REPUBLIC OF LIBERIA - World Bank · 2016. 7. 11. · Liberia has put in place several policies and...

ESMF of HSSP for MOHSW, Liberia, February 2013 i |

REPUBLIC OF LIBERIA

MINISTRY OF HEALTH & SOCIAL WELFARE HEALTH SYSTEM STRENTHENING PROJECT (HSSP)

PROJECT ID: P128909

ENVIRONMENT AND SOCIAL MANAGEMENT FRAMEWORK

(ESMF)

February 2013

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ESMF of HSSP for MOHSW, Liberia, February 2013 ii |

LIST OF ABREVIATIONS AND ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ARI Acute Respiratory Illness

BOD Biochemical Oxygen Demand

BP Best Practice

CEC County Environment Committee

CH&SWT County Health and Social Welfare Team

cm Centimeter

CTBT Comprehensive Nuclear Test Ban Treaty

DHS Demographic and Heath Survey

DEOH Division of Environmental and Occupational Health

LDHS Liberia Demographic and Health Survey

EA Environmental Assessment

EHU Environmental Health Unit

EIA Environmental Impact Assessment

EPA Environmental protection Agency

ESIA Environmental and Social Impact Assessment

ESMF Environmental and Social Management Framework

GDP Gross Domestic Product

HSE Health, Safety and Environment

HSSP Health System Strengthening Project

HIU HSSP Implementation Unit

HIV Human Immuno Virus

HSIU HSSP Sub-project Implementation Unit

IDA International Development Agency

IDPs Internally-Displaced Peoples

IMCI Integrated Management of Childhood Illness

ESMF of HSSP for MOHSW, Liberia, February 2013 iii |

IPRS Interim Poverty Reduction Strategy

ISDS Integrated Safeguards Data Sheet

km Kilometre

LACE Liberia Agency for Community Empowerment

m Meter

MCC Monrovia City Corporation

MDAs Ministries, Departments and Agencies

MDGs Millennium Development Goals

mg/l Milligram per Litre

ml Millilitre

mm Millimetres

MoHSW Ministry of Health and Social Welfare

MPW Ministry of Public Works

MRD Ministry of Rural Development

MSDS Material Safety Data Sheet

MWMP Medical Waste Management Plan

NBSAP National Biodiversity Strategy and Action Plan

NECOLIB National Environmental Commission of Liberia

NGO Non-Governmental Organization

NNE North-North-East 0C Degrees Celsius

ESMF of HSSP for MOHSW, Liberia, February 2013 iv |

Table of Figures FIGURE 6-1: LOCATION OF LIBERIA ................................................................................................. 25 FIGURE 6-2: TOPOGRAPHICAL REGIONS OF LIBERIA ....................................................................... 26 FIGURE 6-3: ANNUAL RAINFALL DISTRIBUTION ACROSS LIBERIA .................................................... 27 FIGURE 6-4: MOUTH OF THE SINOE RIVER NEAR THE COAST IN GREENVILLE ................................ 29 FIGURE 6-5: WETLANDS WITH WATER HYACINTH ALONG BENSON RIVER NEAR BUCHANAN CITY

.......................................................................................... ERROR! BOOKMARK NOT DEFINED. FIGURE 6-6: MANGROVES OF THE MESURADO WETLANDS NEAR MONROVIA . ERROR! BOOKMARK

NOT DEFINED. FIGURE 6-7: DISTRIBUTION OF POPULATION BY COUNTY, LIBERIA 2008 ....................................... 33 FIGURE 6-8: POPULATION CHANGE, LIBERIA 1962-2008 ................................................................ 34 FIGURE 10-1: JFK HOSPITAL-WEST WING SELECTED FOR MAJOR REHABILITATION UNDER HSSP

.......................................................................................... ERROR! BOOKMARK NOT DEFINED. FIGURE 10-2: ONGOING INFRASTRUCTURE REHABILITATION ACTIVITY AT GRAND BASSA

GOVERNMENT HOSPITAL ................................................. ERROR! BOOKMARK NOT DEFINED. FIGURE 11-1: STEERING COMMITTEE (SC) ...................................................................................... 94 FIGURE 11-2: ESMF IMPLEMENTATION ARRANGEMENT ............................................................... 95 FIGURE 13-1: TYPICAL ENVIRONMENTAL SCREENING PROCEDURE ............................................. 105

List of Tables

TABLE 5.1: SUMMARY OF SOME KEY CONSULTATION ISSUES .... ERROR! BOOKMARK NOT DEFINED. TABLE 6.1: GENERAL STRATIGRAPHY OF ROCKS ............................................................................. 29 TABLE 6.2: WETLANDS OF LIBERIA ........................................... ERROR! BOOKMARK NOT DEFINED. TABLE 8.1: COMPLIANCE WITH OP 4.01 AND NATIONAL LEGISLATION .......................................... 53 TABLE 9.1: HEALTH –CARE WASTE GENERATION IN LIBERIA ......................................................... 57 TABLE 10.1: POTENTIAL ENVIRONMENTAL IMPACTS OF CONSTRUCTION ...................................... 65 TABLE 11.1: STRUCTURES INVOLVED IN HSSP ENVIRONMENT AND SOCIAL MANAGEMENT ......... 75 TABLE 11.2 : CONTENTS OF ENVIRONMENTAL STUDIES .......... ERROR! BOOKMARK NOT DEFINED. TABLE 11.3: PROCEDURES FOR EIA ................................................................................................ 78 TABLE 11.4: PROCESS MONITORING INDICATORS OF EMP MEASURES ......................................... 84 TABLE 11.5: INDICATORS AND MONITORING MECHANISM OF ENVIRONMENTAL AND SOCIAL ISSUES

.......................................................................................... ERROR! BOOKMARK NOT DEFINED. TABLE 11.6: SUMMARISED ENVIRONMENTAL SCREENING PROCESS AND RESPONSIBILITIES ......... 85 TABLE 11.7: GENERAL MITIGATION MEASURES ............................................................................... 87 TABLE 11.8: SUMMARY OF ENVIRONMENTAL MITIGATION MEASURES .. ERROR! BOOKMARK NOT

DEFINED. TABLE 11.9: MEDICAL WASTES IMPACTS AND MITIGATION MEASURES ........................................ 89 TABLE 11.10: INSTITUTIONS RESPONSIBLE FOR IMPLEMENTATION OF ESMF ................................ 92 TABLE 11.11: INSTITUTIONAL ARRANGEMENTS FOR ESMF IMPLEMENTATION ERROR! BOOKMARK

NOT DEFINED. TABLE 11.12: TRAINING SCHEDULE ......................................... ERROR! BOOKMARK NOT DEFINED.

ESMF of HSSP for MOHSW, Liberia, February 2013 v |

TABLE 11.13: TIMETABLE FOR IMPLEMENTATION AND MONITORING OF ENVIRONMENTAL ACTIVITIES ............................................................................................................................... 97

TABLE 11.14: ESTIMATED COSTS OF TECHNICAL MEASURES .... ERROR! BOOKMARK NOT DEFINED. TABLE 11.15: TRAINING AND AWARENESS MEASURES COSTS ......................................................... 99 TABLE 11.16: SUMMARIZED ESTIMATED BUDGET FOR ENVIRONMENTAL AND SOCIAL IMPACT

MANAGEMENT ...................................................................................................................... 100 TABLE 11.17: ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN ....... ERROR! BOOKMARK NOT

DEFINED. TABLE 13.1: ENVIRONMENTAL AND SOCIAL CHECKLIST ............................................................... 107 TABLE 13.2: GUIDANCE ON ESMF BY PROJECT PHASES .......... ERROR! BOOKMARK NOT DEFINED. TABLE 13.3: EXAMPLES OF INFECTIONS CAUSED BY EXPOSURE TO HEALTH-CARE WASTES,

CAUSATIVE ORGANISMS, AND TRANSMISSION VEHICLES . ERROR! BOOKMARK NOT DEFINED.

