A Policy Analysis of the Primary Health Care Approach in Liberia

Primary health care (PHC), a holistic approach to health, was proposed at Alma-Ata in 1978 and has been the guiding principle for the health system rebuilding of Liberia, a post-conflict, low-income country. However, since its adoption, health care delivery and outcomes remain less than optimal. A comprehensive literature review of all current health policy documents in Liberia, with a focus on the PHC approach, was identified and analyzed using the Walt and Gilson policy framework. Three major policy-related gaps were identified. 1. The lack of explicit inclusion of the community as an actor in the formulation of several of the policy documents. 2. The lack of timely revision of some policy documents. 3. The lack of an explicit PHC strategic approach in the implementation plans of multiple policy documents. The poor health outcomes in Liberia, therefore, are indicative of problems with PHC that go beyond implementation to the policy level.


Introduction
The World Health Organization (WHO) defines health policy as decisions, plans, and actions that are undertaken to achieve specific health care goals within a society [1]. Policies on primary health care (PHC) are governed by principles established at the Alma-Ata Declaration of 1978, which called for health for all, promoting PHC as the basic unit of a functional health care system.
Remarkable achievements have been made on the global scene since the Alma-Ata declaration. Notwithstanding, globally, the PHC approach has undergone several evolutions that have necessitated policy reforms in some instances [2]. Global economic, political, environmental, and social situations have shifted the focus of PHC implementation across different contexts and at different points in time. In many low-and middle-income countries (LMICs), varying degrees of gaps exist due to epidemiological transitions, the emergence of outbreaks, wars, and occasionally the lack of governance [3]. To mitigate the impact of these limitations, some LMICs, such as Tanzania, for instance, have adopted a reform to its PHC policy that allows contracting non-state providers (NSPs) for the delivery of PHC services [2]. Others such as Sri Lanka, a middle-income country that has achieved outstanding health indicators and is deemed to be a success story in PHC implementation, adopted a selective PHC approach that is restricted to addressing the most serious health problems in a community, as opposed to the comprehensive PHC model recommended at Alma-Ata [4].
In Liberia, a low income, West African country, following 14 years of civil crisis that ended in 2003 and the subsequent destabilization of the healthcare system, the Ministry of Health and Social Welfare (MOHSW) formulated the post-conflict National Health and Social Welfare Policy and Plan (NHSWPP) of 2007-2011 [5]. The bedrock of the policy was a PHC approach, with a complimentary Basic Package of Health Services (BPHS) [6], meant to provide essential care at every level of the health system. Cardinal to this policy was making PHC services at every level free of user fees to increase access to high-quality healthcare [5].

Materials and Methods
This paper is a policy review of national policy documents and articles relating to the PHC approach in Liberia. A comprehensive web-based search was performed using the following search engines: Google and Google Scholar. Other online databases sourced were PubMed and Mendeley Library, employing different combinations of the keywords, "Primary Health Care", "Primary Health Care Policy", "Liberia", "Primary Health Care Approach", "Health Policy Analysis", "sub-Saharan Africa" and "Low-And-Middle-Income Countries". All potentially relevant information was downloaded for analysis. Current national, international, peer-reviewed, and grey literature were sourced, then snowballing was employed to include key publications found older than the selected timeframe (1 January 2001 to August 2019). The search was designed for the latest versions of all national health policy documents as well as relevant supporting articles to be accessed electronically. Only English language documents were considered for analysis and communication of this research findings.
The policy documents included in this analysis ranged from 2000 to 2020 (Table 1). The policy documents selected and analyzed were based on the criteria of being currently implemented policies and their alignment with one or more of the eight (8) PHC essential elements. It must be acknowledged that the search conducted was limited only to electronically available documents. Documents not publicly available and those not adopted formally were not included for analysis. Consequently, the possibility exists that some current, up-to-date, relevant documents may not have been included in this paper. The Walt and Gilson health policy analysis framework ( Figure 1) was used for the extraction and analysis of all identified policy documents. The framework focuses on several key factors (Actors, Context, Process, and Content) and the complex interactions/interrelations between these factors within a given context [20,21]. The framework was selected because it affords a multidimensional approach to health policy analysis, and it provides an excellent means for analysis of the Liberian Health Care Policy, which has undergone several changes over the past decades. The conceptual framework, which was developed in 1994 by Gill Walt and Lucy Gilson, focuses on several key factors (Actors, Context, Process, and Content) and the complex interrelation and interaction between these factors within a given context to influence health policy formulation and implementation and the consequential impact on the general health of the population.
Actors refer to all vested stakeholders, for example, national, international, nongovernmental organizations (NGOs), pressure and social society groups, funding organizations, private sector companies, etc., whose actions impact the health policy; anyone who has power and exercise it through the policy process [20,21].
Content is the materials covered within a given health policy in fine detail, while Process refers to the way policies are started, developed or formulated, negotiated, communicated, implemented, and evaluated.
There were no limitations identified with the utilization of the framework. However, because of the interconnected nature of the various components of the framework, several factors were identified to interact and overlap quite frequently, and this is reflected in the results and discussion sections of the paper.

