Why is Liberia an Exemplar?

In the wake of two devastating civil wars between 1989 and 2003, and an Ebola epidemic from 2014 to 2016, Liberia’s national health system was decimated. Only one-third of the country’s health facilities still functioned, and just a few dozen remained, leaving a significant portion of the country’s residents with no access to primary health care.^1,2

Even before the Ebola epidemic, the health system failed to reach approximately 30 percent of the Liberian population – those in rural communities more than five kilometers from the nearest health facility.³  A 2012 study in rural southeastern Liberia found that half the population had to travel six to 10 hours to reach the nearest health facility.⁴  A 2008 study found that only 15 percent of rural Liberians could access basic services for childhood diseases like diarrhea, pneumonia, malaria, measles, and malnutrition.⁵

The wars and the Ebola epidemic made matters far worse, displacing or killing many health workers, considerably shrinking the footprint of the health system and, along with it, access to essential care, leaving the country vulnerable to unchecked epidemics.

Recognizing the existential danger, Liberian officials, partners, and donors moved quickly in the aftermath of the epidemic, with the goal of providing basic health care to all Liberians, no matter where they live, and also establishing an early warning system to guard against future epidemics.

The country established a robust community health worker (CHW) program that, by most measures, reaches more Liberians than ever before. In just three years, from its launch in 2016 to mid-2019, Liberia recruited, trained, and fielded 3,177 of what will soon total 4,000 CHWs (called community health assistants, or CHAs, in Liberia) and 344 of 400 clinical supervisors —the nurses, midwives, and physician assistants who supervise CHWs and are based at over 300 health facilities.

CHWs currently provide primary care in 14 of the country’s 15 counties, for an estimated 715,000 rural people. That means they reach about 70 percent of the target population (rural populations living more than five kilometers from health facilities). Liberia expects to reach 90 percent coverage of target communities by 2021.

The speed of this scale-up in Liberia is remarkable, especially given that it is the third poorest country in the world and has been significantly weakened by wars and an epidemic. The lessons from Liberia’s achievement may be relevant for other post-war and resource-poor countries struggling to reach remote populations.

Early indications show that Liberia’s CHW program is delivering essential primary health care in vulnerable communities and is improving health broadly. Each month, CHWs visit about 10,000 pregnant women, provide about 9,000 women with modern family planning methods, and treat about 12,000 cases of malaria, 2,000 cases of diarrhea, and 3,000 cases of acute respiratory infection. This workforce has identified over 4,000 potential epidemic events, and each year carries out about one million home visits.⁶

We can see the impact of CHW visits in the diagnosis and treatment of common, and often deadly, diseases. At the community level, the number of malaria cases diagnosed increased from only 91 cases to 132,863 cases between 2016 to 2018.⁷ This increase in reported malaria cases is likely driven by CHWs and a new the implementation of national information systems and reporting mechanisms that were implemented around the same time that the CHWs began working in their communities. that did not exist before the launch of the National Community Health Assistant Program. Despite the lack of certainty regarding how much of this increase we can attribute to the CHW program, it is clear that Tthe nationalized distribution of rapid diagnostic tests (RDT+) for malaria to trained CHWs and the more proactive diagnosis and treatment by CHWs has contributed to an increase in the proportion of confirmed malaria cases at the community level. Catching malaria cases at the community level is important for a number of reasons. It means cases are caught earlier when they are less severe, and it means that individuals do not have to leave their communities and travel great distances to access diagnostics and care.

Now, more than one million home visits are conducted every year and about a fifth of all RDT+ malaria diagnoses in children under five are now made by CHWs. Up to mid-2019, CHWs treated over 668,000 cases of malaria, pneumonia, diarrhea and malnutrition screenings to children under five,⁸ and have referred over 35,000 pregnant women for facility-based deliveries.⁹

While it is too early to fully capture the program’s impact, there are indications that the program is reaching rural communities previously excluded from the health system. For example, a study of CHWs in the Konobo district of Grand Gedeh County documented substantial increases (from 77 percent to 91 percent between 2015 to 2018) in facility-based delivery,¹⁰ and an increase (from 45 percent to 60 percent) in iCCM treatment (malaria, pneumonia, diarrhea) between 2015 to 2019 in implementing districts of Rivercess County, where 67 percent of inhabitants live more than 5 kilometers from a health facility.¹¹

Beyond the speed of rollout, coverage, and service delivery outputs, Liberia’s program is noteworthy because it includes many best practices identified in large CHW programs in other countries, such as Rwanda and Ethiopia. These best practices include:

• A robust national and centralized monitoring and evaluation system that harnesses CHWs in the field as data collectors
• Enhanced compensation and supervision for CHWs
• Formalized and universal training
• A package of health services that closely mirrors the local disease burden and includes curative care
• Supply chain support that provides CHWs with critical supplies, and a strategy that places CHWs in teams with frontline clinicians and community clinics, integrating them into the larger health system

Many of these elements were later identified as key characteristics of high-performing CHW programs by the WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programs.¹²

It should be noted that Liberia managed to build this program with a diverse group of donors and partners who provided critical support and, at times, tried to mold the program to suit their own preferences. Liberia proactively managed partner expectations and contingencies, appealed for donor transparency, and consistently pushed for its own vision and strategy. In the end, the country secured long-term financing for a program of its design. The program has since achieved some measure of stability, having weathered changes in administrations within Liberia.

The experience of Liberia offers the following relevant lessons for other countries:

• Low-income countries, especially fragile states with stark health inequities, may draw lessons from Liberia’s success in harnessing partners’ capabilities and funding to deliver health care to remote, marginalized populations.
• Countries that are heavily donor-dependent and have yet to develop health sector donor-alignment strategies may draw lessons from Liberia’s early success.
• Countries revising their community health strategies may draw lessons from Liberia having built a CHW program integrated with the rest of the health system.
• Countries working to balance best practices with best fit in a resource-constrained context can learn from Liberia’s program design process, in which the country weighed trade-offs to produce a program that costs less than five percent of the total health budget.