Liberia south east region primary health care project (SER PHC) : final report, June 1984-August 1989

The project agreement was signed in 8/3, the TA contract with the MEDEX Group of the University of Hawaii, John A. Burns School of Medicine was signed in 5/84, and a TA team arrived in country in 8/84. The first phase of the project was completed in 9/89. A self-sustaining, locally controlled PHC network has been established in which communities collected money to start revolving drug funds, appointed health committees, and encouraged health activities: (1) larger towns have been assigned physician assistants and certified midwives to develop health centers/posts; (2) smaller communities have selected community health workers (CHW's), trained and supervised by physician assistant; (3) traditional midwives (TM's) have received training and supervision from the certified midwives; (4) vs. targets of 125 CHW's and 125 TM's trained per county, by the end of the project, 109 CHW's and 337 TM's had been trained. Efforts to improve planning and management have focused on both the county and central MH&SW levels. (1) Management systems for personnel, finance, drug supplies, communications, transportation, facilities management, health information systems, and general supplies were developed in each county. (2) Personnel have been hired and trained to implement these systems. Efforts at decentralization have begun, and a limited degree of autonomy has been given by the MH&SW to the counties to make decisions in selected areas such as finance. (3) Because personnel are centrally paid by the MH&SW, it is expected that sufficient additional funds will be generated locally from user fees and the revolving drug funds to make each system self-supporting. A foundation has also been laid at the central level for the development of the national PHC program: (1) manuals for each of the 8 decentralized management systems were developed and distributed to the counties and to MH&SW personnel; (2) a National Drug Service (NDS) has been organized to supply drugs and medical supplies at low cost for the nation; (3) national health training institutions have been strengthened with standardized and improved curricula to support PHC; (4) the capacity of the MH&SW to plan, and to develop health management systems, as well as to collect health statistics, has been improved; and (5) appropriate personnel at all levels have been trained to support PHC activities. This training was accomplished at the national and district levels, as well as at Liberian and U.S. training institutions. As the Project completes the first 5 years, there are a number of issues and problems which need to be addressed before the PHC system is expanded to other counties. Provision of foreign exchange for the NDS is a major issue which jeopardizes not only the life of the NDS but also the county PHC systems. Much has been accomplished in the area of decentralization, but major steps have yet to be taken in decentralizing the personnel and finance systems. The counties have accomplished much in this area, and the central level needs to renew its commitment to decentralize management systems within the MH&SW. Supervision is the key to sustainability of the PHC system in the counties. The supervisory system has been weak, but improvements have been made during the past months. However, there is still a need for improvement, and supervision should be the major focus of the county level PHC effort. (Author abstract)