CONTENT
The socio-political, cultural and health system context within which policies governing Primary Health Care are developed

CONTEXT
The objectives, values, vision, service, models, guidelines and implementation plans for the Primary Health Care aproach outlined

ACTORS
The range and charachteristics of participants (individuals, groups or organization) in the policy development process, including their roles, relations, interest amd expertise in Primary Health Care

PROCESS
The processes folloed to consult with key stakeholders across government sectors (health, social care, education), nongovernement sectors and other relevant civil organizations Context is the political, economic, social, and cultural factors, at the national and international level, that have a bearing on health policy. These factors could be classified in several different ways according to the nature of the factor and the role they play in the policy development process for policymakers. They could be macro-level context factors which include political, social, and economic factors; meso-level context factors-these are health systems' factors and micro-level context factors-factors more associated with the implementation process [20,21]. They could also be categorized as situational factors-mostly transient factors that are subject to change easily, such as civil conflict, leadership change, natural disasters, etc.; structural factors-more rigid, relatively unchanging elements such as political, economic, demographic, and technological factors; cultural factors-gender norms/inequity, ethnicity, and linguistic factors, stigmatization, religious factors, etc.; and international/global factors-international agenda, international cooperation in health, etc. [20,21].
Content is the materials covered within a given health policy in fine detail, while Process refers to the way policies are started, developed or formulated, negotiated, communicated, implemented, and evaluated.
There were no limitations identified with the utilization of the framework. However, because of the interconnected nature of the various components of the framework, several factors were identified to interact and overlap quite frequently, and this is reflected in the results and discussion sections of the paper.

Results
Of the thirteen identified policy documents related to PHC, one was outdated, and therefore it is not being implemented currently and consequently was not considered for further analysis (Table 2). Of the remaining documents, two were found to have been drafted, and last revised over a decade but remain current operational policy papers.
In addition to an overarching National Health Policy, national drug, mental health, community health, and nutrition policies were common policy documents guiding PHC policy formulation and implementation that were identified in Liberia and therefore listed in (Table 1) [22][23][24][25]. The Basic Package of Health Services (BPHS), the Essential Package of Health Services (EPHS), and the Investment Plan for Building a Resilient Health System in Liberia were not identified as actual policy documents. They were found to be papers complementing the overarching policy on PHC implementation. However, both the BPHS and EPHS were similarly identified in studies from other LMICs in terms of PHC papers, hence warranting their inclusion on the list.

Primary Health Care Policy
A stand-alone policy document on PHC in Liberia was not found. At the National level, however, the overarching NHSWPP (both the outdated and current versions) [5,7] was documented implicitly based on a comprehensive PHC approach that was identified. Several other supporting and complementary documents to the NHSWPP were also identified.
All the supporting documents included implementation plans to complement that of the NHSWPP. However, of the twelve documents, only five had explicitly outlined PHC strategic plans. The remaining seven policy/complementary papers lacked clear implementation plans on the PHC approach.

