A synthesis of concepts of resilience to inform operationalization of health systems resilience in recovery from disruptive public health events including COVID-19

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict' Health systems resilience has become a ubiquitous concept as countries respond to and recover from crises such as the COVID-19 pandemic, war and conflict, natural disasters, and economic stressors inter alia. However, the operational scope and definition of health systems resilience to inform health systems recovery and the building back better agenda have not been elaborated in the literature and discourse to date. When widely used terms and their operational definitions appear nebulous or are not consistently used, it can perpetuate misalignment between stakeholders and investments. This can hinder progress in integrated approaches such as strengthening primary health care (PHC) and the essential public health functions (EPHFs) in health and allied sectors as well as hinder progress toward key global objectives such as recovering and sustaining progress toward universal health coverage (UHC), health security, healthier populations, and the Sustainable Development Goals (SDGs). This paper represents a conceptual synthesis based on 45 documents drawn from peer-reviewed papers and gray literature sources and supplemented by unpublished data drawn from the extensive operational experience of the co-authors in the application of health systems resilience at country level. The results present a synthesis of global understanding of the concept of resilience in the context of health systems. We report on different aspects of health systems resilience and conclude by proposing a clear operational definition of health systems resilience that can be readily applied by different stakeholders to inform current global recovery and beyond.

Developing technical support and strategic dialogue at the country level to achieve Primary Health Care-based health systems beyond the COVID-19 era

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Pursuing the objectives of the Declaration of Alma-Ata for Primary Health Care (PHC), the World Health Organization (WHO) and global health partners are supporting national authorities to improve governance to build resilient and integrated health systems, including recovery from public health stressors, through the long-term deployment of WHO country senior health policy advisers under the Universal Health Coverage Partnership (UHC Partnership). For over a decade, the UHC Partnership has progressively reinforced, via a flexible and bottom-up approach, the WHO's strategic and technical leadership on Universal Health Coverage, with more than 130 health policy advisers deployed in WHO Country and Regional Offices. This workforce has been described as a crucial asset by WHO Regional and Country Offices in the integration of health systems to enhance their resilience, enabling the WHO offices to strengthen their support of PHC and Universal Health Coverage to Ministries of Health and other national authorities as well as global health partners. Health policy advisers aim to build the technical capacities of national authorities, in order to lead health policy cycles and generate political commitment, evidence, and dialogue for policy-making processes, while creating synergies and harmonization between stakeholders. The policy dialogue at the country level has been instrumental in ensuring a whole-of-society and whole-of-government approach, beyond the health sector, through community engagement and multisectoral actions. Relying on the lessons learned during the 2014-2016 Ebola outbreak in West Africa and in fragile, conflict-affected, and vulnerable settings, health policy advisers played a key role during the COVID-19 pandemic to support countries in health systems response and early recovery. They brought together technical resources to contribute to the COVID-19 response and to ensure the continuity of essential health services, through a PHC approach in health emergencies. This policy and practice review, including from the following country experiences: Colombia, Islamic Republic of Iran, Lao PDR, South Sudan, Timor-Leste, and Ukraine, provides operational and inner perspectives on strategic and technical leadership provided by WHO to assist Member States in strengthening PHC and essential public health functions for resilient health systems. It aims to demonstrate and advise lessons and good practices for other countries in strengthening their health systems.

Fonctionnalité des concentrateurs d’oxygène hospitaliers au Nord Kivu, République Démocratique du Congo

INTRODUCTION

Nord-Kivu is facing a high prevalence of hypoxemia diseases requiring the use of oxygen concentrators.

PURPOSE OF RESEARCH

This article describes the level of functionality of oxygen concentrators in 31 hospital structures, in North Kivu province of Democratic Republic of Congo (DRC).

METHODS

This descriptive cross-sectional study carried out a survey of managerial and maintenance personnel and the removal of parameters on the operation of oxygen concentrators from 31 hospitals handling Covid19 cases in North Kivu. The collected data was encoded and analyzed using SPSS version 26 software.

RESULTS

The oxygen concentrators were of 28 different brands, and in 65.8% of cases with a 5-liter capacity. They were used in 70% of cases in 4 departments (Intensive care, operating room, emergency room, internal medicine). They were donated in 66.2% of cases (n=225), without accessory equipment in33.6% of cases and without training of maintenance technician in three of five cases or users in one in two cases. In 45% of cases, maintenance was provided. In 67.6% of cases oxygen concentrators were not functional (n=225), with impaired volume flow in 54.9% of cases and oxygen levels in 34,6% of cases. The oxygen deficit was variable depending on the type of hospital structures (p=0,005) but not the volume flow (P>0.05).

