Strengthening the community health program in Liberia: Lessons learned from a health system approach to inform program design and better prepare for future shocks.

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.