Policy Analysis using the Walt and Gilson Policy Triangle
Ten pertinent contextual factors were identified ( Table 3). Determinants of the factors were varied but collectively based on a need to address the overwhelming high maternal and child mortality, high burden of communicable diseases, lack of access to quality health care, inequity in access to health care, the financial impoverishment brought on by high out-of-pocket (OOP) expenditure for health, the poor nutritional status of the general population, poor access to safe water and sanitation and stigmatization against individuals with mental health illnesses.
In terms of the context categories, three broad categories were identified, structural factors, global factors, and cultural factors [36]. An important cultural factor: gender norms/inequity, was not identified in the NHSWPP. Additionally, situational factors such as leadership change and social unrest were not identified as factors shaping the policy. Table 3. Key factors influencing the National Health Policy on the primary health care approach.

Structural
The  Major international (WHO, United Nations Children Funds (UNICEF), United States Agency for International Development (USAID) and the European Union (EU)) and national stakeholders, including other non-health governmental ministries and agencies, functioning in capacities ranging from financial to technical supports were identified (see Table 4).    Three documents, the National Policy and Strategic Plan on Health Promotion, the National Health and Social Welfare Financing Policy and Plan, and the overarching NHSWPP, had no documented evidence of service users (the community) representation or consultation in the process of the policies formulations. Additionally, there was an underrepresentation of professional bodies and local health care providers identified, as evidenced by only four out of the twelve policies mentioning such representation.
There was no documented evidence of the private sector's engagement in the policy process, although the WHO recommends a participatory engagement with the private sector [37].

The Content
The NHSWPP mainly focused on the provision of PHC and made specific references to a PHC approach in the implementation strategy. This includes eleven essential areas of service deliveries and five priority support systems to provide PHC (Table 5). The services identified were consistent with the PHC elements and expanded beyond that in three other service provisions, school health, prison health, and eye health services.
The EPHS, BPHS, and the National Community Health Services were found to have a focus on PHC through provisions of universal access to basic and essential health services free of user fees as well as strengthening of community health delivery services.
The remaining policy documents were found to complement the NHSWPP and were focused on various aspects of general health and social service provision. Nonetheless, there were no specific references to PHC identified in their strategic plans.  This is to be achieved through decentralization and intersectoral collaboration on elements of the PHC approach not in the direct purview of the MoHSW.
The PHC approach is implicitly mentioned in the accompanied Health Plan, to be affected by the Essential Package of Health Services (EPHS) through eleven service delivery areas: 1.
Maternal and Newborn Health Service 2.
Child Health Services 3.
Reproductive Health Service 4.
School Health Services 5.
Prevention and Control of Communicable Diseases 6.
Prevention and Control of NTDs 7.
Prevention and Treatment of NCDs 8.
Eye Health Service 9.
Emergency Health Services 10.
Mental Health Services 11.

Prison Health Services
And five priority support systems:  Aside from three of the documents that lacked relevant data (Liberia National Community Health Services Policy, National Nutrition Policy, and the EPHS), a total of four approaches were identified in the policy formulation process (Table 6). Two out of the four, consultation, participation, or a mix of both, were methods of engagements with the policy actors that were identified in the process. These approaches described the type of engagement. The last two approaches, identified as the 'bottom-up approach in response to the need of stakeholders or 'top down', responding to national priorities, which are methods of engagement, were also identified. The MOHSW was identified as the main agency for monitoring and evaluation of the policies at the national and sub-national levels. However, all policy documents reviewed lacked evidence of community participation in monitoring and evaluation of any aspect of policy implementation.

The Gaps
Gaps were identified as either policy-related or implementation-related (Table 7). Of the policy gaps, the lack of end-users (community) representation in the policy development process was identified in eight of the twelve policy documents examined. A lack of timely policy revision was also identified as a policy-related gap in one of the policy papers, and the lack of explicit PHC strategic plans in the implementation plans of eight out of the twelve documents analyzed was also identified as a direct policy-related gap. The remaining gaps identified were all implementation-related gaps.