FINAL DRAFT ESMF of HSSP for MOHSW, Liberia, February 2013 6 |

EXECUTIVE SUMMARY

Background This ESMF is a revised version of the former ESMF prepared in the context of the Liberia Health System Reconstruction Project 2009, and adapted to the new Liberia Health System Strengthening Project (HSSP), and its components/activities. The Health System Strengthening Project (HSSP), financed by IDA, supplements efforts toward health sector reform and development. In essence, the HSSP builds on the work carried out by the MOHSW and international partners in implementation of the national health plan. Project objective The Project Development Objective (PDO) is to “improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities”.1 The proposed Liberia Health Systems Strengthening (HSS) Project aims to strengthen the institutional foundations needed to improve maternal health, child health, and infectious disease related health outcomes at target facilities through an innovative approach involving systematic and coordinated improvements to the quality of services delivered at target facilities (through performance-based incentives), and an expansion of health worker skills. Specifically, the project will: (a) focus on improving the quality of care standards (in both diagnosis and treatment) for services with proven effectiveness; (b) increase the availability of qualified graduate physicians (pediatricians, obstetricians, general surgeons, infectious diseases internists, and anesthesiologists); (c) enhance the clinical capabilities and competencies of medical and auxiliary health workers - including nurses, midwives, and physician assistants- in emergency obstetrics, surgery, pediatrics, and infectious diseases; and, (d) improve provider-accountability mechanisms related to both the achievement of results, and health-worker performance at selected facilities. These improvements should provide a thrust towards improved outcomes. Environmental and Social Management Framework (ESMF) The objective of the ESMF are the following: (i) identification of environmental and social impacts arising from activities under these HSSP sub-projects (ii) the implementation of proposed mitigation measures (iii) monitoring and implementation of mitigation measures, (iv) capacity

1 Project interventions, therefore, are expected to focus largely on improving MDGs 4, 5 and 6. MDG 4 is to: “reduce child mortality rates”; MDG 5 is to: “improve maternal health”, and MDG 6 is to: “combat HIV/AIDS, malaria and other diseases”.


building, (v) proper management of biomedical wastes and other wastes and (vi) the budgetary allocations for the implementation and the chronology. Policy, Legal, Institutional Framework For Environmental Management Liberia has put in place several policies and signed a number of protocols aimed at improving environmental management in the country. These range from national laws, regulations, policies, strategies and action plans to multilateral environmental agreements. As the government tries to put the country back on the path of sustainable development, the challenge will be the effective implementation of these various laws and regulations. The Environmental Protection Agency (EPA) is the government authority mandated by law to monitor, coordinate and supervise environmental issues in the country.

Institutional Framework Administratively, the Republic of Liberia is divided into 15 counties namely Bomi, Bong, Gbarbolu, Grand Bassa, Grand Cape Mount, Grand Gedeh, Grand Kru, Lofa, Margibi, Maryland, Montserrado, Nimba, River Cess, River Gee and Sinoe. Counties are further divided into Districts, Townships and Villages. Townships are made up of a number of villages. In the traditional structure, the county is also divided into clans, which are subdivided into sub-clans. Townships are grouped into clans depending on the language groups and traditional affiliations. The County administrative head is the Superintendent. A District is headed by a Commissioner, a Clan by a paramount chief, a sub-clan by a clan chief, a township by a town chief and the village by a village chief. In Liberia, the responsibility for environmental protection and management lies with the Environmental Protection Agency (EPA) and within the EPA each county is assigned a County Environmental Officer and a County Environment Committee. While the EPA now exists, County Environmental Officers and County Environment Committees had not yet been established at the time of preparation of this ESMF. The County Health and Social Welfare Service Administration is the operational management structure, which includes the County Health and Social Welfare Team (CH&SWT). County health authorities manage county health facilities, including county hospitals. The following are Ministries whose jurisdictions are relevant to various health facilities:

• Ministry of Gender and Development - created 2002 (the role of gender in development);


• Ministry of Internal Affairs (administration of political subdivisions from counties to towns);

• Ministry of Lands, Mines and Energy (Land Administration Issues); • Ministry of Planning and Economic Affairs (long-term national

planning, coordination of international aid programs, National Health Planning, Financing and Implementation);

• Ministry of Rural Development (integrated rural development including agricultural development); and

• Ministry of Public Works (Infrastructure Planning and Development). • Ministry of Justice (Policy coordination and regulation for the

pharmaceutical sector).

Overview of the World Bank’s Safeguard Policies The HSSP has triggered one of the World Bank Safeguard Policies, namely the OP 4.01 Environmental Assessment. The remaining operational policies are not triggered by the HSSP. Potential Environmental And Social Impacts Of The HSSP The main environmental issues for the project relate to the handling and disposal of medical waste and other medical products and waste generated during the provision of health care. It also involves the management of construction waste during the rehabilitation of JFK and a couple of other health care facilities. Current Healthcare Waste Management Practices In Liberia The Health-care wastes are generated from various sources. These sources can be classified as major or minor. The Teaching/Specialist and the Regional hospitals form the major sources. County Hospitals, Private Laboratories, Health Centres/, other health facilities form the minor sources. The composition of the waste is often a characteristic of the type of source. For example, the operating theatres and surgical wards generate mainly anatomical waste such as tissues, organs, body parts and other infectious waste. Solid waste generation depends on numerous factors, such as established waste management methods, type of health-care establishments, the proportion of patients treated on a daily basis and the level of complexity and degree of specialization of the health facility. Hence, the Teaching Hospitals generate larger quantities of waste per unit than other facilities.

Potential Environmental And Social Impacts Of HSSP Positive Environmental Impacts:

- Aesthetics of Health-care facilities Improvement - Reduced Health Risks


Negative Environmental Impacts The health-care facilities rehabilitation will result in the generation of construction waste, dust generation and noise pollution. Health and safety issues and health-care service delivery interruption will arise in course of the rehabilitation. There would be possible conflicts between constructional activities and ongoing health-care services delivery.

Potential Impacts of Health-care Waste Health-care waste includes a large component of general waste and smaller proportion of hazardous waste. Exposure to hazardous health-care waste can result in disease or injury. The hazardous nature of health-care waste may be due to one of the following characteristics:

• It contains infectious agents; • It is genetoxic; • It contains toxic or hazardous chemicals or pharmaceuticals; • It is radioactive; • It contains sharps.

Positive Social Impacts

- Employment Creation - Materials and Equipment Supply Opportunities - Removal of Geographical Inequalities - Improving Socio-cultural Access - Increase in Household Resources

Negative social impacts Under the HSSP, no new construction activities will be financed and therefore there will be no land acquisition. Hence there are no issues of involuntary resettlement under the project.

The environmental and social screening process A screening process, selection and evaluation of HSSP subprojects is required to manage environmental and social aspects of these activities. The extent of environmental and social measures required for HSSP activities depend on outcome of this process. The Screening Process The purpose of the screening process is to determine whether sub-projects are likely to have potential negative environmental and social impacts; to determine appropriate mitigation measures for activities with adverse impacts; to incorporate mitigation measures into the sub-projects design; to review and approve sub-projects proposals and to monitor environmental parameters during implementation. The extent of environmental and social work that might be required for the sub-projects prior to implementation will depend on the outcome of the screening process. Thus the results of this screening process will determine whether (i) no environmental work will be


required; (ii) the implementation of simple mitigation measures will suffice; or (iii) a separate EIA will be required. Summarized Environmental Screening Process and Responsibilities

Stages Management responsibility

Implementation responsibility

1. Screening Environmental and Social Infrastructure Project: Selection including public consultation

HSSP Secretariat

ESMS, HSUI, CH&SWT, NGO

2. Determination of appropriate environmental categories

2.1 Selection validation

2.2 Classification of Project Determination of Environmental Work Review of screening

HSSP Secretariat

ESMS EPA

3. Implementation of environmental safeguards

3-1. If EIA is necessary 3.1.a Preparation of terms of reference

HSSP Secretariat

ESMS

3.1 b Consultant selection HSSP 3.1 c Realization of the EIA, Public Consultation Integration of environmental and social management plan issues in the tendering and project implementation,

ESMS/HSSP Infrastructure Unit of MOHSW/HSSP

Consultant

4 Review and Approval

4.1 EIA Approval (B1) EPA EPA 4.2 Approval simple measures (B2&c)

ESMS ESMS/EPA

5. Public Consultation and disclosure

HSSP Secretariat

ESMS/Proponent/Consultant

6. Surveillance and monitoring HSSP/EPA/ ESMS/ M&E officer / Proponent

7 Development of monitoring indicators

HSSP ESMS / Consultant


Capacity Strengthening for ESMF Implementation In order for HSSP Secretariat to effectively carry out the environmental and social management responsibilities for sub-project implementation, institutional strengthening will be required. Capacity building will encompass MOHSW/HSSP Secretariat and sub-project executing institutions such as the Regional, County and District Hospitals. The HSSP Secretariat should therefore ensure that the following concerns and needs are addressed: − Institutional structuring within the relevant departments to ensure that

required professional and other technical staff are available; − Establishment of consultancy groups to ensure cross departmental

discussions and information exchanges. Institutional arrangements for implementation of ESMF Below are summarized the tasks assigned to different institutions in the EHSS implementation: EPA

• The EPA will review and approve the environmental classification of subprojects of types B1, conducts the review of the B2 and C; EIA approval.

