This pre-feasibility study of community based financing in Liberia aims to provide the Ministry of Health
and Social Welfare with information to decide upon a possible role of community financing in Liberia’s
health financing strategy, in the short and medium term.
There is a wide variety internationally in types of CBF with differences in technical design, management
and organisational characteristics. Rigorous studies are not conclusive about the impact of CBF on
access to care and financial protection (lowering out-of-pocket expenditure when using care): access to
health care is not systematically higher for CBF members, nor do they spend systematically less out-ofpocket
when visiting health facilities. The population penetration rate of CBF in Africa is generally low. In
Rwanda, for example only 2% of the population is covered by CBF; this is 0.5% in Senegal. In 13 selected
African countries CBF cover between 5,000 and 200,000 individuals per country. CBF only modestly
contributes to resource mobilisation for health. CBF in Cameroun collect on average US$ 8.4 per year
per individual covered, the highest in the pool of selected countries studied. This is US$ 0.23 per year
per individual covered in Niger, the lowest in the pool. Loss ratios (the proportion of collected funds
paid out to beneficiaries) are between 31% and 81%. Notwithstanding their modest contribution to
health financing nation-wide many CBF contribute to some cost-recovery in the local health systems
they collaborate with. CBF schemes offer services to those that would otherwise be excluded from any
health risk and resource pooling mechanism. These are mostly informal sector populations. At the same
time there is increasing evidence that CBF do not reach the poorest households in the society.
The conclusions from international evidence are sobering, as there is little conclusive evidence that CBF
actually increase utilisation and decrease out-of-pocket expenditure. Their resource mobilisation
potential is generally modest, and they do not include the poorest households in society.
Despite the introduction of a free BPHS in 2007 Liberian households contribute out of pocket 35% to
total health expenditure. This may be due to rationing in the public system where many drug and lab
test stock outs and long waiting times drive patients to private providers, which are not free. Not
surprisingly 85% of total household out-of-pocket expenditure is spent on private providers.
Nevertheless most Liberians report that they do not experience financial barriers to accessing care.
However, the fact that poorer households spend significantly less on care then richer households may
suggest that poorer households experience a level of unmet health need possibly induced by the cost
care. This can then be compounded by high transport costs to seek care, which is particularly the case
for rural households. Unmet need together with high transport costs then suggests some room for CBF,
especially for poorer and rural populations, assuming health care is a priority for them.
Quality of care measures suggest that there is a long way to go to ensure high quality health provision in
Liberia, certainly by ‘objective’ quality of care standards. The population, in contrast, seems to be
moderately positive, as shown in the CWIQ survey where 60% of the population was ‘satisfied’ with
health services, and in a reasonable level of utilisation rate in primary care RBHS facilities. These findings
suggest that the current levels of quality of care are good enough for CBF and that further
improvements in quality of care would support CBF development in Liberia.