Liberia has taken a bold step in tackling non-communicable diseases with the first phase of a national diabetes response. At its completion, we explore the challenges and milestones of a decade-long journey taken by a resilient network of partners.
24 May 2024 Andreea Enea
A little rain each day will fill the rivers to overflowing.
This Liberian proverb seems to embody the progress in addressing non-communicable diseases (NCDs). With WDF funding, Liberia’s first national NCD programme completed this year has been showing how small, consistent actions can drive results in a country in recovery.
Home to 5.4 million people, Liberia has endured many hardships – a 14-year civil war (1989-2003) shattering its political and economic stability, followed by the Ebola epidemic (2014-2015) and an ongoing malaria burden – leaving 85% of the population below the poverty line. The severely strained health system could hardly prioritise NCDs like diabetes, given the prolonged focus on communicable diseases causing multigenerational losses in the country. This added to the pressure on patients and their families, to whom living with diabetes continues to equal to battling food insecurity, inaccessible care and using faith to cope, a 2023 study reveals. To navigate this sensible landscape informed by the Liberia NCDI Poverty Commission Report, which stated that NCDs accounted for 37.9% of disability-adjusted life years and 43% of all deaths in the country in 2016, Liberia has slowly shifted to rebuilding the health workforce and infrastructure to address NCDs.
In support, local and international organisations rallied to empower Liberia to lead change for people with diabetes living in low-resource settings – including WDF. Throughout our more than a decade-long engagement in the country, our partners have been improving diabetes care in the most remote areas of Liberia. The seed planted in 2009 through a local project initiated by a faith-based hospital in Nimba County has since grown into the recent national programme led by the Ministry of Health (MoH).
As the programme is ending this year, we went to Liberia to revisit our partners and take stock of the changes they have enabled, with a resilient young generation at the forefront.
Between 2010-2023, four WDF-funded projects in Liberia accomplished the following:
• Trained >1,800 health workers and volunteers, reaching over half of the adult population• Supported screening of >311,000 people for diabetes.• Pioneered the first diabetes clinic, as well as local self-support groups and outreach programs to reduce stigma and empower patients in self-management.
• Updated the essential package of health services to include NCDs• Enabled the first diabetes national guidelines and protocols, developed by MoH• Integrated NCD care in secondary and tertiary facilities in 14 out of 15 counties• Empowered the Ministry of Health and community leaders to decentralise care
In 2010, Ganta United Methodist Hospital and Primary Care (GUMH) launched the first WDF-funded project in Liberia (WDF09-0483) covering the hospital and 25 nearby village clinics. GUMH, which became one of our key local partners, was the only one providing basic diabetes care in the country. Despite limited funding, the pilot enabled GUMH to open Liberia's first diabetes clinic – a major milestone given the severe shortage of doctors (only six for half a million residents of Nimba County), delayed treatment, and high rate of diabetes complications. The pilot facilitated protocols for standardised diabetes care and a diabetes program led by two trained specialists to improve self-management using existing (and limited) healthcare resources.
The diabetes specialists helped educate nearly 300 healthcare workers in monitoring the condition and further educating peers and patients, and approximately 400 families learned to manage diabetes, reducing the need for costly, long-distance hospital visits. These outcomes attracted interest from healthcare providers outside Nimba County, as well.
The project nurtured a strong community for people with diabetes. Community engagement was key to sustaining the improvements and helped screen over 5,000 people, while the facilitation of local self-support groups ensured them a platform to share experiences and help each other, reducing stigma and promoting their well-being.
The groups have continued to make a difference in subsequent WDF-supported projects up until today. Changing the perception of a diagnosis from a death sentence to a manageable condition has brought hope for patients, caregivers and healthcare providers altogether.
The story of Reverend Dale, who has been part of the MoH-led NCD programme, is one fitting example.
Reverend Dale became a patient of ELWA Hospital in Montserrado County in 2013, when he was diagnosed with diabetes. At that time, few knew what diabetes meant. ‘Now we are afraid to do things like before when we were ignorant and caused ourselves problems,’ says the reverend. Today, he is a local advocate and leader of the hospital’s self-support group. ‘Now we know those things were not good because the nurse educates us all the time’. Having specialists teach them about vital aspects like nutrition has greatly improved their self-management skills. ‘Although we pay for medication sometimes, it puts us in a position to be on top of our health. Our health is regulated. Sometimes people say, oh you are diabetic, and you feel like dying; but when the specialist explains things to us, we go home happy.’ Read Reverend Dale’s full story here.
Romelle Hunter, a nurse working at ELWA Hospital for over two decades, echoes the reverend's thoughts. After getting diabetes training at GUMH, she saw the urgent need for a clinic and a self-support group. ‘We started getting doctors involved, we started getting nurses involved,’ she shares. ‘For every patient admitted from other wards, the hospital ensures they come to the clinic and are taught what to do: eat this, limit this, do more exercise’.
