Fair Research Partnerships in European Commission Funded Research

The EU is clearly not the only research funder that struggles with ‘partnerships’ – in fact, we are not aware of any widely accepted framework related to effectiveness, efficiency, impact or ‘fairness’ of research partnerships anywhere. There is also no systematic learning happening – we are not sharing best practices – we are not learning what happens in other parts of the world.

In response, COHRED has developed the Research Fairness Initiative (RFI)  aimed at creating a due diligence instrument and compliance tool for exactly this : ensuring that partnerships work and are ‘fair’

By Carel IJsselmuiden, Executive Director

and Kirsty Klipp, Research Fairness Initiative – RFI Implementation Manager

Council on Health Research for Development – COHRED

Fair Research Partnerships in European Commission Funded Research – Do We Know What is Actually Happening with Public Funds?


The EU Directorate-General for Research and Innovation (DG-RTD) is responsible for EU policy and action on research and innovation aiming at making the EU globally competitive, creating jobs and economic growth, building EU-wide research infrastructure, tackling the big societal challenges, and supporting general EC’s mission to promote justice and human rights and become a global actor.

That is quite a portfolio. Commensurate to the task, the resources available for achieving the mission and strategies of the DG-RTD are substantial. The Horizon 20/20 programme alone already has more than €70 billion allocated to it. With all types of added special funds and special interests of member states, the total is certainly much higher.

In the context of pursuit of justice and of Europe as a global actor, special programmes such as the EDCTP (European and Developing Country Clinical Trials Programme)  add substantially to the total funds available to low and middle income countries to help build their research and innovation systems and resilience. Similar aims within Europe are pursued with programmes like WIDESPREAD that aim to bring ‘underperforming’ EU and Associated countries to a higher level of research performance.

Irrespective of the specific focus of programme – almost all EU funded research programmes and research calls aim for two specific outcomes. Firstly, improvement in knowledge and understanding – advancing specific scientific fields that have been prioritized by the DG-RTD.

The second focus, although implied and hardly visible but nevertheless a cornerstone of any EU funding, is to bring EU institutions together in research partnerships: within the EU to improve the research and innovation infrastructure within the EU, and with external countries to either access expertise needed to make EU more globally competitive (in case of collaboration with high-income countries) or to support low and middle income countries to build up their own research and innovation systems and become more economically resilient.

In brief – EU funded research focuses on specific scientific advancement and on supporting institutional research partnerships.

The first – specific scientific advancement – is well measured.  DG-RTD holds EU wide consultations, involves citizens, pays consultants, holds meeting – and, above all, has an extensive metric with which to assess cutting edge research, researchers and research institutions. This metric is based on globally acceptable standards and on EU developed criteria that are well worked out, public and made obligatory for reviewers in judging proposals for funding submitted in response to research calls by the DG-RTD. So far, no problem.

It is the second one where problems appear – supporting institutional research partnerships. A short view on the H2020 call page today (25 April 2018) shows long lists of calls – almost everyone has ‘collaboration’, ‘partners’, ‘joint’, ‘regional’, and more expressions showing the centrality of partnership to achieving research and innovation goals.

Yet, there is hardly any criteria by which to measure impact nor with which to equip reviewers of calls to make informed and transparent selection of applications successful in this second core aspect of EU calls.

The best summary is informal. We have ‘discovered’ 3 criteria – one of which is ‘hard’ but largely meaningless, and the other 2 cannot really be objectively interpreted, and seem to run against reality.

Criteria 1 – if the call specifies a certain number of partners, then the check is simple. Meets or does not meet. Very objective and very accurate, but hardly of any relevance to the goal.

Criteria 2 and 3 – focus on ‘approximate similar budgets’ and ‘approximately similar responsibilities’ to safeguard against calls serving only one or a few institutions where the others are added pro-forma. This may be especially important in joint research with low and middle income institutions and reduces the massive resource imbalance between partners. However, it is not clear how this rewards partnerships where some partners really have higher expertise, equipment, facilities whereas others are just starting. There is no ‘right figure’ for ‘approximately similar budget’ or ‘approximately similar responsibility’ – and, in fact, this is not a criteria which reviewers can reasonably use transparently. The EU can also not really measure impact of the partnership component – for example in achieving competitiveness, or in achieving research system building in low and middle income countries.

The EU is clearly not the only research funder that struggles with ‘partnerships’ – in fact, we are not aware of any widely accepted framework related to effectiveness, efficiency, impact or ‘fairness’ of research partnerships anywhere. There is also no systematic learning happening – we are not sharing best practices – we are not learning what happens in other parts of the world. It seems that science has deserted its own core – there is no systematic study and learning of the second pillar of successful and competitive science infrastructure: partnerships.

In response, the Council on Health Research for Development – COHRED has developed the Research Fairness Initiative (RFI) aimed at creating a due diligence instrument and compliance tool for exactly this: ensuring that partnerships work and are ‘fair’.

Essentially, the RFI proposes a global reporting system for academic and research institutions, government agencies, research funders and business engaged in research – in fact, it is applicable to all key stakeholders in global (health) research. The RFI Report is written around pragmatic and universally applicable indicators of the quality and fairness of research collaborations. Originally aimed at research collaborations that involved low and middle income countries, it is now clear that it applies across sciences and across socio-economic strata of countries.

The concept is simple: every institution prepares their own RFI Report once every two years. The report consists of the answers to a series of questions focusing on the quality, fairness and equitability of research collaborations. The questions are simple – the answers are usually simple – but action to improve may be intensive : i) what is your institution’s current policy or practice related to … ; ii) if you have examples of good policies and practices, please share this, and iii) what improvements are envisaged in the short term. This is repeated for 15 key topics – each assessed by 3 indicators.

This will achieve transparency in how research partnerships are set up and managed, create a pool of shared practices and systematic learning from which new standards and benchmarks can be developed.

There is no doubt that institutions at the beginning of the research excellence curve need international partnerships to develop their science base further – and there is also no doubt that many of the current partnerships are far from optimal these institutions – for example, in terms of sharing intellectual property, authorship, data ownership, decision making, and access to funding – all issues that the RFI requests answers to.

A first RFI Report has been published now by the Tropical Disease Research and Training Programme of the WHO (WHO/TDR). This enables you to see how the RFI works, what an RFI Report can look like. The RFI Reports of three Senegalese institutions and of the Institute of Tropical Medicine and Hygiene of the New University of Lisbon are nearing completion. Others are in the pipeline.

It is time that one of the world’s biggest research funders begins to focus seriously on improving metrics, transparency and impact of the thousands of partnerships it promotes and supports through its funding by adopting the RFI as a key due diligence tool – that is readily available, increasingly used and creates the first systematic learning platform for improved research and innovation partnerships.

Why not insist that a lead organization in any EU funded partnership submits their own institutional Research Fairness Initiative Report as evidence that it has thought seriously about 15 of the most frequently mentioned aspects that make or break partnerships?

Surely – €70+ billion in partnership funding requires such a tool.







Health Breaking News: Link 284

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 284


At development financing forum, top UN officials urge breakaway from ‘short-termism’ 

The EU must put poverty reduction before corporate profits when financing development 

Will the UK Labour Party’s Big Idea of an Inequality Target Help or Hinder Development? 