• The EPA will monitor at national level implementation of environmental measures.

The Secretariat of the HSSP

It will recruit the ESMS. ESMS main task is to screen the subprojects, participation in EIA review, monitoring activities of mitigation measures implementation. The HSSP Secretariat will provide support to DEOH staff of MOHSW to achieve the following objectives:

propose measures that are compatible with sustainable development while implementing the project

promote awareness by its personnel and the general public regarding environmental protection,

HSSP Monitoring and evaluation activities The monitoring program will focus on continuous monitoring, supervision, mid-term and annual evaluation. Support provided in the budget is needed for local monitoring by the ESMS and the EPA. Thus, in terms of environmental and social requirements of HSSP, it is essential to strengthen the Secretariat staff centrally by an environmental specialist in charge of


supervision / coordination of different activities related to environment and social issues. Recommendations The following recommendations are necessary:

Hiring ESMS by the HSSP Secretariat of the MOHSW; Organization of meetings in the areas concerned by

the sub-projects in order to provide some information on the project.

There should be a screening process in order to screen the HSSP sub-projects.

COSTS The total budget for implementing the ESMF is 145,000 USD as detailed below

Measures Actions Responsible Costs USD

Institutional measures

ESMS recruitment HSSP Secretariat PM

Technical measures

Perform ESMF monitoring and evaluation (continuous monitoring, mid-term and annual assessment) Health and safety Plans Monitoring

HSSP Secretariat 75 000

SUB-TOTAL INSTITUTIONAL AND TECHNICAL MEASURES 75 000

Training

Training in environmental and social management and monitoring

HSSP Secretariat 20 000

Awareness

- Information and awareness campaigns on the nature of work, environmental and social issues

- Awareness creation on HIV / AIDS

HSSP Secretariat

50 000

SUB-TOTAL TRAINING AND AWARENESS 70 000 GENERAL TOTAL 145 000


1.0 INTRODUCTION

Liberia has made significant efforts in its transition from humanitarian assistance to recovery, reconstruction and development. The government developed the Poverty Reduction Strategy in 2005 highlighting the development priorities over a period of three years. In 2011, The Liberian government developed the Agenda for Transformation.(AfT) In the health sector, the Ministry of Health and Social Welfare (MOHSW) has developed the national health policy and plan and reviewed the priorities proving the foundation for health development. This plan reaffirms the MOHSW’s commitment to working toward the achievement of the Millennium Development Goals. The Health System Strengthening Project (HSSP), financed by IDA, supplements efforts toward health sector reform and development. In essence, the HSSP builds on the work carried out by the MOHSW in Health System Reconstruction Project (HSRP) 2009- 2011 and was financed by IDA.. The present project (HSSP) aims, therefore, to:

(i) Strengthen policy making and management functions for the MOHSW, and

(ii) Provide critical inputs to sustain the referral system needed to support essential health services, by financing three components:

a. Support systems to enhance monitoring and evaluation capacity of the MOHSW;

b. Human resources for health; and c. Infrastructure and equipment.

The realization of investments related to the latter component (infrastructure and equipment) may generate adverse effects on the biophysical and social: The main environmental issues relevant to the project are medical waste management and construction related issues like occupational health and safety.

Pursuant to the requirements of the World Bank, an ESMF is conducted. In fact, the Bank requires the description of measures taken by the HSSP/MOHSW (the Borrower) to address the safeguard policy issues and a provision of an assessment of HSSP/MOHSW’s capacity to plan and implement the measures described.

1.1 PURPOSE OF THE ESMF A general framework for Environmental Management (EM) of development projects is provided in the Environmental Assessment and Regulations of


Liberia. The Liberian government development projects are usually supported by development partners such as the World Bank. The development partners usually have their Environmental and Social (E&S) safeguards which provide guidelines for the projects. As part of funding arrangements for the Liberia Health System Project therefore, the Bank’s E&S safeguards policies (OP/BP 4.01 - EA must apply. The Liberian Health Strengthening Project has the following attributes (quite distinct from project-specific level assessment):

• Various developmental stages to be carried out in modules; • A number of components, sectors and sub-projects involved; • Sub-project encompass a wide geographic spread; • Implementation duration spread over 5 years; • Involvement of several institutions at the national and county levels

and;

These attributes are typical of a program-type undertaking for which the appropriate level of EA is the Strategic Environmental Assessment (SEA) under the Liberian EA Procedures. The term ESMF is used by the World Bank to depict operations with multiple sub-projects, various phases and spread over a long period - similar in concept to SEA. The ESMF spells out the E&S safeguards, institutional arrangements and capacity required to use the framework. This ensures that sub-projects meet the national and local E&S requirements, are consistent with OP 4.01 and OP 4.12, etc and sets out principles and processes for the sub-projects agreeable to all parties. The other objectives of the ESMF include:

• Assessment of potential adverse E&S impacts commonly associated with sub-projects and the way to avoid, minimize or mitigate them;

• Establishment of clear procedures and methodologies for the E&S planning, review, approval and implementation of sub-projects;

• Development of an EA screening system for the sub-projects; and • Specification of roles and responsibilities and the necessary reporting

procedures for managing and monitoring sub-project E&S concerns.

1.2 OBJECTIVE OF THE ESMF

The objective of the Environmental and Social Management Framework (ESMF) is to assess the potential environmental and social impact of the HSSP with emphasis on activities related to disposal of medical waste and rehabilitation of seven county hospitals, JFK hospital and at least 200 clinics nationwide and this at stage of planning and development sub-projects. The framework will incorporate environmental and socio-economic assessment of potential impact of the project activities, as well as appropriate mitigation measures and monitoring plans.


A Medical Waste Management Plan (MWMP) has been prepared to complement the ESMF, which provides detailed guidelines on the handling of medical waste, and the project attributes to the implementation of this framework. Specifically, the ESMF focuses on:

• Assessing environmental and social impact of the HSSP; and to propose a screening process

• Recommending practical and cost-effective actions and processes to mitigate any potential adverse environmental and/or social impacts that could arise during project implementation; and

• Identifying capacity building needs for the MOHSW and recommending actions to strengthen the Ministry and its partners to ensure sustained environmental and social compliance monitoring. The implementation of the ESMF will address the safeguard policies of the World Bank and relevant laws of Liberia. A key element of the ESMF is to determine the institutional arrangements for implementing the project, including those relating to capacity building.

Also, as part of the ESMF development, there was identification the key stakeholders and describe mechanisms for consultation and disclosure of safeguard policies, with emphasis on potentially affected people.

The ESMF covers the environmental and social issues related to the health sector in general and help implement a national plan beyond the project life. 1.3 OVERALL APPROACH AND METHODOLOGY

This ESMF is a revised version of the former ESMF prepared in the context of the Liberia Health System Reconstruction Project 2009, and adapted to the new Liberia Health System Strengthening Project (HSSP), and its components/activities. The Health System Strengthening Project (HSSP), financed by IDA, supplements efforts toward health sector reform and development. In essence, the HSSP builds on the work carried out by the MOHSW and international partners in implementation of the national health plan.

This updated ESMF has been prepared in accordance with applicable World Bank safeguard policies and Liberian environmental assessment guidelines.


2.0 PROJECT DESCRIPTION

2.1 CONTEXT AND OBJECTIVES OF HSSP

The project is innovative in supporting and incentivizing the expansion of health worker skills and enhanced quality of services in a systematic and coordinated way at target facilities. Target secondary level facilities (which include five county-level hospitals) cover approximately 30 percent of the population of Liberia (see Table 1 below2), and include a mix of semi-urban and semi-rural health facilities. To make target hospitals accountable and motivated to improve the quality of services provided, a defined quality checklist comprised of key indicators of interest pertaining to clinical outcomes (e.g. adherence to predefined obstetric protocols), structural aspects of services (e.g. availability of drugs and equipment) and intermediate outcomes (e.g. patient satisfaction) will be incentivized. This quality checklist will initially include routine high impact services, but will be updated annually and scaled up, in line with the introduction of training on more complex services. The achievement of quality improvement will be heavily dependent on both graduate residents and faculty from the GMRP, as well as enhanced in-service training of lower cadres of health workers. Notably, in-service training for lower-level will be aligned with the continuous introduction of more complex skills over the life of the project. 2.2 Project Components The project will achieve its objectives through the following two components: (a) improving the institutional foundations needed to improve the quality of selected health interventions at target facilities (Component 1), and (b) improving health worker competencies to address key health-related concerns (Component 2). A third component will focus on Project Management.

