatient services.” Disease specific or specialized services focusing on tuberculosis, HIV, and reproductive health are also being developed by certain providers. Partial restoration of electricity and standpipe water in Monrovia by the Sirleaf administration is a giant step forward. In the rural areas, for example, in Gbarnga, the Lutheran Church operates Phoebe Hospital. The United Methodist Church operates a hospital in Ganta. In Saclepia, MSF administers a clinic. Other such medical institutions exist around the country.

Yet, one would still suggest that rural residents remain severely underserved in a wide variety of arenas given their political and social marginalization and the inequalities that have for so long being ingrained in Liberian society. The incidence, prevalence, mortality and disease burden of the rural sector is high compared to its urban counterpart. Shortage of primary physicians, more injuries, coupled with the added burden of inadequate access to health resources, and other professionals; count among the many problems that the war wrought or aggravated for rural inhabitants. This is not to suggest that the condition for city residents is much better, perhaps a tidbit. The fact that secondary and tertiary facilities are certainly far removed from many villages and towns, financial resources are scarce and information on ways to improve health conditions are minimal or nonexistent in some rural locations, all combine to put more Liberians living in the rural sector at risk to die from illnesses (cholera and other water-borne diseases) that are easily treatable. These could possibly be averted or mitigated, if advances were made in our healthcare delivery system; and more trained healthcare professionals were added to the existing pool.

More broadly Liberian society lacks or is just beginning to develop effective mechanisms for managing chronic diseases like diabetes, HIV/AIDS, and asthma. In the absence of strong and widespread disease management capacity, these manageable conditions become instant killers. Liberians living abroad diagnosed with these illnesses, who could return to contribute to rebuilding the nation in manifold spheres cannot afford to risk their health or that of family members knowing the enormity of dangers associated with poor disease management systems. If the government neglects the medical and social service needs of its citizens, it also risks attracting Liberians and foreigners alike that could help revive the economy. It is possible that the government is intervening in some of these issues, but the absence of a public outreach and engagement campaign regarding steps that are being taken adds to the deepened streak of public cynicism and suspicion.

Importance of Allied and Auxiliary Healthcare Professionals
Paramedics, dental hygienists, radiation therapists, ultrasonographers, pharmacy techs, phlebotomists, medical laboratory technologists, medical coders, and many other allied health professionals make up a long list of personnel that have immense value for transforming our healthcare system. Let me underscore that this is not an effort to discount the immense importance of physicians and nurses, the two foremost medical practitioners that exist in the consciousness of most patients. Policy makers are known to downplay the shortage of allied and auxiliary healthcare workers, while clamoring when physician and nurse shortages come to the forefront. What is quite disappointing is the failure of policy makers to recognize that auxiliary healthcare workers including nurse assistants, home health aides, habilitation aides, and personal care assistants as well as human services professionals like psychologists, social workers, marriage and family therapists and mental health advanced practice registered nurses; play a vital role in ensuring that the health care system function at an optimal level. Add to this list speech pathologists and audiologists, and you will understand why the assertion is made that healthcare delivery is a team sport at the least. Human services professionals and their other peers perform essential functions that meet the needs of families, children, and the elderly as well as people with special needs, those with disabilities, included. Recovering from such a devastating war and recognizing the sheer scale of the mental health disorders, chemical dependency problems, and psychosexual dysfunctions, require gigantic psychological intervention. The providers of choice are often clinical social workers, psychologists, marriage and family therapists and psychiatrists, many of whom are scarce in Liberia.