The origins of global institutions and development May 2, 2018 12:15 PM – 2:00 PM, Auditorium 3, Eilert Sundts hus, Oslo 

Time for EU to take charge of global health research agenda 


2018 IMF and World Bank Spring Meetings: the Bank has more money, but promises little change 

5 takeaways from the World Bank Spring Meetings 

A new type of leadership from national governments is essential for success of the SDGs 

Some examples of South Africa’s global and regional health diplomacy in the SDG health era  

Homegrown Help: The Rise of Africa’s New Philanthropists 

Trends in tuberculosis in the UK 

A cluster of multidrug-resistant Mycobacterium tuberculosis among patients arriving in Europe from the Horn of Africa: a molecular epidemiological study, TM Walker et al, Lancet Infectious Disease April 2018 

World Malaria Day, 25 April 2018 

On World Malaria Day: thinking and acting locally for global malaria elimination 

The clock is ticking on malaria 

Beating Malaria in Zambia 

World Immunization Week, 24-30 April 2018 

The evidence around vaccines – fact vs. myth 

How immunisation is vital to win the war against disease 

Point-of-care tests for syphilis and yaws in a low-income setting – A qualitative study of healthcare worker and patient experiences 

World Meningitis Day: 5 Questions with the CEO of NCDC 

The Belgian commitment to pharmaceutical quality: a model policy to improve quality assurance of medicines available through humanitarian and development programs 

Infant Deaths Fall Sharply in Africa With Routine Antibiotics 

Interpol Highlights Takedown Of Deadly Global Fake Food And Drink Operations  

Could violent conflict derail the London Declaration on NTDs?  

New publication calls for urgent action on energy to achieve Global Goals 

How Integrating Health Care With Other Services Offers Significant Potential Benefits 

The Alternatives – approaches towards a Life in Full 

The Alternatives: Global perspectives for healthier lives 

Human rights Reader 445 

TIME 100’s Nice Nailantei Leng’ete Honors the People Working to End Female Genital Mutilation 

USA: New Dangers For Immigrants And The Health Care System 


Quality-Assurance of Medicines in Humanitarian and Dev Programs: A Proposal from Belgium

A “Commitment to Quality Assurance for Pharmaceutical Products” was signed in 2017 in Brussels by the Belgian Deputy Prime Minister and Minister for Development Cooperation Alexander De Croo, and by 19 Belgian implementers. With the signature of this policy, the Belgian State commits to manage the quality risks of medicines in the medical programs funded overseas, while the Belgian implementers commit to set up adequate quality assurance systems, and to prove that the medicines they supply are in compliance with the standards of the WHO and International Conference of Harmonization

By Raffaella Ravinetto

Public Health Department, Institute of Tropical Medicine Antwerp, Belgium

Who is Taking Responsibility for the Quality-Assurance of Medicines Supplied in Humanitarian and Development Programs? A Proposal from Belgium


Universal access to quality-assured essential medicines is a determinant of the fulfilment of the right to health (1), but unfortunately substandards and falsified medicines still represent a serious concern for global health (2). Recent data of the World Health Organization (WHO) suggest that at least about 10% of medicines available in low- and middle-income countries are of poor quality (3). Their often-undetected consequences include therapeutic failure and direct toxicity; contribution to emerging resistances; and, at health system level, erosion of public trust in medicine, and waste of resources. Medicines regulation is theoretically the responsibility of the National Medicines Regulatory Authorities in the recipient countries, but many under-resourced Agencies in the South lack the financial resources, human resources and infrastructure needed to adequately verify the quality of medicines supplied from the international market (4), which is increasingly complex due to the rampant globalization of production and distribution.

In countries with limited resources and poor regulatory capacities, a great deal of medicines provided through the public sector (and/or during public health emergencies) are funded by external donors and procured by Non-Governmental Organizations (NGOs) and other implementers. The quality of these medicines thus depends, more than on national regulators, on the procurement policies of such donors, NGOs and implementers. This implies a great variability in the level of pharmaceutical quality assurance: while organizations such as Médecins Sans Frontières (5) and the Global Fund (6) have stringent criteria in place, other actors lack procurement policies with adequate quality requirements. This is often due to lack of awareness of the actual risks taken when administering a medicine the quality of which has not been adequately verified: for instance, therapeutic failure due to an under-dosed medicine can be mistakenly attributed to other reasons (e.g. poor adherence, late intervention, wrong diagnosis…). Thus, the victims of poor-quality medicines remain in most cases voiceless.

The case of humanitarian and development programs brings additional moral challenges to this issue, because patients served by these programs should not receive medicines with a quality-assurance level that would not be acceptable in the country of the donor or of the implementer: “there should be no double standard in quality. If the quality of an item is unacceptable in the donor country, it is also unacceptable as a donation” (7).

As an innovative attempt to acknowledge and address these challenges, a “Commitment to Quality Assurance for Pharmaceutical Products” was signed in 2017 in Brussels by the Belgian Deputy Prime Minister and Minister for Development Cooperation Alexander De Croo, and by 19 Belgian implementers (8) (https://www.itg.be/E/Article/belgian-commitment-on-quality-of-medicines-is-unique-says-institute-of-tropical-medicine-antwerp). With the signature of this policy, the Belgian State commits to manage the quality risks of medicines in the medical programs funded overseas, while the Belgian implementers commit to set up adequate quality assurance systems, and to prove that the medicines they supply are in compliance with the standards of the WHO and International Conference of Harmonization. The implementers may integrate a specific budget for pharmaceutical quality assurance in their financing applications, and they should consider how costs “could be rationalized and mutualized by aligning the strengths of the various implementers”. Importantly, to mitigate the risk of weakening the local pharmaceutical supply systems in the countries of intervention, the implementers should prioritize existing local structures for storage and distribution, and they should design adequate plans of capacity building for local actors when needed.

The promoters of the new policy, which will be implemented in a stepwise approach and with ongoing peer-reviews, hope that “more and more policy-makers, implementers and donors become aware that investing in quality assurance results in gains for health (improved quality of care), ethical behavior (no double standards between patients in affluent and poor countries) and even cost-effectiveness (better quality of care means less therapeutic failures, and decreased long-term health costs)”. They also underline that, “if more donors and implementers joined forces in requiring quality-assured products, they would create a “market incentive” to quality that could in the long-term lead to broader availability and lower prices of quality-assured products”.


This contribution is based on a paper recently published in the Journal of Pharmaceutical Policy and Practice (https://joppp.biomedcentral.com/): Ravinetto R, Roosen T, Dujardin C. The Belgian commitment to pharmaceutical quality: a model policy to improve quality assurance of medicines available through humanitarian and development programs. Journal of Pharmaceutical Policy and Practice 2018; 11:12: 1-5. Available at https://joppp.biomedcentral.com/articles/10.1186/s40545-018-0136-z   


1) Hogerzeil HV. Essential medicines and human rights: what can they learn from each other? Bulletin of the World Health Organization 2006; 84:371-375.

2) World Health Organisation. Substandard and falsified medical products. 70th World Health Assembly; 2017 22-31 May; Geneva, Switzerland [cited 2017 Nov 5]. Available from: http://www.who.int/mediacentre/news/releases/2017/dementia-immunization-refuguees/en/

3) World Health Organization (WHO). WHO Global Surveillance and Monitoring System for substandard and falsified medical products. WHO/EMP/RHT/2017.01. WHO 2017. Geneva, Switzerland.  ISBN: 978-92-4-151342-5

4)  World Health Organisation. Assessment of medicines regulatory systems in sub-Saharan African countries. World Health Organisation, 2010. Last accessed on 11/11/2017 at http://apps.who.int/medicinedocs/en/d/Js17577en/.

