title: Community-based health care is an essential component of a resilient health system: evidence from Ebola outbreak in Liberia.
abstract: Trained community health workers (CHW) enhance access to essential primary health care services in contexts where the health system lacks capacity to adequately deliver them. In Liberia, the Ebola outbreak further disrupted health system function. The objective of this study is to examine the value of a community-based health system in ensuring continued treatment of child illnesses during the outbreak and the role that CHWs had in Ebola prevention activities.
  
  
  
  A descriptive observational study design used mixed methods to collect data from CHWs (structured survey, n = 60; focus group discussions, n = 16), government health facility workers and project staff. Monthly data on child diarrhea and pneumonia treatment were gathered from CHW case registers and local health facility records.
  
  
  
  Coverage for community-based treatment of child diarrhea and pneumonia continued throughout the outbreak in project areas. A slight decrease in cases treated during the height of the outbreak, from 50 to 28% of registers with at least one treatment per month, was attributed to directives not to touch others, lack of essential medicines and fear of contracting Ebola. In a climate of distrust, where health workers were reluctant to treat patients, sick people were afraid to self-identify and caregivers were afraid to take children to the clinic, CHWs were a trusted source of advice and Ebola prevention education. These findings reaffirm the value of recruiting and training local workers who are trusted by the community and understand the social and cultural complexities of this relationship. "No touch" integrated community case management (iCCM) guidelines distributed at the height of the outbreak gave CHWs renewed confidence in assessing and treating sick children.
  
  
  
  Investments in community-based health service delivery contributed to continued access to lifesaving treatment for child pneumonia and diarrhea during the Ebola outbreak, making communities more resilient when facility-based health services were impacted by the crisis. To maximize the effectiveness of these interventions during a crisis, proactive training of CHWs in infection prevention and "no touch" iCCM guidelines, strengthening drug supply chain management and finding alternative ways to provide supportive supervision when movements are restricted are recommended.
authors.affiliation: HealthBridge, 1 Nicholas Street, Suite 1004, Ottawa, ON, K1N 7B7, Canada.
authors.forename: Kendra
authors.initials: K
authors.lastname: Siekmans
authors.affiliation: Canadian Red Cross Society, 170 Metcalfe Street, Ottawa, ON, K2P 2P2, Canada. Salim.Sohani@redcross.ca.
authors.forename: Salim
authors.initials: S
authors.lastname: Sohani
authors.affiliation: Ministry of Health and Social Welfare, P. O. Box 10-9009, 1000, Monrovia, 10, Liberia.
authors.forename: Tamba
authors.initials: T
authors.lastname: Boima
authors.affiliation: Liberia Red Cross Society, 107 Lynch Street, 1000, Monrovia, 20, Liberia.
authors.forename: Florence
authors.initials: F
authors.lastname: Koffa
authors.affiliation: Canadian Red Cross Society, 170 Metcalfe Street, Ottawa, ON, K2P 2P2, Canada.
authors.forename: Luay
authors.initials: L
authors.lastname: Basil
authors.affiliation: Canadian Red Cross Society, 170 Metcalfe Street, Ottawa, ON, K2P 2P2, Canada.
authors.forename: Saïd
authors.initials: S
authors.lastname: Laaziz
mesh_terms: D019090:Case Management / Q000458:organization & administration; D002648:Child; D003153:Community Health Services / Q000458:organization & administration*; D003150:Community Health Workers / Q000458:organization & administration*; D062309:Community Integration; D003967:Diarrhea / Q000517:prevention & control; D004196:Disease Outbreaks / Q000517:prevention & control*; D005260:Female; D017144:Focus Groups; D006078:Government Programs; D019142:Hemorrhagic Fever, Ebola / Q000517:prevention & control*; D006801:Humans; D007988:Liberia; D008297:Male; D008483:Medical Assistance; D011014:Pneumonia / Q000517:prevention & control; D012111:Residence Characteristics
keywords: Community health worker; Diarrhea; Ebola; Health system; Integrated community case management; Liberia; Pneumonia