Table1: Project Target Facilities

County District Facility Name Owner Catchment Population

1. Montserrado Greater Montserrado Redemption Hospital GOL 341,344

2. Margibi Firestone Firestone Medical Center PFP 119,984

2 These facilities were selected because they have weak quality of care outcomes, and more specifically, because: a) the semi-urban facilities (1-3 in Table 1) have the capacity to act as A1 teaching facilities; and b) the semi-rural and semi-rural facilities are strategically located, and ensure that the project benefits will spill-over to a large catchment population in both semi-urban and semi-rural areas.


3. Bong Suakoko Phebe Hospital NFP 248,300

4. Lofa Voinjama Tellewoyan Hospital GOL 66,010

5. Nimba Tappita

Jackson F. Doe Memorial Hospital (JFD Hospital)

GOL 177,285

Component 1: Strengthening the institutional foundations needed to improve the quality of selected health interventions at target facilities (US$10 million- US$5million IDA, and US$ 5 million HRITF) 1. Recognizing that quality of care is multidimensional, and encompasses both clinical processes, and structural aspects, this component aims to support improvements to the quality of care related to maternal health, child health, and infectious disease interventions at selected hospitals in Liberia through the provision of performance-based incentives to support: (a) improved clinical practice; (b) adherence to well-established and defined clinical and treatment protocols; (c) health worker motivation (both intrinsic and extrinsic); (d) structural improvements (e.g. availability of drugs and commodities, and health facility rehabilitation); and, (e) improved management capacity, governance, monitoring and record keeping at health facilities. In addition, select under-utilized/ under-provided services (defined in Table 2.1, Annex 2) will also be incentivized. Importantly, these improvements (as shown in Figure 1 above) will be heavily dependent on strengthened health worker competencies developed under component 2. A technical overview of PBF (including a glossary of key terms) is provided in Annex 6. Further details on this component are discussed in Annex 2.

2. This component design is innovative in that it: (i) clearly focuses on the quality of services at target hospitals, given both the existing poor quality and lessons learned from hospital PBF schemes in other countries3; and (ii) aims to incentivize appropriate clinical processes of care. In addition, this component will be rolled-out in a phased approach (i.e. pre-pilot in Montserrado county and larger roll out). This will allow the project design to be modified in response to lessons learnt from the pilot, and ensure that the existing management capacity particularly at the national level is not over-stretched. Subcomponent 1.1: Performance-based contracts with target facilities (US$7.5 million)

3 Early lessons on hospital PBF that are being examined in greater details include: (i) hospitals PBF seems to be very expensive but not increase utilization if incentivized on quantity of services (Lemiere, 2012); and (ii) incentivizing the utilization of primary care services at hospitals may distort the health system by taking patients from primary facilities.


3. Performance-based contracts: To address the systemic bottlenecks related to poor quality of care, and health system deficiencies discussed above, target health facilities will sign performance contracts with the MOHSW for quality improvement. Performance contracts will define the quality indicators that will be monitored and incentivized across key categories (e.g. maternity, pediatric/ neonatal, surgery, management hygiene and patient satisfaction, and health worker performance). Importantly, the weighting of indicators on clinical processes and structural indicators will be expected to shift over time, with an increase in the number of clinical process indicators (vis a vis structural indicators), as the capacity of health facilities (and structural conditions) improve. 4. Improving poor quality-of-care involves not only giving better care but also eliminating under-provision of essential clinical services. As such, contacts will also define the (limited) services whose utilization will be incentivized (i.e., quantity indicators) and associated financial incentives for each unit of these service provided. This includes, for example, major and minor surgery and the treatment of referred newborn children for emergency neonatal care. Primary care level services and outpatient services will be excluded from the package to avoid the unwanted shift of patients from the primary level facilities to the hospital level. The incentivized package of services is outlined in Annex 2 (Table 2.1).

5. Notably, seventy-five percent of incentive payments to health facilities will be based on quality improvements, and twenty-five percent will be linked to improved utilization of incentivized services. The level of incentives will be adjusted to take into account equity considerations; for example, the remoteness of a health facility. Incentives will also be reviewed quarterly, and periodically as needed based on results achieved (or lack thereof) and budget disbursement (e.g. faster or slower than anticipated disbursements).

6. Use of Performance Incentives: There is a strong emphasis on providing health facilities with sufficient autonomy to manage funds for further improvement of service delivery outcomes so as to be able to achieve the results. Performance payments can be used for: (i) health facility operational and capital costs, including maintenance and repair, drugs and consumables, outreach activities (e.g., for transport, performance payment to community workers, and demand-side incentives); (ii) quality-enhancement measures (e.g. teaching infrastructure and supplies to support the faculty and residency training requirements); and, (iii) financial and non-financial incentives for health workers according to defined criteria4. Notably, performance based incentives will be complimentary to (traditional and) existing input-based financing at target facilities from the MoHSW budget allocation for all facilities- except Phebe Hospital which receives its funding 4 Tentatively, health facilities can use up to 50 percent of the earned performance bonus for financial incentives for health workers, and the rest on health facility operational and capital costs.


directly from the Ministry of Finance (MoF).

7. Verification: Facilities that are provided with financial incentives linked to quality and utilization for specific services, have an incentive to over-report. As such, a strong emphasis will be placed on verification of results through both ex-ante (i.e. prior to making a payment), and ex-post verification. Specifically, the quantity and quality of services delivered will be verified through independent verification by the Liberia Medical and Dental Council (LMDC)- prior to making the payment. Ex-post verification will be carried out in two ways. First, semi-annual counter-verification of quantity and quality of services in all target facilities will be facilitated by the PBF unit, and will be led by 2- 3 GMRP faculty members. This will seek to (re-)verify both the quality and quantity of services provided, and random verification of whether activities are adequately complied with (e.g. forms are completed accurately), and conditions have been adhered to. Second, a community based organization (CBO) will be contracted by the MOHSW in each county to visit homes of randomly chosen clients (selected from the health facility registers). This is discussed further in Annex Subcomponent 1.2: Management and Capacity building (US$2.5 million) 8. This sub-component aims to provide intensive technical support to build institutional capacity to manage the PBF approach discussed above, and support its long-term (institutional and technical) sustainability provided expected results are achieved. Specifically, this sub-component will support technical assistance and independent verification in the following 4 key areas:

(a) Capacity building of key stakeholders (e.g. relevant MoHSW staff,

LMDC, County Health and Social Welfare Teams (CHSWTs) and hospital directors) as needed in areas such as quality improvement, business plan development and implementation, reporting and results-monitoring, quality verification and hospital management. A capacity building plan is detailed in Annex 2 (Table 2.2).

(b) Development of rigorous quality and quantity verifications systems; (c) Development of a secure and user-friendly website to post RBF

results for payment; and, (d) Knowledge sharing and dissemination workshops- this will ensure

that there is a rigorous and systematic program of learning, and will include, for example, workshops for hospital management of target facilities to discuss results achieved, implementation challenges and approaches being employed to overcome these challenges.

Component 2: Improving health worker competencies to address key health-related concerns at target facilities (US$4.2 million IDA)


9. Component 2 will complement efforts to improve the quality of care at target health facilities (discussed under component 1), by improving the availability and competencies of health workers in these facilities, in critical areas- obstetrics, pediatrics, surgery and infectious diseases. Whereas PBF is expected to narrow the gap between what health workers know how to do, and actually do by providing funding to improve inter alia, provider-accountability for results, health worker motivation, and the availability of inputs, further performance improvements in quality of care at the target hospitals are dependent on an increase in the numbers of health workers with improved competencies. 10. Cognizant of this, component 2 will support: (a) the GoL’s ongoing effort to develop and implement an innovative graduate medical residency training program (GMRP) to increase the number of physicians with specialized certified skills and competencies in the areas of obstetrics, pediatrics, surgery and infectious diseases; and, (b) the development of an innovative continued professional development and outreach (targeted and needs-based) training program for lower level cadres- nurses, midwives and physician assistants (PAs)- in intervention facilities as well as satellite health centers, which leverages the increased capacity of residents and faculty under the GMRP.

