Table 2 shows the characteristics of the interviewed participants while Table 3 presents key illustrative quotes to demonstrate the authenticity of the findings. The results are presented within the context of the CHA policy and its influence on NTD programme delivery, and the hard and software-related factors elaborated on in Kok et al’s conceptual framework on CHW performance.
The context of the CHA policy and its influence on NTD programme delivery
The document review shows that the CHA policy is centred around the CHSS and CHAs who are formally recognised and ‘paid’ community health cadres while informal or volunteer CHWs are categorised as community health volunteers (CHVs). Table 4 presents the types of CHWs operating in Liberia, their key roles and responsibilities and the training required under the revised NCHSP. The NCHSP categorises CDDs as CHVs. The KIIs show that high-level political will and mobilisation influenced by CHW policy reforms in other African countries such as Ethiopia and the drive to achieve UHC were key factors shaping the reform and implementation of the CHA policy.
Under health systems hardware dimension, opportunities and challenges associated to CHW training, supervision, renumeration and logistics and supplies are influenced by several contextual policy related factors. These enable inequities between cadres of CHWs, thwarts supportive supervision and hinder access to medicines, supplies and equipment which adversely influence CDDs motivation and performance and equitable NTD programme delivery in Liberia.
The NCHSP stipulated pre-service and in-service training with requirements for CHAs, CHSSs, and CHVs from the document review further detailed in Table 4. The policy emphasises the need for coordination with the Ministry of Education (MoE) to embed community health content into existing pre-service health training programmes with the potential for accreditation of the CHA programme. Although the document review shows an expectation for biannual in-service training through focused supportive supervision and/or linked to periodic interventions, this is less detailed. For CHAs, the review shows that training provided by non-governmental organisations (NGOs), national and county level health training staff should be built around four key modules covering different health topics and delivered over four months as a hybrid of classroom and practical community-oriented activities. Most key informants positively described CHA training as didactic training with supervised role-plays that CHAs are expected to complete. However, KIIs conducted in unsupported implementation areas showed that CHA training in such areas is still ad hoc and linked to specific programmes with CHVs reportedly feeling excluded when not selected for CHA training. Some KIIs added that some recruited CHVs had not completed the CHA training because funding partners had ceased their support [funding] for program implementation in those communities.
For NTD programming, training for MDA is cascaded using a train the trainer model. Key informants reported that training for Officers in Charge (OIC) is delivered by county health teams (CHTs) and is scheduled for about three days. This is however frequently shortened to a day and a half to minimise subsistence costs; accommodate high health staff workloads; delays in drug delivery to health facilities, requiring rapid MDA intervention rollout to avoid expiration of medicines; and tight reporting deadlines. Same systems barriers experienced by OICs also account for rapid training times for CDDs. Consequently, most CDDs were dissatisfied with the training they received which they reported was usually rushed, lasting for at most, half a day with training content focused on reviewing eligibility criteria and giving medicines. CDDs requested more information about side effects and provision of training manuals and Information, Education, and Communication (IEC) materials.
In life and job histories, CDDs who had been recently engaged within the CHA program reported an in-depth NTD focus within the CHA training which provided them with critical skills to conduct and complete MDA activities, suggesting that some vertical programme barriers to training as identified amongst other CDDs have been alleviated.
A description of the cascade of supervision as outlined in the NCHSP (Fig.1) shows that supportive supervision relies on integrated and standardised supervisory checklists and tools which are monitored by the community health services division (CHSD). In unsupported implementation areas, inadequate supervision was cited by Key informants as a reason for the poor retention of CHVs. They explained that OICs of health facilities are charged with the supervision of CHV activities and reviewing monthly referrals to the health facility. OICs reported providing additional supervision to CHVs such as CDDs during health campaigns such as MDA when additional resources such as fuel for motorbikes, or scratch cards to call CDDs are provided. CDDs reported that the number of times they received supervision varied particularly during MDA with some CDDs indicating that they received supervision at least twice during the MDA campaigns. Other CDDs reported that although they might receive some supervision during campaigns, the timing and frequency are not pre-determined. Several CDDs stated that supervision ceased when campaigns ended which they felt reduced their engagement in other health activities.
In supported districts, CDDs who had undergone CHA training and recruitment as CHAs reported feeling satisfied and supported in their duties because they received more supervision, usually from the CHSS. However, the heavy workload of OICs and CHSS and large catchment areas assigned to each CHSS for supervision activities were cited by key informants and CHSS respectively as key reasons for the ineffective supervision processes in some areas. Several OICs and CHSS reported incurring personal out of pocket costs during supervision.
CDDs frequently reported that the lack of supportive supervision was demotivating. Key informants elucidated that inadequate availability of health resources including the provision and fuelling of motorbikes to transport supervisors to the various communities and shortage of health workers resulting in high workloads for supervisors as critical barriers to the provision of supportive supervision at all levels of the health system, regardless of implementing partner support, or campaign activity. In communities where there were no health facilities, there were no CHSS to supervise CHAs or such communities were merged with communities where CHSS are stationed.
