John Flomo, a community health assistant in Donfah, speaking to residents CREDIT: Peter Yeung/The Telegraph
In the shade of a grand old mango tree, John Flomo is carrying out one of his routine checks for child malnutrition in Donfah, a remote village in Liberia’s Bong county.
Flomo takes out a colour-coded tape to measure for malnutrition and wraps it around the arm of a two-year old boy, with a beaming smile.
“Your boy’s doing just fine,” Flomo tells the boy’s mother, Linda Williams. “He’s going to grow up to be a big, strong man. But make sure that you feed him plenty.”
Flomo is a community health assistant for Donfah, where he was born, went to school, and for many years worked as a farmer before being nominated by his community for this important new role.
There are around 4,000 community health workers like Flomo across the west African nation’s 15 counties, providing health services to remote villages.
Sianneh McCarthy with her son CREDIT: Peter Yeung/The Telegraph
Together they are a crucial cog in Liberia’s fragile healthcare machinery. The country’s health system is currently undergoing a bold revolution, after being pushed to the brink by brutal civil wars between 1989 and 2003 that killed 250,000 people. By 2008, there were only 51 doctors in Liberia serving a population of 3.7 million, roughly one per 70,000 people. That year the government overhauled its health system, with the aim of encouraging the use of community-based health volunteers. Then, in 2014 a deadly Ebola outbreak hit Liberia, and this served as a catalyst for the national deployment of the workers. From 2016 they began to receive proper pay and training as their role was formalised.
“That was one of the lessons learned from the Ebola outbreak,” says Sumo Lomax Flomo of the National Public Health Institute of Liberia. “We saw a lot of cases coming from the community who were very ill or already dead. The community was not used for surveillance. Once it was, our fight was transformed.”
The primary role of community health workers is the diagnosis and treatment of children under five for malaria, pneumonia and malnutrition. But they also focus on community health education, disease surveillance and maternal health.
A set of scales to weigh babies at the Zeansue clinic CREDIT: Peter Yeung/The Telegraph
The health workers’ mission is to provide treatment in remote areas far from health clinics. As they come from the local community they are also more likely to be trusted by their fellow villagers when it comes to thorny issues such as vaccination. The scheme has the added benefit of bringing income and employment to poverty stricken rural areas with few job opportunities.
“I’ve been very impressed with the scheme,” says Robert Yates, director of the global health programme at policy think tank Chatham House. “It's very cost effective and it reaches a lot of people. But the benefits go way beyond the immediate health sector. It creates employment and improves women’s livelihoods. It’s very clever.”
Since the community health scheme officially launched in 2016, it has made startling progress. About 70 per cent of Liberia’s 700,000 rural residents now have access to care and some 1.8 million free screenings and treatments for diseases such as pneumonia and diarrhoea had been carried out on under fives as of June 2021.
A study published in August found that community health workers now treat 45 per cent of all malaria cases among children under five in those areas, with that figure rising year-on-year. And, crucially, children get treated faster. The number of malaria cases treated in less than 24 hours rose from 12,807 in 2016 to 93,530 in 2020, according to Ministry of Health data.
In Dofah, it can take several hours to walk to the nearest health facility under the energy-sapping Liberian sun. But residents say treatment and diagnosis is now faster, convenient and accessible. “We felt bad when we had to go to the clinic,” says Linda Williams. “It was exhausting if you couldn’t afford the motorbike. Back then I had to rush to the hospital, but now I just go to Flomo’s house.”
Esther Kollie with her daughter and mother in Donfah CREDIT: Peter Yeung/The Telegraph
Flomo was nominated by the Donfah community for the role in 2016. The job requires a minimum of primary level education and completion of a written literacy test. Each community health assistant must go through four modules of training over several months, from household registration to family planning and malaria diagnosis. They are then paid $70 (£52) a month for around four hours work a day, but must be on call for emergencies.
“I enjoy the job, I’m proud,” says Flomo. “These are my friends, family and former classmates. I’m preventing their sickness. I feel respected in my community, people see me as the Big Dada. They thank me so much. They call me if they need anything. ‘John, my child has a fever’, ‘John, I need to go to the clinic’.”
For Linda, this deep-rooted connection with the community can’t be replicated by outside health workers parachuted in for brief visits. “I’ve known the man since I was small, we grew up together,” says the 35-year-old mother. “I trust the man in a way I couldn’t with some stranger.”
George Tamatai, a Ministry of Health official in Bong, says the scheme has reduced the workload in the county’s clinics, freeing up capacity for more specialised work. “Community workers identify illness earlier, which means there are fewer patients for clinics to deal with and fewer severe illnesses that develop,” he says.
The early detection offered by community-based health workers is also seen as a vital tool for stopping the spread of emerging infectious diseases. The Independent Panel for Pandemic Preparedness and Response has said community health workers made a “critical difference” in countries’ responses to Covid, establishing trust in government policy, extending services and relaying scientific information.
The Zeansue health clinic in Bong county CREDIT: Peter Yeung/The Telegraph
In Donfah, given the relatively narrow focus of Flomo’s remit – easily treatable diseases for under fives – much of the support he gives to the rest of the community involves early diagnosis and clinic referrals rather than in-situ treatment.
At the Zeansue Clinic, four miles away from Donfah, there are signs that those referrals are running smoothly. Esther Bonndo, a mother from the nearby Palala village, has come to get her three-month old vaccinated for pneumonia after being reminded by her community health assistant. “It wasn’t any effort at all,” she says.
Yet despite the huge strides taken in Liberia’s provision of care, one of the great challenges remains timely and sufficient supply of drugs in the face of funding shortfalls and the logistical difficulties presented by the country’s poor roads. There are fears these could undermine the entire community health programme.
“We often don’t have enough medicine,” says Massayan K Jallah, community health department director for Bong’s nine health districts. “And when it’s insufficient, it’s bad for the community. If the drugs aren’t available, they might have to walk two or three hours to the facility. And they might not even have any there. It can be really demotivating and risks undoing all our good work.”
Another crucial obstacle on the horizon is securing financial sustainability. Liberia’s community health programme is currently heavily reliant on funding from organisations such as USAid and the International Rescue Committee (IRC), which are backing the scheme in the counties of Bong, River Gee, Grand Kru and Lofa. “The government’s ownership of the project is something that must be worked on,” says Dianah Bedell-Majekodunmi, the IRC’s project director in Liberia.
Linda Williams and her son CREDIT: Peter Yeung/The Telegraph
But for now, Liberia’s poverty-stricken, remote and rural communities are benefiting from improved access to healthcare in a way that is revolutionising the fight against infectious disease in sub-Saharan Africa.
During the civil war, Sianneh McCarthy was forced to flee violence in the capital Monrovia, walking roughly 100 miles to Donfah. Her three-year-old son suffered chronic anaemia due to iron deficiency and died. “We had no car to take him to the hospital,” she says.
Now she is visited by Flomo two or three times per month – but if any of her children get sick, he comes straight away. Just two days before, her three-year-old son, Emmanuel had a “runny stomach”, and was given oral hydration solution (ORS) by Flomo.
“He can take care of us quick,” says Sianneh, clasping her skinny young boy tightly. “By the grace of God, it’s much better. It’s different now. My son wouldn’t have died if it was like today.”
This project was funded by the European Journalism Centre, through the Global Health Security Call. This programme is supported by the Bill & Melinda Gates Foundation