Health Financing, Health-System Strengthening, and Health Outcomes in Liberia and the Mano River Union: A Systematic Review

Background: The Mano River Union (MRU) countries (Liberia, Sierra Leone, and Guinea) face persistent health-system constraints related to conflict, epidemics, underinvestment, and weak institutional capacity. Progress toward universal health coverage (UHC) requires evidence on how financing and system-strengthening strategies affect service access, equity, and resilience. This review synthesized evidence on health financing and health-system strengthening in Liberia and the wider MRU, including their implications for health outcomes, equity, and community health systems. Methods: This PRISMA 2020-compliant review was registered in PROSPERO (CRD420251243931). PubMed and African Journals Online were searched for English-language sources published from 1 January 2015 to 31 December 2025, and gray literature was sought from the World Health Organization, World Bank, UNICEF, African Development Bank, and Liberia Ministry of Health. Two reviewers independently screened records and extracted data, and primary empirical studies were appraised using the Mixed Methods Appraisal Tool 2018. Findings were integrated using narrative thematic synthesis within a health-systems framework informed by PECOS. Results: Database searches identified 1,254 records, and organizational sources identified six additional records. After 312 database duplicates were removed, 942 database records were screened; 934 were excluded, and eight reports were retrieved and assessed. All six organizational records were retrieved and assessed. No reports were excluded after full-text assessment, and all 14 reports were included, comprising six journal articles (including two reviews) and eight institutional or technical reports. Five themes emerged: chronic underfunding and low government prioritization of health; mixed, mechanism-dependent performance of financing reforms; geographic and socioeconomic disparities in maternal and child health access; central but donor-dependent community health systems; and Ebola-related disruption with uneven recovery. Governance fragmentation and donor coordination were cross-cutting concerns. Liberia's average health-budget allocation of 3.46% from 2010 to 2018 illustrates the financing gap. Conclusions: Although the evidence base is limited by heterogeneous designs, reliance on policy and technical sources, and the absence of Guinea-specific studies, evidence from the MRU indicates that underinvestment, inequity, and governance weaknesses continue to constrain health-system performance. More predictable domestic financing, equity-oriented reforms, and sustained support for integrated community health systems are priorities for advancing UHC in fragile and post-conflict settings.