Romelle has also been part of the nationwide programme, as the hospital clinic's NCD focal person, and she often visits communities to conduct screenings and increase access to quality care. ‘We need more awareness, people need to know that diabetes is real and has many complications’.
With the pilot underscoring the vast scope of the healthcare challenges, the lingering effects of war, and the need for expansion, GUMH was encouraged to design another initiative that, with continued support from WDF, would deepen the roots of enhancing diabetes care in Liberia.
This is how the second WDF project came to life.
In 2015, Emmanuel Kpon Saye, a young nurse with tremendous dedication, took over as the head of the diabetes clinic at GUMH.
At that time, the Ebola epidemic claimed thousands of lives and shattered GUMH’s clinic, and he decided to solve the most urgent needs: finding insulin for patients with type 1 diabetes and lowering the number and severity of late-stage type 2 diabetes complications. Others helped with the first issue, WDF helped with the second.
Emmanuel’s resourcefulness earned him a three-month diabetes training in Tanzania through WDF’s Partner2Partner Academy. There, he met Dr Kaushik Ramaiya, WDF Board member and a prominent physician and leader in diabetes research – a moment that, he says, changed his life.
‘He asked me, “And now, what will you do with this new knowledge?”. At that time, I was only thinking about the work we were doing in Nimba. But this question made me think bigger, aim higher and work harder. I realised I could use what I had learned to help more people’, Emmanuel recalls.
Concretely, the answer came as the community-based project pioneering diabetes care services (WDF15-1273), expanded to the entire Ganta catchment area. At a time when NCDs were overshadowed by communicable diseases like HIV/AIDS at the policy level, this project brought a diabetes curriculum that attracted interest from MoH. Emmanuel worked with GUMH on the proposal.
The pilot helped train two diabetes nurse specialists, over 160 healthcare workers, 130 midwives and community health workers. Over 5850 people were screened and educated.
The goal of the second WDF-funded project was to reduce mortality and morbidity caused by complications of diabetes such as peripheral neuropathy. 39,145 people were screened for type 2 diabetes and 3,843 people screened for diabetic foot.
Nearly 200 healthcare professionals and volunteers were empowered through specialised education and treatment protocols for managing diabetes, which helped prevent almost 300 amputations. The treatment protocols were implemented in 25 clinics in Nimba County, yet many more facilities needed strengthening to reach people in vulnerable settings.
Despite reducing stigma and misconceptions about diabetes, accessibility and affordability of care remained major challenges for many Liberians lacking the means to communicate or travel to clinics. The project allowed our local partners to adopt an inclusive outreach model where 15 rural leaders selected youth from their communities to be trained as General Diabetes Community Health Volunteers (gDCHVs).
Additionally, 78% of the residents learned about diabetes through localised awareness campaigns and a reporting and recording system was created for the first time, providing MoH with relevant data.
Facing increasing cases of diabetic foot and no endocrinologists in the country, new collaborations branched out. The Diabetes and Endocrine Society of Liberia (DESoL), co-founded by Nigerian endocrinologist Prof Sunny Chinenye in 2016, rose to meet these challenges and were encouraged to work on their own project proposal to WDF to complement the progress made with past projects.
‘Prof Chinenye invited me for a strategic consultation after learning about the successful intervention funded by WDF in Nimba’, remembers Emmanuel, ‘to discuss the successes and lessons from our experiences and the potential for DESoL to apply for a WDF grant’. The successful application marked a significant milestone paving the way for future collaborations.
This third WDF-funded project in Liberia (WDF17-1488) was led by DESoL with help from MoH and the Liberia Medical and Dental Council. It strengthened 24 primary-level and 19 secondary-level facilities in five counties through community screening, patient education, and capacity building. It also developed the first MoH-endorsed diabetes guidelines and protocols based on international standards.
Community leaders, from county health and education officers to mayors and religious leaders, were empowered to help educate over a million people about diabetes. Over 500 health workers were trained in diabetes management, and more than 7,500 people were screened.
Now joined by MoH, the partners began to strategise a national response, at a time when the Ministry was already taking steps in that direction by working on making the non-communicable diseases and injuries (NCDI) unit a standalone division and launching the first National NCD Policy and Strategic Plan (2017-2021) and the first Liberia NCDI Poverty Commission Report. The NCD agenda was finally getting traction at a wider institutional level.
GUMH continues to provide care, support community volunteers, and lead educational activities until today. For over a decade, the local partner has been a leader in diabetes care and prevention at times when national attention went to other pressing issues like communicable diseases.
DESoL has played a pivotal role in the development of the third WDF project aiming for a larger scale impact, and contributing to the development of the subsequent national NCD programme led by MoH. The organisation has provided much-needed technical expertise.