The focus on allied and auxiliary healthcare workforce is that the delivery of healthcare services is more than a one person sport. Instead, it is a “team sport” comprising of professionals who manage the different segments of the continuum, each having indispensable value to the wellness and care giving enterprises. The notion that physicians alone are critical to healthcare delivery is patently false. In cases where there is complete dependence on physicians, the outcome is often that the physicians are likely to be overwhelmed, which results in diagnostic and other medical/practice errors. This concern magnifies when one views it through the lens of the war-torn context in Liberia - where physicians carry a lopsided amount of the work load. Physicians administer nearly all aspects of the diagnostic processes and receive minimal support from the cast of actors that are regularly available to their counterparts in more developed nations. In remote and rural communities where the needs are acute, the considerable portion of the burden for healthcare delivery rests with the physician. In most situations, physicians are sporadically or not accessible at all. This condition intensifies the shortage and related gap in access.

Recruiting, developing the talent, and retaining allied and auxiliary healthcare workers can help alleviate rural-urban disparities given their general willingness to serve in remote and rural communities, especially if incentives, including better wages, benefits, and work conditions are provided to spur and maintain such interests. If allied and auxiliary workers hail from the local communities in which they work, and speak the language or dialect in those communities, it is possible that they would have heightened sensitivity to cultural concerns, which can increase client satisfaction and strengthen adherence to treatment.

Exploring the Workforce Shortage
Our policy makers, both those in the executive and legislative branches of government and even their counterparts in the judiciary need to take serious note of the healthcare workforce shortage. This is the only way that they can address this concern and the complex array of negative side effects that it generates. Those in the judiciary can only jail so many Liberians for offenses that are in part driven by undiagnosed and untreated mental health needs. The government has a finite budget and can only care for a limited number of prisoners. In the absence of treatment programs to rehabilitate mentally ill people and to integrate them into civilized society, Liberia will remain a wasteland of lawless and despondent people. Without proactive interventions, the consequences are likely to be severe, causing decline in quality of life and economic losses, which eventually might reproduce state collapse.

It is difficult, in the absence of needs and pervasiveness studies to explain the causes of the workforce shortage. Reasons for the shortage are myriad, complex, and complicated. Brain drain is a sure contributing factor. We can also guess that our workforce is increasingly becoming older. Another culprit could be that training or professional development is not commensurate with advances in medical science. In addition, it is possible that the level of coordination relative to developing an integrated response to the workforce shortage between the various government agencies is not yet fully engaged. When the links between government agencies and higher education institutions are tepid it is impossible to forecast the supply and demand for healthcare workforce, and impossible to derive “reliable, timely and consistent” information on the workforce needs to be “reevaluated and updated regularly.”

A fragmented governance process produces second and third rate results. Recall that quality of care is measured by outcomes. More so, Liberia like all world nations operates in a globally competitive environment, where the need for experienced and highly skilled labor spans the globe. If conditions are unsatisfactory in the homeland, Liberians will seek better opportunities abroad. Healthcare is a knowledge-based profession, and technological changes are increasing the demand for skilled healthcare workers. This reality must impel the Sirleaf government and the legislators to make a concerted effort to recruit, support, develop the talent, and retain the qualified Liberian workforce. The shortage is bound to get worse, if the government neglects its responsibility to become innovative in addressing the problem.

Possible Avenues of Intervention

1. Role definitions and linkages between the different government agencies with regards to their involvement in healthcare governance would have to be clearly defined. If the governance structures are not agenda-focused, it would be hard to make a compelling case to the public about the changes that the Sirleaf administration wants to achieve.

2. The creation of a robust system for capacity building in allied healthcare professionals would bridge the gap between doctors, dentists, specialists, and allied/auxiliary health professionals especially in remote and rural communities. To boost enrollments, the government or its designee would have to promote awareness and interest in allied and auxiliary healthcare professions within elementary, junior high and high schools around the country. Preferably, a commission charged with developing an educational response to the workforce challenges that is aligned with updated innovations and systems changes in healthcare might be necessary.

3. What existing educational structures might the Sirleaf administration feasibly transform to make these ideas possible? Die-hard believers in formal education, which moves from high school to college, might find this idea less interesting. K-12 students should have adequate processes and programs to prepare them for careers in healthcare. A special focus on students who dropped out of school and are facing difficulties continuing their formal education (i.e., former child soldiers, those with limited capacity to pay for formal education, etc) as well as single mothers could be motivated to become allied and auxiliary healthcare professionals. As the ex-combatants mature as adults, they can always take steps to increase their skills or transition to another profession within the healthcare field.

