The West African country of Liberia is the world’s third poorest country, with an estimated per capita gross domestic product (GDP) of $694 in 20171 and a Gini coefficient of 0.33.2 About half the country’s population, and 72 percent of rural residents, are classified as poor.
A large proportion of the country’s rural population, about 60 percent, lives in remote communities that are more than five kilometers away from the nearest health facility.3 For many of these isolated communities, the nearest clinic or hospital is several hours away and can be reached only by foot, canoe, or motorbike on narrow paths through the rainforest.
The country's recent history can be roughly divided into four periods.
1. Civil wars (1989–2003)
This series of conflicts killed 250,000 Liberians and prompted another one million Liberians, or nearly one-quarter of the population, to flee. An entire generation that came of age during this period grew up without access to education.4
By the end of the civil wars, the country was ranked twelfth from the bottom in the United Nations Human Development Index,5 unemployment stood at 85 percent, and Liberians relied on foreign aid for basic needs. Many government services did not exist, and those that did were usually weak and unreliable.4 For example, only 51 doctors remained to serve 4.5 million Liberians, and only 354 of the country's 550 health facilities were functioning.6 The remaining facilities served only 41 percent of the population, leaving the majority of Liberians without access to health care.7
2. Post-war economic recovery (2004–2013)
The post-war democratic government set an ambitious reform agenda to rebuild the country with four key priorities:
- Consolidate peace and security
- Revitalize the economy
- Strengthen governance and the rule of law
- Rehabilitate infrastructure and deliver basic services4
During this period of economic expansion, the annual GDP growth rate reached 7.6 percent and per capita GDP growth reached 4 percent.1 Life expectancy improved from 54 years to 61 years and Liberia achieved Millennium Development Goal 4 – reducing its child mortality rate from 194 deaths per 1,000 live births in 2000 to 94 in 2013.8 9 Progress, however, was uneven and health indicators remained poor in remote communities. For example, the proportion of children in some rural areas receiving treatment for acute respiratory infection remained as low as 6.6 percent.10
Change in under-five mortality rate (U5MR) versus change in gross domestic product (GDP) per capita
It was during this period that Liberia’s Ministry of Health and nongovernmental organizations trained a fragmented cadre of community health volunteers to serve rural and peri-urban areas. But this unpaid and under-supported cohort proved ineffective and unreliable. Recognizing this gap, the Ministry of Health began working with NGO partners to develop and pilot a model using professionalized CHWs to deliver primary care to rural areas. At the time, however, many development donors were hesitant to embrace this shift in policy, and the volunteer model remained the standard throughout much of the country. The lack of paid, well-supported CHWs helped fuel the spread of Ebola during the next phase of the country’s modern history, claiming thousands of lives and devastating the country.
3. Ebola epidemic (2014–2016)
Ebola infected 10,678 people and killed 4,810, including 10 percent of Liberia’s doctors and eight percent of nurses and midwives. It also brought GDP growth into negative territory (GDP growth declined from 8.7 percent in 2013 to 1.6 percent in 2016),11and exposed and exacerbated the weaknesses of the national health system.12 Fear of contamination during the epidemic reduced the number of health care providers willing to treat patients and reduced the number of people seeking treatment. As a result, visits to public health facilities decreased by 61 percent, antenatal care decreased by 43 percent, institutional delivery decreased by 38 percent, and measles vaccinations decreased by 45 percent, between August and December 2014, compared with the same period in 2013.
4. Post-Ebola period
Since the end of the Ebola epidemic, Liberia’s leaders have worked to address critical health system vulnerabilities and build resilience against future shocks. The government developed the Investment Plan for Building a Resilient Health System in 2015.13The plan outlined the top priorities for rebuilding the health sector, including establishing a stronger national community health worker program. To achieve this goal, the country needed to tap significant resources provided by donors. Supported by the international community of donors and implementing partners, the government launched a new CHW program (called the National Community Health Assistant Program, or NCHA) in Liberia.
One constant throughout Liberia’s recent history has been a shortage of doctors. Following the civil war in 2003, a mere 51 physicians served the entire country. The most recent data from 2015 showed that Liberia had 0.37 doctors per 10,000 people. That is just a fraction of the WHO-recommended minimum of 14 doctors per 10,000 people.14
(See Milestones section for full timeline.)
Liberia’s health worker shortage is compounded by the fact that the overwhelming majority of physicians and other medical providers live in urban areas, and about half of Liberia’s 4.7 million people live in rural areas.15 3As a result, access to primary health care is highly inequitable, which has a significant detrimental impact on health outcomes. Liberia has among the highest maternal mortality and child mortality rates in the world, with 725 deaths per 100,000 live births, and 70 deaths per 1,000 live births, respectively.16 17
Liberia would not have been able to launch its CHW program without substantial funding from donors.