Discussion
Findings generated from the utilization of the conceptual framework are largely in consonance with PHC approach implementation across sub-Sahara Africa (SSA). In Liberia, similar to many SSA countries, PHC is recognized as the modality for achieving health for all, and it is implicitly highlighted in most national health policies [10,14].
The main contextual factor within which the overarching NHSWPP was developed was the need to achieve the MDGs health objectives by addressing the high maternal and child mortality, high burden of communicable diseases, the lack of equitable access to health, the poor nutritional status of the population, high OOP for health and the poor access to safe water and sanitation that existed in the country [7].
Other drivers could have also weighed in on the considerations made, such as the availability of donor funding and incorporation of donors' priorities, as is the situation in most developing health care systems that are donor-dependent. Nonetheless, donor funding was not identified as such. However, for a public institution such as the Liberian government, emerging from a civil war with a poor economy and competing priorities for highly constrained public budgets, and which relies heavily on donor funding [38], donor funding might have been a highly ranked factor had such ranking been documented. Findings from Pakistan and Cambodia showed the huge influence and nature of donors on national health policy processes in LMICs [39].
Additionally, based on the four-system categorization of contextual factors [36], only three categories were identified: structural, cultural, and global/international. Situational factors, the fourth factor, which are transient factors such as civil conflicts and natural disasters, was not identified.
A striking observation in the situational analysis of the present National Health Policy of Ghana was the issue of unequal gender relations, a pertinent cultural factor [38]. This was not identified in Liberia's health policy as an issue factored in by policymakers. While gender equity issues were considered a component of the guiding principles of the NHSWPP, it was not articulated as a social problem directing policy prioritization. Yet gender inequity is an issue that exists in Liberia and has a documented impact on health-seeking behavior and the overall MMR [40]. In Liberia, only 54% of females are literate compared to 77% of males; 54.6% of female-headed households face food insecurity compared to 49.9% of male-headed households [41]. This illustrates the issue of gender inequity that should have been a paramount consideration, especially for a country embracing the PHC approach, which is grounded on a right-based foundation.
A broad range of local and international stakeholders was identified. It is crucial to create an environment that allows a complex mix of actors representing a full spectrum of interests and agendas in public policy processes. Actors' involvements were identified as either in a financial or technical capacity and for most international stakeholders, both capacities.
As is often the case in most policy processes, there is an asymmetry in the influence that is wielded among actors, and one study found that this asymmetry is even more pronounced between donors and domestic health policy actors in LMICs. The study found that donors' influences are exerted at different stages of the health policy process; control of financial resources was commonly associated with priority setting and policy implementation, while technical expertise was associated with the policy formulation stage [39]. While these results might hold in Liberia, they were not identified.
Of the twelve documents reviewed, documented evidence of the community representation, as key stakeholders in the process, was identified in only three of the policy papers. Additionally, representation of professional councils/experts was identified in only four. The significance of the community and professional bodies in the health policy development process has been recognized and advocated for, particularly in PHC [37].
Professional bodies provide technical guidance as well as advocacy for service providers' and patients' interests in the policy development process, and the importance of this role cannot be overemphasized, especially in a low-resourced health system such as Liberia. The WHO advocates that meaningful engagement with a broad range of actors, including professional bodies, through a participatory process, is required in the governance and support of policy frameworks integrating PHC into the broader health system context [37].
Only three of the complementary documents overtly addressed PHC as the overarching NHSWPP. Strategies for PHC service provisions were identified in the strategic plans of these documents; however, the explicit outline of plans for several key policy options was lacking, with user fees suspension being one of the most important. With the introduction of the BPHS in 2007, user fees suspension for basic PHC services was introduced and remains in place to date. This exemption underpins the PHC approach in Liberia [6]. This policy option has been implemented in many LMICs with varied incentives for the institution. In Liberia, the policy option was adopted to improve the health and social welfare status and promote equity in access to health in a post-conflict setting; by averting high OOP expenditure for the health of a population already improvised by civil conflict [6].
Like in most settings where this policy option has been adopted, it falls short of full achievement of the intended objectives, and several inconsistencies emerging from the NHSWPP were identified for this occurrence. (i) A lack of clear definition of services to be included-the NHSWPP refers to the services affected by user fees suspension as "priority services" without an explicit explanation of what they are [7]. This ambiguity causes implementation difficulties at the service delivery end, which leads to heterogeneity in the implementation of the policy and inequity in utilization; (ii) Lack of explicit categorization of vulnerable groups-the policy aims to target certain "vulnerable groups" to encourage uptake of services [7]. For example, in Ghana where exemption of health service fees for some "categories" of users was unsuccessfully implemented because, among other factors, service providers had difficulties in the identification of the exempted categories [23], the interpretation and application of the fee exemption to the labeled vulnerable groups in Liberia is being left largely to service providers; (iii) Inadequate monitoring system for policy implementation. As such, there are high occurrences of indirect OOP charges for services that should otherwise be free [6]. This creates an environment for corruption, and an unintended negative effect of limiting access to PHC services because of perceived cost; and (iv) Poor gatekeeping system patients are known to frequently self-refer at levels inconsistent with their health needs due to several factors at the peripheral levels including frequent stock out of essential medications [7].
