Liberia: World Bank Report Sees ‘Serious Weaknesses’ in ‘Unprepared’ COVID19 Response

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“Respiratory diseases, like SARs, MERS, and COVID-19, are not part of Liberia’s active surveillance. Therefore, early identification in communities and health facilities, compliance with infection prevention and control measures, contact tracing, and good hygiene practices remain major challenges.” – World Bank Project Report on Liberia’s COVID-19 Response


Monrovia – A project document obtained by FrontPageAfrica, prepared by the World Bank on Liberia’s response to the deadly COVID-19 pandemic has concluded that despite efforts to contain the virus, serious weaknesses remain, and Liberia is not prepared to respond to COVID-19. 

“Respiratory diseases, like SARs, MERS, and COVID-19, are not part of Liberia’s active surveillance. Therefore, early identification in communities and health facilities, compliance with infection prevention and control measures, contact tracing, and good hygiene practices remain major challenges,” the report noted.

The report dated and prepared on March 26, 2020 when Liberia had reported as of March 17, 2020, three confirmed cases of COVID-19 in Montserrado County, the capital city, where more than 45 percent of the population live. “Health authorities continue to trace all primary and secondary contacts of index cases, and the National Public Health Institute of Liberia (NPHIL) has activated its preparedness plan. Considering the contextual and health system challenges in Liberia, in the absence of a rapid, effective, and sustained response, a COVID-19 outbreak would have a devastating impact on the health system, health outcomes, and the broader Liberian economy.”

Today, Liberia has recorded a total of 120 cases, 11 deaths with 634 contacts being traced.

Report Preceded US$7.5M Grant

The project document was a prelude to the recent World Bank approval of a $7.5 million International Development Association (IDA) financing to help Liberia respond to the threat posed by the Coronavirus outbreak. 

The financing which consists of a $3.75 million grant and $3.75 million concessional IDA credit, will strengthen the Government of Liberia’s immediate capacity to respond to the COVID-19 outbreak and in the longer-term, strengthen its response to disease outbreaks and emergencies.  This complements ongoing support provided through the Second Regional Disease Surveillance Systems Enhancement (REDISSE II) project which has made available up to $9.5 million for the response.

This COVID-19 Emergency Response project for Liberia aims to mitigate and contain the transmission of COVID-19, ensure adequate management of confirmed COVID-19 cases, and strengthen the laboratory network systems for COVID-19 detection and other infectious diseases. In addition, the project will provide required support to healthcare workers and families affected by COVID-19 and strengthen coordination among partners for the COVID-19 response.

“This support builds on Liberia’s experience in dealing with the 2014 Ebola outbreak which was further strengthened by the REDISSE II project that focuses on emergency preparedness and response. We look forward to working with other development partners in supporting the Government’s efforts to fight the COVID-19 pandemic,” said World Bank Liberia Country Manager Khwima Nthara.

Liberia – Among Weakest Healthcare System in World

The World Bank Group is rolling out a $14 billion fast-track package to strengthen the COVID-19 response in developing countries and shorten the time to recovery. This immediate response includes financing, policy advice and technical assistance to help countries cope with the health and economic impacts of the pandemic. The International Finance Corporation is providing $8 billion in financing to this effort to help private companies affected by the pandemic and to preserve jobs. The International Bank of Reconstruction and Development and IDA are making an initial $6 billion available for the health response. In order to provide broader support to meet country needs, the World Bank Group will deploy up to $160 billion over 15 months to protect the poor and vulnerable, support businesses, and bolster economic recovery.

The International Development Association (IDA) is the World Bank’s fund for the poorest. Established in 1960, it provides grants and low to zero-interest loans for projects and programs that boost economic growth, reduce poverty, and improve poor people’s lives. IDA is one of the largest sources of assistance for the world’s 76 poorest countries, 39 of which are in Africa. IDA resources help effect positive change in the lives of the 1.6 billion people living in the countries that are eligible for its assistance. Since its inception, IDA has supported development work in 113 countries. Annual commitments are constantly on the rise and have averaged $21 billion over the past three years, with about 61% going to Africa.

The World Bank report states that Liberia’s overall state of preparedness has been assessed as moderate (67 percent) across nine technical domains.  “Moreover, Liberia continues to have one of the weakest health systems in the world. This is evident from the severe shortage of human and financial resources (2016 per capita health spending: US$68.3), limited institutional capacity and infrastructure, weak health information systems, and critical gaps in the availability of essential inputs including drugs, equipment and medical supplies. A COVID-19 is likely to further strain the already fragile health system and reverse gains made in the health sector specifically, and Liberia more generally.”

Key Liberia Fault: ‘Uneven Economic Performance’

Much of Liberia’s fault, according to the report, lies in the country’s uneven economic performance over the last four decades, which has largely been driven by the twin shocks of two civil wars and the 2014 Ebola Virus Disease (EVD) outbreak.

