Context

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.

Recent history

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:

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

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 3}As 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}  

Contextual factors

Funding

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.

Local evidence

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.

Liberia used local research in three ways:

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:

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.