While CHAs and CDDs requested regular and structured supervision structures, they also proposed that phone-based supervision and regular health facility-based meetings could alleviate some supervision challenges. Some key informants suggested the establishment of a new cadre of CHWs to play an intermediatory supervisory role between OICs and CHSS; They added that more in-depth CHA training in districts with implementation support motivated CHAs to provide peer supervision for each other. They further reported that although there are sustainability challenges, the utilisation of existing community structures, such as community health development committees (CHDC) and health facility development committees (HFDC) for supervision had proven valuable in monitoring and supervision and providing feedback to CHSS and health facilities.
The review shows the NCHSP providing a clear distinction between incentives, motivation, performance-based incentives, career development and retention for CHWs. This policy provides a standardised incentive of 70USD per month for CHAs providing at least four hours of routine community health care packages at the household level per day. Key informants reported that the monthly incentive for CHAs had been introduced in partner supported districts as the only financial remuneration provided for CHAs, but the incentive was being poorly implemented because it was not linked to CHA performance. National level KIIs added that bureaucracy between donors and the LMoH led to delays in fund payments and resulted in at least quarterly CHAs payments instead of monthly payments.
Moreover, the NCHSP details that all community health cadres are entitled to receive other forms of motivation from the programme or community. Described as opportunities for receiving rewards for working on project-specific initiatives, the NCHSP stipulates the following criteria for standardising such rewards:
- Daily disbursement fees of 5USD per day, not exceeding 10 days per month.
- For programmes requiring ongoing engagement of community cadres, a flat rate of up to 50USD per month (commensurate to work) should be provided or compensation at rates established before 2015 but not exceeding rates received by CHAs.
Yet, the irregular or ad-hoc disbursement of financial remuneration was described by KIIs as demotivating and resulting in attrition of CHAs and CHVs. In unsupported districts, KIIs reported the lack of regular financial remuneration for CHVs within programme specific initiatives as stipulated by the NCHSP which was influenced by the availability of government funding and donor stipulations. CHV dissatisfaction with accessing such financial rewards is reportedly aggravated by the fact that some donors who had previously paid their monthly allowances had stopped because their projects ended in the district. CDDs expressed dissatisfaction with irregular financial remuneration and explained that communities that had previously provided remuneration to CDDs had stopped because they perceived CDDs as adequately compensated by the NTD programme. Harsh economic circumstances experienced by households also contributed to communities’ inability to sustain motivating CDDs with gifts. CDD dissatisfaction was compounded by some CDDs having the opportunity to be selected for training and recruitment as CHAs while other CDDs did not have the opportunity to be selected into the CHA program.
Some facility-level key informants explained that they had made efforts to communicate with CHVs to keep them motivated and rotate CHVs to engage in ‘one off’ vertical disease campaigns that could bring the promise of financial reward for CHVs. A KII reported the importance of supporting CHVs as ‘they were leaving things they normally do’ to voluntarily support health service provision. Particularly for male CDDs who volunteered on the NTD programme while working additional jobs to financially provide for their families, they faced criticism from family members who felt that they received financial remuneration from the NTD programme but were not bringing the money home.
Finally, the NCHSP proposes the development of performance-based financing practices and career development and retention opportunities in collaboration with other ministries for cadres of CHWs, but key informants reported this was not operational partly due to the infancy of the policy.
Supplies and Equipment
Box 1 shows the key steps outlined by the NCHSP, that the CHSD and the MoH are expected to undertake to ensure adequate and quality-assured medicines, supplies and logistics. In practice, participants indicate that implementation challenges in managing and coordinating the logistics and supply chain has had adverse implications on CHWs motivation. For the NTD programme, in districts where the CHA policy implementation is not supported by funding partners, inadequate logistics and protective clothing were reported as factors affecting CHAs and CDDs performance and completion of job roles. CDDs suggested that they should be provided with identification badges to further authenticate them in the communities and mobile phone calling cards to facilitate communication with supervisors. Some CDDs added that since they work in places that ‘they just could not reach by foot, they should be provided with bikes to facilitate their travel. Some county and district level key informants mentioned that inadequate supply of fuel meant that even when supplies and logistics are available for distribution, they incurred personal pocket costs to transport them to CHWs. Both KIIs and CDDs recommended improving logistics, supply, and equipment to enable CDDs to improve their coverage areas to include far to reach places and reduce travel distance and size of CDD catchment communities.
The inadequate supply of logistics and equipment was also reported in partner supported districts. KIIs reported that in districts receiving funding support to implement the CHA policy, although CHAs and CHVs have been supplied with logistics such as rainboots, they still lacked supplies such as hand sanitisers, books, and pens. They added that the provision of such supplies and logistics including the issuing of certificates for CHAs and or CHVs would be crucial to motivating and improving CHA performance in the communities. For instance, while several CDDs requested supplies and logistics to support NTD program delivery, some CDDs mentioned intrinsic motivational factors including knowledge gained from the NTD training programme, personal experiences of losing relatives leading to taking up the CDD role and the potential of progressing to becoming a health worker.
