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Health information, research, evidence and knowledge

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Data are crucial in improving health.[1] The ultimate objective of collecting data is to inform health programme planning as well as policy-making and, ultimately, global health outcomes and equity. A well-functioning health information system empowers decision-makers to manage and lead more effectively by providing useful evidence at the lowest possible cost.

A health information system has been aptly described as "an integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research". It consists of:

  • inputs (resources)
  • processes (selection of indicators and data sources; data collection and management)
  • outputs (information products and information dissemination and use).

The role of a health information system is to generate, analyse and disseminate sound data for public health decision-making in a timely manner. Data have no value in themselves. The ultimate objective of a health information system is to inform action in the health sector. Performance of such a system should therefore be measured not only on the basis of the quality of the data produced, but also on evidence of the continued use of these data for improving health systems' operations and health status.

The health information system[2]

The availability and use of information enables:

  • improved definition of a population
  • recognition of problems
  • setting of priorities in the research agenda
  • identification of effective and efficient interventions
  • determination of potential impact (prediction)
  • planning and resource allocation
  • monitoring of performance or progress
  • evaluation of outcomes after interventions
  • continuity in medical and health care
  • healthy behaviour in individuals and groups.

It also empowers citizens by enabling their participation in health care, policy and decision processes; and empowers countries and international partners by enabling better transparency and accountability through use of objective and verifiable processes.

Health knowledge gaps are where essential answers on how to improve the health of the people in Lesotho are missing. This is an issue related to the acquisition or generation of health information and research evidence. The “know-do gap” is the failure to apply all existing knowledge to improve people’s health. This is related to the issue of sharing and translation of health information, research evidence, or knowledge. Although there are major structural constraints, the key to narrowing the knowledge gap and sustaining health and development gains is a long-term commitment to strengthen national health information systems.

This section of the Health information, research, evidence and knowledge profile is structured along the following lines:

Contents

Analytical summary

In 2011, the national reporting coverage for outpatient services in Liberia was 77%, compared with 76% in 2010, with variations across counties. Counties with high reporting coverage included: River Gee (100%), River Cess (99%), Margibi (96%) and Grand Kru (96%); while Montserrado reported the lowest coverage (52%). The figure presents outpatient department reporting coverage by county in 2011.

Health facility outpatient reporting coverage by county. Source: Ministry of Health and Social Welfare Annual Report, 2011

Improving and increasing the reporting coverage of hospitals and health centres remains a challenge, especially for private health facilities in Montserrado County. In 2011, the national coverage for inpatient reporting was 40%. Despite this low rate, River Cess (100%), Bong (97%) and River Gee (94%) attained high inpatient reporting coverage, while Montserrado (83%), Nimba (35%) and Margibi (42%) recorded the lowest coverage1. The figure presents health facilities inpatient department reporting by county in 2011.

Health facility inpatient reporting coverage by county. Source: Ministry of Health and Social Welfare Annual Report, 2011



Context

The current health management information systems in Liberia evolved from the use of calculators and typewriters to the introduction and use of modern information and communication technology equipment, including computers, printers, servers, etc. County-level reporting to the central Ministry of Health and Social Welfare has transitioned from paper-based to electronic reporting. Monthly health facility reporting has improved to over 75% with reports at the county level being entered and processed into the district health information systems (DHIS) 2.0 software.

A research unit, re-established in 2011 after an absence of nearly 20 years, is working to strengthen research coordination and management.

Enabling environment

In 2009, the national Health Management Information System Policy and Strategy were developed to support the collection, analysis, interpretation, dissemination and use of health information. Health information was also identified as a major priority by the national health sector. Much effort has been exerted by the Government of Liberia and partners to develop a functional health management information systems at all levels of the health systems in line with international standards. Despite these efforts, the system continues to face a number of challenges. There is no national policy specific to information and communication technology, or even one for information and communication technology for health information. This is also the situation with eHealth policy and strategy, although the Ministry of Health and Social Welfare has had a series of consultations with a range of stakeholders to think through the process of developing these documents.

A substantial amount of financial support is needed to establish a fully functional system. Recent funding for the system has been provided by the Government and its development partners but this is not adequate to establish a fully functional system at all levels. There is a public–private partnership for health information between the Ministry of Health and Social Welfare and its partners in the health sector.

To ensure the privacy of health information, the system is protected by the Statistics Act, Public Health Act and other Acts on privacy.

Infrastructure

Currently, Liberia lacks a national cohesive and integrated approach for the implementation of a modern information, communication and technology for health information. There are plans for the development of a national information technology policy; meanwhile an information technology standard operating procedure is being developed. In the past 2 years, the information technology infrastructure at the Ministry of Health and Social Welfare has being boosted with the development of the Ministry of Health and Social Welfare's website, the establishment of a universal birth registry and the installation of a VSAT (very small aperture terminal) satellite Internet system in seven counties.

