Early impact of the Liberian National Community Health Assistant Program on under-five mortality in Grand Bassa County: A non-randomized stepped wedge evaluation

Liberia instituted a National Community Health Assistant Program (NCHAP) to increase primary healthcare access for residents living >5 km from health facilities. We evaluated the impact of this program on under-five mortality in rural Grand Bassa County as it was rolled out, between 2018 and 2022. The program was implemented in a stepped manner two districts at-a-time across Grand Bassa County from 2018 to 2022, allowing for a quasi-experimental observational stepped-wedge impact evaluation. We conducted a household census in 2022 to collect birth and death histories from all mothers in the program catchment area. We fitted mixed-effects Cox proportional hazards models to estimate the relative hazard of death among children <5 in the before- and under-intervention periods. We also compared data from the 2022 survey with a 2018 baseline household survey to estimate changes in care-seeking and healthcare service delivery coverage. We surveyed 22,315 female respondents about 32,743 children <5 who contributed person-time to the analysis. We found no difference in <5 mortality between the before- and under-intervention periods (unadjusted U5MR under intervention was higher at 62.0 versus 56.3 deaths per live births; adjusted hazard ratio 1.03 (95%CI 0.82-1.31). Care-seeking from a qualified healthcare provider for fever, diarrhea, or acute respiratory infection increased (27.0% to 53.7%; p < 0.001); and care-seeking decreased from drugstores (16.4% to 4.9%, p < 0.001) and black-market providers (42.4% to 22.7%, p < 0.001). Full vaccination among 12–23-month-olds decreased (16.2% in 2018 to 3.5% in 2022 (p < 0.001)) while facility-based delivery increased (41.0% to 57.1% (p < 0.001)). We detected no reduction in under-five mortality during initial implementation of the national CHA program in one Liberian county. Coverage of childhood treatment for high-priority conditions improved, and we observed a shift in care-seeking to trained providers. These results suggest potential program benefits, but additional interventions, some of which are already underway, will be needed to reduce under-five mortality.