CONCLUSIONS

Low functionality of oxygen concentrators increases patient risk and shows the interest to implement a provincial strategy for the management and maintenance of bio-medical equipment and its integration into regional health development plan.

Policy dialogue as a collaborative tool for multistakeholder health governance: a scoping study

Introduction

Health system governance is the cornerstone of performant, equitable and sustainable health systems aiming towards universal health coverage. Global health actors have increasingly been using policy dialogue (PD) as a governance tool to engage with both state and non-state stakeholders. Despite attempts to frame PD practices, it remains a catch-all term for both health systems professionals and researchers.

Method

We conducted a scoping study on PD. We identified 25 articles published in English between 1985 and 2017 and 10 grey literature publications. The analysis was guided by the following questions: (1) How do the authors define PD? (2) What do we learn about PD practices and implementation factors? (3) What are the specificities of PD in low-income and middle-income countries?

Results

The analysis highlighted three definitions of policy dialogue: a knowledge exchange and translation platform, a mode of governance and an instrument for negotiating international development aid. Success factors include the participants’ continued and sustained engagement throughout all the relevant stages, their ability to make a constructive contribution to the discussions while being truly representative of their organisation and their high interest and stake in the subject. Prerequisites to ensuring that participants remained engaged were a clear process, a shared understanding of the goals at all levels of the PD and a PD approach consistent with the PD objective. In the context of development aid, the main challenges lie in the balance of power between stakeholders, the organisational or technical capacity of recipient country stakeholders to drive or contribute effectively to the PD processes and the increasingly technocratic nature of PD.

Conclusion

PD requires a high level of collaborative governance expertise and needs constant, although not necessarily high, financial support. These conditions are crucial to make it a real driver of health system reform in countries’ paths towards universal health coverage.

An assessment of the core capacities of the Senegalese health system to deliver Universal Health Coverage

Senegal is firmly committed to the objective of universal health coverage (UHC). Various initiatives have been launched over the past decade to protect the Senegalese population against health hazards, but these initiatives are so far fragmented. UHC cannot be achieved without health system strengthening (HSS). Here we assess the core capacities of the Senegalese health systems to deliver UHC, and identify requirements for HSS in order to implement and facilitate progress towards UHC. Based on a critical review of existing data and documents, complemented by the authors' experience in supporting UHC policy making and implementation, we evaluate the main foundational and institutional bottlenecks relative to the six health system building blocks, together with an analysis of the demand-side of the health system, which facilitate or hamper progress towards UHC. Despite the fact that many institutions are now in place to deliver UHC, important weaknesses limit progress along the two dimensions of UHC. Substantial disparities characterise resource allocation in the health sector, and health risk protection schemes are highly fragmented. This spreads down to the rest of the health system including service delivery and consequently, impacts on health outcomes. These constraints are acknowledged by the authorities, solutions have been proposed, but these necessitate strong political will. Moreover, progress towards UHC is constrained by the difficulty to act on social determinants of health and a lack of fiscal space.

Realist evaluation of the role of the Universal Health Coverage Partnership in strengthening policy dialogue for health planning and financing: a protocol

INTRODUCTION

In 2011, WHO, the European Union and Luxembourg entered into a collaborative agreement to support policy dialogue for health planning and financing; these were acknowledged as core areas in need of targeted support in countries' quest towards universal health coverage (UHC). Entitled 'Universal Health Coverage Partnership', this intervention is intended to strengthen countries' capacity to develop, negotiate, implement, monitor and evaluate robust and integrated national health policies oriented towards UHC. It is a complex intervention involving a multitude of actors working on a significant number of remarkably diverse activities in different countries.

METHODS AND ANALYSIS

The researchers will conduct a realist evaluation to answer the following question: How, in what contexts, and triggering what mechanisms, does the Partnership support policy dialogue for health planning and financing towards UHC? A qualitative multiple case study will be undertaken in Togo, Liberia, Democratic Republic of Congo, Cape Verde, Burkina Faso and Niger. Three steps will be implemented: (1) formulating context-mechanism-outcome explanatory propositions to guide data collection, based on expert knowledge and theoretical literature; (2) collecting empirical data through semistructured interviews with key informants and observations of key events, and analysing data; (3) specifying the intervention theory.

ETHICS AND DISSEMINATION

The primary target audiences are WHO and its partner countries; international and national stakeholders involved in or supporting policy dialogues in the health sector, especially in low-income countries; and researchers with interest in UHC, policy dialogue, evaluation research and/or realist evaluation.