Cultural and linguistic diversity and cultural identity

As the health information system is still being developed, cultural and linguistic diversity and cultural identity functions are yet to be introduced into Liberia.

Existence of multilingual projects, translation and cultural adaptation

At present, there are no multilingual projects associated with the current health information system in Liberia. However, the health information system was developed based on the adaptation of systems of other countries. There are plans to established links with other international information systems.

Content

With the exception of freely available websites and online journals, Liberia's Ministry of Health and Social Welfare does not subscribe to any international journals and there are no national online journals for health. Plans are underway to establish a national open archive or repository for health information. This proposed system will be an Internet-based health information portal set up on a server and will provide information services for the general public, health professionals, researchers and policy-makers. In addition, the portal will be linked with other national and international health information systems.

Capacity

An assessment of the health system in Liberia identified human resources as one of the gaps. There are plans for strengthening the human resource capacity of the health information system. At present, the Ministry of Health and Social Welfare's Division of Information Technology has an acting director and seven staff linked to national programmes. Several capacity-building workshops for information technology staff from central and county levels are planned, to be held in collaboration with partners.

Structural organization of health information

Organogram of the Ministry of Health and Social Welfare. Source: Bureau of Vital Statistics, Ministry of Health and Social Welfare
The Ministry of Health and Social Welfare is headed by a Minister and contains four departments (Health Services; Planning, Research and Human Development, Administration and Social Welfare) each headed by a Deputy Minister (see figure). The departments are subdivided into bureaus headed by Assistant Ministers. The Assistant Minister for Vital Statistics under the Department of Planning, Research and Development has oversight for health information generation, verification, analysis and presentation for use.


Organization and management

The Division of Monitoring, Evaluation and Research is one of three divisions of the Government of Liberia's Ministry of Health and Social Welfare; the others are Information Technology and Universal Birth Registration, under the Bureau of Vital Statistics (see figure).

Structure of the Bureau of Vital Statistics. Source: National Monitoring and Evaluation Policy

The Division of Monitoring, Evaluation and Research comprises a Monitoring and Evaluation Unit, a Research Unit and a Health Management Information System Unit. The Division is headed by a director who coordinates the activities of the three units.

The central Monitoring and Evaluation Unit, which previously had four full-time staff, is now manned by one member of staff following the departure of the others to pursue graduate studies. A recruitment process is ongoing to fill the vacant positions. Two research assistants with Masters in Public Health steer the affairs of the Research Unit while the Health Management Information System Unit has an acting director and is supported by data managers of the various programmes.

The primary objective of health services is to ensure that the highest levels of health and social well-being are achieved for the majority of the population. The Health Management Information System Strategy proposes to utilize information to the fullest in pursuit of this objective. It recognizes that there is a need for a set of rules to ensure the availability of the highest quality information and their full and correct use in health services planning and management.

Implementation of the Health Management Information System Strategy requires a range of developmental activities and changes in organization, management and culture. This presents significant challenges throughout the sector, thus an effective change of management processes is particularly important. The success of the Strategy depends on a strong central driving force and mechanisms that ensures its consistent, effective and timely implementation.

A limited number of skilled and trained staff are available to support the management of information in the health sector. There is still a need for staff and or training in the areas of the health management information system, demography, public health, biostatistics and research to deliver on the actions mentioned in the Health Management Information System Strategy.

The Health Management Information System Policy recognizes that a collection of informational subsystems make up the health management information system. To date, the routine health information system is the most developed component of the health management information system (see figure). Substantial funding and technical support is needed to establish and operationalize the other components in a coherent manner.

Components of the health management information system. Source: National Health Information System Policy and Strategy[3]

As shown in the figure, the following are components of the health management information system:

  • Infrastructure Development Information System (IDIS): database of all health facilities including functionality, population, GPS, etc.;
  • Health Information System (HIS): Essential Package of Health Services programme reporting on individual programme interventions, for example Essential Programme of Immunization, malaria, HIV/AIDS, Integrated Disease Surveillance and Response;
  • Human Resource Information System (HRIS): database of health workers to track their work by health facility, promotion and training;
  • Essential Medicines and Supplies Information System (EMSIS): pharmaceutical management system to track to drug stocks and supplies;
  • Community-Based Information System (CBIS): tracking Community Development Councils as well as community-based interventions;
  • Health Budgeting and Spending: this database would summarize the status of budgets and spending for health facilities and counties;
  • Health Mapping: capacity to integrate information from the various databases to visualize and map interventions, planning and monitoring.

Overview of the flows of information

Reporting of information to the Government of Liberia's Ministry of Health and Social Welfare is bidirectional, moving in both vertical and horizontal directions (see figure). The data are received from health facilities; statistical tables and analytical reports are then generated and reported back to the reporting facilities for their use in health services planning and management. Similarly, statistical tables are submitted to the Ministry headquarters for its information and use in policy-making and strategic decision-making.