11. In addition to improving much needed health worker skills and competencies at the target secondary-level facilities, the interventions supported under component 2 are expected to result in a number of positive externalities. This includes: (i) shift in the availability of higher level health worker cadres, as well as the culture of health worker training5, to health facilities outside of urban Monrovia (residents will be mandated to rotate between semi-urban and rural training sites); (ii) reduce the need to pursue specialization and training abroad (and thus reduce outmigration); and, (iii) improve the overall motivation of health workers (globally, opportunities for further education are a significant motivator), and thus the quality of services delivered. Sub-Component 2.1: Improved physician competencies through support to the Graduate Medical Residency Program (GMRP) (US$4.2 million) 12. This sub-component will support the design and implementation of a progressive and nationally accredited GMRP, for both recent medical graduates, and practicing physicians in defined critical specialist areas of obstetrics, surgery, pediatrics, and infectious diseases. This will respond to 5 Diversifying the training of physicians away from urban training locations, and exposing health workers to rural practice and working conditions, may also contribute towards longer term goals of ensuring more systemic and equitable distribution of health workers. Training health workers in rural areas- in combination with other interventions is not only linked to improvements in both the relevancy and quality of training but also the likelihood that physicians will choose to practice outside of the capital after their training.


immediate needs to develop and upgrade relevant skills needed in order to address poor quality of care at target facilities. 13. Specifically, under this subcomponent, the project will provide critical support in identifying, recruiting and funding relevant faculty (through developing MOUs with Teaching Hospitals in African and non-African countries) to mentor and train residents at target facilities in defined critical specialist areas. As part of the residency program requirements, the project will support resident rotations between Liberia’s only tertiary hospital JFK (located in Monrovia), specialist training sites in semi-urban target facilities in Montserrado, Margibi and Bong Counties, and so-called affiliated training sites in target hospitals which are located in very marginalized, rural counties- Lofa, Nimba and Maryland. Furthermore, the design of the residency program will leverage the teaching capacity developed under the GMRP, and mandate and incentivize faculty (and in situ residents) to also train existing lower-level health workers (in addition to residents). This is discussed further under sub-component 2.2. Notably, the country’s main teaching facility and only tertiary hospital- JFK Hospital- is part of the resident rotation but will not be directly funded under the project, unless there are justifiable and exceptional circumstances. As discussed, a large proportion of government funding is already channeled through this hospital. 14. In terms of funding, this sub-component will fund faculty, as well as financial incentives to support and facilitate the rotation of residents to semi-rural health facilities. Funding for minor infrastructure, equipment and supplies, to accommodate the residency program, will not be provided under this sub-component, but will be covered under component 1 (discussed above). This will ensure that target hospitals (specialized teaching and affiliated teaching) can accommodate the influx of residents and faculty provided under this sub-component, as well as meet minimum teaching standards with regards to equipment and supplies. Facility needs supported under component 1, will be determined based on a needs assessment, with the West African Health Organization (WAHO) Accreditation requirements used as a benchmark to the extent possible. Sub-Component 2.2: Improved competencies of lower level health cadres by support to critical in-service training programs 15. This subcomponent will leverage the teaching capacity made available under sub-component 2.1 to provide specialized training in obstetrics, pediatrics, surgery and infectious diseases to midwives, nurses, and PAs in the 6 target hospitals as well as satellite health centers. This will address a key concern that health workers across all cadres are insufficiently receiving both in-service training and opportunities for continuous professional


development. This negatively affects their competencies and motivation, and ultimately service delivery outcomes.6 16. Specifically, the faculty recruited and placed in target facilities under the residency program (as well as some senior residents) will be mandated contractually to carry out training sessions to other clinical health workers in both the intervention hospitals where they are stationed, as well as in satellite health centers (located in the hospital catchment areas) as part of mandated community outreach. Notably, in close alignment with the PBF mechanism under component 1, hospital managers will be incentivized (under the Package of Services defined in Annex 2) to ensure that a relevant number of training and outreach sessions are provided by faculty and selected senior residents to medical and auxiliary staff. Training will conform to a number of innovative and new, but also well tested and frequently utilized formats; this will include Team Training Sessions, Grand Rounds, Practical Clinical Training Sessions, Team-based Teaching & Learning, IT-moderated skill labs, and workshops focusing on particular specialized topics. 17. Over the project implementation period, an estimated 60 percent of lower level cadre staff – including nurses, midwives, PA’s in project target facilities- will receive continuous professional development training in key relevant competencies linked to obstetrics, pediatrics, surgery and infectious diseases. This includes staff at both the 6 project target facilities, and satellite health centers, through the mandated outreach to be provided. Component 3: Project Management (US$0.8 million IDA) This component will support the operational capacity of the MoHSW to effectively manage the project. This will include support to the operational costs of a project- specific unit- the HSSP Coordination Office- within the MoHSW that will be responsible for coordinating project activities. Notably, this Office was directly responsible for project coordination under the recently closed World Bank Health Systems Reconstruction Project (HSRP), and benefitted from significant capacity building in areas such as FM, and procurement. The former Coordinator will also take on this role for the new project.

2.3 IMPLEMENTATION

A. Institutional and Implementation Arrangements

18. As previously noted, the HSSP Coordination Office within the Project Management Unit (PMU) of the MoHSW will have direct responsibility and oversight for overall project coordination and management. Specifically, the 6 National HRH Plan, 2011-2021


PMU will work closely with the PBF Unit and GMRP Council to coordinate the overall project (both the PBF and training components); organize technical support (e.g. capacity building of the Liberia Medical and Dental Council (LMDC), CHSWT, and target facilities); and provide overall financial oversight of the project for both the PBF and training components. The HSSP Coordination Office will have direct responsibility for coordinating the procurement of related goods, services, and any civil works at the central level (e.g. international faculties for the training component, and TA). The project implementation arrangements are diagrammatically outlined in Figure 2 below. 19. Component 1: Implementation arrangements for improving quality of care through a PBF approach will span three levels - county-level, central-level, and health facility levels, and will ensure that there is separation of functions between: a) the regulator (MOHSW- Dept of Health Services, and CHSWT at the county-level); b) the fund holder for payment (OFM); c) the purchaser (MOHSW- Dept of Administration); d) verifiers (LMDC and CBOs); and, e) providers of health services.

At the central level, the PBF Unit will be the technical focal point, and will be expected to work closely with the PMU, M&E Unit, OFM and other relevant units on oversight, payment, PBF data management, and in facilitating counter-verification. Incentive payments will flow directly from OFM to health providers. In addition, semi-annual counter-verification will be led by 2-3 faculty members hired by the GMRPC 20. To safeguard the institutional sustainability introduced by the project (under both components 1 and 2), significant local capacity and technical skills will be developed over the course of project implementation, including in relevant MOH units (e.g. the Dept. of Administration and PBF unit), LMDC, the specialized and affiliated teaching hospitals, and the GMRP Council which will be responsible for coordinating and managing the medical residency program, and scaling up teaching capacity. This will ensure that a system is developed which can be seamlessly scaled-up and maintained by local counterparts. The project implementation arrangements are diagrammatically outlined in Figure 1 below. Component 1 will be implemented in close technical partnership with other donors (e.g. USAID/RBHS, and pool Fund donors (e.g. DFID, UNICEF) and EU. It is expected that this partnership, which shares the MOHSW’s vision of full PBF roll-out, will jointly discuss the progress of the various projects, implementation arrangements and results with the view to ensure harmonization and comprehensiveness. 21. Component 2: Administration of the GMRP will fall under the GMRP Council (GMRPC). The GMRP Council, jointly with the Liberia College of


Medical (COM) - which is represented on the Council-, is responsible for tasks such as the recruitment of faculty, and development of residency curricula and standards. It will be supported by the West Africa College of Physicians and Surgeons, which falls under the authority of the West African Health Organization (WAHO), and the Ghana College of Physicians and Surgeons. They will work jointly to, inter alia, accredit the GMRP nationally, while gradually progressing towards regional WAHO accreditation standards and the Ghana College of Surgeons Accreditation standards.

22. The GMRP Council will work closely with the PMU on all aspects related to the development and implementation of the GMRP. The Council, which is headed by a national chairman, includes the Dean of the Liberia COM, and liaises with the academic chairs in Obstetrics, Pediatrics, Surgery and Infectious Diseases (amongst others), as well as the concomitant chiefs of department at the JFK Teaching Hospital. Under a special MOU, they will work closely together and with the PMU and other relevant agencies to develop and implement all key program activities related to the GMRP. This includes: sourcing and hiring of relevant faculty; academic and clinical supervision of faculty and residents; administering rural incentives for rotation; and overall program monitoring including relevant indicators under the PBF quantity and quality checklists.

