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Background Arising from the Ebola virus disease (EVD) outbreak, the 2015-2021 Investment Plan aimed to improve the health status of the Liberian population through building a resilient health system that contributes to achieving equitable health outcomes. Recognizing the significance of community participation in overcoming the EVD outbreak, strengthening community systems emerged as one of the most important strategies for bridging the gap in accessing primary health care (PHC) services. This study reviewed the community health policy development process in order to draw lessons from the health system strengthening efforts in Liberia post-EVD crisis. Methods A government-led health system analysis approach was applied to assess, review and revise the community health program in Liberia. The mixed method approach combines the use of an adapted tool to assess bottlenecks and solutions during workshops, a qualitative survey (key informant interviews and focus group discussions) to assess perceptions of challenges and perspectives from different stakeholders, and an inter-agency framework – a benchmarks matrix – to jointly review program implementation gaps using the evidence compiled, and identify priorities to scale up of the community program. Results Stakeholders identified key health system challenges and proposed policy and programmatic shifts to institutionalize a standardized community health program with fit for purpose and incentivized community health assistants to provide PHC services to the targeted populations. The community health program in Liberia is currently at the phase of implementation and requires strengthened leadership, local capacities, and resources for sustainability. Lessons learned from this review included the importance of: establishing a coordination mechanism and leveraging partnership support; using a systems approach to better inform policy shifts; strengthening community engagement; and conducting evidence-based planning to inform policy-makers. Conclusions This article contributes toward the existing body of knowledge about policy development processes and reforms on community health in Liberia, and most likely other African settings with weak health systems. Community-based systems will play an even bigger role as we move toward building resilience for future shocks and strengthening PHC, which will require that communities be viewed as actors in the health system rather than just clients of health services.
In January 2015, the community health technical working group (CHTWG) was reactivated and several sub-groups (Recruitment and Remuneration; Training & Supervision; Supply Chain, and Monitoring & Evaluation), headed by various Ministry of Health (MoH) departments, were tasked with revising the Community Health Policy in line with the Investment Plan for Building Resilient Health Systems in Liberia (2015-2021). A systematic methodology was adopted. The health systems approach was applied to revise the existing community health policy, and to re-establish the community health system with an appropriate, well-trained, supervised, and incentivized cadre of community workers to provide PHC services to populations with limited health care access. The community health program in Liberia was developed through a government-led process (Figure 1), and used a combination of sources of evidence, including bottleneck analysis, a qualitative study, and benchmarks matrix [21]. Country stakeholders met during a series of program review meetings held in March/April 2015 in all 15 counties of Liberia. The workshops followed a pre-defined agenda, where stakeholders assessed the bottlenecks to scaling up community health programs and discussed solutions to address them. An adapted Tanahashi framework was used to assess health system bottlenecks linked to the following determinants: availability of commodities, availability of human resources, geographic accessibility, utilization (initial and continuous) of services, demand for services (community engagement), and quality of care [22,23]. This approach has previously been used to identify bottlenecks in reproductive, maternal, newborn and child health (RMNCH) service delivery [23]. Assessment of the enabling environment, including the functionality of the community health structures, was done, to understand the potential impact on service delivery. Workshop participants used available program reports from MoH, administrative data, and professional experiences to identify the health system bottlenecks to scale up community health. Then participants proposed potential strategies to address identified bottlenecks. The CHTWG reviewed workshop reports and identified common issues raised by participants for each domain of the health system. During a 3-day retreat in Bong county in April 2015, MoH program managers and designated CHTWG sub-group members collated and shared the first analyses with all participants for discussion; this further informed the revision of the Community Health Policy which was later revised and validated in December 2015 [24]. Between September and November 2015, a qualitative study was conducted in five counties (Bomi, Bong, Grand Gedeh, Montserrado, and River Cess), to explore stakeholders’ opinions and perceptions on strengthening the community health program. Methods included focus group discussions (FGDs) and in-depth interviews (IDIs). A two-day training was conducted for interviewers, field coordinators, and note-takers, and covered field operations, ethics, interviewing techniques, transcription, and safety. The semi-structured interview guide was developed through review of previous research interviews and consultations with experts involved in community health programs. It included the thematic areas of policy and strategy development, coordination, performance management, and facilitators and barriers for the planning and/or implementation of the community health strategy. One county was randomly selected from each of the five health regions of Liberia. Participants for IDIs were selected through purposive sampling, and included policy-makers, program managers, health care workers involved in community health programs, and County/District Health Team members. Participants for FGDs included gCHVs, community leaders/representatives, pregnant women, and mothers and fathers of children under 5 years. Five teams, each comprising one interviewer and two note-takers, conducted the data collection through interviews, of 90 minutes each, over a two-week period. Interviews were audio-recorded, transcribed, and entered into NVivo (version 9). Analyses were carried out using a general inductive approach to systematically summarize views regarding specific research questions, rather than seeking to develop a new theory, or describe a phenomenon or lived experience [25]. Data were read with the research areas in mind, but no a priori models were imposed. Contents were aggregated across interviews, and lower order units of meaning were identified and clustered into themes and sub-themes. Data were coded using these themes, and quotes encapsulating themes were selected. Ethical approval for this study was obtained from the University of Liberia Institutional Review Board. Verbal consent was sought from participants, after explaining the study and assuring confidentiality. The iCCM interagency framework has been used to assess progress made in planning and implementing community health programs [26]. Based on the learning from the EVD outbreak that had a negative impact on health services, the MoH in Liberia expanded the package of care for children from iCCM to a broader package of RMNCH services including community-based surveillance. The benchmarks matrix proposed by McGorman et al uses a health systems approach, and offers insights on the design and implementation level of community programs [26]. The interagency framework includes eight health systems components: coordination and policy setting; costing and financing; human resources; supply chain management; service delivery and referral; communication and social mobilization; supervision and performance quality assurance; and monitoring and evaluation. These components mirror the six WHO health systems’ building blocks with the addition of communication/social mobilization and supervision/quality assurance. The benchmarks are grouped into three phases: advocacy/planning, pilot/early implementation, and scale-up [26]. The CHTWG met several times in 2015 to review documents shared with the government by partners (program/research reports, published and unpublished articles, presentations, and policy documents), highlighting bottlenecks and achievements of the community health program during the past 10 years. The CHTWG compared these findings with results from the bottleneck analysis and the IDIs/FGDs, using the domains of the benchmarks matrix, to identify common issues, review achievements against the benchmarks, and assess the community health program implementation.
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