5) MSF Medical Product Qualification Scheme. Last accessed on 8/1/18 at http://www.msf.org/en/article/msf-medical-product-procurement

6) Global Fund Policy. Available at  https://www.theglobalfund.org/media/5894/psm_qapharm_policy_en.pdf

7) World Health Organization (WHO). Guidelines for Medicines Donation. WHO, Geneva, Switzerland. Third Edition 2011. ISBN 978 92 4 150198 9

8) Commitment to quality assurance for pharmaceutical products, between the Belgian Development Cooperation and the actors involved in the implementation of programmes including the purchaseing, storage, distribution and/or control of pharmaceutical products. Brussels, Belgium, 25 October 2017. Available at https://diplomatie.belgium.be/nl/Beleid/Ontwikkelingssamenwerking/Wat_doen_we/Thema/Sociale_ontwikkeling/Gezondheid?






Health Breaking News: Link 283

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 283


Integrated Care: Your opinion counts! 

Integrated Care Solutions© Webinar: The Implementation Model for Integrated Care 

Thirty-three civil society groups write to Commissioner Malmström expressing concerns over the European Commission’s plans to create an EU Watch List 

A “Gold Standard” For Population Health? Revisiting The FDA’s Relationship With The Hippocratic Oath 

Answering Senator Bill Cassidy’s Questions About Health Care Price Transparency 

Hepatitis C Drugs Can Cost $84,000. This New One May Be Just As Good—But Cost $300 

KEI sues NIH over license of CD30 CAR T patents to Gilead 

Charles Gore, Founder Of World Hepatitis Alliance, To Head Medicines Patent Pool 

Carlos Correa Named Head Of Intergovernmental South Centre 

China unveils int’l development cooperation agency 

2017 development aid figures: A half empty mixed bag  

WHO: public health round-up 

Latest findings on non-communicable diseases: what is happening in Asia and the Pacific? 

China, India lead rise in global antibiotic consumption 

Taking up Africa’s cancer challenge 

UK leads fight to eliminate blindness 

Opinion: African experts warn big changes needed to eliminate malaria 

Commonwealth Leaders to halve malaria by 2023

The Nigeria Centre for Disease Control 

Unveiling vaccine hesitancy in the Federation of Bosnia and Herzegovina 

PLWH Network Launches New Concept Clinics in Ukraine 

HIV in Georgia: is there any stigma

With improvements in child marriage fight, some fear a funding drop 

Expert calls for men’s inclusion in family planning advocacy 

Financial inclusion is improving around the world—but women are still missing out 

UNPO: Thousands of Uyghurs To Protest Against ‘Re-education’ Camps in Brussels on 27 April 2018 Friday 27 April 2018 | 10:00 — 14:00 

Human Rights Reader 444 

Protect indigenous people’s land rights and the whole world will benefit, UN forum declares 

A global campaign to combat ageism 

Cooperation at heart of Africa Climate Week talks 

UN Shipping Agency Endorses First-Ever Target for Slashing Emissions 

Argentina Aims for a Delicate Climate Balance in the G20 

Latin America Faces Uphill Energy Transition 

Europeans will have to recycle half of their waste by 2025

Health Breaking News: Link 282

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 282


Randall Packard: learning to learn from global health history 

MSF: Open Letter to European Commissioner on EU India Free Trade Agreement and its impact on access to medicines 

MSF statement on resumption of EU-India FTA negotiations  

7 April 2018: Launch of the campaign: One year to say no to the commodification of health! 

Universal health coverage depends on solid data 

How States Rank On A New Summary Population Health Measure Depends On How Important Health Equity Is 

Canada as an SDG role model for High-Income Countries? 

Human Rights Reader 443 

More Mobilization and Impact: Adapting MDB Private Finance Models 

8 Ideas on Reforming the MDBs for the Eminent Persons Group  

Hope For Hepatitis C Patients In Poor Countries – New Affordable Combination With High Cure Rate 

Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi 

Gene Editing for Good. How CRISPR Could Transform Global Development  

TDR joins the MIM to mark 20 years of malaria science and collaboration: 7th Pan African Malaria Conference 15-20 April 2017, Dakar, Senegal 

Lancet Commission to develop first-ever roadmap for malaria eradication 

UN-backed campaign to protect nearly a billion people in Africa from yellow fever by 2026 

Study: Global Consumption Of Antibiotics Rising, In Particular In LMICs; Policy Change Needed 

World’s First Case of Drug-Resistant Gonorrhea Highlights the Growing Danger of Antimicrobial Resistance 

Antibiotic stewardship interventions in hospitals in low-and middleincome countries: a systematic review 

Quality of WHO guidelines on snakebite: the neglect continues 

Regulatory evaluation of biosimilars throughout their product life-cycle 

Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services 

Noncommunicable disease partnerships and conflicts of interest 

Copenhagen: KEI questions The Lancet Taskforce on NCDs and economics on drug pricing & delinkage  

Penny Mordaunt: five ways the UK can deliver renewed global leadership  

A Grass-Roots Movement For Healthy Soil Spreads Among Farmers 

‘Silent, invisible’ malnutrition seen as threat to generations in Congo 

Multicontaminant air pollution in Chinese cities 

China’s Answer to the World Bank Wants Green, Clean Asian Infrastructure 

UN urges developing nations to incorporate climate change in urban planning 

Health Breaking News: Link 281

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 281


Optimism meets realism: the politics of technology and innovation in global health security 

Accountability and strong laws are key to effective tax collection in Africa 

What’s Happening to the World Income Distribution? 

China’s Grand Idea For The 21st Century: Will The New Silk Road Transform Global Health Assistance?

With New Spending Bill, Congress Steers Foreign Assistance Away from Deep Cuts 

The Medicaid Access Proposed Rule Would Undermine Access, Not Promote It 

2018: USTR report chastises India for “vocal encouragement and propagation” of policies that erode IPRs 

‘Policy Implications for Community-based Interventions to Strengthen Healthcare Delivery, Based Upon a Formative Study of Community Capacity in Urban Monrovia, Liberia’ Corresponding Author Richard A. Nisbett 

Lessons from Liberia with Ellen Johnson Sirleaf – CGD Podcast 

‘The alarming collapse of the Venezuelan healthcare system’ by Pietro Dionisio  

The End of Antibiotics? 

Research suggests gonorrhoea can resist last-resort antibiotics and maintain growth rate 

What are the strategies to make 2018 the year for TB action? 