MoH capitalised on existing initiatives and achievements and, informed by local and global data indicating the increasing NCD burden, took the lead in the latest WDF-supported project in the country, Integrating routine diabetes service provision across healthcare facilities - the first attempt to establish NCD services nationwide and systematically implement MoH’s NCD Plan. Co-developed with GUMH, DESoL, and Partners in Health (PIH), the scale-up programme improved diabetes prevention and care delivery at all levels – policy, healthcare, community.
‘The partnership between GUMH and the NCDI Unit started after a strategic discussion with Dr Ramaiya, who was interested in my idea to work with the unit’, explains Emmanuel, appointed by the hospital to be the project manager. ‘Looking back, I can see that talking to Dr Ramaiya made me want to become a leader in healthcare in Liberia,’, Emmanuel says. ‘This has guided my work on the WDF projects. It was a turning point, moving from focusing on one place to thinking about the whole country.’
Back from training, he asked his friend Zoe Taylor Doe, the deputy director of the NCDI Unit, for help. After they discussed with Dr Fred Amegashie, the director of the division at that time, Emmanuel and Zoe prepared the grant proposal for the national programme.
‘This was the official start of our collaboration’.
Emmanuel has worked closely with the NCDI Unit, responsible for NCD management guidelines, resources and message dissemination in English and local languages. The unit works with the Community Health Services Division to raise awareness, but also with other departments and ministries, to elevate quality and access to healthcare services for as many people as possible.
‘Despite facing significant challenges, the project undeniably played a crucial role in advancing NCDI care, both a health facilities and central levels,’ shares Zoe, who has been the project responsible.
One example is the impressive involvement of the county health teams in implementing the project's activities.
Dr Dorfelson Jayguhwoiyan, NCD focal person for Lofa County under the programme, has many responsibilities, including monitoring and mentoring NCD clinics’ focal persons, data analysis and MoH reporting. Despite a busy schedule, he continue to help improve lives.
‘With the programme, with early detection, we have been able to see increasing cases and put people with diabetes in care; this has been a great change’, he says. ‘And as clinicians, we know the consequences of diabetes not being managed’. Now, patients are routinely tested and educated on self-management. However, diabetes can be an isolating experience for many. ‘They become stigmatised and depressed, but in a self-support group, you are not alone. With advice and medication, people can live normal lives.’
Read the full story here.
Looking back, Zoe reflects on the impact these partnerships had. ‘It is evident that it has made significant strides in advancing NCDI service delivery in Liberia. By addressing key challenges and implementing targeted interventions, the programme has laid a foundation for improved NCDI care, contributing to better health outcomes for the population’.
The collective efforts of the partners involved have helped:
• Address the critical need for capacity building among healthcare workers, which in turn improved the quality of care and NCD awareness• Enhance diagnostics and ensure availability of essential medicine and medical supply through a very reliant collaboration• Advocate for and facilitate NCDI service integration into current healthcare programs• Improve data management systems for better monitoring and decision-making.
MoH led the way in empowering healthcare professionals by reviewing, integrating, and adopting relevant tools (policies, treatment protocols, M&E indicators) to enhance the quality of diabetes services at secondary and tertiary levels.
A number of community health workers, the bridge between healthcare and people, have been trained in diabetes management and have integrated care into existing community health tools.
At the local level, our partners have engaged communities in overcoming sociocultural barriers through awareness campaigns and empowered leaders such as traditional healers to inspire change for effective diabetes self-management. In addition, local self-support groups were created to encourage the adoption of sustained healthy behaviours and diets.
There have been meaningful contributions from county NCD focal persons, clinical supervisors, and nurses who kept records of patients with diabetes complications, raised awareness in remote communities, and started vegetable gardens to promote physical activity and access to affordable food. However, limited progress has been made towards achieving diet-related NCD targets, as multisectoral partnerships are needed to overcome the systemic barriers.
The county health teams have shown a remarkable determination in supporting their communities’ health. Due to their essential role and impact, they need a stronger presence in addressing NCDIs and meeting local needs. Along with the healthcare providers, who have also been actively supporting patients, the counties have expressed interest in more training to limit and prevent diabetes complications.
The essential package of health services has been updated to include gestational diabetes. While NCD clinics have served hundreds of patients, very few with hyperglycaemia in pregnancy attended follow-up consultations.
The next step could build capacity for better integration of gestational diabetes, while the solid collaboration between county teams and healthcare providers could enhance screening and management protocols ultimately improving maternal and fetal health outcomes.
Additionally, MoH and health facilities could open doors to more decentralisation by leveraging HIV/AIDS or reproductive health programmes and a forum to discuss challenges and solutions.
The outcomes and insights from various stakeholders, including WDF’s experience on the ground, show promise in sustaining these results and inform the direction of future steps.
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In Zoe’s perspective, they would involve the development of comprehensive policy, the integration of NCDI service delivery at the primary care level, continued capacity building, data strengthening and monitoring, and tackling logistical challenges.
As Liberia continues building on this transformative decade, addressing these points would get the country closer to achieving equitable access to quality NCDI prevention and care.