Box 1: Logistical and Supply Chain Management Stipulations in NCHSP
MoH CHSD shall:
- Ensure that national supply chain and commodity documents are reflective of the latest international guidelines and protocols for community health programs and similarly that curriculum and SOPs for CHAs are aligned national protocols;
- Ensure that all key pharmaceutical policy documents incorporate CHA supply chain requirements;
- Ensure that all materials intended to facilitate CHA activities are delivered to CHAs through a clearly defined framework within the health facility;
- Work closely with the Supply Chain Management Unit (SCMU) to ensure medicines, medical supplies and other logistic needs or CHAs are adequately quantified at the national level, based on county needs and are supplied to health facilities in a timely manner to prevent stock-outs at community level
- Ensure that oversight responsibilities for rational utilization are clearly delineated to the responsible pharmaceutical arm of the MoH and in coordination with county level administration.
The health systems software dimensions shows policy related contextual challenges involving selection and recruitment and community engagement and dialogue in CHW programming which facilitate inequities between the various cadres of CHWs which hinder CDDs motivation and performance for efficient health care delivery.
Selection and Recruitment
CHSS are selected through a formal application and interview process as they are trained in formal health care roles such as nurses or midwives. The NCHSP highlights the importance of Community Health Focal Points in supporting the selection and replacement of CHAs. The NCHSP emphasises the need for communities to be highly engaged in the work of CHAs and so, communities are guided by CHTs to select members of the community health committees (CHCs) before the selection of CHAs. CHA selection is based on core criteria outlined in Box 2.
Box 2: CHA Selection Criteria (Exert from NCHSP pg9)
- Must be a permanent resident in the community in which s/he serves;
- Must be between 18 and 50 years of age;
- Should be trustworthy and respected;
- Should be interested in health and development matters;
- Should be a good mobilizer and communicator;
- Should be available to perform CHA tasks;
- Should be physically, medically, mentally and socially fit to provide the required services, including walking long distances up to one hour or more to provide health services to people in their designated catchment area;
- Should have been involved in community project/s in the past;
- Should be able to demonstrate the ability to read, write, add, subtract and multiply in English to successfully complete a test of literacy as part of their recruitment process;
- Fluency in the dialect that is spoken in the village or town where s/he is serving;
- Must be a Liberian; and
- Females should be given preference.
Communities commonly propose previous CHVs for CHA roles. Key informants described their role as facilitative with OICs playing a more direct role in the CHA selection process. KIIs reported the availability of community members willing to volunteer as CHAs but their inability to meet the selection criteria such as literacy and gender often hindered their recruitment. For example, CHVs have to complete a literacy test before embarking on the CHA training programme. Thus, poor literacy levels in communities were a significant barrier to the selection of CHVs as CHAs irrespective of gender, although exacerbated for women due to education preferences favouring males. Most CHAs are therefore often selected from outside the community. Key informants added that literacy-based challenges had been experienced for many years in the selection of CDDs and other CHVs.
Historically, there has been no prioritisation of specific population groups within CDD selection processes, with community selection of CDDs often being influenced by underlying community power dynamics. KIIs reported that the prioritisation of females for selection within the CHA policy could therefore support establishing a balanced health workforce as there have been challenges to recruiting female CDDs. Over time, attrition of CDDs had led to a decline in participatory approaches to community selection, with CDD replacements often being selected by OICs or community leaders, with minimal community dialogue. While the NCHSP shows an awareness of gender-based challenges in the recruitment of females as CHWs, it proposes engagement with the Ministry of Education to narrow gender gaps in terms of literacy access and retention. To address these challenges, KIIs described working with women (and some youth) to improve their literacy levels through community-based adult education programs to enable them to participate in the CHA program. They proposed that embedding literacy programmes within CHA training or creating educational scholarship programmes would better support the participation of women and other CHVs with literacy challenges.
Community relationships and responses
Both the review and the interviews across all levels emphasised the importance of embedding CHWs within their communities which allows them to ‘add respect and rapport’ between the health system and communities while ‘educating community dwellers to make decisions about their own health’. Embeddedness within communities allowed CHWs to support health surveillance activities which KIIs reported as a critical role ‘in case there are outbreaks and there needs to be a focus in a specific area’. Within the NTD programme, delays within the drug supply chain result in a reduction of time to complete awareness and drug distribution activities which hinder community connectedness and CDDs interaction with community members. Some CDDs described community members refusing to accept medicines or negative interactions because of the limited time they have to connect with community members as demotivating factors to their role. They requested support from the CHA programme in completing awareness activities and using strategies such as group sensitisation meetings and involving community leaders to enhance their work.
 (including CDD training)
 a suggestion stemming from the actions of an implementing partner which had in a previous program created ‘Quality Assurance Officers’ who supervised CHSS to reduce the supervisory workload of OICs.
 both monetary or in-kind for transportation and gifts