Said the report: “For a quarter-century, Liberia’s two civil wars caused widespread loss of life, destroyed vital infrastructure, and suppressed economic growth. Thereafter, Liberia entered a period of sustained economic growth with an average annual growth rate of 7.4 percent between 2004-2013. However, the 2014 EVD outbreak, coupled with a sharp decline in global prices for iron ore and rubber, disrupted Liberia’s economic recovery. The real gross domestic product (GDP) growth rate slowed to 0.7 percent in 2014, zero percent in 2015, and the drawdown of the United Nations mission pushed the economy into recession in 2016. The macro-economic situation has continued to deteriorate. In 2019, both inflation and exchange rate depreciation remained high (30 percent), mostly due to sustained growth in monetary aggregates, and the economy is estimated to have contracted by a further 1.4 percent driven by falling demand, as indicated by the evolution of taxes and bank credit The impacts of the shocks were compounded by the transition to a new political administration in 2018, as the relative inexperience of the incoming administration increased policy uncertainty and weakened economic management. 

The report notes that prevailing resource constraints and persisting fragility have hindered the government from improving the living standards of the population. 

According to the report, more than half of Liberia’s population of 4.7 million people live in urban areas, and one quarter resides in Monrovia. “Adolescents and youth (10-24 years old) represent approximately one-third of the total population. Poverty is widespread and increasing, and in 2016, almost half the population (2.2 million people) were unable to meet their food needs.”

The report puts the headcount poverty rate rose from 54.1 percent in 2014 to 61.2 percent in 2016, and poverty rates are higher in rural (71.6 percent) than urban areas (31.5 percent). “In addition to the high levels of poverty, Liberia has amongst the worst human capital and human development outcomes. Liberia ranks 181 of 189 countries tracked on the 2017 Human Development Index, and 153 of 157 countries tracked on the 2018 Human Capital Index. Moreover, the HCI estimates that a child born in Liberia today is expected to receive only 4.4 years of school and realize, at best, 32 percent of their human capital potential.

Breaking Down the Purpose of the US$7.5M

A total of US$1 million is intended to strengthen the human resource surge. “This subcomponent will support costs related to the mobilization of additional health personal to support the surge response, training, and provision of salaries and hazard/indemnity pay consistent with the Government’s applicable policies. This subcomponent will also support activities aimed at minimizing risks for patients and health personnel, including training of health facilities staff and front-line workers on risk mitigation measures, and providing them with the appropriate protective equipment and hygiene materials, including personal protective equipment (PPE) kits.”

World Bank Project Report on Liberia’s COVID19 Response

Part of the US$7.5 million is intended to support National and Sub-national, Preparedness and Response for a total of $0.3M. This subcomponent, the report notes,  “will contribute to financing of: activities needed to support relevant sectors jointly coordinate and implement the Liberian COVID-19 preparedness and response plan such as stakeholder coordination meetings, development of  contingency plans counties, development of Points of Entry (PoE) contingency plans and activities, and conduct simulation exercises; (ii) activities that enhance country health system capacities for the management of disaster recovery priorities such as support for emergency response team, including capacity for the integration of community-center emergency care into the broader healthcare system.”

A total of US$0.6 million of that money is intended to support for case detection, confirmation, contact tracing, recording, reporting.($0.6M) “This subcomponent will support costs related to: (i) the training and equipping point of entry (PoE) staff, contact tracers, Community Health Assistants/hygiene promoters and Community Animal Health Workers to support cross border surveillance, community surveillance/case detection and reporting at PoE; (ii) training and equipping of frontline health care workers in infection, prevention, and control (IPC) (iii) strengthening of disease detection capacities through the provision of technical expertise to ensure prompt case finding and contact tracing, consistent with WHO guidelines in the Strategic Response Plan; (iv) strengthening of emergency operations centers (EOCs) and support for (v) epidemiological investigations and strengthening of risk assessments.”

A total of US$0.1 million of that money is intended to support the surveillance system to facilitate recording and on-time virtual sharing of information. “This subcomponent will contribute to financing of: (i) the roll out of the electronic data management system activities; (ii) training of data monitors; (iii) supervision of data collection at different levels of the response. This will complement the ongoing activities being rolled out through REDISSE II related to the strengthening the electronic Infectious Diseases Reporting System (IDSR).”

A total of US1million of that money is intended to support preparedness through Laboratory System Strengthening. “This component would support activities to strengthen disease surveillance systems in public health laboratories and epidemiological capacity for early detection and confirmation of cases. This components will finance the: (i) strengthening of the sample transfer system at a national and county level; (ii) establishment of two satellite laboratories in prioritized counties to support the National Reference Laboratory (NRL), and ensure that the links between NRL and satellite laboratories are strengthened; (iii) training of laboratory staff and support laboratory surge capacity; (iv) procurement of laboratory equipment, consumables and laboratory tests.”

