Belated greetings from Liberia, folks. It’s been six days since I touched down in Monrovia and there’s a lot to report on. This trip marks a lot of ‘firsts’ for me. Not only is it my first time in Liberia and West Africa in general, but it’s also my first time working on health financing issues. Over the past week, I’ve been shuttling back and forth from government ministries, plugging in 12 hours a day at the never-ending tasks at hand. Surprisingly, I couldn’t be happier. While a lot of it has to do with the novelty of beginning a new assignment in a new place—the beach and sunshine certainly help, too—the main reason has been the work itself. Health financing is an absolutely fascinating topic. In fact, I’m of the opinion that health financing one of the most important areas of international development today. I’ll get to that later.
As with most global health topics, health financing is ultimately about serving the people — ensuring that people have access to quality care without suffering serious financial burden. Ironically, however, one of the challenges of working in policy is that one becomes quickly removed from the day-to-day life of the very people you hope to serve. Between the hotel and the office, there’s been little time left to explore and engage with the communities. I decided that I would change that.
As it turned out, I didn’t have to go very far. A few blocks from my hotel, I came across a clearing that overlooked the narrow peninsula that captures most of Monrovia. Eager to start using my new camera, I laid out the frame and took the following shot:
All of a sudden, a voice sounded behind me.
“You take a photo of our community, you need to pay five dollars to give back.”
I turned around to look at the man. Dressed in faded blue shorts and dirty flip flops, the young man stared at me unapologetically, his piercing gaze becoming ever more uncomfortable with each passing millisecond.
Comments like this are not unusual, particularly in the developing country context. “But I’m showing the world the beauty of your country,” I replied. From my few days here, I had already learned that friendliness and joking went far in building relationships or, in this case, defusing a situation.
But the man was not amused. “There is no beauty in Liberia. Only poverty.”
“There is poverty, but beauty everywhere as long as you’re willing to look for it.”
“Sure. But will it pay for my surgery?”
He stared back at me in silence.
I wanted to tell him that I understood, that I empathized. After all, it’s why I’m here: because the system is broken. The health system in Liberia has offered limited social protection, nor does it deliver on the aim of ensuring access to quality care.
As the oldest republic in Africa, Liberia is still recovering from the civil conflict that lasted from 1989 to 2003, which resulted in one of the largest recorded economic collapses, destroyed all forms of infrastructure, and drove up the national debt to a staggering 800% of GDP.  An opportunity for change arose in 2006, when Liberia’s President Ellen Johnson-Sirleaf became the first woman elected head of state in Africa. Under the new government, a National Health Plan was developed in 2007, including the implementation of a Basic Package of Health Services (BPHS) through a free-care model.
While the implementation of the BPHS has been successful in certain areas (e.g. the reduction in under-five morbidity and mortality), it has proved incomplete for the full needs of health care delivery. The BPHS does not cover treatment of common illnesses such as non-communicable (diabetes, cancers, hypertension, etc.) and neglected tropical diseases. Additionally, the rigid salary scales make it difficult to retain health workers in remote areas, and recent studies show that approximately 40% of the population still lives more than one hour walk from a health facility.  Most importantly, limited free care does not protect the population from unexpected health expenditures, which can be catastrophic for families, particularly the estimated 76% of the population that lives below the poverty line. As a result, there is still no safety net. If you get sick, tough luck.
Such was the case for the man standing before me. He was angry and, in my opinion, rightly so.
So when people ask me why I decided to abandon a life in Washington DC to come to Liberia, this is it. I’m here to work with the government and partners to reimagine what health care could be like in this country. I don’t have all the answers, nor is knowledge alone sufficient for change, but I’m going to give my full attention to this issue over the next few months.
Thanks for reading along.
[i] Country Situational Analysis Report, MOHSW, 2011
[ii] Jacob Hughes, Amanda Glassman, and Walter Gwenigale. Innovative Financing in Early Recovery: The Liberia Health Sector Pool Fund. Washington DC: The Center for Global Development, 2012.
 Essential Package of Health Services. (2011) Ministry of Health and Social Welfare. Liberia.