After Ebola outbreak, Liberia’s health care system struggles to rebound

MONROVIA, Liberia — Dr. Senga Omeonga had been working at Saint Joseph’s Catholic Hospital for four years when Ebola arrived. As the coordinator of the emergency room, he had spent his career responding to medical emergencies. He was prepared for the worst.

He was not prepared for Ebola. When the hospital director, Brother Patrick Nshamdze, came down with a fever last July, his blood test came back negative for the virus. (It was later discovered that the understaffed lab was responsible for a number of false negatives during that time.) Believing they were safe, the staff members who were caring for the director removed their protective equipment. It was one of several mistakes that characterized the hospital’s — and the country’s — response to the epidemic that was sweeping West Africa.

Within a week, Ebola had overrun the hospital, infecting Omeonga and 14 other health-care workers at Saint Joseph’s. Nine of his colleagues succumbed. “I experienced death,” the doctor says. “It was a gift to survive.”

The hospital was not as lucky. On Aug. 5, the facility was shuttered. It remained closed until late November. Now, with the help of international donors, the hospital has reopened, beginning with the maternity ward. The management is trying to live up to its pre-Ebola reputation of being one of the best places in the country to deliver a baby. The hospital has renovated the maternity ward, complete with a state-of-the-art ultrasound machine. The International Committee of the Red Cross is training health care staff in new infection-prevention protocols and has committed to funding free maternal health care through the end of July. Since the reopening of the maternity ward, thousands of women have had antenatal consultations, and more than 600 have safely delivered their babies. Saint Joseph’s has also become a referral hospital for complicated cases.

But in August, when the free maternal health care will end, it will be up to the hospital to find additional support. The Ministry of Health has committed to covering the pediatrics ward, which will soon reopen, for the foreseeable future. Omeonga is grateful for the donor support, but he says what the hospital really needs is cash. “We are really struggling,” he says. “We don’t have enough nurses, and we don’t have money to pay the nurses we have. We don’t receive money. We receive equipment, medicine and protective gear. But without money, this place can’t continue to operate.”

In some ways the story of Saint Joseph’s mirrors the larger story of Liberia’s battle with Ebola. Like the hospital, the nation struggled to cope with the epidemic. Before the virus struck, Liberia was not prepared to deal with such an outbreak. Now its already-anemic health care system has deteriorated further. Though Liberia is awash in donor money, a recent government audit revealed expenses that could not be accounted for. While the amount is relatively small, the revelation has stalled leadership appointments at the Ministry of Health. Bureaucratic hiccups in the distribution of salaries are discouraging health care staff from working during another epidemic. And, as with Saint Joseph’s, it is unclear what the country will do once the cash spigot has been turned off.

By all accounts, Liberia’s health care system was inadequate even before Ebola hit. By some counts, the country had only 50 working doctors for a population of 4 million, many of whom left once the virus was confirmed. According to the World Health Organization, without a national strategy to deal with infection prevention, health care workers were between 21 and 32 times more likely than those working outside the health-care system to contract the virus. In total, 189 health care workers died in Liberia from Ebola during the recent outbreak. Across the region, more than 800 became sick.

On May 9, after almost a year of battling the virus, the country was officially declared Ebola free, and the national government shifted to rebuilding what was left of the health care system. Strict sanitation and triage protocols have been implemented to control the spread of infection. Efforts to train and recruit new health care workers are underway. Since the outbreak began, just over $1 billion has been pledged to fight Ebola in Liberia, more than in Guinea and Sierra Leone combined, likely due to the scale of the outbreak in the country and its close relationship with the United States.

The U.S. Centers for Disease Control and Prevention estimated the virus had infected just over 27,000 people at last count. Globally, there have been 11,222 confirmed deaths, 43 percent of which were in Liberia. The actual death toll may be harder to quantify. At the peak of the crisis, the closure of hospitals and clinics meant that many patients, particularly those injured in traffic accidents or suffering from common ailments like malaria, were left to fend for themselves.

