by Marilyn Yekua Quaidoo
Addressing the policy needs of a country which has experienced 14 years of civil conflict and three decades of economic and institutional demise requires a careful selection and adoption of policy reforms that will enhance public services in the country. Since the defeat of Charles Taylor and his warlords, the Liberian government with the support of the international community has primarily focused on peacebuilding, reconciliation and poverty reduction policies to promote post-conflict reconstruction within the country. In recent times, the government has also emphasized the importance of maintaining its judicial systems, basic social and public services, and protective institutions for women and girls who were most victimized during the war. However, the prolonged deficiencies within the political and judicial system continue to undermine and exacerbate the development of such policies. In Liberia, one of such key policy areas that has proven weak and needs immediate attention is health care. The outbreak of the recent Ebola epidemic unarguably demonstrates the need for the Liberian government to formulate well-founded health reforms that will facilitate development efforts and enhance the livelihood of citizens.
Nature and Context
The key challenges associated with rebuilding a war-torn country like Liberia are deep-seated in the destructive nature of the conflict. The main outcome of any prolonged war is that, during the conflict, both civilians and soldiers are deprived of their citizenship rights including basic rights to quality education and health care. For instance, by the end of the war, hospitals and clinics were vandalized and destroyed leaving only 345 operational health facilities functional  in the country. Evidence suggests that in most conflict territories, emergency response which is limited to “short-term emergency needs, through service delivery”  has proven futile over time. In Liberia, such short-term humanitarian interventions have also been emphasized throughout the country’s peace building and reconstruction phase. The implementation of the Agenda for Transformation, the National Commission for Disarmament, Demobilization, Reintegration and Rehabilitation, among other temporary health commissions demonstrated the government’s ambition to make Liberia a more peaceful, healthy and economically friendly environment. Thus, World Bank reports suggest that prior to the 2014 Ebola outbreak, Liberia’s economy grew steadily and showed positive recoveries from the deteriorating effects experienced during the civil war. 
However, the Ebola crisis had a catastrophic impact on Liberia’s health and development. The World Bank Economic Impact on the Ebola Crisis reports that Liberia lost approximately $240 million  in GDP after the epidemic. Thus, today, the health care system in Liberia is highly dependent on the international community. Though NGOs and other international agencies currently provide 90% of healthcare services in Liberia, more than 75% of the population still has no access to these services.  Evidently, the Ebola crisis exposed the serious shortfalls of the government in implementing universal quality health services across the country. These frailties therefore question the inclusiveness of the current recovery strategies in addressing public service needs especially in rural communities where health care systems are nonexistent. Can Liberia suffice another epidemic or viral outbreak with its current health system? The current state of Liberia underscores the need for the Liberian government to amend its priorities from short term emergency policies to long term policy reforms that will enhance the health care sector.
Policy Focus: Human Rights-Based Approach
One of the many successful policy reforms that has been extensively adopted by many governments as a long-term strategy for enhancing public service delivery is the Human Rights-Based Approach (HRBA). In 2003, UN agencies adopted a common language on human rights-based approaches to inform development practices and ensure that human right principles are implemented globally. According to the UN consensus, a human rights-based approach is a “conceptual framework for the process of human development that is normatively based on international human rights standards and operationally directed to promoting and protecting human rights”  with an objective of: 1) fulfilling human rights; 2) strengthening capacities of rights-holders and duty-bearers; and 3) guiding programs to adopt principles derived from international human rights agreements. Therefore, a human rights-based approach to health addresses inequalities, and discriminatory practices that impede health rights of citizens by recognizing the importance of the right to health. 
Two countries that have successfully adapted the rights based approach to development in both the political and health sphere are Peru and South Africa respectively. In South Africa, the Treatment Action Campaign (TAC) has been used extensively to create a national social mobilization to empower people to demand the right to health from government and pharmaceutical companies. Till this end, the TAC has also encouraged the delivery of healthcare services within poor communities as a matter of right in relation to HIV/AIDS care . In Peru, rights-based initiatives in conjunction with clientelist approaches have also been used to transform rural civil society practices to encourage marginalized groups to participate in political activities.  Essentially, rights based approaches have enhanced democratic activities in both Peru and South Africa which can be replicated in other communities like Liberia where citizenship and human rights have been impeached.
HRBA Policy Alternatives for Improving Health Care
The evidence and success of Human Rights Based Approaches in South Africa, and Peru among other countries suggests that by systematically integrating rights into policies and programs, the Liberian government can also address some of its public service challenges. In line with the human rights based approaches, the health care policies need to be readily available, accessible, and acceptable to ensure inclusion such that the right to health is enjoyed by all citizens. Likewise, health policies need to be crafted and implemented in such a way that they are devoid of any discrimination and gender mainstreaming elements. Some of the ways that the Liberian government can incorporate rights based policies to improve health services across the country include and are not limited to the following policy recommendations outlined below.