A total of US$3 million of that money is intended to support case management and clinical Care.

A total of US$0.6 million of that money is intended to support for case detection, confirmation, contact tracing, recording, reporting.($0.6M) “This subcomponent will support costs related to: (i) the training and equipping point of entry (PoE) staff, contact tracers, Community Health Assistants/hygiene promoters and Community Animal Health Workers to support cross border surveillance, community surveillance/case detection and reporting at PoE; (ii) training and equipping of frontline health care workers in infection, prevention, and control (IPC) (iii) strengthening of disease detection capacities through the provision of technical expertise to ensure prompt case finding and contact tracing, consistent with WHO guidelines in the Strategic Response Plan; (iv) strengthening of emergency operations centers (EOCs) and support for (v) epidemiological investigations and strengthening of risk assessments.”

World Bank Project Report on Liberia’s COVID19 Response

As COVID-19 would place a substantial burden on inpatient and outpatient health care services, the report noted. “This component would finance the strengthening of public health services to increase the capacity of the public health system for the response to COVID-19.”

Additionally, a total of US$1.6 million is intended for strengthening of health facilities and service delivery. “This subcomponent will support financing of re rehabilitation and equipping of prioritized primary health care facilities and hospitals in high transmission areas for the delivery of critical medical services. Moreover, it will increase the availability of isolation rooms, ambulatory areas for screening and address the immediate health system needs for medical supplies and medical equipment to treat severe cases of COVID-19.  It will support promoting the use of climate smart technologies including the use of solar power where possible.  The sub-component will support the development of increased hospital bed availability through the repurposing of available bed capacity and ward space. This sub-component will also contribute financing to: (i) the development of intra-hospital infection control measures, (ii) as part of clinical care, it will support necessary improvements for water and oxygen management at selected health facilities to ensure safe water and basic sanitation.  The subcomponent will also finance procurement of electricity generators in health facilities and (iv) strengthening of medical waste management and disposal systems. Considerations will always be given to the procurement and mobilization of energy efficient equipment. Moreover, it will support the strengthening of clinical care capacity through the financing of plans for establishing specialized units in selected hospitals, treatment guidelines, clinical training of health workers, and hospital infection control guidelines. The project will also support more stringent triage for admission, and earlier discharge with follow-up by home health care personnel.”

A total of US$1.75 million is intended to support community engagement. “This component remains one of the key pillars for both mitigation and containment of the COVID-19 epidemic.  Support will be provided to develop systems for community-based disease surveillance and multi-stakeholder engagement. This component would support rebuilding community and citizen trust that can be eroded during crises, through engagement with local traditional leaders, political and religious leaders. 

World Bank Report on Liberia’s COVID19 Response

A total of US$1 million is intended to strengthen the human resource surge. “This subcomponent will support costs related to the mobilization of additional health personal to support the surge response, training, and provision of salaries and hazard/indemnity pay consistent with the Government’s applicable policies. This subcomponent will also support activities aimed at minimizing risks for patients and health personnel, including training of health facilities staff and front-line workers on risk mitigation measures, and providing them with the appropriate protective equipment and hygiene materials, including personal protective equipment (PPE) kits.”

Also, a total of US0.4 million is intended for Logistics and emergency ambulance services. “This sub-component will cover costs related to logistics for COVID-19 management, and the procurement of ambulance services or ambulances as the case maybe for transportation of COVID-19 patients.”

A total of US$1.75 million is intended to support community engagement. “This component remains one of the key pillars for both mitigation and containment of the COVID-19 epidemic.  Support will be provided to develop systems for community-based disease surveillance and multi-stakeholder engagement. This component would support rebuilding community and citizen trust that can be eroded during crises, through engagement with local traditional leaders, political and religious leaders.  The project would support training for animal health workers, extension professionals, and paraprofessionals who would receive hands-on training in the detection of clinical signs of COVID-19. The project would also provide basic biosecurity equipment such as sprayers and protective equipment. This component will also support the procurement of IPC materials and kits.”

A total of US$0.475 million is intended to support risk communication and advocacy (US$ 0.475 Million). “This subcomponent will finance activities including, but not limited to developing and testing messages and materials to be used in the COVID-19 disease outbreak, and further enhancing infrastructures to disseminate information from national to counties and local levels, and between the public and private sectors. Communication activities would include support for cost-effective and sustainable methods such as marketing of “handwashing” through various communication channels via mass media, counseling, schools, and workplaces. Risk engagement for awareness of social distancing measures, seen as an effective way to prevent contracting the COVID-19, as well as risk communication training of county education officers and superintendents, will be supported for implementation to impact on immediate term responses. Support will also be provided for information and communication activities to increase the attention and commitment of government, private sector, and civil society, and to raise awareness, knowledge, and understanding among the general population about the risk and potential impact of the COVID-19 pandemic and to develop multi-sectoral strategies to address it.”

