The use of health facility data to assess the effects of armed conflicts on maternal and child health: experience from the Kivu, DR Congo

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis

BACKGROUND

Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu.

METHODS

Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation.

RESULTS

The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones.

CONCLUSIONS

MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

Ensuring leadership at the operational level of a health system in protracted crisis context: a cross-sectional qualitative study covering 8 health districts in Eastern Democratic Republic of Congo

BACKGROUND

This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC.

METHODS

A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes.

RESULTS

The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership.

CONCLUSIONS

Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.

Adaptive Mechanisms of Health Zones to Chronic Traumatic Events in Eastern DRC: A Multiple Case Study

BACKGROUND

The Eastern part of the Democratic Republic of Congo (DRC) has been affected by armed conflict for several years. Despite the growing interest in the impact of these conflicts on health service utilisation, few studies have addressed the coping mechanisms of the health system. The purpose of this study is to describe the traumatic events and coping mechanisms used by the health zones (HZs) in conflict settings to maintain good performance.

METHODS

This multiple case study took place from July to October 2022 in four HZs in the South Kivu Province of DRC. HZs were classified into "cases" according to their conflict profile: accessible and stable (Case 1), accessible but remote (Case 2), unstable (Case 3), and intermediate (Case 4). Eight performance indicators and the amount of funding provided to the HZs by non-governmental organizations (NGOs) were recorded. A graph was created to compare their evolution from 2013 to 2018. A thematic analysis of qualitative data from individual interviews with selected health workers was conducted.

RESULTS

Both battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, strikes) were recorded according to the case conflict-profile. Although the cases (3 and 4) most affected by armed conflicts occasionally performed better than the stable ones (1 and 2), their operational action plan was poorly carried out. The coping mechanisms developed in cases 3 and 4 were the deployment of military nurses in preventive and supervisory activities, the solicitations of subsidies from NGOs, the relocation of health care facilities and the implementation of negotiation strategies with the belligerents.

CONCLUSION

Armed conflict results in traumatic events that disrupt the execution of the operational action plan of HZs. The HZs' management team expertise, its strong leadership, and substantial financial support would enable this system to develop reliable and sustainable adaptive mechanisms.

Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

BACKGROUND

Women and children bear a substantial burden of morbidity and mortality due to armed conflict. Life-saving maternal and child health (MCH) services are low-quality in most conflict-affected regions. Previous studies on armed conflict and MCH services have been mostly cross-sectional, and a causal relationship between armed conflict and MCH services utilisation cannot be inferred.

METHODS

First, we constructed a utility equation for maternal health-seeking behaviour. Next, we extracted MCH data from the Multiple Indicator Cluster Survey led by the UNICEF. Armed conflict data were obtained from the Uppsala Conflict Data Programme; 55 683 women aged 15-49 from Chad, the Central African Republic, the Democratic Republic of Congo (DRC) and the Republic of Iraq were selected as participants. We fitted a difference-in-differences (DID) model, taking before or after the conflict started as an exposure variable to estimate the effects of armed conflict on maternal health-seeking behaviours.

RESULTS

According to the results of the DID model, in the regional sample, armed conflict had a positive effect on tetanus vaccination (β=0.055, 95% CI 0.004 to 0.106, p<0.05), and had a negative effect on antenatal care at least eight visits (ANC8+) (β=-0.046, 95% CI -0.078 to -0.015, p<0.01). And, the effects of armed conflict on ANC, ANC4+, institutional delivery and early initiation of breast feeding (EIB) were not statistically significant. As for the country sample, we found that armed conflict had a negative effect on EIB (β=-0.085, 95% CI -0.184 to 0.015, p<0.1) in Chad. In Iraq, armed conflict had positive impacts on ANC (β=0.038, 95% CI -0.001 to 0.078, p<0.1) and tetanus vaccination (β=0.059, 95% CI 0.012 to 0.107, p<0.05), whereas it had a negative effect on ANC8+ (β=-0.039, 95% CI -0.080 to 0.002, p<0.1). No statistically significant associations were discovered in DRC based on the DID model.

CONCLUSIONS

There might be a mixed effect of armed conflict on maternal health-seeking behaviours. In the absence of humanitarian assistance, armed conflict reduces certain maternal health-seeking behaviours, such as ANC8+. When practical humanitarian health assistance is provided, the damage can be alleviated, and even the prevalence of maternal health-seeking behaviours can be improved, such as tetanus vaccination. Providing humanitarian assistance to conflict-affected regions improved the accessibility of MCH services for women living in those areas. However, the goals of saving lives and alleviating suffering still need to be achieved. In conflict-affected regions, humanitarian assistance on ANC, institutional delivery and breast feeding need strengthening.

Feasibility of establishing a core set of sexual, reproductive, maternal, newborn, child, and adolescent health indicators in humanitarian settings: results from a multi-methods assessment in the Democratic Republic of Congo

Background

Reliable and rigorously collected sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) data in humanitarian settings are often sparse and variable in quality across different humanitarian settings, and there is a lack of consensus about a core set of indicators that humanitarian actors including national health systems should report on. To address this gap in quality data, the World Health Organization (WHO) developed a core set of indicators for monitoring and evaluating SRMNCAH services and outcomes and assessed their feasibility in four countries, including the Democratic Republic of Congo (DRC) with the goal of aggregating information from global consultations and field-level assessments to reach consensus on a set of core SRMNCAH indicators among WHO partners.

Methods

The feasibility assessment in the DRC focused on the following constructs: relevance/usefulness, feasibility of measurement, systems and resources, and ethical issues. The multi-methods assessment included five components; a desk review, key informant interviews, focus group discussions, facility assessments, and observational sessions.