Unitaid’s investments support global drive to end TB 

Tuberculosis services in Moscow extend “health for all” even to the most vulnerable  

Il Sole24Ore: Tubercolosi, immigrazione e Italia. Tutti i numeri 


Shedding Some Light on Skin Cancer in Tanzania 

TogetHER: Working Together to Save Women from Cervical Cancer  

Integration of postpartum healthcare services for HIV-infected women and their infants in South Africa: A randomised controlled trial 

Major Study Finds Taxes On Soda, Alcohol, Tobacco Help Curb NCDs; Study Restarts UN Momentum  

A New Way to Finance Green City Projects, With a Boost From Foundations 

Wind of change: Air and Health in 2019 

Study counts lives saved with push for 1.50C climate target 

Not enough done at EU level against imported deforestation 

“It Takes Time.” In Africa, a Test of Philanthropy’s Quest to Bring Safe Water to All 

World Bank Group report: Women, Business and the Law 2018 

Webinar: Integrated Care Matters Series 2: District Nursing, Case Management & Buurtzorg Model 18th April, 2018 12.00 – 13.00 (GMT) 

How an uproar over aid and sexual exploitation ignored women’s actual experiences 

UNPO Newsletter March 2018 edition 

PRESS RELEASE – 7 April: European action day against the commodification of health « All for Health » 

Map of the 7 April 2018 actions 

Human Rights Reader 442 



Urban Monrovia Health Policy Study

Urban population growth in Africa will continue to exert strong pressures on the delivery of healthcare services. The diseases of poverty thrive in conditions of high population density, poverty, poor infrastructure and wealth disparities. Community-directed interventions (CDI) for neglected tropical diseases have been demonstrated by the WHO/TDR research agenda to improve coverage, empower communities and build stakeholder capacity in rural Africa. We offer this formative study of community capacity in post-conflict, pre-Ebola Monrovia as a case study of the utility of formative community-based collaborations. We used community-based participatory research to assess the feasibility of CDI for urban Liberia. The communities ranked malaria, diarrheal/water-borne illnesses, and acute respiratory infections (ARI) as the highest priorities. Furthermore, communities perceived these health priorities in the overall context of water & sanitation/hygiene/solid-waste management. While the health delivery system is donor-driven and under-resourced, we found stakeholder and community enthusiasm for partnering to achieve health goals. Resilience and shared accountability are critical features of sustainability which should be supported by health policy and  insinuated into priorities seeking to build social capital and community capacity for health-care delivery

Richard A. Nisbett*†, Stephen B. Kennedy*, Fulton Q. Shannon II‡, and C. Benjamin Soko¥

*University of Liberia-Pacific Institute of Research and Evaluation, Africa Center (UL-PIRE)                                     

†WVS Tubman University, Harper Liberia

‡Liberian Ministry of Health and Social Welfare, Monrovia Liberia

¥National Public Health Institute of Liberia, Monrovia Liberia

Policy Implications for Community-based Interventions to Strengthen Healthcare Delivery, Based Upon a Formative Study of Community Capacity in Urban Monrovia, Liberia

Keywords: Urban Health, Health System Strengthening, Diseases of Poverty, Community-based Participatory Research, Community Capacity, Shared Accountability



Because global health deals with transboundary issues which require collective action, it is by necessity a multi-lateral and multi-sectoral endeavor. One of the more salient global health issues in the 21st century will be the rapid increase of people living in cities where growth has outpaced the ability to provide essential infrastructure (UN-Habitat 2010a). In the next quarter century, the population of the Developing World is projected to increase by more than 30% to almost 7 billion, with 90% living in urban areas which today are experiencing increased levels of poverty.  The Population Reference Bureau estimated that in 2007 for the first time in history, the majority of the global population lived in urbanized areas (PRB 2008).

Urbanization and Health System Strengthening in Africa

In Africa, the annual urban growth rate is projected to be 3.4% with perhaps 60% of all Africans, about 1.2 billion, living in urban areas by 2050 (UN-Habitat 2010b). Furthermore, this UN-Habitat report projected that while the populations of all one million-plus cities in Sub-Saharan Africa are expected to expand by an average of 32%, seventy percent (70%) of all African urban population will occur in smaller cities of less than 500,000. Such growth will exert tremendous pressure for services and infrastructure. The Executive Director of UN-Habitat has stated that:

No African government can afford to ignore the ongoing rapid urban transition taking place across the continent. Cities must become priority areas for public policies, with hugely increased investments to build adequate governance capacities, equitable services delivery, affordable housing provision and better wealth distribution. (Ibid.)

The infectious diseases of poverty (DOP) thrive on high population density, poor infrastructure, and wealth inequities. As has been asserted by social scientists, disease occurs within a context of lives fraught with complexity (Allotey et al. 2010) which has been understudied and underappreciated in the past (Madon et al. 2007). Defining urban health systems as “the determinants and outcomes of health and the activities that link them,” Harpham (2009) reviewed recent evidence for the vulnerability of the urban poor, the deteriorating health of the urban poor in Africa and studies suggesting that urban populations sometimes have greater health risks and mortality than their rural counterparts (see Montgomery et al. 2004) despite the presumed better availability, access and appropriateness of health services.  While there is a tendency to think of urban poverty and disease burden in terms of slum dwellings, using data from 85 Demographic and Health Surveys Montgomery and Hewett (2004) found considerable household wealth heterogeneity in Developing World cities, i.e., that as a rule, poor urban households do not tend to live in uniformly poor communities but often in mixed communities.  Harpham presented evidence that regardless of access or heterogeneity, the poor received low-quality care from both the private and the public sectors. Taken together, these data and findings underscore the need to strengthen urban health systems.

The renewed focus on health systems strengthening (HSS) has resulting in guiding principles (Swanson et al. 2010), strategies to integrate the control of DOPs into health-care delivery systems (Gyapong et al. 2010), and addressing “capability traps” (Pritchett et al. 2010). Various recent reports and declarations have reaffirmed the urgency of re-committing to primary health care (PHC) in order to strengthen healthcare delivery, outlining strategies and approaches and all emphasizing the roles of community engagement and stakeholder partnerships to integrate and harmonize programs (WHO 2006, WHO 2008a, WHO 2008b). Compelling evidence from community-based (CBI) and community-directed interventions (CDI) for neglected tropical diseases (NTDs) has demonstrated persuasive health gains from multi-stakeholder programs involving community participation. Pioneered by WHO/TDR, the CDI strategy for building multi-lateral partnerships and community capacity building has shown through a rigorous multi-country protocol to not only improve coverage and adherence for a variety of NTDs but also to build community and health system competence in rural Africa (WHO/TDR 2008). One desired outcome of such approaches is building linkages and creating shared accountability (Azim et al. 2018). Without improved accessibility, affordability and HSS the present obstacles and disparities characterizing urban health will most likely result in increased risk factors, incidence and prevalence for vulnerable, marginalized persons as well as their more affluent neighbors in mixed communities.

It is our view that these challenges must be addressed at the policy and implementation levels.

Emerging and resurging DOPs underscore the urgency of both HSS and shared accountability. During the 2013-2014 West African Ebola Virus Disease (EVD) Epidemic, frontline communities took the lead on EVD and deserve much of the credit for stemming the epidemic (Kennedy and Nisbett 2015; Nisbett and Vermund 2014; Fallah et al. 2017). Here, we present a case study of communities in urban Monrovia to demonstrate the potential of formative studies to empower communities, build stakeholder linkages and create the added value of shared accountability.

Case Study Objectives

The purpose of our formative phase study was to assess urban communities in greater Monrovia in order to ascertain the potential for adapting and testing the CDI approach for urban Africa. The primary objective was to determine if the CDI process as deployed in rural Africa for delivery of health interventions will be feasible for urban healthcare delivery in underserved and marginalized communities. The operational objectives for the formative phase study were: (1) to document the current delivery process of existing health interventions; (2) to identify poorly served urban communities; (3) to identify potential stakeholder and community networks which could contribute to CDI implementation; (4) to identify community priorities that can be addessed by the CDI process; (5) to explore the community networks and delivery mechanisms suituable for urban CDI; (6) to engage stakeholdes in contemplating the value of the CDI process for post-conflict urban Monrovia; (7) to explore mechanisms and community partnerships for monitoring and evaluation (M&E) and impact evaluation of CDI; (8) to map the extant resources at all levels of the system from local health committees and providers to the national level; (9) to determine with communities and stakeholders the types of interventions desired; and (10) to conduct situational analyses and generate sufficient baseline data to inform the decisions regarding how best to implement urban CDI.


