Helping hands for health workers in fragile states

Nowhere is the global health worker crisis more acute than in fragile states – those countries where the government cannot or will not deliver core functions to the majority of its people. Since the civil war, Liberia has an absolute shortage of health workers. Merlin is working with the government to help train health workers and rebuild the shattered health system.

Midwife Sarah Shaffa teaches at the Merlin/Ministry of Health Midwifery School in Liberia, remote south eastern region

Amy Waddell tells the story.

In 2007, fragile states received only 38.4 per cent of Overseas Development Aid. Fifty per cent of that benefited just five countries, with the rest divided up among the remaining 41 states. Yet fragile states carry a disproportionate level of the global health burden: one third of women who die in childbirth and half of all children who die before their fifth birthday live in fragile states.

Sustained investment in health, especially health workers, in fragile states is vital to save lives and to meet the Millennium Development Goals.


Before the civil war, Liberia boasted 237 doctors providing health care for a population of two million people. By 2005, an evaluation estimated there were less than 20 doctors left in the country. Fourteen years of government coups and rebel clashes had shattered the health system and caused the death or emigration of many qualified health workers.

With the commitment of President Ellen Johnson Sirleaf, the Ministry of Health and Social Welfare (MoH&SW) is tackling the huge challenge of rebuilding Liberia’s health infrastructure including the health workforce – yet with minimal resources.

Since 1997, Merlin has been supporting the MoH&SW. Initially running mobile clinics for people displaced by fighting, the organisation has expanded its role to support the delivery of a third of the country’s health care. Merlin’s key focus is the training and supervision of health workers; helping to implement Liberia’s ambitious National Health Plan, which highlights the need to strengthen human resources.
In Liberia the shortage of health workers is most acute in rural areas, such as the isolated south eastern region. Until June 2009, there had not been a permanent doctor in a county of 185,000 people for almost six months.

Reaching the south east can take a 20 hour drive on dirt roads that are barely passable during the rainy season, from March to October. Health workers sent by the MoH&SW make their own way to take up their remote roles, often only to resign and return to the capital, Monrovia, months later.

With inadequate housing and few schools, there is little to encourage health workers to stay. Leaving their families in Monrovia, Liberia’s health workers struggle both to support their main family home and feed themselves; a bag of rice in the south east costs $45 instead of the usual $30, because of transport costs. Health workers receive no added incentives to live and work in this remote region.

Investing in Health Workers

An example of one project addressing just such issues is the Midwifery Training School, based in Grand Gedeh.

Supported by Merlin, this MoH&SW school re-opened in December 2008 after a forced closure of almost 20 years. Returning to pre-war ideals, a two year full-time course, accommodation, uniforms and materials are provided free of charge to all students.

In a bid to retain health workers in the south east, the school only advertises across the region’s six counties – encouraging men and women, aged 18 to 45, to apply for the 40 places that are offered, on average, each year. The sole condition for the Midwifery School’s free training: that students sign a bond to work in their communities for at least three years after graduation.

By recruiting future health workers from their home counties, areas where health workers are most sparse, the Merlin-supported MoH&SW school offers a sustainable solution to Liberia’s health worker crisis.

For now, it is a small step towards equipping Liberia with the estimated 1000 midwives it needs; by 2010, over forty students will be providing pregnant women in isolated communities with rare access to a trained health worker.

Merlin believes investing in health systems and health workers is the most effective use of funding to the sector. Investment, especially in fragile states, is vital – without it, the world has little chance of reaching the Millennium Development Goals for health by 2015.
With this in mind, Merlin’s international campaign, Hands Up For Health Workers, is calling for urgent and sustained investment in health workers in fragile states. Central to this are health workforce plans which cover the equitable distribution of health workers and the incentives required to keep them where theyare most needed.

Campaign for change now at
Amy Waddell, Merlin

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