摘要：Objectives. To assess a community health worker (CHW) program’s impact on childhood illness treatment in rural Liberia. Methods. We deployed CHWs in half of Rivercess County in August 2015 with the other half constituting a comparison group until July 2016. All CHWs were provided cash incentives, supply chain support, and monthly clinical supervision. We conducted stratified cluster-sample population-based surveys at baseline (March–April 2015) and follow-up (April–June 2016) and performed a difference-in-differences analysis, adjusted by inverse probability of treatment weighting, to assess changes in treatment of fever, diarrhea, and acute respiratory infection by a qualified provider. Results. We estimated a childhood treatment difference-in-differences of 56.4 percentage points (95% confidence interval [CI] = 36.4, 76.3). At follow-up, CHWs provided 57.6% (95% CI = 42.8, 71.2) of treatment in the intervention group. The difference-in-differences diarrhea oral rehydration therapy was 22.4 percentage points (95% CI = −0.7, 45.5). Conclusions. Implementation of a CHW program in Rivercess County, Liberia, was associated with large, statistically significant improvements treatment by a qualified provider; however, improvements in correct diarrhea treatment were lower than improvements in coverage. Findings from this study offer support for expansion of Liberia’s new National Community Health Assistant Program. Liberia ranks among the worst nations globally in child health outcomes, with a mortality rate for those younger than 5 years estimated at 94 per 1000 live births. 1 Although Liberia attained the 2012 Millennium Development Goals for child mortality in 2012, 2 rural areas continue to suffer the greatest burden of mortality because of poor access and utilization of health care services. 3,4 Furthermore, progress in reducing child mortality rates was interrupted by the 2014–2015 Ebola virus disease epidemic. Approximately 40% of deaths among those younger than 5 years in the region are attributable to malaria, diarrhea, and acute respiratory infections (ARIs). 5 To reduce childhood mortality, many countries have implemented an integrated community case management (iCCM) strategy, which relies on community health workers (CHWs) to treat uncomplicated cases of childhood illness in the community and refer complicated cases to the nearest health facility. 6 After implementing iCCM interventions, mortality reductions have been observed attributable to increased delivery of malaria, ARI, and diarrhea treatments, 7–12 as well as bed net distribution. 13,14 In response to Liberia’s poor maternal and child health outcomes, Last Mile Health, a nongovernmental organization, partnered with the Liberia Ministry of Health to implement a CHW program, which included an iCCM component, in 2 counties in Liberia. This program built upon Liberia’s existing “general community health volunteer” program, which included iCCM but lacked systematic supervision, supply chain systems, and monetary incentives. This demonstration project informed the development of a national-scale, government-led program called the National Community Health Assistant (CHA) Program, which uses a cadre of workers called CHAs performing similar duties as the CHWs in this study, which was launched by the Ministry of Health in 2016. A previous evaluation of the program found significant improvements in child health outcomes with an uncontrolled before–after study design in a single implementation area. 15 We expanded upon that study to assess the impact of the demonstration program after a controlled implementation in a second county. Our principal aim was to assess whether the program increased treatment of fever, diarrhea, and ARI compared with a control area during the 1-year implementation period.