“They needed help, and they couldn’t get that help,” says Tolbert Nyenswah, the deputy minister of health designate, who oversaw the country’s Ebola response. During the epidemic, pregnant women were forced to give birth on the street because they could not find a hospital where they could deliver, and the United Nations Population Fund estimated maternal death rates in Liberia doubled. Immunization campaigns were suspended, leading to outbreaks in both measles and whooping cough. “We’ve learned that health care is not just hospital care,” he says. “Health care is about prevention.” According to Nyenswah, the country must focus its efforts on training health care workers in triage techniques and the use of personal protective equipment. “These are the things that give confidence in the health care workers and the people who visit these facilities.”

Nathaniel Doville was a midlevel bureaucrat in the Ministry of Health when the government called upon him to investigate the mounting epidemic. He traveled to Guinea and Sierra Leone to better understand what was happening and come up with solutions that could be adapted for use in Liberia. “Before Ebola, we didn’t have triage, not the way you see it now,” he says. “We’ve had to change the way we think of health care in this country.”

Doville put his newfound knowledge to good use in Eternal Love Winning Africa hospital, known locally as ELWA. Just down the road from Saint Joseph’s, ELWA was the epicenter of Liberia’s Ebola response, and it was celebrated for its swift response to the epidemic. In sharp contrast to Saint Joseph’s, not a single ELWA health care provider died of the disease.

At the height of the outbreak, the hospital had three units dedicated to treating Ebola, one of which was run by Doctors Without Borders, known by its French acronym, MSF. But now MSF has moved most of its staff to Sierra Leone and Guinea, which are still struggling to bring their epidemics under control. ELWA’s makeshift Ebola wards, which look more like refugee camps than medical facilities, have gone quiet. Rubber boots hang in neat little rows, unused and baking under a hot sun. On a scorching afternoon in May there are only two patients, one of whom is no longer sick, just old, a senile white-haired man without anyone to care for him.

The calm has given the doctors and nurses time to reflect.

Dr. Ian B. Pabs-Garnon, who worked side by side with Doville for most of the outbreak, says that despite their successes, there’s still a long way to go. “Even if we have another outbreak, we are not prepared. … We need a rapid-response team. We need a facility where we can do laboratory work quickly.” Doville agrees: “The first challenge is who would go to work in that unit again?”

The problem, they explain, is their salary. While the government promised additional monthly hazard pay of $825 for doctors and $435 for nurses and laboratory technicians, no one at ELWA-2, one of the hospital’s Ebola wards, has received any payment at all since February. In the months since, they have received some of their back pay, but not all of it.

According to the Health Ministry’s Nyenswah, fairly compensating health care workers is a key component of the government strategy to rebuild the system. He says it’s true that health care workers often went “three or four months at a time” without receiving a salary, due to a complicated method of accounting for who should be paid. More troubling, he says, is the lack of job security. “They are not on the payroll,” he explains, meaning they acted more like contract workers, without consistency in salary, even before the Ebola outbreak. “That’s not right.”

But delayed payments are perhaps indicative of Liberia’s larger problem: a ballooning bureaucracy. There are about 10,400 people employed in the public-health sector in Liberia. They are doctors and nurses, but also drivers, secretaries and administrative staff. After the education sector, health care has the second largest workforce in the country. To arrange payment, workers’ names are collected by local bureaucrats and funneled through a series of complicated steps with little security or oversight, allowing corrupt officials to add or remove names at will. The process has resulted in both long payment delays, but also fraud, with people often being paid for work they never performed.

“We have to decentralize the system,” says Nyenswah, who knows that it isn’t working. He believes rebuilding Liberia’s health care system will require more than medicine and equipment. It will require a complete administrative overhaul.

In mid-May, about a week after the last Ebola patient had succumbed, the General Auditing Commission of Liberia released a report on the National Ebola Trust Fund, a pot of money set up by the Liberian government to assist with emergency expenditures in the early days of the Ebola outbreak. The audit examined the period from August to October of 2014, when the fund disbursed close to $14 million.

According to the audit, expenditures made by the Fund “were marred by financial irregularities and material control deficiencies.” Close to $700,000 was given to the Ministry of Defense for fuel, food, salaries and communications, but there were no receipts for any of it. Generators that had been purchased for seven counties could not be found. In total, almost $800,000 was unaccounted for.

