In 2006, the Government of Liberia, through its Ministry of Health and Social Welfare
(MoHSW), and in consultation with its development partners, embarked upon an ambitious
process of reconstructing and reforming the health services in Liberia. A key part of the
process is the development of a National Health Financing Policy and Strategic Plan
(NHFP&SP;) that underpins the mission and objectives set out in the National Health Policy
and Plan 2007–10.
In July 2009, the MoHSW conducted a consultative workshop with government ministries,
county health officials, facility health workers, development partners and community
representatives to deliberate on the formulation of the national health financing policy. As a
major outcome of the consultative workshop, the MoHSW identified the next steps for
completing the NHFP&SP;.
In 2010, Oxford Policy Management (OPM) was contracted to assist in the process. As part
of the task of assisting the MoHSW to develop an NFP&SP;, OPM was expected to consider
new financing options in order to broaden the sources of financing health services in Liberia,
as well as reduce the current over-dependence on both external financing and household
health expenditures through out-of-pocket payments. Specifically, the feasibility of
implementing community-based health insurance schemes and a broad-based analysis (prefeasibility
study) of whether there is a reasonable case for social health insurance (SHI) in
Liberia were to be explored. This is a stand-alone report on SHI in Liberia.
The pre-feasibility study undertaken involved three major activities. The first was an
assessment of the extent to which an enabling environment for introducing SHI exists
currently, or is likely to exist in the medium to long term in Liberia. The factors that contribute
to the enabling environment include:
? a priority need for SHI;
? an adequate level of income and rate of economic growth;
? the presence of administrative capacity;
? a reasonable earning base;
? a favourable structure of the labour market/economy;
? an adequate provider network;
? urban bias in the distribution of the population;
? a general understanding of SHI;
? consensus on SHI;
? solidarity within society; and
? political will/commitment/stability.
The existence of the enabling environment is, however, a necessary but not sufficient
condition for the successful introduction of SHI.
The second major activity was to hold consultations with as many relevant stakeholders as
possible, to seek their opinions on the desirability or otherwise of SHI, as well as their
preliminary views on how to go about designing and implementing SHI in Liberia. The broad
categories of stakeholders consulted were:
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? beneficiaries (employees);
? employers in both the public and private sectors;
? officials of certain ministries, including the MoHSW;
? insurance organisations;
? donor organisations;
? legislators;
? political parties; and
? the National Social Security and Welfare Corporation (NASSCORP).
The third major activity was to undertake a review of the experiences of SHI in a number of
developing countries, particularly in Africa, to draw on lessons learned from countries in
similar stages of development whose health sectors face similar types of challenge.
A general finding is that most of the factors contributing to the enabling environment are
currently weakly met. Such factors include the current level of income and the rate of
economic growth, the earnings base, administrative capacity, and the structure of the labour
market/economy in terms of the size of the formal sector.
Factors that were found to be averagely met are:
? a priority need for SHI;
? an adequate provider network;
? availability of basic data to design the scheme;
? the distribution of the population in terms of the degree of urbanisation; and
? political will/commitment/stability.
Although it is felt that most of the environmental factors might at least achieve average
ratings in the medium to long term, the factors considered to be most important are:
? the level of income and rate of economic growth;
? the earnings base, the distribution of the population; and
? political will/commitment/stability.
These factors will determine not only the desirability, but also the feasibility of SHI in Liberia
in the medium to long term.
The major findings from the stakeholders consultation is that SHI is desirable in Liberia and,
therefore, that its feasibility in the medium to long term is worth investigating. However, the
major concerns expressed by most of the stakeholders relate to factors that could affect the
initial feasibility of SHI. These include:
? the high level of poverty;
? the high unemployment rate;
? the low level of workers’ salaries/incomes;
? the small size of the formal sector;
? the lack of adequate health infrastructures in rural areas; and
? sustaining the political will/commitment.
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Some opinions expressed by the stakeholders relate to the design of SHI and include:
? ensuring that the contribution rate by employees is affordable;
? making the benefit package more comprehensive than any of the existing medical benefit
packages (the Basic Health Package of Services, the medical benefits currently enjoyed
by employees under the Group-Term Life, Accident and Medical Scheme);
? extending benefit coverage to at least the principal beneficiary (the employee), the
spouse and four dependants;
? allowing those covered to use public as well as private health facilities; and
? the establishment of an independent agency to administer the scheme.
Suggestions provided by stakeholders include:
? the need to mount extensive public awareness campaigns on SHI;
? expanding the network of functional health facilities, particularly in the under-served
areas;
? close involvement of the stakeholders in the planning and implementation of SHI in
Liberia; and
? enhancing the quality of services provided in both public and private facilities.
The review of the SHI plans of Lesotho, Swaziland, Kenya and South Africa, as well as the
SHI implementation experiences of Rwanda, Ghana, Tanzania and Nigeria, provides many
useful lessons that could guide the future planning and implementation of SHI in Liberia.
Indeed, Liberia might benefit from undertaking study tours to some of the countries that are
already implementing SHI prior to designing and implementing SHI in Liberia.
In accordance with the scope of the pre-feasibility study, this report will be presented to
stakeholders in a workshop for validation. If the findings of the study are supported by the
stakeholders and approval to proceed is given, then a detailed feasibility study for SHI in
Liberia will be the next step. The final sub-section of this report therefore provides a
framework for undertaking such a study by providing suggestions on:
? the ideal composition of the study team;
? the approach to the study;
? the preliminary design of SHI through stakeholders’ discussions;
? the data requirements;
? the main activities with their durations; and
? the expected output of the study.