Dr. Cuallau Jabbeh-Howe, Director, County Health Services, Liberia

“I would welcome an international health governance collaborative which would push intelligent and honest information sharing, build advocacy together, with the political classes, within parliaments.”

“My staff sometimes calls me an army woman”, Dr. Cuallau Jabbeh-Howe (51) confesses with a twinkle in her eye, “While I never set foot in that institution.”

Jabbeh-Howe, Liberia’s Director County Health Services, has served her Ministry of Health for many years, in a variety of roles. Originally a county health officer, she moved to the central Family Health Division of the central Ministry in Monrovia, and was called to her current position in 2015, at the time of the Ebola crisis, which hit her country very badly. 

“Our already underscoring counties were not prepared for that disaster. Even knowledgeable people did not have the right infrastructure or equipment. Twenty to thirty percent of the health staff stayed at home, went to less severely affected areas or left the country. 

“The illness was new to us. Many did not know exactly how to act. As a matter of urgency, we therefore began by organizing building staff capacity. With the help of the World Health Organization, we formed a small army of 150 health workers who went in 15 teams into the counties. They went from facility to facility, to ensure that the remaining staff knew what to do.

“It was not easy at all. People and patients kept moving. The population initially had no clue about the severity of things or what to do. At one point, the number of deaths was so overwhelming that we had to start cremating people, while cremation is very un-Liberian and counter to our traditions.  

“We used a funeral place, which belonged to our Indian community. Trolleys were collecting the bodies from the different places. Every siren we heard sent a shiver down my spine, since I knew a new truckload of dead people would be arriving. I had not seen any such devastation since the war.

“And while people became very scared to visit the clinics, a lot of normal procedures also came to a standstill. Pregnant women were not delivering in the health facilities, the figures of casualties in childbirth went up.

“The crisis really exposed a range of issues that had been prior challenges to the health system before. There were not enough doctors in country and this is still a problem. A lot of our doctors also had to play administrative roles, and are quite overburdened with these double duties.

“Liberia receives a lot of international assistance, and some international agencies and NGOs bypass the central level. Everything is pushed down to our decentralized counties where things start to get crazy. Many of the vertical programmes pull quality staff from the facilities. They have them follow trainings, produce evaluation upon evaluation. Each programme has its own demands and requirements: the Global Fund, TB control, HIV control, malaria control, the communicable diseases, the non-communicable diseases, reproductive health. 

“It scatters a lot of staff in fragmented settings. Some programs may stem from one donor, such as USAID, but even there the fragmentation continues.”

So why is there not more pushback and coordination from the central ministerial level? Jabbeh-Howe looks vexed. 

“I have now imposed some coordination. If international agencies do not have a pass from my office, they do not have access to the counties. But in practice, this rule is not always followed. Cash-starved facilities and other agencies in the system accept a lot, for financial reasons. 

“We need real leadership that should coordinate what partners do in the country, put some check on NGOs, invest in results-based programming in counties, with clearly coordinated indicators and accountability structures. In the current configuration there are too many inefficiencies, too many leakages and impunity.”

A lot of people talk about leadership these days, what does it mean in practice?

“There is indeed a lot of discussion about leadership. After Ebola, with much external funding pledged and floating around, a legal team was set up at the Ministry of Health to deal with impunity. We try to make more work of penalizing those who are caught red-handedly stealing from the system. But one legal team is not enough. The problem is more endemic. 

“My main current concern is that health workers are not paid enough and hence start looking for other sources of income. They cannot grow enough in their profession and upgrade their status, so they look for other opportunities. The money that is around should be dealt with more accountability. We know there is false reporting. We also attempt to work more on reconstruction with the emergency funds and reprogram things more systematically.”

Cuallau Jabbeh-Howe talks with passion and commitment. Why did she herself not leave? 

Without hesitation: “I am a civil servant.” 

After a pause … “Ministries are all about hierarchies, you try to work within that reality. Directors are third in-line, after the Minister and the Chief Medical Officer. So yes, we have a voice, we have some power. But even when you’re strong within yourself, you cannot single-handedly transform a whole system. 

I would welcome an international health governance Collaborative which would push intelligent and honest information sharing, build advocacy together, with the political classes, within parliaments. The magnitude of things, the little leverage we have, I wish we could do more.”