Flow of health information. CHV, community health volunteer; CHT, community health team; HF, health facility; MOHSW, Ministry of Health and Social Welfare; TBA, traditional birth assistant. Source: National Health and Social Welfare Plan 2011–2021[4]

Ten indicators were suggested as milestone indicators; four of these indicators are new: the Essential Package of Health Services, human resources, support systems, infrastructure, finance, partners, maternal and newborn care, child health, reproductive health, and disease control. A total of 36 indicators are confirmed for the county level, which includes national indicators, covering different domains of the core business and support systems:

As part of the health information system implementation, a number of indicators and corresponding data elements were introduced into the district health information systems database. All these fragmented and ad hoc indicators and datasets were examined against their purpose and the final set of national core and common indicators was determined.


Specific regulatory framework

In Liberia, a Health Management Information System Policy has been developed and this serves as the regulatory framework for the flow of information at the different levels of the health system. The guiding principles are as follow:

  • adherence to international standards
  • equity, quality and social justice
  • accountability
  • communication
  • decentralization
  • inclusiveness.


Data sources and generation

In Liberia the health management information system obtains information and data from the health management information system repository as well as other systems within and outside the health sector. These include:

  • human resource information system
  • finance management information system
  • vital registration
  • censuses
  • rapid assessment surveys
  • operational research
  • disease surveillance
  • logistics management information system
  • community-based information system
  • physical assets management information system
  • health information systems
  • geographical information system
  • health determinants and status

These sources and their current performance status and each of their strengthening strategies are described briefly in the sections below.

Censuses

In Liberia, population data are the foundation of the health management information system. Up-to-date population figures are available for health facility catchments and counties to plan for health services and measure changes. The health system continues to obtain population data from the national census. Target populations for each year have been projected for each level using the intercensus growth rate for that particular level. The Ministry of Health and Social Welfare provides its population data requirements to the Liberia Institute of Statistics and Geo-Information Services to be incorporated into the decennial census. The 2008 census data is available for 10 297 enumeration units, with each of their latitude and longitude addresses. Working in collaboration with the Liberia Institute of Statistics and Geo-Information Services, the Ministry's Monitoring, Evaluation and Research Division has derived total catchments population for each health facility and estimated target populations for each service on an annual basis.

Civil registration and vital statistics systems

Registration liberia.png
In Liberia, the Ministry of Health and Social Welfare has the mandate for vital registration. Though the vital registration is mandatory by law, the registration rate is fairly low. Liberia has started birth registration as part of universal child registration as an entry point to vital registration. Death registration has been incorporated into the vital registration system with strategies being devised to ensure the registration of all deaths throughout the country.



Health surveys

The latest Demography and Health Survey was conducted in 2007. Such surveys are conducted periodically to update population data on health outcomes and impact indicators. A health facility census and three consecutive health facility accreditation surveys (2009, 2010 and 2011) have been implemented in a coordinated manner that avoided duplication and complement one another. Additionally, a National Malaria Indicator Survey was conducted in 2009 and another was conducted in 2011 (data analysis and report writing in process).

Surveillance systems

Occurrence of diseases of public health importance in Liberia are being investigated, analysed and results fed back to the management structure at the facility, county and national levels for their appropriate response in a timely manner. National guidelines for Integrated Disease Surveillance and Response have been developed with the goal of improving the country’s ability to detect and respond to diseases and conditions that cause high levels of death, illness and disability.[5]

Owing to the high maternal and neonatal deaths in the country, the President of Liberia, by proclamation, has put these events under active surveillance and as such should be reported within 24 hours of occurrence.

Currently, the following diseases are under active surveillance system at the Ministry of Health and Social Welfare's Epidemiology Unit:

  • acute flaccid paralysis
  • cholera
  • acute water diarrhoea
  • other haemorrhagic fevers
  • bloody diarrhoea
  • Lassa fever
  • measles
  • meningitis
  • tetanus
  • yellow fever
  • rabies
Example of weekly epidemiological bulletin. Source: Epidemiology Unit, Ministry of Health and Social Welfare

The Epidemiology Unit coordinates the active surveillance system at the county and facility levels which, with the exception of maternal and neonatal deaths, provides weekly updates to the Unit. The reports, with inputs from WHO, are consolidated in a weekly epidemiological bulletin (see figure) and circulated to programme units, the counties, nongovernmental organizations, donors and health development partners for action.



Systematic documentation of contextual and qualitative data

With the exception of ad hoc studies commissioned either by the Government of Liberia's Ministry of Health and Social Welfare or other stakeholders that utilize qualitative means of data collection with the corresponding output, there is no routine, systematic documentation of qualitative data.


Health research

Health research plays a crucial role in the on-going development and provision of quality health care that best meets the needs of both individuals and the general population of Liberia. The Liberia Institute for Biomedical Research was established in 1970 and is involved with the management, coordination and conduct of biomedical research in the country. Units within the Ministry of Health and Social Welfare are also involved with health research, as are nongovernment organizations that incorporate research into their project activities.

