Abstract
ABSTRACTBackground: Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients. PIH simultaneously deployed a socioeconomic assistance program with three core components: transportation reimbursement to clinics; food support; and additional social assistance in select cases.Objective: This study aimed to evaluate how a CHW program for community treatment support and addressing socioeconomic barriers to care can impact patient outcomes in a post-conflict and post-epidemic context.Methods: Retrospective observational study utilizing registry data from 513 TB, 447 HIV and 75 leprosy patients at three health facilities in Maryland County, Liberia. Treatment coverage and clinical outcomes for patient cohorts enrolled in the pre-intervention period (January 2015 to June 2015) and the post-intervention period (July 2015 to July 2017) are compared using logistic regression analyses.Results: TB treatment coverage increased from 7.7% pre-intervention to 43.2% (p < 0.001) post-intervention and lost to follow-up (LTFU) rates decreased from 9.5% to 2.1% (p = 0.003). ART treatment coverage increased 3.8 percentage points (p = 0.03), with patient retention improving 63.9% to 86.1% (p < 0.001); a 6.0 percentage point decrease in HIV LTFU was also observed (p = 0.21). Despite an 84.3% treatment success rate observed for leprosy patients, pre-intervention data was largely unavailable and statistical significance could not be reached for any treatment outcomes pre-post intervention.Conclusions: The PIH approach to CHW community treatment support in Liberia demonstrates how, with the right inputs, excellent clinical outcomes are possible even in post-conflict and post-epidemic contexts. Care should be taken to position and support CHWs so that they have the opportunity to succeed, including full integration and recognition within the system, and the addition of clinical system improvements and social supports that are too often dismissed as unsustainable.
Highlights
Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients
We disaggregated treatment outcomes for HIV, TB and leprosy patient cohorts by month registered in the respective periods: January 2015–September 2016 for both TB and leprosy, and January 2015–July 2017 for HIV
We compared the outcomes of 36 HIV, 84 TB, and five leprosy patients enrolled in the preintervention period (January 2015 to June 2015) and 411 HIV, 429 TB, and 70 leprosy patients enrolled in the post-intervention period (July 2015 and after)
Summary
Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients. Prior to the 2014 EVD outbreak, Liberia’s Human Development Index was just 0.39, ranking 174 out of 187 countries [5], and the national representation of health workers included just one health worker for every 100,000 people [6]. This loss of human resources – and distrust in the health care system during and immediately following the EVD outbreak – had major effects on health outcomes. The EVD outbreak disproportionately affected the more remote counties of Liberia due to inequality in the distribution of health care resources: over 60% of health workers work in and around Monrovia, where just 30% of the Liberian population reside [7]
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