Financing for Liberia’s Ministry of Health began ramping up during the period leading up to the Ebola epidemic. Development assistance for the health sector increased from $23 million in 2004 to $137 million in 2013. In 2015, during the height of Liberia’s response and recovery from the Ebola outbreak, and one year before Liberia launched the CHW program, funding for the health sector spiked to $642 million, an increase of 468 percent since 2013. The United States government, the Global Fund, and the World Bank are the leading funding sources for Liberia’s CHW program. This influx of funding, driven by donors’ desire to end the Ebola outbreak and strengthen the resilience of the country’s health system to prevent such a costly crisis from reoccurring, created a context in which Liberia was able to launch the new CHW program without cutting funding for existing programs.
Development assistance for health in Liberia
Liberia benefited from a wealth of local research to help inform or drive policy. This critical resource is unusual for a small, low-resource country.
Annual number of research publications with medical subject heading (MeSH) "Liberia"
Liberia used local research in three ways:
- To demonstrate that CHW programs were feasible and potentially highly impactful in Liberia
- To understand which models had been tested and had a track record of proven impact in Liberia
- To provide a robust evidence base for funders and government officials
This foundation of local evidence helped Liberia expedite design, implementation, and funding of its CHW program.
Chief among this research were peer-reviewed articles documenting impressive returns on investments in proactive, professional, and integrated CHW programs. Particularly influential was research based on Liberia’s CHW pilot programs, which demonstrated large increases in facility-based delivery (from 56 percent to 84 percent) over a three-year period in Liberia’s Grand Gedeh County,18a 42 percent increase in fever (malaria) treatment, and a 29 percent increase in diarrhea treatment over a single year in Rivercess County.19
Growing recognition of the need to invest in high value of health care workers
In addition to the availability of greater development assistance in the health sector in 2016, the Liberia CHA Program also benefited from a growing sense among government and donor stakeholders at that time that greater investment and programming was needed to support Liberia’s health workforce. This emerging consensus was driven by five factors:
- The crucial role of health workers and the hazards of their work was highlighted by the fact that Ebola killed roughly 10 percent of Liberia’s doctors and eight percent of its nurses and midwives. The death of health workers in neighboring Guinea also increased appreciation for Liberia’s public health workforce.20
- The evidence, from the Ebola outbreak and response, of the immense risk posed by a low-functioning frontline health system that could not perform critical disease surveillance functions to help detect and respond quickly and efficiently to future epidemics. Liberia recognized the potential for community health workers to play a key role in strengthening resilience against future disease outbreaks by delivering epidemic surveillance services.
- Frequent health work strikes, in response to poor pay and a lack of equipment, disrupted access to primary health care and illustrated the critical role played by frontline health workers.21 22 23
- Recognition that many health workers were not being paid on time prompted the government to take steps to redress this problem and recognize health workers’ critical role in public safety.
- Liberia's CHW program was developed during a time of increased international interest in CHW programs. One example of this is a 2015 op-ed in Time magazine, by World Bank President Jim Kim in which he observed "communities must be empowered to serve as the front line for disease prevention and response..." 24
These factors helped motivate key stakeholders in Liberia to support the development of a professionalized cohort of CHWs, which has proved critical to delivering high-quality care in vulnerable communities.
- 1The World Bank. DataBank. World Development Indicators. https://databank.worldbank.org/reports.aspx?source=world-development-indicators. Last updated July 10, 2019. Accessed August 27, 2019.
- 2Liberia Institute of Statistics & Geo-Information Services (LISGIS). Household Income and Expenditure Survey 2016. Monrovia, Liberia: LISGIS; 2017. http://microdata.worldbank.org/index.php/catalog/2986/download/41609. Accessed August 27, 2019.
- 3Table 2.5. Method of travel and travel time to nearest health facility. In: Liberia Institute of Statistics and Geo-Information Services (LISGIS), Ministry of Health and Social Welfare (Liberia), National AIDS Control Program (Liberia), ICF International. Liberia Demographic and Health Survey 2013. Monrovia, Liberia: LISGIS, ICF International; 2014: 15. https://dhsprogram.com/pubs/pdf/FR291/FR291.pdf. Accessed August 27, 2019.
- 4Friedman J. Building Civil Service Capacity: Post-Conflict Liberia, 2006-2011. Princeton, NJ: Innovations for Successful Societies, Princeton University; 2012. https://successfulsocieties.princeton.edu/sites/successfulsocieties/files/Policy_Note_ID203.pdf. Accessed August 27, 2019.