Overall administration of the in-service training sub-component will also fall under the GMRP Council, which, jointly with the COM, will work closely with the Liberia Medical and Dental Council (LMDC), the representative body for all health professions in Liberia. Specialized Faculty recruited under the GMRP will follow strict in-service training curricula and guidelines developed by the LMDC. As discussed under the implementation arrangements (Annex 3), the LMDC is represented in the GMRP Council. The GMRP Council is also tasked with overall coordination and administration of training during project implementation.

FINAL DRAFT ESMF of HSSP for MOHSW, Liberia, HSSP, February 2013 25 |

3.0 BIOPHYSICAL AND SOCIO-ECONOMIC ENVIRONMENT

3.1 THE BIO-PHYSICAL ENVIRONMENT

3.1.1 Location, Size and Characteristics

Liberia is situated on the southwest corner of the West Coast of Africa. It lies between the longitudes of 7o30' and 11o30' west and latitudes 4O18’ and 8o30' north. It covers a surface area of about 111,370 km2 (about 43,506 square miles). The dry land extent is 96,160 km2 or 37,570 sq. miles.

Figure 6-1: Location of Liberia

Liberia is bordered on the west by Sierra Leone, on the north by Guinea, on the east by Côte d’Ivoire and on the south by the Atlantic Ocean. The perimeter is 1,585 km (990 miles), excluding the Atlantic Ocean. The border with Guinea is 563 km (352 miles), Cote d’Ivoire 716 km (446 miles), and Sierra Leone 306 km (191 miles). There are four topographical regions at different altitudes, each with distinct physical features. Along the sea coast is the coastal plain of 350 miles (560 km), an almost unbroken sand strip, which starts from the lowest elevation up to 30 meters above sea level. Next to the coastal plain is the belt of inundated plateau followed by the belt of high lands and rolling hills in the north and northwest. The lowest point is the Atlantic Ocean at zero meters and highest elevation is the northern highlands, which includes Mount Wutivi (1380 meters), the highest point in Liberia.


Figure 6-2: Topographical Regions of Liberia

Rivers

The geomorphologic structures and relief determines the drainage patterns of the watersheds or river systems. The major river basins drain the territory in a general northeast to southwest direction to the Atlantic Ocean. Major exceptions to the pattern is the middle reaches of the Cavalla and Dugbe in eastern Liberia, which flow parallel to the coast in their lower reaches before entering the Atlantic Ocean. There are six major rivers, which drain 66 percent of the country. These are Rivers Mano, St. Paul, Lofa, St. John, Cestos and Cavalla. The short coastal watercourses drain about 3 percent of the country and include the Po, Du, Timbo, Farmington, and Sinoe rivers. The largest and longest is the Cavalla River. These rivers are not navigable and therefore do not supports water transport and industrial fishing.

Lakes

There are only two major lakes in Liberia – Lake Shepherd in Maryland County and Lake Piso in Grand Cape Mount County. Lake Piso is the larger of the two. Both of them are along the Atlantic Ocean. Lake Piso is characterized by a vast expanse of wetlands and lowland forest vegetation. They are one of six proposed protected areas of Liberia. There are other large ponds, which people refer to as lakes. The most popularly known in this category is the Blue Lake in Tubmanburg, Bomi county. This large pond was created from iron ore mining that left a large unclaimed land. It is now a tourist attraction.


3.2 Climate and Hydrology

The equatorial position and the distribution of low and high-pressure belts along the African continent and Atlantic Ocean determine the climate of Liberia and more generally, West Africa. Because of this position and the moderating influence of the ocean, a fairly warm temperature throughout the year with very high humidity is common. Liberia’s equatorial position puts the sun almost overhead at noon throughout the year giving rise to intensive insulation in all parts of the country, a consequence of high temperature with little monthly variations. Notwithstanding the temperature would have been much higher had it not been for the effect of the degree of cloud cover, air, humidity and rainfall, which is influenced by the luxurious vegetation cover of the country. The Atlantic Ocean also has an additional ameliorating effect on the temperature along the coast with maximum annual and daily variations. As a whole, the temperature over the country ranges from 270C to 320C during the day and from210C to 240C at night. High altitude explains a pleasant climate near the Guinean border.

Figure 6-3: Annual rainfall distribution across Liberia

The Country has two seasons: raining and dry seasons. The dry season lasts from mid-


November to mid-April; raining season from mid April to late October. Average annual rainfall along the coastal belt is over 4000mm and declines to 1300 mm at the forest-savanna boundary in the north (Bongers, F et al, 1999). Relative humidity is generally high throughout the country; on the coastal belt it does not drop below 80% and on the average is above 90%. There is a wider variation in the interior; it may fall below 20% during the harmattan period. A relative air humidity of 90% to 100% is common during the rainy season. During the dry season it decreases between 80% and 85%. In March and February the driest period of the year, relative air humidity decreases to as low as 65%. Total wind speed is greatest in the rainy season and lowest in the dry season. However, there are local variations, with the coastal area having much more wind than the interior of the country. The low wind speed in the interior can be attributed to the vegetation cover. The largest recorded wind speed (45 miles/hour) has been in Buchanan, a coastal city. The inter-tropical Front, which is the boundary of the air masses, moves south. Also Harmattan influences the climate of much of West Africa, it blows from the Sahara Desert, and reaches Liberia at the end of December with low relative humidity percentage. It brings along a considerable amount of dust and low and chilly temperatures during the night. The equatorial position and the distribution of high and low pressure belts over the African continent and the Atlantic Ocean influence the climate of Liberia. Rainy and dry seasons with a transitional period can be distinguished. The months of heaviest rainfall are June, July and September. Notwithstanding the rainy season lasts from late April to October. The dry season begins in November and ends early April. It does not rain continuously during the rainy season. It is common to have sunny days during the months when the rain is heaviest. This is also true for the dry season; there are some rainy days during the dry season. The rainfall ranges from 2000 to 4000 mm/year with an average of 2,372mm. The internally produced renewable water resource is estimated at 200km2. This amount of water is drained into the Atlantic Ocean by two-river systems. The major basins drain the territory in a general northeast –southwest direction. There are six major rivers, which drain the country with north-south pattern: Mano, St. Paul, Lofa, St. John, Cestos and Cavalla. They drain 66% of the country. The short coastal watercourses drain about 3% of the country and include by not limited to the Po, Du, the Timbo, the Farmington, and Sinoe rivers (see map, rivers of Liberia).


Figure 6-4: Mouth of the Sinoe River near the Coast in Greenville

3.3 Geology

The rocks of northern Liberia generally form part of the West Africa Cretan, recognized by its stability and general absence of tectonic activity during the last 2.5 billion years. This old and stable base was subsequently penetrated by younger rocks and then covered by metasedimentary and metavolcanic rocks of at least two younger tectonic events.

Table 6.1: General Stratigraphy of Rocks

Tectonic Period Type of Rock Age (Million years)

Liberia Age Metamorphic and Igneous Rocks

2,500-3,000

Eburnean Metamorphic and Igneous Rocks

2,150 ± 100

Pan-African Age Metamorphic and Igneous Rocks

600 + 100

Post Pre-Cambrian Unmetamorphosed Sedimentary Rocks and Igneous Intrusives

Less than 600

The rocks of Liberian Age extend into neighbouring Sierra Leone, Guinea, and Ivory Coast and predominately are highly foliated granitic gneisses exhibiting a regional foliation and structural alignment in a north-easterly direction. Major faults along sections of the Lofa and the St John River are parallel to regional lithological units and have significantly influenced present topography. Massive unfoliated to weakly foliated granitic rocks exist over large areas in the extreme north of the country. Within the Liberian Age Province are


Metasedimentary rocks, such as quartzites, amphibolites, pelitic schists and banded ironstones technically called itabarite. Granitic gneisses and the metasedimentary rocks have been intruded by numerous northwest trending diabase dikes. These are parallel to the coast and represent intrusive activity associated with the onset of continental break-up in Jurassic time. Rocks of Eburnean Age are restricted to southeast Liberia where they extend into the Ivory Coast. Their structural trend is similar to those of the Liberian Age Province but is more biotite rich. A major tectonic feature within rocks of the Eburnean Age province is the Dube shear zone. It intersects the coastline about 40km west of Harper and strikes a NNE direction into the Ivory Coast. It is 2 to 3km wide and has been delineated on the basic of outcrops, topography and magnetic data. Rocks of the Pan-African Age are found along the coast from northwest of Greenville in the southeast to Sierra Leone. Unlike the north-eastern regional trends of both the Liberian and Eburnean Age Provinces, structural trends within the Pan-African Province generally are north-westerly and parallel to the coastline. The rock types in this province range from basic igneous to peletic rock metamorphosed to the granulite and amphibolite grades. The Post Pre-Cambrian rocks in Liberia outcrop principally along the low- lying coastal area between Monrovia and Buchanan. Two onshore, sediment- filled basins also are located along this section of the coastline: the Roberts Basin filled with sediments of the Farmington River formation and Paynesville sandstone, and the Bassa Basin filled with material from the St John River Formation. Rocks found in Liberia have been of economic importance and should continue to be in the future. Crystalline Rocks (igneous and metamorphic) are used locally in the construction industry as roadbed materials in building construction and as foundation stones in building construction. Post Pre-Cambrian rocks are used in the building industry where beach and river sands form the major constituents in the manufacture of concrete blocks.

