By Tolbert G. Nyenswah, LL.B., M.P.H., DrPH
Liberia’s journey toward sustainable development and economic independence has been closely linked to its performance on the Millennium Challenge Corporation (MCC) scorecard. Between 2016 and 2021, the country implemented its first MCC Compact, amounting to $257 million in investments.
These resources supported key national priorities, including the rehabilitation of the Mount Coffee Hydropower Plant, improvements in electricity transmission and distribution, and the strengthening of road infrastructure. As Liberia now positions itself for a potential second compact, greater attention must be directed toward one of the most critical pillars of human development—health, education, water, sanitation and hygiene (WASH), and social protection.
The MCC’s “Investing in People” indicators, particularly those focused on health expenditure, immunization, chronic diseases (e.g., COPD, hypertension, diabetes, heart diseases, etc.) and child health outcomes, remain central to assessing whether Liberia is effectively building the well-being, productivity, and resilience of its citizens.
Why Health, Education and WASH Indicators Matter
Under the MCC framework, the ‘Investing in People’ category measures how well a government is investing in its citizens’ capacity through health, education, and resource management. The health sector indicators include Health Expenditure (the share of government spending on health as a percentage of GDP), Child Health (a composite measure that includes child mortality, access to improved water, and access to improved sanitation), and Immunization Rates. Passing these indicators is critical, but the MCC also considers progress over time, whether a country is demonstrating credible and sustained improvements.
In the most recent 2026 MCC scorecard, the Child Health indicator remains a sobering reflection of the state of Liberia’s health system. This indicator captures three interlinked dimensions across the core building blocks of the health sector—service delivery (the quality and reach of care provided in clinics, health centers, and hospitals across all 15 counties and community health), financing, governance and leadership, health infrastructure, data systems, pharmaceuticals, and inter-sectoral coordination. Liberia’s performance in the MCC score card for Child Health over the past five years paints a deeply troubling picture: 35% in 2021, 33% in 2022, 33% in 2023, 37% in 2024, and 36% in 2026, yielding an average score of approximately 34.8% a massive failure of this important composite indicator.
This persistently low average indicates that critical elements of the health system are failing to deliver essential outcomes. Immunization programs are stagnating, nutrition interventions remain underfunded, and water, sanitation, and hygiene (WASH) services continue to deteriorate. Together, these shortcomings expose a system struggling to meet even the most basic health needs of its population. Ultimately, the Child Health indicator serves as a stark mirror of the broader systemic collapse—showing how inadequately Liberia’s health system safeguards its most vulnerable citizens, children under five years of age.
Liberia’s Trajectory on Health and Human Capital Investment
Liberia’s performance on the MCC ‘Investing in People’ indicators between 2016–2021 and 2022–2026 reveals both progress and persistent weaknesses. During the first compact period, the country’s average health expenditure hovered around 8% of GDP, while the child health composite averaged about 56.1. From 2022–2026, however, average health expenditure has fluctuated still below the 15% target set by African Union member states under the 2001 Abuja Declaration.
Immunization rates, another critical health indicator, improved from 54% in 2016 to around 87% by 2020, but have since stagnated. The 2019–2020 Liberia Demographic and Health Survey (LDHS) revealed that only 51% of children aged 12–23 months were fully vaccinated against basic preventable diseases, while 6% received no vaccination at all. The Child Health composite score has remained relatively flat—hovering around 56 points before transitioning to a 0.407 score in 2026 (below the median of 0.459)—a clear sign that Liberia continues to struggle with basic health outcomes.
The Paradox of Higher Spending but Poor Outcomes
Despite modest increases in health expenditure in recent years, child health outcomes have not improved proportionately. This paradox points to challenges in budget execution, supply chain reliability, and coordination between health and water sectors. Many facilities lack clean water and sanitation, undermining child survival efforts and reducing the impact of investments in vaccines and clinical care. The LDHS data also indicate that while initial vaccine coverage is relatively high for first doses, completion rates for second and third doses decline significantly—a sign of weak follow-up systems and community engagement.
What Liberia Must Do to Qualify for a Second Compact
To improve its standing and strengthen its case for a second MCC compact, Liberia must demonstrate measurable and sustained progress in both health financing and outcomes.
First, the government should adopt a medium-term expenditure framework that guarantees predictable and adequate funding for Primary Health Care (PHC), the Expanded Program on Immunization (EPI), and Water, Sanitation, and Hygiene (WASH) initiatives. This framework must also include robust systems for disease surveillance and outbreak response, ensuring that infectious diseases such as Ebola, COVID-19, and the recently announced Mpox do not reverse the country’s hard-won health gains post-Ebola resilient health initiatives.
The resurgence of Mpox should serve as a wake-up call—underscoring that Liberia remains on the brink of another severe outbreak if urgent preventive measures are not implemented. To restore confidence among citizens and development partners alike, the government should publish quarterly health budget execution reports to promote transparency, strengthen accountability, and build the credibility needed to attract sustained donor investment and support.
Second, the Ministry of Health, in collaboration with the Ministry of Public Works, Liberia Water and Sewage Cooperation (LWSC) and other partners, should prioritize WASH investments in health and education facilities and communities to address the underlying causes of diarrhea and other waterborne diseases that drive child mortality. A county-by-county WASH Compact could help align resources and ensure accountability for results.
Third, quickly adapt the concept of “Universal Health Coverage”, “Health -4-All” by introducing health insurance for the formal and informal sectors and for vulnerable populations, such as pregnant women, children and disable.
Four, immunization coverage must be revitalized through county-level microplans, improved cold-chain logistics, and a defaulter-tracing system implemented by community health workers. The government should also strengthen data quality systems to identify low-coverage areas and rapidly deploy outreach campaigns, ICT technology for health. Integrating child health services, such as nutrition, malaria prevention, and routine immunization, at the PHC level will yield the greatest impact.
Governance and Partnerships
Liberia’s first MCC compact demonstrated that strong governance and inter-agency collaboration can deliver tangible results. The same approach should be applied in the health sector and human capital development sectors. Developing county-level performance compacts with measurable health, education and WASH outcomes, combined with transparent reporting and third-party verification, will strengthen Liberia’s case before the MCC Board. These mechanisms will also ensure that improvements in health financing translate into real-world outcomes for children and families.
Conclusion
Liberia’s progress toward a second MCC compact depends on translating economic growth into visible improvements in people’s lives. By prioritizing consistent health financing, strengthening Primary Health Care delivery, expanding WASH and Education access, and improving immunization and child health outcomes, Liberia can demonstrate that it is investing effectively in its people.
Such reforms will not only improve MCC scores but also lay the foundation for a healthier, more productive nation. In the spirit of the Abuja Declaration, Liberia must reaffirm its commitment to allocate at least 15% of its national budget to health, ensuring that no child dies from preventable causes and that every Liberian can contribute to the country’s development.
About the writer
Tolbert G. Nyenswah, LL.B., M.P.H., DrPH is a senior associate with the Johns Hopkins Bloomberg School of Public Health, Department of International Health. CEO of PandemicShield, LLC a US-Based global health security consultancy firm. He is an internationally recognized legal scholar and a global public health expert. Former director general of NPHIL, incident manager of the 2014-2016 Ebola epidemic response, former deputy minister of health, former assistant minister of health. 20 years’ experience in global health.
