A variety of qualitative methods were used to elicit views of stakeholders at all levels of the health system. These methods were as follows:

• Key informant interviews with stakeholders at national, county, district and facility level to explore the realities of Mass Drug Administration (MDA) implementation from a health systems perspective and focused on what helps and hinders the programme with specific reference to financing, leadership and governance, health workforce and service delivery.
• Life and job histories of Community Drug Distributors (CDDs). This data was collected to elucidate motivations of the work that CDDs do, training they have had and the ways that they are supported in their roles. The purpose of these interviews was to understand current levels of job satisfaction and level of engagement with the NTD programme to be able to assess what strategies could be utilised to better support CDDs.
• Focus group discussions (FGDs) and social mapping to explore general perceptions of MDA and health communication preferences. FGDs incorporated the use of participatory social mapping to explore physical and social community structures that are currently used or could be better used in NTD programme delivery
• In depth interviews with acceptors, refusers and absentees of Ochocerciasis, Lymphatic Filariasis and Soil-transmitted Helminth (STH) MDA to understand their knowledge, perceptions and experiences of existing MDA strategies.
• Interviews with parents of school-aged children linked to Schistosomiasis MDA, seeking to understand their knowledge, perceptions and experiences of Schistosomiasis MDA.

The research highlighted several challenges in ensuring that communities are aware of NTDs and associated programmes and challenges affecting effective implementation of Mass Drug Administration (MDA) in Liberia.

Recommendations regarding communities which have come from this research are as follows:

1. To ensure maximum inclusion of all community members, both house to house and fixed- point distribution methods should be used during MDA. Proper awareness should also be completed in advance of distribution using these strategies.
2. Research should be completed that explores how CDDs could use simple tools to identify community level distribution preferences and how they could be given the flexibility to adapt service delivery strategies at the local level. 
3. Health communication and awareness messaging should be guided by the newly developed NTDs communication strategy and should focus on the use of a variety of communication tools, including but not limited to; workshops, face to face discussions, radio campaigns and other social behaviour change communication techniques (SBCC) such as radio jingles and posters/flyers etc. Messaging should be delivered in local languages or simple English.
4. Explore with communities the most appropriate times of day, week, year and month that awareness and distribution should take place and how flexibility in drug delivery timelines can be achieved. This could include additional time be allocated for awareness activities prior to MDA campaigns coupled with ongoing disease awareness between campaign periods.
5. Investigate the best ways to improve information sharing regarding side effects as well as referral systems for people experiencing side effects.

 Recommendations regarding the MDA Health Workforce in Liberia are as follows:

1.    Training should be lengthened at all levels within the training cascade and cover all areas of programme implementation.

2.    Training manuals and other associated materials (e.g. posters, leaflets etc) should be developed at the national level (including adaptations for the different levels of participants) and be available at all points on the training cascade. To reduce the burden on the OIC in the training cascade, NTDs could consider establishing a facility based NTD focal point who could be trained alongside the OIC and deliver training to CDDs. At the county level, the NTD focal point should have NTDs as their primary role, rather than having multiple roles, however this will rely on more flexible funding provisions to be able to support implementers and compete with other programmes.

3.    Explore what would be the most effective methods of supportive supervision for CDDs in a resource limited programme and how existing community and health system platforms could be better leveraged to support alternative supervision models that are sustainable both during and external to the MDA campaign period. The use of mobile phones to improve communication between CDDs and their supervisors should be considered.

4.    Research the impact of out-of-pocket expenditure on CDDs and frontline implementers, with an explicit focus on how this could be minimised.

5.    Investigate the feasibility of implementing standardised procedures for the reimbursement of expenditure for CDDs and programme implementers during programme delivery. Guidelines should prioritise equity and look at relative costs based on distances travelled.

6.    Lobby with NGDO implementing partners to provide equitable levels of support to NTD programme staff at the national level and explore how this can align to any existing Ministry of Health salary or incentive scales to ensure consistency in financial remuneration.

7.    Explore the cost implications of providing essential logistical supplies and resources to CDDs and other frontline implementers. Examples of supplies that may be provided are rain gear, calling cards, bikes, ID badges and medicine bags. Consideration of how often these supplies should be provided (e.g. as a one off or annually) will be important.

8.    Understand what opportunities there are for further integration of NTD programme delivery into new and existing community and health systems platforms for example the CHA programme. Ongoing financial remuneration by the CHA programme to some CDDs may present an opportunity for NTDs in integration and could harness evidence around the benefits of financial remuneration vs. other support packages in Liberia.

Further reading can be found in the following policy briefs:

Liberia Policy Brief - Implementing and integrating NTD programmes in Liberia

Health Workforce policy brief

Liberia Community Perspectives on MDA