3. Bringing healthcare to people living in rural areas in Liberia

Olasford Wiah
Liberia Ministry of Health
Siobhan Kelley
Last Mile Health
Katey Linskey
Last Mile Health

People living in rural areas have limited access to healthcare

In Liberia, half of the country’s 4.6 million people live in rural areas and 29% of the population live more than 5 km from the nearest health facility. Distance, coupled with an extreme shortage in the healthcare workforce, has resulted in some of the worst health outcomes in the world. For example, mortality rates for children under five years are 120 per 1 000 live births in rural Liberia compared to 106 per 1 000 live births in urban areas.1

Community health worker (CHW) programmes are a cost-effective way of extending primary healthcare services to rural populations when designed and supported adequately. However, an array of issues, such as fragmented service delivery and a lack of government ownership, can prevent these programmes from achieving their full potential. In Liberia, strong ministerial leadership and partnership allowed the national programme to overcome these common challenges and extend quality community health care access to rural populations.

A community health worker programme brings healthcare services to rural areas

In response to the country’s rural health needs and fragmented community health structure, the Liberia Ministry of Health, with support from Last Mile Health, made a bold commitment to develop and launch a national community health services policy and programme following the Ebola epidemic. The programme involves a number of implementing partners, including the Clinton Health Access Initiative, the International Rescue Committee, Plan International, Partners In Health, and the United Nations Children’s Fund. Building on experience from Last Mile Health’s pilot programmes in Konobo District and in Rivercess County, and best practice from other implementing partners, the Government of Liberia formally launched the National Community Health Assistant Program in 2016.

The national programme includes key features that ensure success and quality at scale, including standard recruitment, training, and remuneration packages, supervision protocols, and supply chain support. The programme has already made tremendous progress. Today, county health teams and implementing partners are working across 14 counties to bring the programme to national scale. These implementers have already recruited, trained, and deployed approximately 3 011 of the target of nearly 4 400 CHWs and clinical supervisors across Liberia, which means the programme is already scaled up to cover 70% of the country.

As of March 2018, community health workers had carried out over 340 000 home visits; treated over 61 000 childhood cases of pneumonia, malaria, or diarrhoea; screened nearly 75 000 children for malnutrition; and supported 30 000 pregnancy visits since the official launch of the programme. At Liberia’s 2017 national health conference, multiple counties reported increases in children receiving malaria, pneumonia, and diarrhoea treatment of over 50%, and facility-based deliveries in one remote district increased from 55% to 84%.

A recent study published in the American Journal of Public Health2 by Liberia’s Ministry of Health, Last Mile Health, and researchers from Harvard and Georgetown Universities demonstrates that, in just one year, community health workers supported with medical supplies, supervision from clinic-based nurses, and monthly pay packets increased total treatment rates for childhood diseases from 28.5% to 69.3% in the intervention area.

Strong ministerial leadership and a continued focus on quality and sustainability are key to success

The National Community Health Assistant Program is on a path to fundamentally shift the way Liberia’s primary healthcare system operates. Success factors include the following:

  • Government leadership and advocacy: Liberia’s Ministry of Health, with support from Last Mile Heath, has built a strong coalition of central ministry staff, county health teams, non-government organisations and donors to leverage lessons learned from the Ebola outbreak into policy.

  • Links with a larger health system: From its inception, the National Community Health Assistant Program was designed to be fully integrated into Liberia’s public health system. This integration has involved building a national monitoring framework and a joint research agenda, reforming data information systems, and standardising training. In addition, CHWs are trained to refer advanced cases to the facility to ensure patients have access to the full spectrum of primary health care. Critically, it also included mobilising and coordinating funding from public sector donors in Liberia. While complex, this process has resulted in significant government ownership and a clear strategic vision.

  • Continual learning, adaptation, and quality: Liberia’s National Community Health Assistant Program employs both qualitative and quantitative monitoring methods that allow for active trouble-shooting as well as evaluation of the programme as a whole.

What next?

Three actions will be critical in ensuring further success and impact for the National Community Health Assistant Program:

  • Reaching scale and sustaining quality: The programme will achieve full coverage by 2021 and will rely on monitoring systems to identify any gaps in service delivery and improve quality.

  • Cultivating leadership: The long-term sustainability of the programme depends on government-wide ownership of a strategic initiative that will provide benefits beyond the health sector. For example, the National Community Health Assistant Program is the largest employment opportunity for rural women and youth so is critical for advancing the Government of Liberia’s pro-poor agenda, as well as its efforts to advance universal health coverage.

  • Building a pathway towards financial sustainability: The Government of Liberia will co-ordinate current donor financing, increase domestic contributions and health budget allocations, and emphasise that strong investments in community health have the opportunity to revolutionise rural healthcare delivery in Liberia and beyond.

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