The Liberian Civil War (1989-2003) destroyed health infrastructure and workforce capacity and created many challenges for research into health system functioning.  Prior to the outbreak of hostilities, very few evidence-based community health initiatives had been undertaken.  We assembled a team of 12 project staff based at UL-PIRE located in greater Monrovia (Montserrado County) to conduct a formative investigation in partnership with colleagues at the Ministry of Health and Social Welfare (MoHSW).

Capacity Building for Community-based Participatory Health Research

Several weeks, cumulatively, were devoted to staff training and skills-refresher exercises on the methods and techniques of rapid ethnograpy, qualitative approaches, and community-based participatory research (CbPR) (Minker and Wallerstein 2008, Ulin et al. 2004, WHO 2003). Topics and techniques included document review, community mobilization and meetings, key informant interviews (KII), focus group discussions (FGD), transect and asset mapping, photodocumentation, and field journaling (diary entries).

Community Selection and Activities

We deployed a two-pronged design: formative phase-stage 1 was exploratory and primarily relied on KIIs and the available health system data and documents for extant communities. Formative phase-stage 2 was an in-depth investigation using a more extensive skillset of CbPR tools. Based on previous community-based and social-marketing interventions conducted by UL-PIRE, we targeted ten (10) underserved communities in urban Monrovia for exploratory studies (Stage 1). We categorized communities in greater Monrovia into either “interior” Monrovia (inland areas) or “coastal” Monrovia (marine or estuarine environments). We collated and analyzed the available (if sparse) census, GIS demographic data, and available government and NGO documents in order to select the 10 communities. We used KIIs of government officials, community leaders and health stakeholders to generate qualitative data on these 10 communities. Using a weighted formula (government health facility present/absent, functional leadership structure, vulnerability to environmental health threats, population density, geography [e.g. discreteness to eliminate contamination of interventions due to proximity/contiguity], and our previous experiences implementing health interventions), we selected five (5) focal communities from the original 10 communities for in-depth CbPR (Stage 2) assuming that we would implement randomized case-control studies for a subsequent intervention phase. The five focal communities were selected to sample (i) two communities of equivalent structure and relatively low population density in “interior” Monrovia; (ii) two communities of equivalent and relatively high population density in “coastal” Monrovia; and (iii) an outlier community judged to have exceptional leadership by which to better understand social capital, community capacity vis-à-vis the four (4) proposed match-control communities.




The primary results are presented in several tables and discussed for each operational objective.  Table 1 shows the population parameters and KII totals for each of the 10 communities. The population density for the coastal communities is about three and one-half times that for the interior communities.

Key:Population from LISGIS 2010; +Population from HIC 1997; +Density from HIC 1997 = pop./acres;

  • Interior Monrovia = Barnersville, Bassa Town, Chicken Soup, Chocolate City, Chugbor = 36.52 Pop. Den. Vs. ¥“Coastal Monrovia = Blamo Town, Peoples, Riverview, Slipway, Soniwein = 133.31 Pop. Den.

Table 2 gives the outputs for the five communities in Stage 2. These communities were subjected to more intensive and extensive interactions.

Key: Stage 2 Focal Communities were Chocolate City (CC); Chicken Soup Factory (CS); People’s United Community (PU); Slipway (SL); Soniwien (SO); 1CSR—a typed report summarizing the Team’s observations in the community; 2Asset Map—a typed description of the salient health threats and opportunities for each community; 3Physical Map—a hand-drawn geographic map showing environmental health threats, community facilities (e.g, health, education, religious, community office, etc.); 4Clinic Tables—summary tables of selected health indicators as collected by the local clinics and reported to the MoHSW.

Table 3 summarizes the governance structure and stakeholder analyses for the five focal communities (Objectives 1, 3, and 5.).

Key: Community abbreviations same as Table 2; E= Executive board or council; B= Block leaders structure; Y=Youth Committee

Table 4 gives a ranking of health priorities by communities (Objectives 4 and 9). These rankings come from KIIs of government health officials, health providers and stakeholders and community key informants.

Key: Community abbreviations same as Table 2; Ranked in order by KII response; multiple entries per rank order is due to ties (frequencies)


The Study Area

Since the 1980 coup, Liberia has experienced a quarter-century of declining health services. The Civil War of 1989-2003 brought about destruction of the healthcare infrastructure and decimation of the healthcare workforce. The war resulted in the death of perhaps one-tenth and the external- or internal- displacement of about one-third of the pre-war population of three million. Recent surveys in the immediate post-conflict setting (UNDP 2006, CSFSN 2006) estimated a maternal mortality rate of 974/100,000, a child mortality rate of 195/1,000 and for those aged <5 years, stunting at 39% and wasting at 7%. Malaria is both holoendemic and hyperendemic with the highest incidence occurring in urban and peri-urban environments during the rainy season. During the conflict and post-conflict periods, most health services were provided by INGOs resulting in service discontinuities, a top-down emphasis, and consequently a lack of capacity building for key stakeholders from the national to the community levels.

The best estimate for the current population of greater Monrovia is about 900,000-1,000,000 (personal communications based on DHS 2007, LISGIS 2009), with a population density ranging from 10-400 persons/sq. km. The highest population density geographically occurs in the constricted coastal zones such as West Point (a peninsula formed by the Atlantic Ocean and Mesurado River), New Kru Town (hemmed in by the Atlantic and St. Paul’s River), and “Central Monrovia B,” the central city inland from the coastal diplomatic enclaves of the Mamba Point area. (See Figure 1). Most of the other zones are highly dense and congested as well but due to the terrain and topography the population densities are lower. Greater Monrovia contains much uninhabitable land due to the confluence of the St. Paul’s and Mesurado Rivers which yield a huge inland area of interior estuarine mangrove swamp and inundated lowlands.

Community Capacity

Community capacity is both an input and outcome of health interventions. It consists of human and material resources utilized as assets. The MacArthur Foundation defines it as a community’s ability to mobilize energy and talents to secure outside resources and foster quality-of life; McLeroy defines it as community characteristics which enable it to identify, mobilize  and address public health problems (in DiClemente et al. 2002). For our purposes in this formative phase study, we have viewed community capacity as a community’s perception of its public health needs, its health assets and its willingness to collaborate with partners to improve its own well-being.


The following description and data regarding the government of Liberia (GoL) health system come from several internal and unpublished grey documents shared with our team during this study. These documents include: (1) The Republic of Liberia National Health Policy (2007); (2) The Republic of Liberia National Health Plan 2007-2011 (2007); (3) MoHSW Annual Report (2009); (4) Basic Package of Health and Social Welfare Services for Liberia (2008); (5) MoHSW Community Health Committee Operational Guidelines (2007); (6) GoL Overview of Poverty Reduction Strategy for the Health Sector (2008); (7) USAID PMI Malaria Operational Plan for Liberia (2010); and the Monserrado County Health & Social Welfare Budget 2009-2010 (2009).

Health Facilities and Access to Health Care

By 2006, MoHSW reported that country-wide 18 hospitals, 50 health centers, and 286 health clinics were functional. By 2009 there were 163 functional GoL health facilities (28% of the total number of health facilities country-wide) and 257 NGO facilities; in Montserrado County, there were 37 functional health facilities, 21 NGO facilities and 120 private facilities. However, there are few available data on health service utilization and access. The Interim Poverty Reduction Strategy (2006) reported that 41% of the population had access to health services. Most sources and authorities suggest “low service consumption and gross imbalances” across Liberia.