Sunshine and Temperature

The sun is overhead at noon throughout the year, giving rise to intense insolation in all parts of the country. This results in high temperatures with little monthly variations. Temperatures would have been much higher had it not been for the effect of the degree of cloud cover, air, humidity and rainfall, which are influenced by the vegetation cover of the country. Daily sunshine hours are at a minimum during July, August and September. The days with longest hours of sunshine, fall between December and March, averaging more than six hours per day (MPEA 1983). The Atlantic Ocean also has an additional ameliorating effect on the temperature along the coast with


maximum annual and daily variations. As a whole, the temperature over the country ranges from 27-320C during the day and from 21-240C at night. High altitude explains a pleasant climate near the Guinean border in the north. Along the coast, the average annual temperature ranges from 24-300C (75-850F). In the interior it is between 27-32oC (80-900F) (MPEA 1983). The highest temperature occurs between January and March and the lowest is between August and September. The low temperatures are mainly caused by the amount of cloud cover.

3.4 Rainfall

The country has two seasons: rainy and dry seasons. The rainy season is from May to October, and the dry season runs from November to April. Average annual rainfall along the coastal belt is over 4000 mm and declines to 1300 mm at the forest-savannah boundary in the north (Bongers and others 1999). The months of heaviest rainfall vary from one part of the country to another, but are normally June, July and September Rainfall is caused by the South Atlantic sub-tropical high wind called the southwest Monsoon of the Maritime Tropical Air between April and October. For the rest of the year, the Inter-Tropical Front moves south, and most of West Africa comes under the influence of the low pressure from the Sahara Desert. At this time low humidity prevails usually from the end of December to January, and sometimes till February. This dry wind sweeps across the continent and reaches Liberia between December and February bringing considerable amounts of fog and dust with low cool temperatures during the night. Since the soils in Liberia have low moisture storage capacity, the amount and frequency of rain during the dry season becomes a limiting factor for crop cultivation. Despite the heavy torrential rainfall, it does not rain continuously during the rainy season. It is common to have sunny days even during months when rain is heaviest. Observations concerning the diurnal distribution of rainfall prove that two-thirds of the rain along the coast, particularly in Monrovia and its environs, falls during the night between 18.00 and 07.00 hours. Most of the rest of the rain usually falls during the morning while only a minimum of rain is recorded between mid-day and early afternoon. This is one of the reasons why the rainy season in Liberia is not as inconvenient and disturbing as in other parts of West Africa. Data on Liberia’s isokeraunic (thunderstorm) condition is not available, but 150 thunderstorms days per annum have been recorded at Roberts International Airport (Schulze 1975).


Humidity

Relative humidity is generally high throughout the country. Along the coastal belt it does not drop below 80 per cent and on average is above 90 per cent. There is a wider variation in the interior, where it may fall to below 20 per cent during the harmattan period. A relative air humidity of 90-100 per cent is common during the rainy season. In Monrovia, the relative humidity shows a relationship with the existing air temperature and its variation depends on the prevailing season and the hour of the day. During the dry season it decreases to 80-85 per cent. In March and February the driest period of the year, relative air humidity may be as low as 65 per cent. Regardless of the season, the relative humidity at night and in the early morning is usually in the range of 90-100 per cent. Data from other weather stations such as Bomi Hills, Harbel and Greenville show similar results. Only the zone, north of the Inter-Tropical Front, where the continental air masses prevail from mid-December to end of January show arid conditions. At times due to the extreme dryness of the harmattan, the humidity may drop to below 50 per cent (Schulze, W. 1975) 3.5 SOCIO-ECONOMIC ENVIRONMENT

The Liberia economy has been in decline since the 1980s due to extreme social and political upheaval and mismanagement. The war destroyed productive capacity and physical infrastructure on a massive scale. The result has been a precipitous economic decline and the deepening of national poverty. Liberia- a nation that had achieved food security and middle income status in the 1970s- is totally a shell of the past. Per capita Gross Domestic Product (GDP) in 2005 prices declined from us$1,269 in 1980 to US$163 in 2005, a decline of 87%. It is estimated that three fourths of the population is living below the poverty line on less than US$1 a day (IPRS 2007). During the war, agricultural production dropped precipitously as people fled their farms and markets closed. Mining and timber activity nearly ceased, rubber plantations closed, manufacturing dropped sharply and services ground to a halt. Basic infrastructure was badly damaged by the conflict. There was virtually no public source of electricity or piped water in the country for 15 years until recently, when power and water was restored to parts of Monrovia in July 2006. Schools, hospitals, and clinics were badly damaged, and most government buildings are in shambles. Many roads are still impassable, which seriously constrains peace building efforts, weakens economic activity and undermines basic health and education services.


Demography

The total population of Liberia on the night of 20th/21st March 2008 was 3,476,608. Given the population in 1984 as 2,101,628, there has been a rise of 1,374,980 people and this increasing trend has been seen since 1962 (Figure 6.1: Population Change, Liberia 1962-2008). The annual population growth rate is 2.1 percent. The total population is seen to be unevenly distributed among the counties. Ever since 1984, the population distribution favours “the big six”-Montserrado, Nimba, Bong, Lofa, Grand Bassa and Margibi Counties in descending order of magnitude. They account for 75.4 percent of the total population count, up by 0.6 percent what it was in 1984. Montserrado, Nimba and Bong Counties hold exactly 55 percent of the population. From the other end of the scale, the “small five”- Grand Kru, Rivercess, Rivergee, Bomi and Gbarpolu Counties-continue to hold the least population totals. They together have 10.5 percent of the national count and each of them contributed less than 2.5 percent (Table 5). The fact that the bottom set of five counties in 1984 had a population of 12.0 percent shows that there has been a tendency for the population to gravitate towards counties with higher populations during the inter-censal period. In 2008, the population density of Liberia was 93 persons per square mile. This represents 66 percent rise over the figure of 56 attained in 19984. The population age structure shows a substantially larger proportion of persons in the younger age groups than in the older age groups for each sex. This is a reflection of the young age structure of the population of Liberia and indicates a population of high fertility. Forty-seven percent of the population are below 15years of age, 49 percent are in the age group 15-64, and 3 percent are age 65 or older. However, there is an implausibly large drop-off between ages 10-14 and 15-19. Average life expectancy at birth is estimated by WHO (2006) at 42years, with 44years for women and 39years for men. The total fertility rate (TFR) is 5.2(DHS, 2007). Women under 25years contribute about two-fifths of the TFR in Liberia. The contraceptive prevalence rate has increased from 10 percent of currently married women in the 1999/2000 LDHS to 11 percent in 2007. Liberia households most commonly consist of four or five members, with the average household size being five persons.

Figure 6-5: Distribution of Population by County, Liberia 2008


Figure 6-6: Population change, Liberia 1962-2008


Mortality and Morbidity

Survey data shows that over the past 20years the under-five mortality has been cut in half, from 220 deaths per 1,000 births measured in the 1986 LDHS to 110 in the 2007 LDHS. Still, one in every nine Liberian children dies before reaching age five. For the most recent five-year period before the 2007 survey (approximately calendar years 2002-2006), the infant mortality rate is 71 deaths per 1,000 live births and under-five mortality is 110 deaths per 1,000 live births. The neonatal mortality rate is 32 deaths per 1,000 live births and the post neonatal mortality rate is 41 deaths per 1,000 children surviving to age one year. Mortality rates at all ages of childhood show a strong relationship with length of the preceding birth interval. Under-five mortality is more than twice as high among children born less than two years after a preceding sibling than for those born four or more years after a previous child (208 vs 91 percent per 1,000 births). Survey results show that only 39 percent of Liberia children ages 12-23 months are fully vaccinated with BCG, measles, and three doses of DPT and polio. Nine percent of children under age five years were reported to have had cough with short rapid breathing in the two weeks before the survey that was not just due to a blocked or running nose. Almost six in ten children with fever are taken to a health facility or provider for treatment and the same proportion are given anti malarial drugs. Eight in ten mothers (79 percent) in Liberia receive prenatal care from a health professional. Sixteen percent of mothers receive prenatal care from a traditional midwife and 4 percent of mothers do not receive any prenatal care. Survey results show that more than three-quarters (76 percent) of women age 15-49 with a live birth in the two years preceding the survey took some kind of anti malarial medicine for prevention of malaria during pregnancy. LDHS data shows that the majority of births in Liberia (61 percent) are delivered at home and 37 percent are delivered in health facilities, mostly public sector facilities. Results from the 2007 LDHS indicate 1.5 percent of Liberia adults are infected with HIV. HIV prevalence in women age 15-49 is 1.8 percent, while for men 15-49, it is 1.2 percent. The higher infection level among women is common in most population based estimates of HIV infection. The peak prevalence among women is at age 35-39 (2.5 percent), while among men, prevalence is highest at age 25-29 and 45-49. There is no consistent pattern of HIV prevalence by age among either women or men; rather the levels fluctuate by age group.