While the trend in OOP expenditure as a percentage of current health expenditure has significantly decreased since 2007, with the initiation of the user fee exemption policy, 47.2% in 2016 compared to 66.2% in 2007, it remains noticeably higher than the average SSA value of 36.7% [42].
A wide range of policy processes was identified, including such approaches as topdown, bottom-up, participatory, and consultative engagements with stakeholders. Health policy processes are theoretically broken up into four stages;(i) problem identification and issue recognition; (ii) policy formulation; (iii) policy implementation; and (iv) policy evaluation [36].
Many studies on health policies in LMICs have concluded that the first two stages are relatively well implemented, while the latter two are more problematic. A Ghanaian study found that contextual factors such as political ideologies, economic crises, an election year, change in the government, and international agenda were among issues that directed policymakers in the decision for maternal fees exemption [43]. This is considered the 'top-down' approach, in response to national priorities. Similarly, findings showed that policy actors of the NHSWPP and other policy documents in Liberia took into consideration the situational analysis of the country, incorporating those into the decision-making and eventual policy development process. However, the bottom-up approach, in response to the needs of stakeholders, was also identified.
Optimal community participation as a relevant stakeholder, the bedrock of the PHC approach, was inadequately identified. This has detrimental consequences for the subsequent implementation and evaluation stages. Full community participation allows for a better understanding of policy options, better appreciation by the community of the government's constraints and hence legitimizes whatever policy is eventually crafted. Bottom-up approaches, generated through the community, are generally considered more effective than top-down approaches, where modes of engagement are mandated by external funding initiatives mostly [37].
At the policy evaluation stage, the MoHSW was identified as responsible for monitoring and evaluation (M&E). However, the degree to which monitoring is comprehensively carried out at all levels, from the top central level to the bottom community level, was unclear. Factors impeding effective M&E in other SSA countries such as untrained staffs in the research and statistical units and shortage of data management facilities at the facility, district, and national levels could similarly be problematic in Liberia considering the MoHSW's weak technical capacity and the poor health management information system (HMIS) [44].
In addition, only the National Community Health Services policy listed the community as partners in the evaluation process. The community was noticeably omitted in the NHSWPP and the other policy documents in this regard. High quality of care is essential for building trust in the community and for ensuring the sustainability of the health system. Information on the quality of care can best be generated through periodic M&E of PHC activities that incorporate the end-users of services for the generation of feedback on the actual implementation process and impact. A possible explanation for this omission is that, at the community level, there is a lack of technical capacity to fully understand the indicators which are to be monitored. Nonetheless, if communities are actively engaged in problem identification, they gain better insights and are therefore better equipped to evaluate and monitor activities addressing these problems.
Similarly, considering the multisectoral component of most of the essential PHC elements that need to be fulfilled by policy implementation, a more concerted, aligned intersectoral engagement is required in the M&E stage as well. Yet limited evidence of intersectoral involvement in the M&E processes was identified. While limited evidence could be found elsewhere of this collaboration, beyond the implementation of PHC programs, evidence of the establishment of intersectoral committees and teams to function at different levels of the health system in some SSA countries was identified [44]. Such committees could function in the monitoring of multisectoral PHC projects if such roles were spelled out in policy documents.
Three major policy-related gaps were identified. The lack of explicit inclusion of the community as an actor in the formulation process of several of the key policy papers, a direct policy-related gap identified, raises major concerns about the content and implementation of PHC in Liberia. Community participation, among other principles, is a major focus of the PHC strategy [45], and it extends beyond the availability of Community Health Workers and community health teams, observed in some of the reviewed policy documents. This participation also more critically encompasses the active engagement of the community in identifying and making decisions about their health priorities, both at the subnational and national levels.
The lack of timely revision of some policy documents was another gap identified. The National Drug Policy, for example, was promulgated in 2001 and remains the governing document for drug management across the country. The current drug policy, for instance, lacks a clear strategic approach to updating the country's essential drug lists. As a result, the present essential drug lists of Liberia contain no medication for the management of chronic Hepatitis B; even though WHO's essential list of drugs currently lists Tenofovir disoproxil fumarate, a drug available in Liberia, as a recommendation [46]. While there is no guideline on the frequency of policy revisions and it is mostly institution-specific, the WHO regional office for Africa (AFRO) recommends the cycle of health policy revision to range from five to ten years, while strategic plans are recommended a five-year revision cycle [47,48].
Lastly, the lack of explicit PHC implementation plans in the strategic plans of many of the policy documents was identified as a direct policy-related gap. Since the overarching national health policy focuses on a PHC approach, definitive PHC implementation plans were expected in other complementary documents. A lack of explicit implementation strategies creates the probability of having a disparity between what policymakers intended to achieve by a set policy and what is being realized at the implementation level.
This study has several limitations due to the type of data collected. First, it was only possible to review those health-related policies that were available electronically via web search. It is possible that some policies may exist that were not included in the review due to this reason. Secondly, the analysis was limited to include only those health policies that clearly listed primary health care as an approach; the review did not include those policies from other sectors that were not related to health. Finally, the paper is reflective of the impacts of changing governments, as it analyzes policy documents formulated and adopted by two previous regimes, and they remain the governing health policy documents of the current government (2018-present).