Results

The findings suggest that there is widespread support among stakeholders for developing a standardized core list of SRMNCAH indicators to be collected among all humanitarian actors in the DRC. There are numerous resources and data collection systems that could be leveraged, built upon, and improved to ensure the feasibility of collecting this proposed set of indicators. However, the data collection load requested from donors, the national government, international and UN agencies, and coordination/cluster systems must be better harmonized, standardized, and less burdensome.

Conclusions

Despite stakeholder support in developing a core set of indicators, this would only be useful if it has the buy-in from the international community. Greater harmonization and coordination, alongside increased resource allocation, would improve data collection efforts and allow stakeholders to meet indicators’ reporting requirements.

In humanitarian settings, data collection is often unreliable and not standardized—especially with regards to sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH). In order to address this gap in data quality, the World Health Organization proposed a list of core indicators to four countries, including the Democratic Republic of Congo (DRC). The goal was to use the findings from the DRC context to contribute to the determination of a core set of indicators. This study had two components: a feasibility assessment and a multi-methods assessment. The feasibility assessment in the DRC focused on the relevance of the proposed indicators, the feasibility of measurement, the resources in place, and ethical issues. The multi-methods assessment included a desk review, interviews with key informants, and focus groups and facility assessments. The findings showed that partners in the DRC supported developing a standard set of SRMCAH indicators that can be used among all humanitarian partners in the country. There are many systems in place that could be used or strengthened to improve data collection. However, the findings also showed that there must be better collaboration and coordination between the different partners in the DRC, as well as increased resources, to alleviate burden on frontline staff. In conclusion, though there is a desire to harmonize indicators, more input and resources are needed from the international community to aid in the standardization of data collection in order to meet local reporting requirements and ease burden on local staff.

Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services

INTRODUCTION

There are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women's, Children's and Adolescents' Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation.

METHODS

Monthly routine health facility data by district for the period 2017-2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020.

RESULTS

The completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March-December 2020 was 3.9% (range: -8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=-17.0%) and outpatient admissions (median=-7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from -2% to -6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March-June 2020 for general services, when the response was strongest as measured by a stringency index.

CONCLUSION

The district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.

Human insecurity and child deaths in conflict: evidence for improved response in Yemen

Background

Since the beginning of the ongoing conflict in Yemen, &gt;23 000 air strikes and &gt;100 000 fatalities have been recorded. Data from Yemen Data Project linked &gt;1300 child fatalities and &gt;900 child injuries to air raids. However, there is little literature on the effect of the protracted armed conflict on the pattern of child mortality using data from small-scale surveys. We aimed to identify the pattern of the death rate for children aged &lt;5 years (‘under-5’) and its relationship with human insecurity in Yemen.

Methods

We created a human insecurity index (i.e. severely insecure vs insecure) for the 22 governorates in Yemen from 2015 to 2019, using data from the Armed Conflict Location and Event Database. We matched this insecurity index with the corresponding under-5 mortality data from the Complex Emergency Database. We analysed the relationship between the under-5 death rate (U5DR) and the insecurity level using a Bayesian finite mixture model in order to account for unobserved heterogeneity in clustered finite subsets of a population.

Results

We extracted 72 surveys and 77.8% (n = 56) were included in this study. The mean of the recall period for mortality was 106 days with a standard deviation of 93 days. We identified two subpopulations: Subpopulation I—high average number of child deaths and Subpopulation II—low average number of child deaths. The log posterior mean of the U5DR is 1.10 (95% credible intervals: 0.36, 1.82) in the severely insecure group in Subpopulation I and 3-fold the estimate in Subpopulation II. However, in Subpopulation II, we found no association between the insecurity level and the U5DR.

Conclusion

The pattern of child deaths is crucial in understanding the relationship between human insecurity and the U5DR.

COVID-19 and Health Sector Development Plans in Africa: The Impact on Maternal and Child Health Outcomes in Uganda

INTRODUCTION

Health Sector Development Plans (HSDPs) aim to accelerate movement towards achieving sustainable development goals for health, reducing inequalities, and ending poverty. Reproductive, maternal, newborn and child health (RMNCH) services are vulnerable to economic imbalances, including health insecurity, unmet need for healthcare, and low health expenditure. The same vulnerability influences the potential of a country to combat global outbreaks such as the COVID-19. We aimed to provide some important insights into the impacts of COVID-19 on RMNCH indicators and outcomes of the HSDP in Uganda.

METHODS

We conducted a descriptive study of secondary data obtained from the Ugandan government-led portals, supplemented by analyses of relevant articles published up to 06 May 2021 and deposited in PubMed.

RESULTS

Through synthesizing actionable and relevant evidence, we realized that RMNCH in Uganda is highly affected by the COVID-19 pandemic and the lockdown measures. The impact was across immunization, antenatal, sexual and reproductive health, emergency and obstetric, and postnatal care services. There was a decline sharply by 9.6% for under-five vitamin A coverage, 9% for DPT3HibHeb3 coverage, 6.8% for measles vaccination coverage, 6% for isoniazid preventive therapy coverage, and 3% for facility-based deliveries. Maternal and under-five deaths increased by 7.6% and 4%, respectively. Outreaches were rarely conducted in the lockdown period.

CONCLUSION

The COVID-19 pandemic has created a multitude of questions regarding the optimal policies to mitigate the disease while minimizing the unintended detrimental consequences of RMNCH. The lockdown restrictions threatened to reverse the progress made on the national HSDP for RMNCH. In Uganda, where young women are vulnerable to early marriage, unintended pregnancies, and unsafe abortion, access to RMNCH services should continue regardless of the COVID-19 status in the country. We urge that Uganda and other African countries should build resilient and sustainable health systems that can withstand emerging diseases like the COVID-19.