A total of US$0.475 million is intended to go toward social and community support. “While understanding that this would be a challenging area to support effectively, this project will support activities that relieve the impact of COVID-19 on communities.  This subcomponent will provide social support activities, including mechanisms to eliminate financial barriers for families who seek and utilize needed health services. To this end, financing would be provided for fee-waivers to access medical care.  Moreover, under this component, the provision of food and basic supplies to quarantined populations in isolation, treatment, and precautionary observation centers will be supported.  The component as case maybe support the provision of a discharge package for patients from COVID-19 treatment centers.”

A total of US$0.75 million is intended to support program management and coordination, monitoring and Evaluation.

A total of US$ 0.375M is intended to provide support for the strengthening of public structures for the coordination and management of the GOL’s project coordination efforts. “Existing coordination structures operating through the REDISSE II Project will be utilized to ensure the project is ready at effectiveness. The current REDISSE II project coordination unit (PCU) structure will be strengthened through the recruitment of additional staff/consultants responsible for overall administration, procurement, and financial management. To this end, this subcomponent will finance the activities that support project coordination. The project will support the following activities under this project management strengthen the capacities of national institutions to efficiently perform core project management functions including operational planning, financial management, procurement arrangements, and environmental and social safeguards policies, in accordance with the WGB guidelines and procedures.”

A total of US0.3 million is intended to support monitoring and Evaluation.  “The project will work to strengthen the existing M&E arrangements under the REDISSE II Project.  The project will support the monitoring and evaluation of prevention and preparedness.  Specific activities will include, but not limited to; building capacity for clinical and public health research, including veterinary, and joint-learning across and within countries, training in participatory monitoring and evaluation at all administrative levels, evaluation workshops, and development of an action plan for M&E and replication of successful models.”

Healthcare Workers’ Risks Noted

The World Bank Project report recognized that the main risk in Liberia is that that health care workers and other staff testing and treating COVID19 patients will become infected themselves because the project cannot contain its spread, they have insufficient PPE, lack adequate training, are too overwhelmed to take the necessary protective measures, etc. “Since the project also includes construction and rehabilitation of facilities such as laboratories and quarantine centers, construction phase impacts in terms of use of raw materials, workers and community OHS, environmental impacts from labor camp are also relevant.”

The World Bank projections have been proven right. According to the US Center for Disease Control, healthcare workers caring for patients with Ebola were among the highest risk for contracting the disease. From the start of the outbreak through November 2015, a total of 881 confirmed health workers became infected in Liberia, Guinea and Sierra Leone.

During the current COVID-19 pandemic, a current data of 120 confirmed cases puts health workers at 28 percent of the overall infection. There are also 222 health workers as contacts – 209 in Montserrado and 12 in Nimba. 

Health workers have been complaining of inadequate supply of Personal Protection Equipment (PPE), thereby exposing them to high risk of contracting the deadly virus.

Nurse Murphy V. Dolbah, who was assigned at the Palm Springs Hotel as a tester for COVID-19, became the first healthcare worker to die last week.

Main Social Risks in Liberia

According to the World Bank Report, the main social risks in Liberia are: (i) exclusion of vulnerable people from the treatment or referral service; (ii) potential GBV incident in quarantine facilities; ( iii) health workers exposure to COVID-19; (iv) COVID-19 transmission due to negligence and poor hospital and quarantine facilities; (vi) lack of basic food provision to patient and people who are quarantined; (vii) social trauma, stigmatization and potential for making affected groups outcast; (viii) communication breakdown and potential for social tension; and (ix) potential risk of forced land acquisition and property for construction of facilities.

In a bid to ensure that the US$7.5 million reaches the intended target, the World Bank has put in place a guiding document for the project will be a Project Implementation Manual (PIM). “The existing REDISSE II PIM will be reviewed and modified to accommodate COVID-19 activities as appropriate.  including standard project fiduciary, safeguard, implementation, and M&E requirements.  A reviewed detailed project implementation plan in line with Government approved action plan will be approved by the Bank for project implementation.”

Additionally, according to the report, funds flow and accountabilities for financial reporting will ensure that the current structure operating under the REDISSE II project will be utilized after making a few changes to accommodate the emergency, for flexibility the Designated Account (DA) will be moved to a commercial bank (GT Bank). “The current DA in Central Bank of Liberia (CBL) will be closed.  However, the MOH is responsible for submitting a quarterly h interim unaudited financial reports (IFR), starting from the first quarter following the project’s first disbursement to the WBG no later than 45 days after first Quatre.”

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