Conclusions
As a post-conflict country, the findings highlight the prominent focus that is placed on PHC in Liberia. This is evidenced by the central role the PHC approach is given in the overarching NHSWPP. In consonance with international and regional health care agendas, the country, through the NHSWPP and accompanying policy documents, is fostering an enabling environment to promote universal health care (UHC) and achieve the sustainable development goals (SDGs) for health.
Despite a focus on PHC, with each essential element of PHC addressed by at least a portion of the policy, implementation has largely been less than optimal. In addition to the many financial and technical constraints hindering the effective and efficient implementation of PHC in Liberia, the lack of explicit strategies on the execution of PHC policies in several of the policy documents has left room for misinterpretations at the implementation level.
The NHSWPP, while a bold document with ambitious plans, is not enough. Multisectoral policies, collaborations and actions, empowered communities, and efficient utilization of limited resources are also required.
Liberia's health policy on PHC presents an excellent case study of a post-conflict state embracing the Alma-Ata principles to address the health needs of its people, building on an almost entirely reconstructed health structure. However, there is equal room to learn, not only from the experiences gained to date but also in emulating experiences from other LMICs where the approach has been more successful. Good policies and efficient utilization of resources are also equally required to produce positive results. That said, further research is needed to elucidate more on some of the questions and findings raised in this paper. Future researchers need to conduct further exploratory qualitative research, especially at the community level, to conduct in-depth examinations of the limitations involved with community engagement in the policy process.