Healthcare Delivery Services and Resources

Healthcare delivery is severely fragmented and donor-dependent upon vertical programs funded by external sources. The current health care delivery system is strained and under-funded with dozens of INGOs and local non-governmental organizations (NGOs) delivering a variety of health services in both the urban and rural areas. Community-based delivery of care, based on the CDI model, is not practiced in the urban core of Monrovia. Now moving towards recovery, Liberia is uniquely positioned to benefit from enhanced implementation strategies focused on community-based partnerships such as CDI.

The Government of Liberia (GoL) National Health System

The National Health Delivery System is organized in a hierarchical manner. PHC is considered the foundation of the health system. The National Health Policy states emphatically that: “Interventions will focus on community empowerment—seeking to enhance a community’s ability to identify, mobilize and address the issues that it faces to improve the overall health of the community” [emphasis added].

Leadership/Governance Architecture

The MoHSW is in charge of health services within the territorial frontier of Liberia and is headed by the Minister. The Minister of Health has four deputies to assist him in day-to-day operations of the health delivery system. These deputies are: the Deputy Minister for Administration who oversees all administrative matters of the Ministry, the Deputy for Planning and Human Development, the Deputy for Social Welfare, and the Deputy Minister and Chief Medical Officer (CMO). All of these deputies have an assistant deputy minister who serve as technical arm and support for their activities. The CMO is the highest decision-making person when it comes to Health Services, and is assisted by two Assistant Ministers: the Assistant for Curative services and the Assistant for Preventive Services. The Assistant Deputy Chief Medical Officer for Curative services assigns all Medical Doctors, Physician Assistants, Registrar Nurses, Midwifes and Nurse Aids in all health facilities in Liberia. The Assistant Minister for Preventive Services is responsible for all public health activities, overseeing: Malaria Control, TB control, National Aids Program, etc. The CMO and the Assistant Chief Medical Officer for Preventive Services are required to be MDs. All officers are political appointees.

Current Service Delivery System

The MoHSW, in line with the sector reform process, has restructured the health care delivery by putting in place a decentralized mechanism on the county level. The Basic Package of Health Services (BPHS) is the “cornerstone” for health delivery in Liberia. This is a package of essential health services that is being implemented at both the facility and community levels. The BPHS is being fully implemented at all facilities across the country. Its implementation at the community level has started, but at a very slow rate. However, the post-EVD environment and establishment of a new national public health institute has done much to accelerate consensus and progress.

At the central level the Minister of Health is the first contact person for any health matter in the country. The Minister delegates responsibilities to the appropriate person in charge. For example, if it is health services matter it goes to the CMO for approval. The CMO will approve of the communication and then send it to either of the two deputies according to the nature of the subject. From the central office, the information will then go to the County Health Team (CHT). At the county health level, there is a County Health Officer (CHO) who is the head of the health care system within their respective county. Also, at the county health level, there is a Community Health Director, Clinical Supervisor and Officer-in-Charge (OICs) at the clinics/facilities (GoL public).  The Clinical Supervisor conducts supervisory visits at all government health facilities. The OICs report to the Clinical Supervisor, and the Clinical Supervisor report to the CHO and the CHO report to the offices of the CMO and all these are sent to the appropriate departments.

Within the County, there is surveillance system set up for all priority diseases. This effort is supported by the WHO and all reports from these activities are channeled through the Department of Epidemiology and onward to the WHO. There is a County Surveillance Officer, and District Surveillance Officer.  They also work within the communities and collect surveillance reports for all priority diseases from various clinics and report them directly to the Epidemiology Department at the Central Level of the Ministry of Health and Social Welfare.

The OIC of the catchment health facility, through the Government Community Health Volunteer (gCHV) focal person at the facility, has oversight responsibilities for the health facility area. This person could be a Nurse-Aid at the health facility and other person appointed as gCHV focal person in the Health Facilities. He or she ensures that reports from the CHVs and CHC (Community Health Committee, see below) are forwarded to the OIC, who then passes the report along to the clinical supervisor. The clinical supervisor reports to the CHT. The CHT ensures that in-service training is provided on continual basis. The focal person and OIC at the catchment health facility liaise with district officer and county health team (CHT) and report is sent to CHT. The focal person also maintains records on the composition and performance of each CHC and CHVs. Other program staff members in the ministry liaise with the focal person and OIC in implementation of their programs at community level. The Ministry of Health considers Community Health Volunteer (CHV) as an important component of health care delivery system of Liberia. This is reflected in the national health policy and the basic package for health services. The Basic Package for Health Services (BPHS) identifies specific activities that can be at the community level and by the community. However, in practice there is no funding for CHVs.

The community health services policy states that a functional CHC is a necessary condition for effective community health volunteers: “CHVs are more likely to be effective in active, mobilized communities; it is not realistic to expect that CHVs, by themselves, can be active or empower a community that isn’t ready.” Since the CHV is selected and supervised administratively by the community, it is logical that there should be a structure in the community to perform this function in an orderly fashion. Therefore, MoHSW requires that Community Health Development Committee and/or CHC should be revamped, activated or established as a criterion for selection,  training, and supervision of the CHVs.

Community Health Development Committee/ Community Health Committee (CHC)

The Community Health Development Committee or the Community Health Committee, where applicable, is the umbrella body of the catchment area and has oversight responsibility. They are to provide support to the CHCs in their catchment areas. The CHC is a body selected by the community in collaboration with Ministry of Health and Social Welfare through the County Health Teams and the Community Health Development Committee. The CHC oversees and supports the functions/duties of the Community Health Volunteers in their respective community. All health services going into the community are channeled through the Clinical Supervisors of both partners (as in the case of Merlin, MTI, etc) and the CHT to the facilities and then to the community through their Community Health Committee (CHC) if present. Reports from the community are channeled through the same medium to the Headquarters (MoHSW and partners,  e.g. Merlin).

Salient Issues

Beyond the service delivery aspects of the Liberian Health System, we discuss below several relevant, critical issues regarding provision of health services country-wide and to our selected communities. It is important to emphasize that Liberia is in a rebuilding phase and the majority of the planning documents and policy statements represent idealized programs—like community-based initiatives—that are not yet, or only in an incipient stage of becoming, operationalized.

Health Care Workforce

It has been noted how the Liberian civil conflict severely disrupted the healthcare delivery system. One of the primary disruptions was the loss of trained health care workers through morbidity, mortality or being forced into refugee status. The minimum level of workforce density to achieve the MDGs is 2.5 health workers per 1000 people. The global average is 9.3 while the average for Sub-Saharan Africa is 2.4. Recent WHO data yield an estimate of 0.08 for Liberia: MDs = 0.03, Nurses = 0.18, Midwives = 0.12, Public health workers = 0.04, and community health workers = 0.02.

Health Information/Surveillance

As delineated in the section above regarding the Healthcare Delivery System, there is a routine surveillance system. The MoHSW has also prioritized establishing a proactive Health Management Information System (HMIS). The HMIS will be able to generate reports and trend analyses for the following areas: financial information, human resources, physical assets and equipment inventories, healthcare delivery service statistics and the incipient surveillance system.

Medical Products, Vaccines, & Technologies

The framework to manage pharmaceutical and medical supplies is contained within the National Drug Policy and is centered on the National Drug Service (NDS). Supplies are supported by multilateral donors and private-public partnerships such as the Global Fund. The NDS warehouse is fully stocked and located in Monrovia.

