Transition and Change: Opportunities and Challenges of CHW Policy Reform for Community Health Systems and Vertical Disease Programmes in Liberia

Abstract

Background: Health workforce shortages remain a critical public health challenge. Particularly in low and middle-income countries (LMICs), the re-invigoration of community health workers (CHW) supplement critical health workforce gaps especially during epidemics and pandemics such as Ebola and Coronavirus. National CHW policies can influence CHW motivation and performance. Adaptations to national CHW policies therefore have impacts across the whole health system, particularly for vertical disease programming. Using a case study of Community Drug Distributors (CDDs) working under the Neglected Tropical Disease (NTD) Programme, this paper explores how adaptations to a national CHW policy in Liberia influences health systems and intervention hardware and software factors that impact CHW utilisation, management, and performance in the delivery of vertical disease interventions.Methods: Three qualitative data collection tools were utilized, namely; content analysis of five CHW and NTD program-related policy documents; 25 key informant interviews with facility, county, and national level decision-makers; and 42 life and job histories with CDDs in Liberia. Data were analysed using a thematic framework approach with the coding framework generated in QRS NVivo 11 pro. Transcripts were coded using constant comparison, triangulated, and synthesised with the document review and existing literature for contextual relevance, convergence, and divergence.Results: The health systems hardware dimension shows opportunities and challenges linked to CHW training, motivation, supervision, and logistics and supplies whilst the software dimensions show challenges regarding community engagement and dialogue in CHW programming. Several contextual factors related to the policy adaption potentially facilitate inequities between the various cadres of CHWs, hinder effective supportive supervision and access to medicines, supplies and equipment which shape CDDs motivation and performance which are essential to equitable NTD programme delivery in Liberia. ` Conclusions: This study shows how an adaptation of the CHW policy provides opportunities and challenges for health system hardware and software in varied ways. These have multiple implications for specific intervention hardware and software which provide leveraging opportunities to address gaps and increase CHW motivation and competencies towards better health care delivery and stronger and resilient health systems.