Research

As many low- and middle-income countries scale up community health worker (CHW) programs to achieve universal health coverage, ensuring quality as well as access is critical. Health system responsiveness (HSR) is a core domain of quality patient-centered care, but has not been widely measured in CHW-delivered care. We report results from a household survey measuring HSR and health systems quality of CHW-delivered care in two Liberian counties where the national CHW program for communities five kilometers or more from a health center has been implemented.

We found that HSR was associated with important patient-reported health system quality outcomes, including satisfaction, trust, and confidence in the CHA. Measuring patients’ experience and outcomes of care is important to complement more common measures of technical quality for CHW-delivered care to ensure that this domain of quality is central to community health program design and delivery.

The Revised National Community Health Services Policy (2016-2021) (RNCHSP) and its program implementation, the Liberian National Community Health Assistant Program (NCHAP), exhibit a critical gender imbalance among Community Health Assistants (CHAs) as only 17% are women (MOH, 2016). This study was designed to assess the gender responsiveness of the RNCHSP and its program implementation in five counties across Liberia to identify opportunities to improve gender equity. The study found that despite the Government of Liberia’s intention to prioritize women in the recruitment and selection of CHAs, the planning and implementation of the RNCHSP were not gender responsive. The inequitable gender balance of CHAs has impacted the accessibility, acceptability, and affordability of community healthcare services, particularly among women. Strengthening gender responsiveness within the RNCHSP and its program implementation is key to fostering gender equity in the health workforce and strengthening a key pillar of the health system.

Key findings: In Grand Bassa County, Liberia, where Last Mile Health has managed implementation of the national program since 2018, care of childhood illness by a qualified provider increased by 60.3 percentage points more in areas where the national program has been implemented compared to areas where it has not. The evaluation also identified large improvements in two important components of care: receipt of oral rehydration therapy for diarrhea and rapid diagnostic testing for malaria. In addition, care by a community health worker increased from 0 to 81.6%, and care from unqualified providers decreased in intervention areas. Importantly, this evaluation found evidence that the Liberian National Community Health Assistant Program has increased access to effective care in rural Grand Bassa County.

Key finding: A controlled study in Rivercess County, Liberia, where Last Mile Health has managed implementation of the national program since 2016, demonstrated an increase in children receiving pneumonia, malaria, and diarrhea treatment by 40.8%, a difference-in-differences of over 50 percentage points.