Make healthcare training sites convenient to population centers and local communities to avert geographic and transportation barriers. Invite flexibility in converting program completion requirements from one healthcare discipline to the other – nurse to nurse practitioner, paramedics to nurse, etc. This can be accomplished by creating nationally recognized educational processes through healthcare disciplines to allow people to increase their skills or receive credits between disciplines. A single National Healthcare Education and Registration Board that incorporates all healthcare disciplines with an established minimum criteria or standards and scope of practice would advance this idea further. In addition, it would be critical to add distance learning methodologies for training our allied and auxiliary healthcare workforce, thus broadening the scope and impact.

4. Experience strongly suggests that funding for allied health training should go to the private sector. The private sector has respectable history in developing and administering outcome-based professional development opportunities. For the government to ensure that private providers are providing the needed services, it should work in collaboration with the University of Liberia to develop a non-political body constituting professionals in medicine, business, and the social sciences to collect and publish outcome data collected on the number of graduates, their placements in the workforce, and treatment outcomes, in their respective areas of specialty, and on constituents in the regions of the country where they are assigned. Providers would receive ratings based on their productivity and lose funding for their shortcomings.

5. An unprecedented “brain gain” occurred – via the numbers of Liberians who studied abroad and acquired high levels of skills and experience during their periods of refuge. If only the government can work hard to attract these Liberians by reducing the cost of their return to the homeland; creating a pro-business environment that would translate into positive effects on the political economy.

6. Disparities exist in access to healthcare between rural and urban inhabitants. Build community-based systems of care and train “allied” healthcare professionals, including nurse practitioners to administer them. Centralized healthcare facilities that are located in large cities can no longer suffice. Therefore, build a comprehensive school health service to better serve our children and youth to reduce the pervasiveness of diseases in specific remote, rural, and low income communities.

7. For the life of the nation, we have had a hospital-centered medical system. It would seem that with the world moving toward prevention, in-home, and community-based care, the thought is that allied and auxiliary healthcare workers are playing essential roles in these transitions. Rather than leaning toward over-hospitalization; “hospital avoidance” seems a logical alternative. When we make hospital the last remedy, we invest heavily on the front end as opposed to when the conditions get acute. The preoccupation of healthcare policy makers and professionals with crises only take a toll on minimal resources.

8. We cannot overlook the need to invest heavily in biomedical and applied research to identify and test effective models of care specifically targeted to our different populations, followed by continued refinements to test if they are practical and applicable to the local context. To enable the government to plan for the supply of its workforce and to understand the demand for allied and auxiliary healthcare workers, it should direct the Ministry of Labor and its counterpart - the Ministry of Education to provide “reliable, timely, and consistent” information that can be studied by independent researchers.

9. The legislature should curb the expansion of powers by the executive branch through accountability measures. It should make a firm commitment to cultivating public participation in policy formulation and implementation. Without taking these steps, the transition to a real pluralistic democracy in Liberia would remain an unachievable expectation.

Conclusion
Here are some questions for the Sirleaf administration to ponder. Does it have strategies to rebuild, invigorate, and retain the healthcare workforce? Does the Sirleaf administration have a strategy to redesign the healthcare curriculum and provide ample professional development and higher education? Does the Sirleaf administration have a plan to develop flexible, but rigorous credentialing processes? Does the Sirleaf administration have a plan to substantially redesign the work environment and processes to achieve productivity gains, enhanced outcomes, and job satisfaction? Does the Sirleaf administration have new ideas that can essentially renew its engagement of the electorate to be active partners in transforming the healthcare system? Ultimately, the Liberian crisis cannot be explained exclusively by blaming the war - that too will run its course. The scarcity of foresight and innovation will stand out.

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© 2007 by The Perspective
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