1) Address the right to health care policy by creating health facilities across all regions in Liberia
One of the key goals of the HRBA is to ensure that public services are equally distributed. Within this framework, health officials in Liberia must ensure that they are eliminating all forms of discrimination against marginalized groups such that every citizen has accessible health care. Unfortunately, in many developing countries, the distance that patients in rural communities must travel in order to obtain treatment impedes the opportunity for citizens to use these facilities. Moreover, compared to urban areas, rural communities have sparse health facilities. Coupled with these sparse resources are also the limitations associated with transportation, and the lack of health practitioners in such remote communities.
To reinforce health rights for Liberians, the government should therefore invest in creating health clinics in rural communities. Health policy makers can expand health care support, rehabilitation and institutional capacities in rural communities to ensure equal health coverage for all citizens. In reality, expanding health care facilities across all counties and villages in Liberia is almost an over ambitious strategy. Funds allocated for public services such as health care are almost always low which makes this policy a difficult one to implement. To strengthen accessible health care opportunities for the poor, the Liberian government can therefore manage and improve current health options in rural communities by:
- Training midwives and doctors in remote areas regularly, and introducing new and improved methods of delivering services to them
- Providing rural communities with regular drug and medical equipment supply systems to support the current facilities
- Cooperating with local NGOs and pharmaceutical service providers working in rural communities to increase the capacity of health services being provided in such remote regions
- Establishing regional hospitals that will serve designated counties across the region
By enforcing some of the aforementioned policies Liberian health officials may improve the health rights of rural citizens while providing quality health care in their immediate communities.
2) Establish accountability and participatory frameworks within the health system
In developing countries, accountability and transparency frameworks are not easily enforced at all levels of development. One of the reasons why such frameworks are absent is due to the lack of monitoring and evaluation programs within the political system. While establishing accountability frameworks may be difficult, I believe that war torn countries need to stress the importance of such policies within the community to protect the rights of its citizens. Closely linked with the idea of accountability is the importance of participatory frameworks for citizens; which is equally emphasized in UN’s HRBA scheme. Indeed, active agency and participation of those vulnerable to human rights violations can increase their usage of public health facilities.
By creating a transparent and cooperative environment, citizens will begin to trust their health professionals to provide the services they need. In Liberia, such favorable environments of trust are so essential because the prolonged conflict increased distrust levels within the community. Moreover, supportive frameworks are needed to solve doctor and patient absenteeism problems that are prevalent in developing countries. In Liberia, the rate of doctor absenteeism was exacerbated during the Ebola outbreak such that there were only 51 qualified doctors  present in the country when healthcare provision was highly demanded. New approaches to health policy development must therefore emphasize participatory and accountable frameworks by:
- Establishing internal and external audit systems of health strategies to ensure that human rights is a key component of every health policy
- Creating partnerships among local governments, NGOs, doctors and local citizens to ensure that doctors feel more connected to the communities they serve
- Developing monitoring and evaluation programs and policies to identify loopholes in the health sector and fill gaps where necessary
- Encouraging transparent decision-making processes through forums at the local level to serve as watchdogs for policy makers
- Establishing dialogues and health talks/forums to address the health needs of locals and create social change
3) Increase health literacy and information across the country
Unbiased and relevant public health information encourages positive behavioral changes and creates steady developmental progress. Knowledge is powerful because it expels wrong constructs about health practitioners, and facilities as well as diseases while providing improved lifestyle opportunities for citizens. In the case of Liberia, health literacy and information needs immediate attention because the outcomes of the Ebola crisis highlighted the cultural constructions, community level stigmatization and perceptions that people had towards the Liberian health care system. These outcomes are not surprising as illiteracy rates in Liberia are as high as 52.4%.  In highly illiterate communities, information can serve as catalyst to change wrong mindsets while dismissing any fears within the health sector. Universally, people are also entitled to free and active information that is easily accessible and readily available; which is equivalently outlined in the UN’s HRBA. Thus, increased health literacy also serves to emphasize the importance of rights based approaches to health. Information does not only increase knowledge on good health practices but also improves participatory rights of citizens.
Hence, the Liberian government must adopt health literacy policies that guarantees that: 1) everyone has the right to health information; and 2) health services are understandable and accessible to all.  Health policy practitioners should therefore increase health literacy within communities by:
- Developing and supporting local health education in local dialects
- Creating and disseminating health guidelines and information to all citizens especially during viral outbreaks and epidemics
- Providing information to citizens through repeated campaigns, and advertisements in local and regional media spaces
- Involving local leaders, chiefs, community leaders, unions, etc. to lead health discussions within the community
- Supporting health education at all school levels (primary, secondary, tertiary and vocational levels)
In a nutshell, the deficiencies in the Liberian healthcare system demonstrates the need for health practitioners and policymakers to adopt reforms that conform with UN’s HRBA to enhance the well-being and health rights of citizens. Though the policy recommendations outlined may seem difficult and over ambitious to implement in a peace building country, I believe that by adopting some of these policies, Liberia’s government can champion the fundamental problems that undermine the health rights, care and delivery in Liberia. In the short term, I propose that the government should increase health literacy and information as a first step to addressing the impediments in the health system. Other policies such as addressing accountability and participatory frameworks as well as expanding health facilities in rural communities should be strongly considered as long-term solutions to improve health care opportunities for all Liberian citizens.
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