Academic institutions and private entities such as Subah-Belleh Associates perform research on an ad-hoc basis. The HIV/STD Prevention Research Center at the UL-PIRE Africa Center collaborates with the A.M. Dogliotti College of Medicine at the University of Liberia in the conduct of HIV and sexually transmitted infection related research.


Data management

There is a standard operating procedure for data management at the different levels of the health system (central, county and health facility) in Liberia. The central Health Management Information System Unit is responsible for coordination and management of the health information system in the Ministry of Health and Social Welfare. There is a monitoring and evaluation research team at the county level whose responsibility is to coordinate the collection and entry of health facilities and community data into the district health information system software for submission to the central Health Management Information System Unit.[6] They ensure that the collected data is timely and complete. The registrars in the health facilities extract the data from the facility registers and compile them in the integrated reporting form to be submitted to the county monitoring and evaluation research team.

Data collection

Sample of health facility monthly reporting form. Source: Health Management Information Unit, Ministry of Health and Social Welfare
In Liberia, the Ministry of Health and Social Welfare's central Health Management Information System Unit does not collect data but rather aggregates, stores, analyses and presents data from the counties. Routine data on resource management (e.g. finance, logistics, human resource and population-based data) are collected from reports, surveys and research. Resource data are directly recorded into computers during their transactions. The data recorded as part of these transactions are processed and fed into the national repository. All routine health service delivery data are now condensed into an integrated reporting form (see figure) thereby improving timeliness and completeness of reports and promoting a single data flow mechanism.


Data collection instruments for surveys and research studies are designed based on the purpose and objective of the survey. The Bureau of Vital Statistics is responsible for ensuring inclusion in data collection instruments of data elements required for comprehensive indicators.


Data compilation, storage, management

The Health Management Information System Strategy has clearly indicated that the Government of Liberia's Ministry of Health and Social Welfare will develop and maintain a health information repository at national level. This repository is meant for storing health data that are gathered from all sources. Any bona fide user can access this repository for retrieval of data of interest. The tools required for generating users' needs-specific reports are provided in the repository. Conceptually, any data that would be required for the health sector will be available on the repository. It also means that any health and health-related data that are available in the market will be available on the repository. Data input to the repository is shown in the figure.

Data input into repository. Source: National Health Management Information System Strategy and Implementation Plan[7]

The Health management information system guidelines[8] mandates the Health Management Information System Unit to provide up-to-date data on the repository by obtaining and uploading data from the following sources:

  • County health databases: this is the main source of routine data for the central health management information system repository. The integrated health management information system databases of county health offices electronically feed their data to the central repository.
  • Tertiary hospitals: tertiary care facilities also feed their data to the central repository.
  • Censuses: the Ministry's Health Management Information System Unit obtains up-to-date- population data from the Liberia Institute of Statistics and Geo-Information Services in electronic form and feeds them into the repository.
  • Surveys: the Health Management Information System Unit obtains data from periodic surveys such as the Demographic and Health Surveys, Household Budget Survey, Multiple Indicator Cluster Survey and any other nationally representative surveys, and up-loads these data on to the repository.
  • resource data from national level.

Besides the electronic data from sources described above, the central repository will also obtain electronic data from the following transaction processing system at the national level:

  • human resource management
  • financial management
  • logistic management
  • physical assets management.

With the exception of the routine health information system component, the repository is not yet fully developed and in use.

Though the Health Management Information System Unit and the Monitoring and Evaluation Unit are the custodians of the data stored in the central health management information system repository, the Information Technology Unit is responsible for managing safe storage of data and providing access through a single Ministry of Health and Social Welfare information portal.


Data sharing and access

Information dissemination and targets. Source: Health Management Information System Policy and Strategy[9]

In Liberia, the Ministry of Health and Social Welfare's Health Management Information System Unit is charged with the responsibility of disseminating information according to the format, medium and frequency specified in the table.



Data quality and analysis

The Monitoring, Evaluation and Research Division of the Ministry of Health and Social Welfare is tasked with the responsibility of ensuring that data collected and reported on national indicators are of high quality and can be assessed and verified. The Bureau of Vital Statistics coordinates periodic data quality assurance. In addition, county monitoring and evaluation and research teams, as part of routine monitoring, are encouraged to carry out spot checks and mentoring for facility registrars to improve the quality of data.

Generating reports that are fully customized to meet the specific needs of various stakeholders is the key function of the Health Management Information System Unit at national level. The Unit ensures that the information required by each stakeholder reaches them on time and in the predefined format. Contents of these reports vary depending on target stakeholder and the period of the report. Generally, the Health Management Information System Unit publishes quarterly and annual reports. The quarterly report published for the top management team of the Ministry of Health and Social Welfare is a dashboard report that comprised charts that indicate progress in the quarter under review (see figure).

