Policy Options for Addressing Health System and Human Resources for Health Crisis in Liberia Post-Ebola Epidemic

Addressing poorly training of health workers

Various measures have been used to address the scarcity of trained healthcare workers. One of the measures, also referred to as the Kerala option, calls for the decentralization of powers to local governments or counties so that they can identify the gaps in their local health system and recruit the best physicians (or other health workers) suited to their specific needs.^[15] Some countries have also recruited Physicians from Cuba to carry out clinical treatment and train indigenous medical doctors.^[10]

For the purpose of this paper, there are two policy options that are considered feasible for the Liberian case. The first is the reverse of brain drain. As indicated earlier, most qualified Liberian doctors fled the country due to the civil war and settled in other countries.^[9] A reverse brain drain policy would entice native Liberians in the diaspora to share their knowledge and information with local doctors (as well as student doctors) and to take up short-term placements as doctors or lecturers at the various medical schools in Liberia.^[11,16] The second policy option is the medical scholarship scheme. This policy will encourage more students to pursue careers in medicine by offering scholarships to study abroad.^[16]

Both of these options could include actors from the government of Liberia, international and local partners, community groups, private and public health workers and, diaspora Liberian experts. These policy options, if implemented, could strengthen the human resource capacity of the Liberian health system.^[10,16] The implementation of either policy would be at the national level, because decision-making is still the responsibility of the Minister of Health of Liberia ^[9] The next section of this paper provides details on the implementation of the two proffered policies.

Analysis and implementation of the reverse brain drain policy

Globally, the issue of brain drain is not a new phenomenon. Discussions about brain drain date back to the 1960s when British intellectuals and scientists were migrating to the United States (US) to seek jobs.^[17,18] Over the years, countries have tried two main approaches to reverse brain drain: the first is seeing the brain drain as a loss; and the second is seeing it as a gain.^[17,19] Policies associated with the first approach include restrictive policies (making migration difficult), incentive policies (offering incentives to would-be migrants) and compensatory policies (asking the receiving country (countries) or individual to pay compensation). However, in the case of Liberia, it is difficult to stop people from leaving because freedom of movement is a constitutional right, also the country is recovering from civil war so cannot compete with developed countries on incentives for fleeing health care professional seeking for greener pastures.^[16,20] As for compensation, most Liberians pay for their own education therefore, they are free to migrate in search of better opportunities without any restrictions from the government.^[9]

The second reverse brain drain approach is the diaspora approach (seeing the brain drain as a gain). This is where the Liberian government initiates networks of Liberian medical professionals across the world, encouraging them to work together to share ideas and knowledge amongst themselves and with medical professionals in Liberia.^[19,21] The brain drain becomes a gain because the diaspora professionals' knowledge and experience could be useful to improve the capacity of local health workers.^[17] The government could enlist the support of local residents in Liberia asking them to encourage diaspora relatives to join these networks ^[22] Development partners like the US and the United Kingdom (UK) could support Liberia by encouraging qualified Liberian health professionals living in their countries to take up temporary work placements in Liberia to share their experience and knowledge by ensuring that those Diasporas do not lose their permanent job positions upon their return.^[23] This reverse brain drain approach has been successful in South Africa and the Philippines.^[17]

The benefits to the government of using the diaspora approach is that it could be less expensive and could give the government more control over the contents, actors and processes of information and knowledge shared.^[17] Local residence of Liberia could benefit from improvements in the quality of service they receive due to the knowledge exchanged via these networks.^[23] There could be government and international partners' support for this option because it is less expensive to implement, with money being saved re-allocated to other projects, which could also be a benefit to local communities.^[17] Another group that will potentially benefit from this policy is doctors working in Liberia, who would have access to new knowledge to develop their capacities.^[17]

However, there are some disadvantages of using this approach. These include the time needed to set-up the networks; the inability of Liberian-based professionals to comprehend the information being shared; and the possibility of diaspora Liberians requesting remuneration for their time and knowledge which might be unaffordable to the Liberian government.^[23] Another potential problem could be resistance from the local health workers.^[24] Evidence in Liberia suggests that local people are very suspicious of diaspora Liberians, believing that their motives for return is to take their jobs.^[24] This could make it harder for diaspora Liberians to contribute to the development of the human capacity of the health system. Local doctors could view this approach as a top-down relationship, therefore being unsupportive.^[20]

Analysis and implementation of a medical scholarship policy

The second policy option is the medical scholarship scheme. In the 1980s and early 1990s, Ghana, another West African country, provided the evidence for medical scholarship as a p policy option to address health human resource crisis.^[25] The then President Jerry Rawlings of Ghana signed an agreement with Cuba in 1983 to send Ghanaian students to study medicine, among other disciplines, in Cuba to increase the number of qualified health workers, but also to establish medical training institutions in Ghana.^[26] The first Cuban cooperation medical school in Ghana was opened in 1991.^[25]

In the case of Liberia, the government could solicit more scholarships for medical studies abroad from development partners.^[11] In terms of the benefits to different groups, the number of students sent yearly could be shared across the counties, where a set number of students are recruited from each county in Liberia.^[22] This could make it easier to encourage doctors to work in their parts of the country upon return from studying and gain support from local communities.^[22]

The scholarship scheme's advantages could include lower costs for the government if development partners cover the cost of the scholarships; it could also benefit all the counties equally, therefore reducing the chances of resistance to the implementation of the policy.^[22] Inserting scholarship agreements compelling scholars to work in hard-to-reach parts of the country could give the government some control over the scheme and improve access to qualified doctors for local communities; having access to a qualified doctor could also benefit communities by giving them access to adequate healthcare.^[9] International partners would support the scheme because of the benefits of students studying in their countries because interestingly aid money would stay in their economies.^[27]

There are some disadvantages associated with the medical scholarship scheme. These include students absconding after completing their studies and higher costs if there is limited partners' support.^[28] The time needed to train a doctor is approximately five to eight years; thus this could also be a disadvantage because the health system needs more doctors presently.^[10] The government of Liberia might not have complete control over a scholarship scheme if it is funded by development partners.^[20] There is also the issue of corruption. Some people allege that in Liberia, scholarships are allocated on a patronage basis, thus local people might potentially not benefit from the scheme and could therefore resist the deployment of newly qualified doctors perceived as benefiting from their entitlements.^[28]

Human Subjects Review:

No IRB approval was required for this study, which is based on the analysis of existing public-use literature and health databases.

Financial Disclosure:

None.