Financing & Budgets

The national health policy has stipulated the suspension of user fees for the immediate future. The MoHSW budget anticipates about 35% of necessary funding coming from GoL revenues with the remainder coming from external sources in the form of donor restricted and unrestricted funds. The current MoHSW directory lists 65 NGOs accredited to work in the health sector.

Typically, in the post-conflict annual budgets, government expenditure on health care in Liberia is about 17-19% of the GoL budget. The MoHSW total receipts for CY 2009 was US$29,361,565. By revenue source, GoL funds account for 34.7%, Pool funds for 21.7%, the Global Fund for 15%, Earmarked donor funds for 26.2%, and Other donor funds for 2.5%.  By program account for CY 2009, Curative was 72.8%, Preventative was 8.5%, Social welfare was 5.1%, Planning was 2.4%, Vital statistics was 0.7%, and Administration was 10.4%. The total budgeted for Preventative was US$1,713,541.

The Montserrado County Health Department budget for FY 2009 was a total of US$387,049. However, this allocation is restricted to non-personnel expenses only (infrastructure rehabilitation and maintenance, vehicle maintenance, electrical generators, medical and office supplies, and meetings/trainings. In 2009, the USAID-financed Rebuilding Basic Health Services (RBHS) project concluded from costing studies that annual cost projections of clinics without and with laboratories should be between US$34,261 and US$36,250, respectively. The RBHS study estimated the total cost of providing primary and secondary care at health centers to vary from US$36,620 to US$59,083.

Summary of the Operational Objectives

Regarding the operational objectives for the formative phase, we have summarized our data for each, integrating the perspectives from the KII (Key Informant Interviews) and FGD (Focus Group Discussions) survey instruments.

Objective #1–To document the current delivery process of existing health interventions. Our analyses of GoL/MoHSW documents and interviews of cognizant officers and division managers have facilitated the creation of an overview of the healthcare delivery system in greater Monrovia. The MoHSW has curative and a preventative divisions. The former is marginally functional in the capital city while, for the most part, the latter has not yet been operationalized in post-conflict Liberia. While treatment at government clinics is often at minimal or no cost for diagnosis, the challenges for acquiring pharmaceuticals, etc. are formidable for the typical person. Often, as noted in Harpham (2009), drugs are not available at public clinics and unafforadable at private clinics or pharmacies.  In some communities, health education activities are conducted but the quality, availability and uptake are extremely variable. There were no CDI-like programs conducted by the GoL or NGO partners in any of the 10 communities we studied.

Objective #2–To identify poorly served urban communities. Virtually all communities in greater Monrovia are extremely underserved. Typically, there is a single GoL clinic serving each community and a few of the communities we studied had 2-5 private providers. The GoL clinics are required to report a broad range of data regarding surveillance, diagnostics utilized, health education activities, etc. However, the surveillance data we summarized for each clinic were sparse and incomplete. The most reliable data were for malaria testing and treatment—confirming the health priorities from KIIs and FGDs conducted to elicit perceptions regarding priority health threats.

Objective #3–To identify potential stakeholder and community networks which could contribute to CDI implementation. We conducted a stakeholder analysis and situational analysis for each community. Most communities have under-utilized assets and resources but few are health-oriented organizations. Several of the communities have taken the initiative to form their own Community Health Committee (CHC) and two of our five focal communities have Water & Sanitation committees and designated Community Health Workers (CHW). Overall, while there is a dearth of local health partners, we were energized by the leadership in most communities which sought to address salient health issues. The five focal communities we selected exhibited a demonstrated commitment to improve health outcomes and reduce disease burden.

Objective #4–To identify community priorities that can be addessed by the CDI process. During both Stage 1 and Stage 2, we conducted over 110 Key Informant Interviews and 30+ focus group discussions. The ranked priorities across communities were: malaria, diarrheal & water-borne diseases, respiratory diseases and reproductive health (STIs & MMR). For “malaria,” we attempted to triangulate by (1) using probes in KIIs and FGDs to determine informant’s perceptions of malaria symptoms and signs, (2) reviewing surveillance data from the community clinics, and (3) seeking the conclusions of OICs regarding the prominent health threats. The GoL clinics are required to report a broad range of data regarding disease surveillance/diagnostics, attendance at health education activities, availability of drugs and supplies, etc. However, the surveillance and reporting data we summarized for each clinic were spotty and incomplete.

While the more “rural” vector-borne/zoonotic NTDs addressed by the multi-country TDR CDI study were infrequent, we do see a need for surveillance and case identification/treatment due to great urban-rural-urban mobility in present-day Monrovia. However, the majority of CDI programs (malaria treatment, ITNs, Vitamin A, and DOTs for TB), as well as ACT for IPT and Cb HIV/AIDS ART would be most beneficial and welcomed. As part of the KII and FGD process, after explaining the successes and approaches of CDI, the response was uniformly positive at the community level.

Objective #5–To explore the community networks and delivery mechanisms suituable for urban CDI. As for Objective #3, we found under-utilized networks and resources. On the whole, these Monrovia communities are merely trying to rebuild and negotiate the post-conflict environment. On the positive side, communities are demanding input and ownership in their own health. On the negative side, much capacity building, empowerment and delivery infrastructure for CDI will need to be part of the intervention strategy.

Potential stakeholders include: INGOs with their local implementing partners, the County Health Team (community health department), GoL Community Health Facility, Private Clinics, Pharmacy & drug stores, Faith-based groups & schools, Community Health & Watsan Committees, Market Women Association, Women’s Cooperatives & Organizations, Natural helpers (midwives, nurses aides, drug-store owners, herbalists, traditional healers, etc.), Youth Committees, Cuttington University Program in Public Health, and University of Liberia Social Sciences Department. Every community indicated a willingness to provide in-kind resources (labor, food, land, etc.) as incentives to CHW or CHV. In fact, some are already providing meals for youth laborers for environmental clean-up. Also, see Objective # 7 below.

Objective #6–To engage stakeholders in contemplating the value of the CDI process for post-conflict urban Monrovia. The GoL stakeholders (Montserrrado County Health Team, OICs for GoL clinics, etc.) and the local CHCs/CHWs were most enthusiastic about the potential for CDI. The NGOs—both international and local—were less enthusiastic and over-stretched in the current environment. The non-health community partners (schools, faith-based organizations, etc.) represent a willing and educable resource.

Objective #7–To explore mechanisms and community partnerships for M&E and impact evaluation (IE) of CDI. At the present, there is very little capacity for M&E and IE. Designing urban CDI for Monrovia will entail considerable training and beta testing. On the other hand, one of our partners—the Graduate Program in Public Health at Cuttington University in Monrovia—is collaborating with our team in field testing demographic data generation and project implementation for nutrition. Since this partner has human resources (students enrolled in the program) and the desire to collaborate, we are optimistic that we can build effective M&E into a CDI program.

Objective #8–To map the extant resources at all levels of the system from local health committees and providers to the national level. We have constructed asset maps and stakeholder diagrams for each community as it relates to the GoL healthcare delivery system.

Objective #9–To determine with communities and stakeholders the types of interventions desired. We have used CbPR to identify priority health concerns and introduced the CDI concept. Cumulatively, the 5 focal communities prioritzed these “conditions:” (1) malaria, (2) water & sanitation/diarrheal diseases, and (3) respiratory illnesses. One salient limitation is the lack of an ethnograpy of disease symptoms and medical cosmology in these communities.