Sample Ministry of Health and Social Welfare dashboard report for data presentation. Source: Ministry of Health and Social Welfare, Health Management Information System Unit

The National Health Policy advocates for all levels of health and social welfare system to conduct essential analysis of their data and regularly generate necessary information for their core business. Due largely to capacity issues particularly at the health facility and county level, this activity is not occurring with regularity.

The Monitoring, Evaluation and Research Division aggregates and analyses national health and social welfare data annually and provides a comprehensive report for all stakeholders.


Estimation methods

The Liberia Demographic and Health Survey, 2007 and the 2008 National Population and Housing Census provides national and regional estimates of population and health impact and outcome level indicators, including mortality, morbidity and life expectancy. Health outcome indicators are also derived from special studies and assessments, such as the Expanded Programme on Immunization Coverage Survey, Reproductive Health Indicator Survey, HIV Prevalence Study, Micronutrient Survey, etc. Similarly, the Ministry of Health and Social Welfare employs a variety of methods to estimate population projections that are used for the calculation of coverage, rates and proportion. Using the population from the 2008 census, the Ministry has carried out annual population projections up to 2021 for national, counties and health facilities.

Percentage cut-offs are used to estimate age and event specific population. For example, 5% of the total population is estimated as pregnant, 4.5% as deliveried, 3% as children under the age of 1 year and 25% as women of reproductive age.


Statistics

The Government of Liberia's Ministry of Health and Social Welfare routinely analyses data to provide easy to understand and use information to programmes, partners, donors and other stakeholders. Competence exists at the central level for the utilization of analytical software to include Excel, Access, EPI-INFO, Stata, SPSS, etc. However, this competence is lacking at the county level. The Ministry carries out common statistical functions such as percentages, frequencies and cross-tabulations as well as advanced analysis of routine and study data. The data are generally presented as tables and charts.

The Liberia Institute for Statistics and Geo-Information Services deals with the analysis of complex datasets using complex analytical methods.


Access to existing global health information, evidence and knowledge

Access to global health information in Liberia is very limited. The Internet remains the most common source of freely available health information. However, monthly, quarterly and annual health bulletins are available and can be accessed in the offices and libraries of international partners (e.g. WHO, UNICEF, etc.).

Availability and use of indexes of local, non-English, and unpublished

There is no local index available for non-English literature in Liberia but the Ministry of Health and Social Welfare's Research Unit has compiled a compendium of health research conducted in Liberia since 2005. The compendium, though not exhaustive, is composed of both published and unpublished (grey) literature. Update of the compendium is now an annual initiative.


Availability and use of search engines, networking platforms

The freely available search engines, such as Google, are the only means of online search for the Government of Liberia's Ministry of Health and Social Welfare.


Availability and use of open access journals

Only journals in the public domain with no subscription requirements are being accessed by the Ministry of Health and Social Welfare in Liberia.


Access to copyrighted publications

The Ministry of Health and Social Welfare in Liberia has no access to copyrighted publications but the Ministry's Research Unit has initiated discussions with the West African Health Organization to obtain access to the Health InterNetwork Access to Research Initiative HINARI.


Regulatory frameworks on intellectual property

The Government of Liberia's Ministry of Commerce and Industry is responsible for patenting and the regulation and enforcement of intellectual property rights.


Storage and diffusion of information, evidence and knowledge

All data in Liberia will be stored in a central repository, currently under development. The Ministry of Health and Social Welfare proposes that when the repository is fully operational, all records in electronic formats should be copied on a server and also stored in CD-ROMs and safeguarded. All facilities collecting data are responsible for safe storage and easy retrieval of all records under their responsibility and in line with the Government of Liberia's archive regulations. The regulations emphasize that data collected in paper format, including records of patients who die in health facilities, are kept for 10 years.


Availability and use of health libraries and information centres

The Government of Liberia's Ministry of Health and Social Welfare does not have a library and an information centre. However, health libraries and information centres are available at the offices of international partners such as WHO and UNICEF. Although these libraries and information centres are mostly used by staff of these institutions or organizations, they can also be accessed by the general populace.

The universities have libraries and reading rooms but have limitations obtaining and providing current literature. The libraries are largely occupied with outdated materials and only receive limited current materials sporadically.


Availability and use of publications in appropriate formats and languages

All publications are in English, the official language of Liberia. Any communication or publication in a format other than English has to be translated to English.


Consolidating and publishing existing evidence for policy and decision

The Ministry of Health and Social Welfare's Research Unit is currently maintaining a database of health research conducted in Liberia. On an annual basis, all research carried out within a specific time frame is compiled in a compendium. The initial compilation spans the period 2005–2010 and is inclusive of both published and unpublished materials.


Mapping and sharing experiential knowledge, including best practices

In Liberia, sharing experience is a hallmark of the health system and contributes to improved delivery of services. The Ministry of Health and Social Welfare organizes forums such as quarterly reviews wherein local best practices are shared and are ultimately incorporated into national strategies. However, no publications or periodicals exist principally for the systematic and timely mapping and sharing of experiential knowledge.