The audit also held many government officials, including Nyenswah, responsible for the missing money. Though he dismisses the report as “politics,” this is the third time Nyenswah has been indicted by the General Auditing Commission. Between 2006 and 2008, he was accused in two separate Ministry of Health audits of financial and administrative malfeasance. At the time, he served as the deputy manager of the National Malaria Control Program. The 2008 audit alone found that $75,000 was unaccounted for and asked that Nyenswah and the program head Dr. Joel Jones account for the missing funds.

President Ellen Johnson Sirleaf dismissed the recent audit, saying, “In the midst of chaos, something has to be done, and so I am quite sure that it reflects the context of the kinds of urgency that was required in some cases.” Nyenswah, along with several other ministers named in the report, has also issued a scathing response. “You have irresponsibly damaged the hard-earned reputation of members of the senior leadership of the National Ebola Task Force,” he wrote in an open letter to the auditing commission. Referring to expenses that can’t be accounted for, he says to me, “All of these expenditures were made without my supervision, without my knowledge.”

Beyond this, Liberia is a very underdeveloped country, says Nyenswah, who is currently undergoing a lengthy confirmation in the Liberian Senate that would see him promoted to deputy minister of health. Outside of the capital, there is no banking system — no one uses credit cards; there are no ATMs. People must be paid with cash. Sometimes receipts are available, but in times of emergency, receipts are not the priority.

In truth, it’s very difficult to properly audit Ebola money because of the way the money enters the system — through donations made by big relief organizations, foreign governments and individual donors alike — and the number of nonstate actors that are involved. Money from major institutions like the World Bank and the United States Agency for International Development, or USAID, is often given to partners, including smaller nongovernmental organizations that spend the money locally, and not the Liberian government. Some of these partners use 40 to 60 percent of the money they receive on overhead costs.

The $14 million disbursed by the National Ebola Trust Fund that was audited represents a drop in the bucket of donor support received by Liberia. As of May, the World Bank Group had mobilized $385 million for Liberia. USAID has long supported health initiatives in Liberia, but this year the agency pledged an additional $126 million to help rebuild health systems in Liberia, Sierra Leone and Guinea.

In May the government released its recovery plan, detailing the need for more equipment, medicine and health care professionals. The plan called for $489 million in spending over the next two years and an additional $1.21 billion in the following five. This would bring the health care system up to international standards by 2022. But no one seems to know where the money will come from. During the Ebola epidemic, international aid was generous. It’s unlikely that will continue now that the worst of the crisis has past.

Today, Saint Joseph’s is working hard to re-establish itself as one of the best health care destinations in Liberia. With the help of the Red Cross, the hospital has increased its maternity ward from eight beds to 24. Plans are in the works to reopen the pediatric ward. But the general ward remains closed, and Omeonga says there’s a lot of work to do before it can reopen. After it was shut down by the Ministry of Health, the hospital was disinfected with a heavy chlorine spray that left most of the medical equipment broken and useless. That equipment must be replaced. Renovations need to be made to accommodate the new health protocols. New staff needs to be recruited. All of this will cost money. “Before Ebola, about 60 percent of our budget came from patient bills,” Omeonga adds. Without patients, that money is hard to come by.

But slowly, patients are starting to return. On a Friday morning in late May, Patience Johnson waited for her turn to be called. She had arrived at Saint Joseph’s at 5:30, traveling an hour by public car to join the long queue of pregnant women who wanted to be seen by a nurse. Although she was nine months along, this was her first visit to any hospital. She had heard that the treatment at this clinic was free, and since the country had been declared Ebola free, she felt a cautious optimism that she might be admitted. “My time to push has come,” she says. “I’m happy we are Ebola free.”

It’s a different reality than the one a few months ago, when reports abounded that women were dying during labor on Monrovia’s streets. At the time, Johnson was having a difficult pregnancy. Her neighbors eyed her closely as she vomited the little food she managed to eat. “They all thought I had Ebola,” she says. “I was so much afraid they might force me to visit a hospital. Then what?” She resolved then that she would deliver her baby at home, away from the risks of the hospital. It was only after the pleading of her husband, a soldier in the country’s army, that she agreed to visit today. The long line of women like her was reassuring. “I’m happy,” she says.

When the nurse called her name, she jumped and scurried into the consultation room, confident that the country’s best health care was waiting for her just behind the door.