- 5Human development index trends, 1990-2017, Table 2. United Nations Development Programme, Human Development Reports website. http://hdr.undp.org/en/composite/trends. Last updated January 31, 2019. Accessed August 27, 2019.
- 6Lee PT, Kruse GR, Chan BT, et al. An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries. Global Health. 2011;7:37. https://doi.org/10.1186/1744-8603-7-37. Accessed August 27, 2019.
- 7Dahn BT. Foreword. In: Ministry of Health (MOH), Republic of Liberia. Investment Case for Reproductive, Maternal, New-Born, Child, and Adolescent Health, 2016–2020. Monrovia, Liberia: MOH; 2016: 7. https://www.globalfinancingfacility.org/sites/gff_new/files/Liberia-Investment-Case.pdf. Accessed August 27, 2019.
- 8UNDP, Human Development Indices and Indicators: 2018 Statistical Update, Briefing note for countries on the 2018 Statistical Update – Liberia. Available at: http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/LBR.pdf. Accessed January 2019.
- 9Liberia Institute of Statistics and Geo-Information Services (LISGIS), Liberia Demographic and Health Survey (DHS) 2013. Monrovia, Liberia.2015.
- 10Kenny A, Basu G, Ballard M, et al. Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey. J Glob Health. 2015 Dec;5(2):020401.
- 11GDP growth (annual %) – Liberia [dataset]. World Bank Open Data. Washington, DC: The World Bank.https://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=LR. Accessed October 16, 2019.
- 12Case counts, Ebola (Ebola Virus Disease). Centers for Disease Control and Prevention website. https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/case-counts.html. Page last reviewed March 8, 2019. Accessed August 27, 2019.
- 13Ministry of Health (MOH), Republic of Liberia. Investment Plan for Building a Resilient Health System, Liberia, 2015 to 2021. Monrovia, Liberia: MOH; 2015. http://pubdocs.worldbank.org/en/865131479921763514/Liberia-Investment-Plan-Final-May-15.pdf. Accessed August 27, 2019.
- 14Global Health Workforce Statistics, the 2018 update. Geneva: World Health Organization, 2018.https://www.who.int/hrh/statistics/hwfstats/en/. Accessed October 4, 2019.
- 15Wiah O, Kelley S, Linskey K. Bringing healthcare to people living in rural areas in Liberia. In: Organisation for Economic Co-operation and Development(OECD). Case Studies on Leaving No One Behind: A Companion Volume to the Development Co-operation Report 2018. Paris: OECD Publishing; 2018: 19-21. https://doi.org/10.1787/9789264309333-5-en. Accessed August 27, 2019.
- 16Maternal mortality ratio (per 100 000 live births): 2015. World Health Organization website. http://gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html. Accessed August 27, 2019.
- 17Number of deaths (thousands); data by country. World Health Organization website. http://apps.who.int/gho/data/node.main.ChildMort-1?lang=en. Last updated September 13, 2018. Accessed August 27, 2019.
- 18Luckow PW, Kenny A, White E, et al. Implementation research on community health workers’ provision of maternal and child health services in rural Liberia. Bull World Health Organ. 2017;95(2):113-120. https://doi.org/10.2471/BLT.16.175513. Accessed August 27, 2019.
- 19White EE, Downey J, Sathananthan V, et al. A community health worker intervention to increase childhood disease treatment coverage in rural Liberia: a controlled before-and-after evaluation. Am J Public Health. 2018;108(9):1252-1259. https://doi.org/10.2105/AJPH.2018.304555. Accessed August 27, 2019.
- 20Phillip A. Eight dead in attack on Ebola team in Guinea. ‘Killed in cold blood.’ The Washington Post. September 18, 2014. https://www.washingtonpost.com/news/to-your-health/wp/2014/09/18/missing-health-workers-in-guinea-were-educating-villagers-about-ebola-when-they-were-attacked. Accessed August 27, 2019.
- 21Lazuta J. Liberian government talks with striking health workers. Voice of America (VOA). August 1, 2013. https://www.voanews.com/africa/liberian-government-talks-striking-health-workers. Accessed August 27, 2019.
- 22On Ebola ward, Liberian nurses must improvise gear. The Japan Times. September 5, 2014. https://www.japantimes.co.jp/news/2014/09/05/world/science-health-world/ebola-ward-liberian-nurses-must-improvise-gear. Accessed August 27, 2019.
- 23Hinshaw D. Ebola virus: for want of gloves, doctors die. The Wall Street Journal. August 16, 2014. https://www.wsj.com/articles/ebola-doctors-with-no-rubber-gloves-1408142137?mod=rsswn. Accessed August 27, 2019.
- 24Kim JY. What Ebola taught the world one year later. TIME. March 24, 2015 https://time.com/3755178/ebola-lessons. Accessed August 27, 2019.