Indexing of local publications in international indexes

There is currently no system for the indexing of publications in Liberia.


Research

A Research Unit was re-established at the Ministry of Health and Social Welfare in March 2011, after an absence of over 20 years. The process of developing a National Health Research Agenda is ongoing and the main issues relevant to Liberia's health and social welfare are being investigated. The National Health Plan and the National Social Welfare Policy list priority research topics. Decision-makers within the Ministry have determined that research will be inclusive and budgeted as a key component of annual operational plans.


Stewardship

The National Health and Social Welfare Policy (2011–2021) asserts that “The Ministry will promote a culture of inquiry into the best methods for delivering health and social welfare”.[10] To achieve this and to ensure the coordination of research activities in the health sector, the Ministry of Health and Social Welfare has committed to building the capacity of its Research Unit to manage research and attain the research skills necessary to carry out action-oriented research. The Unit will ensure that only a limited number of well-coordinated studies are carried out each year to avoid an abundance of expensive studies that are neither analysed to their full potential nor assembled to form a coherent understanding of the whole sector.

There is no national ethics committee but two institutional review boards (the Liberia Institute for Biomedical Research Ethics Committee and the Pacific Institute for Research & Evaluation Institutional Review Board) apply ethics guidelines and internationally accepted standards in determining the appropriateness of health-related research protocols submitted to them. Coordination between these entities remains poor with the Ministry of Health and Social Welfare now initiating a process of standardizing procedures and improving coordination. With technical and financial support from the West African Health Organization and the Council on Health Research for Development, the Ministry has engaged a range of stakeholders to build consensus on research ethics capacity development, formation of a national committee on ethics and on defining the process of protocol submission and review.


Financing

Although the National Health Policy and Plan and Social Welfare Policy addressed the issue of health research in Liberia, there is no budgetary allocation for health research in the current fiscal national health budget. However, the Government of Liberia has committed to creating and funding a budget line for the conduct and management of research in future budgets. At the end of 2011, WHO assisted in the provision of office equipment to the Ministry of Health and Social Welfare's newly re-established Research Unit to support the management and coordination of research. The conduct of health research is largely funded through collaborative initiatives, mainly private multilateral institutions and United Nations agencies. There is a strong partnership between the Ministry of Health and Social Welfare and its partners for the support of health research.


Creating and sustaining resources

The Government of Liberia's Ministry of Health and Social Welfare has adopted a policy to strengthen and sustain capacity by locally recruiting and training research staff rather than recruiting outside consultants. Following this trend, development partners are now hiring fewer senior, long-term experts instead of many short-term consultants. Concrete measures are being taken to reduce the Ministry's reliance on short-term outside experts, including pre-approval of consultant recruitment by the Ministry’s Programme Coordination Team. Meanwhile, a long-term institutional capacity assessment, gap analysis and development strategy have been developed.

This development strategy consists of several interconnected elements that promote capacity development in a balanced and integrated way, including:

  • career paths and career development opportunities, including mentoring, educational and training, that equip future managers with the knowledge and skills they need to implement the governance and decentralization processes;
  • institutional provisions that promote workforce transparency, accountability, fair competition and rewards;
  • a favourable administrative, political, economic and judicial environment;
  • resources adequate to fuel the growth of the sector;
  • donor agencies supportive of the efforts made in the sector and committed to ensuring its development, respectful of mutual commitments and restrained in pushing individual donor priorities.


Research output

As a result of the long absence of a national regulatory unit for research for health in Liberia, research project development, approval, coordination and subsequent outputs have been fragmented and uncoordinated. Researchers, both local and international, and research institutions had no guidance on the process involved in carrying out research in the country and as a result felt no obligation to share finished work or findings with the Ministry of Health and Social Welfare.

The Ministry had no way of determining the number or scope of research projects in the country, let alone possessing copies of research conducted within any time period. To reverse this situation, the Ministry's Research Unit has prioritized in its action plan the development of a database of all protocols submitted to the institutional review boards. This database will indicate the date of submission, nature of the research, geographic area, researchers/institutions, research timeline, approximate cost and submission outcome. Another database of all final products will be maintained at the Unit.


Use of information, evidence and knowledge

In order to ensure harmonization of information at the Government of Liberia's Ministry of Health and Social Welfare, the Department of Planning is responsible for information products. The Monitoring and Evaluation and Research Division develops information products that are disseminated to stakeholders at both national and county levels. The information products include quarterly service coverage reports, Ministry of Health and Social Welfare annual reports and ad hoc reports, including research reports and findings that emanate from the Ministry. Demand and promotion of the use of information is created through timely supply of accurate and easily understandable information.

Among other things, the information generated is intended to:

  • improve the quality and coverage of services
  • solve practical problems
  • target and emphasize areas of supervision
  • provide evidence for preparing and fine tuning plans
  • coordinate resource allocation, including budget and revision of targets.