3.6 Water and Sanitation

The 2007 LDHS shows that only two-thirds (65 percent) of Liberia households have an improved source of drinking water. By far, the most common single source of water is protected dug wells (54 percent of households). Urban households are much more likely than rural households to use an improved source of drinking water (82 vs. 56 percent, respectively). One-fifth of rural households get their drinking water from lakes and ponds (surface water). Only 10 percent of Liberia households use an improved, unshared toilet facility and 90 percent have access to a non improved facility. Over half (55 percent) of households do not use any toilet facility. These results indicate that considerable resources dedication and effort are needed to improve toilet facilities in Liberia.

Access to Health Care

According to DHS, 2007, over half of Liberia women indicated that the major problems they faced in accessing healthcare are getting money for treatment (54 percent) and the concern that no drugs are available (51 percent). Additionally, distance to health facility, the need to take transport and concern that no health provider will be available are cited by 41-50 percent of women. Only 8 percent of women perceived getting permission to go for treatment to be a very serious problem. Three-quarters of women considered one of the factors above to be a serious problem in accessing healthcare.

Health Care Delivery and Resources

Health care delivery is fragmented and uneven, heavily dependent on donor-funded vertical programs and international NGOs. Disease prevention, and control programs exist for malaria, leprosy, tuberculosis, STDs/HIV/AIDS, and onchocerciasis. Humanitarian relief agencies concentrated their interventions in the most war-affected areas and where refugees and IDPs were resettling. Many health care providers including Community Health Workers are funded by emergency programs, which are being withdrawn as the country stabilizes. The gap created by the reduction in funding for emergency assistance, before development aid starts flowing, has the potential to disrupt health care provision, as witnessed in other post-conflict settings. In 1990 there were 30 Hospitals, 50 Health Canters and 330 Clinics functional. In 2006, 18 hospitals, 50 health centers and close to 286 health clinics were considered to be functional (RAR, 2006). Many of these facilities struggle to attain acceptable performance levels, and are in need of robust infrastructural interventions to become truly functional and respecting referral functions. The hospital component of the health sector is under-sized. Its technical capacity is


grossly inadequate. Large investments are already under way to restore the functionality of some hospitals. In order to improve health care delivery and resources, the Ministry of Health and Social Welfare has developed a National Health Policy and Strategic Plan. A key part of the plan is to have 70 percent of health facilities providing a Basic Package of Health Services (BPHS) by December 2010. In order to meet this goal, the Ministry has been attempting to improve the human and infrastructural resources of the health sector. The Ministry aims to rehabilitate 205 health facilities and double the health workforce from 3,966 to between 6,000- 8,000 workers in the period covered under the current Poverty Reduction Strategy from 2008-2011.

3.7 HEALTH NEEDS AND CHALLENGES

Enabling the health sector to play a full and effective role implies addressing immediate as well as long-term challenges in a holistic and balanced way. The health needs of a distressed and impoverished population must be alleviated by urgent measures, while starting to invest in the areas that will make the future growth of the health sector possible. The post war needs include:-

• Assurance of quality equitable antenatal care and safety in obstetric practices

• Assurance of child health • Addressing nutrition issues • Dealing with the current burden of disease Addressing the high

fertility rate • Meeting demand for access to quality health services Development of a

social welfare policy and strategy. • Meeting population requirements to access safe water and sanitation

The immediate challenge is expanding access to basic health care of acceptable quality, through immediate interventions such as:

• Ensuring the availability of funds at county level to support the continuous delivery of basic services;

• Improving the availability of essential medicines and other critical health commodities;

• Rehabilitating health facilities in under-served areas; • Upgrading the skills of health workers and redeploying them to areas

where they are most needed; • Boosting management capacity at all levels to support the delivery of

services. The step in this direction is improving the information base and evaluation capacity;

• Improving availability of safe water and sanitary facilities.


4.0 POLICY, LEGAL, INSTITUTIONAL FRAMEWORK FOR

ENVIRONMENTAL MANAGEMENT

Liberia has put in place several policies and signed a number of protocols aimed at improving environmental management in the country. These range from national laws, regulations, policies, strategies and action plans to multilateral environmental agreements. As the government tries to put the country back on the path of sustainable development, the challenge will be the effective implementation of these various laws and regulations. The Environmental Protection Agency (EPA) is the government authority mandated by law to monitor, coordinate and supervise environmental issues in the country. There are also many other stakeholders involved in the sector. However, the overall responsibility for managing the environment lies with every Liberian. 4.1 POLICY FRAMEWORK FOR THE MANAGEMENT OF THE ENVIRONMENT

The National Environmental Policy of Liberia offers a set of guidelines for sustainable management of the environment. It is part of a strategic plan of action on which laws and regulations related to the environment are based. The overall goal of the policy is to "ensure the long-term economic prosperity of Liberia through sustainable social and economic development to meet the needs of present generation without compromising the potential of future generations to meet their needs". Particularly, the policy seeks to:

• Maintain ecosystems and ecological processes essential for the functioning of the biosphere;

• Ensure sound management of natural resources and the environment;

• Adequately protect humans, flora, fauna, their biological communities and habitats against harmful impacts, and preserve biological diversity;

• Integrate environmental considerations in sector and socio-economic planning at all levels throughout the nation; and

• Seek common solutions to environmental problems at regional and international levels.

The policy recognizes that environmental concerns are cross-sectoral and require an integrated multi-sectoral management approach. The institutional


arrangement to enhance effectiveness of implementing this policy is principally through two corporate bodies. (i) The National Environmental Council of Liberia, foreseen in the Act Creating the Environmental Protection Agency, will be responsible for policy formulation and implementation of the Environment Protection and Management Law, setting environmental protection priorities, national goals and objectives, ensuring implementation of environmental policies and programs, and collaborating with the Agency on policy affecting the environment. The Council has yet to be formed; and (ii) The Environmental Protection Agency shall be responsible for coordinating, integrating and harmonizing implementation of environmental policy and decisions of the Council and line ministries, shall encourage the use of appropriate environmental technologies, and shall propose environmental policies and strategies.

4.1.1 National Environmental Action Plan

The Act creating the Environmental Protection of Liberia requires the EPA to in every five years, in consultation with the Line Ministries and County Environmental Committees, prepare a National environmental Action Plan, the first of which shall be prepared two years following the effective date of EPA act and shall be submitted to the Council for consideration and approval. The National Environmental Action Plan shall:

• Contain all matters affecting the environment and provide general guidelines for the management and protection of the environment and natural resources of Liberia well as the strategies for preventing, controlling, or mitigating any deleterious effects;

• Be the basis for national environment planning and implementation of development programmes;

• Recommend appropriate economic and fiscal incentives as instruments for environmental protection to be incorporated into the planning and operational processes of the economy and recommend areas for environmental research and outline methods of utilizing research information;

• Recommend methods for building national awareness on the importance of sustainable use of the environment and natural resources for national development;

• Take into account County Environment Action Plans as provided for under section (31) of this Act;

• Identify and recommend policy and legislative approaches for preventing, controlling or mitigating specific as well as general adverse impacts on the environment;


• Be disseminated to the public;

• Without prejudice to subsection (1), be reviewed and modified from time to time to take into account emerging knowledge and realities;

• Be in such form and contain other matters as the agency may prescribe. The National Environment Action Plan shall be binding on all Line Ministries, public organizations, agencies, companies, non-governmental

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REPUBLIC OF LIBERIA - World Bank · 2016. 7. 11. · Liberia has put in place several policies and...

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