Objective #10–To conduct situational analyses and generate sufficient baseline data to inform the decision to implement urban CDI. We have conducted community and County situational analyses. However, we have not yet brought the National Drug Service or other key stakeholders like PMI, GFFTBAM, UNDP, etc. into the dialogue. This omission was intentional as the two lead investigators concurred that the post-conflict environment is not conducive to such discussions until we have something to offer on the table (“No cola nut, no pepper, No talk.”) We have baseline population data and malaria prevalence and incidence (spotty) but will need to generate household-level demographics (age and sex) as well as specific health indicators relevant to particular diseases at baseline. This information is presently nonexistant at the community level.

SUMMARY: Critical Factors, Capability Traps, and Community Capacity for CBI

Healthcare delivery in Liberia is presently donor-driven with scant government resources for CBI, CDI or CHCs. In the seminal multi-country rural study (WHO/TDR 2008), the teams identified several factors critical for successful CDI implementations. These included variables such as: health system dynamics, community support for health volunteers, community engagement, community empowerment, and engaging implementers. Integrating our data from KIIs, FGDs, and the document reviews, we have analyzed these same critical factors to inform the feasibility of CDI in urban Monrovia and present these in Table 5.

We have identified challenges and opportunities, barriers and bridges for CDI implementation in urban Monrovia, a resource-constrained setting. In view of the post-conflict/transitional setting, there appears to be genuine community capacity so we remain cautiously optimistic. The communities exhibit potential and willingness but doubtless are naïve regarding the workload, tenacity and sacrifices necessary to become effective partners over the long-term. One of the more formidable challenges that remains is workforce capacity building for our own UL-PIRE staff and the government implementers. Training for monitoring and evaluation are critical for successful delivery using CDI. Thanks to the efforts of WHO/TDR, CDI has been widely deployed in Sub-Saharan Africa. We feel that the approach would find great resonance and relevance in similarly resource-constrained settings in Latin America and Southeast Asia.

Pritchett et al. (2010) defined “capability traps” as persistent stagnation of administrative capability and designate these as a hindrance to development. The community-level enthusiasm in urban Monrovia for being proactive partners engaged in finding their own solutions and demanding services is encouraging but must be tempered by the realization that there are many capability traps to be overcome. We feel that “resilience,” as a critical feature of sustainability which acknowledges and absorbs change, must be built into any health intervention based on promoting bonding and bridging social capital. Maston (2001) defines resilience as good outcomes in spite of serious threats. Information regarding resilience (“adaptive capacity” according to Harpham) is essential for household health, community capacity/empowerment, and hence for HSS in urban Africa. Finally, we urge policy makers to prioritize formative studies such as the case study here. Such studies are easily interpolated into extant budgets and health initiatives. They facilitate exits from capability traps, empower communities, and build shared accountability.




Richard A. Nisbett



Funding support for this formative study was generously provided by the WHO/TDR. Supplemental travel and logistics support was provided by PIRE-USA and The University of South Florida College of Public Health. We are particularly grateful to the WHO/TDR community-based interventions unit and to our peers in The Urban Research Group (Ghana, Liberia, Nigeria, Democratic Republic of the Congo) for their friendship, insights, leadership and expertise in community-directed interventions. Many individuals have made substantive contributions towards the development of the Urban Study Group’s Mombasa Protocol. For their support and encouragement, we’d be remiss in not mentioning by name the following for their many kindnesses and professional efforts to bring Liberia into this CBI network: Drs. Boatin, Homeida, Diarra, and Sommerfeld. Finally, we’d like to thank yet again the courageous people in urban Monrovian communities, having endured not only unfathomable tragedy and loss due to both Civil War and the EVD Epidemic, but also our incessant interruptions and invasions into their lives, responding always with patience and a cooperative spirit in our common quest to build a new Liberia.



Allotey P, DB Reidpath, S Pokhrel (2010). Social sciences research in neglected tropical diseases 1: The ongoing neglect in the neglected tropical diseases. Health Research Policy & Systems 8:32: 1-8.

Azim T, B Tilahun, S Mullin (2018). Use of Community Health Data for Shared Accountability, MEASURE Evaluation, https://www.measureevaluation.org/resources/publications/tr-18-238.

DiClemente  RJ, RA Crosby, MC Kegler (2002). Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Fransisco: Jossey-Bass.

Fallah M, Skrip LA, Raftery P, Kullie M, Borbor W, Laney AS, et al. (2017) Bolstering Community Cooperation in Ebola Resurgence Protocols: Combining Field Blood Draw and Point-of-Care Diagnosis. PLoS Med 14(1): e1002227. https://doi.org/10.1371/journal.pmed.1002227.

Gyapong JO, M Gyapong, N Yellu, K Anakwah, G Amofah, M Bocharie, S Adjei (2010). Integration of control of neglected tropical diseases into health-care systems: Challenges and opportunities. Lancet 375:160-165.

Harpham T (2009). Urban health in developing countries: What do we know and where do we go? Health & Place 15:107-116.

Kennedy SB and RA Nisbett (2015). The Ebola epidemic: a transformative moment for global health, Bulletin World Health Organization 93(1):2.

Madon T et al. (2007). Implementation Science. Science 318(5857):1728-1729.

Maston AS (2001). Ordinary magic: resilience processes in development. American Psychologist 56(3): 227-238.

Minkler, M and N Wallerstein  (eds) (2008). Community-Based Participatory Research for Health: From Process to Outcomes. San Francisco: Jossey-Bass.

Montgomery MR and PC Hewett (2004). Urban poverty and health in Developing Countries: Household and neighborhood effects. Demography 42(3):397-425.

Montgomery M et al. (Eds) (2004). Cities Transformed: Demographic Change and Its Implications in the Developing World. Washington DC: National Academies Press.

Nisbett RA, SH Vermund (2014). The Liberian Ebola Epidemic of 2014: Witchcraft, Ignorance and Tyranny of the Experts, October 1, 2014, RA Nisbett and SH Vermund, Springer-Verlag Public Health,                http://www.springerpub.com/w/public-health/blog-the-liberian-ebola-epidemic-of-2014-witchcraft-ignorance-and-tyranny-of-the-experts/.

Prichett L, M Woolcock, M Andrews (2010). Capability Traps: The Mechanisms of Persistent Implementation Failure. Center for Global Development Working Paper #234.

Population Reference Bureau (2008). World Population Data Sheet.

Swanson RC et al. (2010). Toward a consensus on guiding principles for health systems strengthening. PLoS Medicine 7(12): E1000385.

Ulin, PR, ET Robinson, and EE Tolley (2004). Qualitative Methods in Public Health: A Field Guide for Applied Research. San Francisco: Jossey-Bass.

UN-Habitat (2010a). Hidden Cities: Unmasking and overcoming health inequities in urban settings. Geneva: WHO Centre for Health Development and United Nations Human Settlements Programme.

UN-Habitat (2010b). The State of African Cities 2010: Governance, Inequality and Urban Land Markets. Nairobi: United Nations Settlement Programme.

WHO (2003). Concepts and Methods of Community-Based Initiatives. Cairo: WHO Regional Office.

WHO (2006). Addis Abada Declaration on Community Health In the Africa Region. Brazzaville: WHO.

WHO (2008a). Ouagadougou Declaration on Primary Health Care and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium. Brazzavile: WHO.

WHO (2008b). The World Health Report 2008—Primary Health Care: Now More Than Ever. Geneva: WHO.

WHO/TDR (2008). Community-directed Interventions for Major Health Problems in Africa, A multi-country study final report. Geneva: WHO.