Formatting and packaging of evidence for policy and decision making

The demand for, and promotion of, the use of information for policy-making and decision-making is created by the timely supply of accurate and easily understandable information. In Liberia, reports formatted by content to the needs of stakeholders are produced by the Monitoring and Evaluation and Research Division of the Ministry of Health and Social Welfare and disseminated periodically to stakeholders including:

  • government officials
  • development partners and donors
  • policy-makers and planners at the Ministry of Health and Social Welfare
  • programme managers
  • county health and social welfare teams and the county stakeholders forums,
  • health facility officers-in-charge and management committees
  • others, including faith-based organizations.


Sharing and reapplying information and experiential knowledge

The Government of Liberia's Ministry of Health and Social Welfare organizes forums such as quarterly reviews at the county level and annual review conferences at the national level. At these gatherings, policy-makers, programme staff, county health teams, researchers and partners discuss progress in achieving targets and challenges that are encountered. These forums, in addition to regular meetings in the counties, are excellent opportunities for experience sharing.


Policy and decision makers' articulation of their need for evidence

The constant insistence on accurate data and information by decision-makers at the Government of Liberia's Ministry of Health and Social Welfare and in the counties is a manifestation of the importance placed on evidence-based decision-making in the country. The recently developed 10-year National Health and Social Welfare Plan (2011–2021) demonstrates the extent to which policy formulators are willing to go in order to ensure that evidence guides and supports every policy and strategy.


Policy and decision makers' participation in the research agenda setting process

In Liberia, the Ministry of Health and Social Welfare's Research Unit is tasked with the responsibility of working with all stakeholders to develop the national research agenda. In July 2011 a conference was convened that brought together policy-makers and decision-makers from the Ministry, donor and developmental partners, academics and academic institutions, United Nations agencies, researchers and research institutions, nongovernmental organizations and other governmental ministries including Agriculture, Education, and Planning and Economic Affairs to identify research topics for health.

The National Health Policy and Plan had earlier proposed a number of research programmes to be carried out within the timeframe of the document and the stakeholders reviewed this listing and made further addition. A subsequent workshop in December 2011 validated and ranked the listing in order of priority.


Policy and decision makers' capacity to access and apply evidence

In Liberia, policy-makers and decision-makers in the health sector, with their level of training and experience, have the ability to assess and apply evidence. This capacity is available at both the central Ministry of Health and Social Welfare and in the county health management structure where evidence-based decisions are made for the effective and appropriate use of scarce resources within the health sector.


Availability and use of networks and CoPs for better use of evidence for policy and decision

With the exception of the quarterly county reviews and the annual health sector conference, there is no other network or community of practice established solely for the purpose of utilization of evidence for policy-making and decision-making. The Health Sector Coordination Committee meeting is a monthly gathering of the Government of Liberia's Ministry of Health and Social Welfare staff and health sector partners for information sharing, reviewing progress and agreeing on decisions. A monthly meeting of programme heads (the programme coordination team) at the Ministry allows programme managers to keep abreast of other programme activities and promotes coordination.

With the provision of more reliable information through these mechanisms, policy-makers and decision-makers are making more evidence-based decisions, which are yielding positive results for the health sector.


Leverage information and communication technologies

Information and communications technology (ICT) has greatly improved health outcomes in Liberia. The funding for ICT has made the system more efficient and effective. The collection, sharing and storing of health information has become easier and less time consuming. In recent years, through leveraging of ICT, information is quickly collected and analysed, which has resulted in evidence-based decision-making.


Level of access to IT infrastructure

Recent assessment of information technology infrastructure in the Ministry of Health and Social Welfare in Liberia shows significant improvement has been made at central and county levels.[11] Typewriters in offices have been replaced by computers and printers, even in the counties. One initiative aimed at improving the information technology infrastructure was the installation of very small aperture terminal (VSAT) satellite Internet in several counties. Through this initiative, the Ministry of Health and Social Welfare and partners can easily access the server that stores all health-related information.


Availability of IT solutions

Information technology (IT) services to the Ministry of Health and Social Welfare are provided by Power-Tech, a local IT service provider, under a contractual agreement. The services provided include IT solutions that are interoperable and scalable. The World Bank is currently providing funding for the IT system, after which the funding responsibility will be assumed by the Ministry. There are concerns that with the current cost, assuming such responsibility will be a challenge, leading to questions of sustainability.[12] Under the current agreement, Power-Tech is also providing similar services to all the central offices and all counties with VSAT (very small aperture terminal) satellite Internet stations.


National eHealth policy or strategy[13]

Liberia has no eHealth Policy or Strategic Plan

eHealth systems

Liberia records births and deaths partially using hand held devices since 2010 in every district but coverage is very low. There is electronic system in place to collect and report health data at district level which is under the Bureau of Vital Statistics (Births and Deaths registration and HMIS) under the Department of Planning and the IT Unit which are under the Department of Administration at the Ministry of Health and Social Welfare. The country has a resource tracking system to report total health expenditure by financing source, per capita. Electronic system (SAGE ACCPAC) is used at national level and paper alongside MS Excel spreadsheet at lower levels. Resource tracking system operates at Regional/District level and are managed by the Office of Financial Management (OFM) at Ministry of Health and Social Welfare, the County Accountants and the County Health Service Administrators (CHSA) at county/district level

Women’s and children’s health policy or strategy

The country has a National Policy and Strategy for Women’s and Children’s Health which infers to the use of eHealth and mHealth. Electronic copy?

Monitoring the status of women’s and children’s health

Maternal mortality ratio, Under 5 child mortality, Children under 5 who are stunted, Met need to contraception, Antenatal care coverage, Antiretroviral prophylaxis among HIV-positive pregnant women, Skilled attendant at birth, Postnatal care for mothers and babies, Exclusive breastfeeding for six months, Three doses of combined DPT vaccine and Antibiotic treatment for pneumonia.

National overview of eHealth initiatives for women’s and children’s health

There are Major Women’s and Children’s Health Initiatives supported by eHealth as shown:

Health services delivery
  • Strengthening Referral Network through Mobile Phones
  • Increasing Polio Immunization Coverage and ITN utilization Coverage through health education
Health monitoring and surveillance
  • Use of Handheld Devices (DPA and GPRS) to conduct Annual Health Facility Accreditation
  • Decentralization of birth registration
Access to information for health professionals
  • Improving health service delivery
Possible barriers to implementing eHealth services

The four most important barriers that hinder eHealth implementation in Liberia are 1) Leadership governance and policy; 2) Infrastructure; 3) Human resources; 4) Financial No efforts have been made to overcome these barriers.

Knowledge base - eHealth for women’s and children’s health

Organizations are willing to add information about their projects into the WHO data base. This information would include project title, objectives, target group, geographical coverage, scale, partners, budget, evaluation and lessons learnt

ICT training for health sciences students

No such training is available

Continuing education in ICT for health professionals

No institution offers such courses

Internet health information quality

There is just voluntary compliance to quality of health information on internet thus potentially dangerous claims may happen. No country website on women’s and children’s health although data on these is regularly published by the concerned ministry.

Online safety for children

No formal guide for children or security technologies for children and internet provider do not provide these tools

Privacy of personal and health-related data

No legislation on privacy of personal health information held in digital format and no parental consent requirement. No legislation on health information sharing.

Social media and women’s and children’s health

No known social media used to promote women’s and children’s health programs


Extent of integration of the HIS

In 2009, printed registers and reporting forms in health facilities in Liberia were available only for the Global Fund to Fight AIDS, Tuberculosis and Malaria supported programmes of HIV/AIDS, tuberculosis/leprosy and malaria. Most registers and forms in use for all other programmes or purposes were hand drawn in plain notebooks and loose sheets. A multiplicity of fragmented reporting forms, driven by individual programme interests, had been introduced into facilities thus leading to focal programme persons visiting facilities at separate times to collect their programme-specific reports. This had huge implications for data timeliness and completeness.

In order to alleviate the situation, the Ministry of Health and Social Welfare made a decision to harmonize all data management tools, inclusive of data collecting, processing and reporting tools. A series of consensus meetings and workshops was held with stakeholders and county health teams to review and standardize all registers in the health facilities. Separate discussions were then held to develop an integrated reporting health information system form that satisfied the reporting requirements of all programmes. This harmonized reporting form is in use in all health facilities in the counties. The information collected using the now-integrated health information system form is entered into the electronic district health information system DHIS2 database at the county level and transmitted electronically to the central Ministry of Health and Social Welfare.


Endnotes:References, sources, methods, abbreviations, etc.

  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. Framework and standards for country health information systems, 2nd ed. (pdf 1.87Mb). Geneva, World Health Organization, 2008
  3. National Health and Social Welfare Policy (pdf 1.56Mb). Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2011
  4. National Health and Social Welfare Plan 2011–2021 (pdf 1.35Mb). Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2011
  5. National guidelines for Integrated Disease Surveillance and Response. Monrovia, Government of Liberia, Ministry of Health and Social Welfare and WHO, 2010
  6. National health information system guidelines. Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2009
  7. National Health Management Information System Strategy and Implementation Plan. Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2009
  8. National health management information system guidelines. Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2009
  9. Health Management Information System Policy and Strategy. Monrovia, Government of Liberia, Ministry of Health and Social Welfare
  10. National Health and Social Welfare Policy and Plan (2011–2021). Monrovia, Government of Liberia, Ministry of Health and Social Welfare, 2011
  11. Interview with Beatrice Lah, Information Technology Director, Ministry of Health and Social Welfare, Government of Liberia, December 13 2011
  12. Interview with Beatrice Lah, IT Director, Ministry of Health and Social Welfare, December 13, 2011
  13. Global Observatory for eHealth
    “eHealth for women’s and children’s health” 2013 survey
    World Health Organization, Country profiles