[Reorganization of the provincial health system in the Democratic Republic of the Congo]

INTRODUCTION

In the framework of implementation of health system reform in the Democratic Republic of the Congo (DRC), and in a context of decentralization dictated by the National Constitution, this study presents the process and results obtained in terms of the provincial level of health care organization in DRC.

METHODS

A two-year multidisciplinary interventional research protocol was elaborated with two phases and 9 steps including organizational analysis, team building, and organizational learning. It resulted in transformational actions and improved knowledge, allowing the development of an innovative organizational model of the intermediate level of the health care system in the Democratic Republic of the Congo.

RESULTS

This interventional research gave rise to function plans set up by the provincial health division (PHD) in order to develop a more participative management and to compensate for the weaknesses of the current structural organization. Experts provided support to PHD for implementation of a new structure in order to institutionalize this new participative management. The new organizational structure of the PHD is based on 4 professions: i) health district support; ii) control and inspection; iii) information, communication and research and iv) resources management. PHD and experts defined these professions and described the required skills. RESULTS were integrated into the new national health plan.

CONCLUSIONS

Apart from the concrete results obtained, two major challenges need to be addressed: i) support the transformation of PHD from the current situation to the new model and ii) extend this new model to the other provinces, according to the same participative approach, a necessary condition to adjust the organization flow-chart to the context.

Health service planning contributes to policy dialogue around strengthening district health systems: an example from DR Congo 2008-2013

Background

This case study from DR Congo demonstrates how rational operational planning based on a health systems strengthening strategy (HSSS) can contribute to policy dialogue over several years. It explores the operationalization of a national strategy at district level by elucidating a normative model district resource plan which details the resources and costs of providing an essential health services package at district level. This paper then points to concrete examples of how the results of this exercise were used for Ministry of Health (MoH) decision-making over a time period of 5 years.

Methods

DR Congo’s HSSS and its accompanying essential health services package were taken as a base to construct a normative model health district comprising of 10 Health Centres (HC) and 1 District Hospital (DH). The normative model health district represents a standard set by the Ministry of Health for providing essential primary health care services.

Results

The minimum operating budget necessary to run a normative model health district is $17.91 per inhabitant per year, of which $11.86 is for the district hospital and $6.05 for the health centre. The Ministry of Health has employed the results of this exercise in 4 principal ways: 1.Advocacy and negotiation instrument; 2. Instrument to align donors; 3. Field planning; 4. Costing database to extract data from when necessary.

Conclusions

The above results have been key in the policy dialogue on affordability of the essential health services package in DR Congo. It has allowed the MoH to provide transparent information on financing needs around the HSSS; it continues to help the MoH negotiate with the Ministry of Finance and bring partner support behind the HSSS.

[Stakeholder representations of the role of the intermediate level of the DRC health system]

INTRODUCTION

Intermediate health care structures in the DRC were designed during the setting-up of primary health care in a perspective of health district support. This study was designed to describe stakeholder representations of the intermediate level of the DRC health system during the first 30 years of the primary health care system.

METHODS

This case study was based on inductive analysis of data from 27 key informant interviews..

RESULTS

The intermediate level of the health system, lacking sufficient expertise and funding during the 1980s, was confined to inspection and control functions, answering to the central level of the Ministry of health and provincial authorities. Since the 1990s, faced with the pressing demand for support from health district teams, whose self-management had to deal with humanitarian emergencies, the need to integrate vertical programmes, and cope with the logistics of many different actors, the intermediate heath system developed methods and tools to support heath districts. This resulted in a subsidiary model of the intermediate level, the perceived efficacy of which varies according to the province over recent years.

CONCLUSION

The "subsidiary" model of the intermediary health system level seems a good alternative to the "control" model in DRC.

[Malaria infection and nutritional status: results from a cohort survey of children from 6-59 months old in the Kivu province, Democratic Republic of the Congo]

BACKGROUND

Despite a reduction in the magnitude of endemic malaria reported in recent years, malaria and protein-energy malnutrition (PEM) still remain major causes of morbidity and mortality in sub-Saharan Africa among children under five. The relationship between malaria and malnutrition remains a topic of controversy. We aimed to investigate malaria infection according to nutritional status in a community-based survey.

METHODS

A cohort of 790 children aged 6 to 59 months and residing in eastern Democratic Republic of the Congo was followed-up from April 2009 to March 2010 with monthly visits. Data on nutritional status, morbidity between visits, use of insecticide-treated nets and malaria parasitemia were collected at each visit. The Z scores height for age, weight for age and weight for height were computed using the reference population defined by the WHO in 2006. Thresholds for Z scores were defined at -3 and -2. A binary logistic model of the generalized estimating equation (GEE) was used to quantify the association between PEM indicators and malaria parasitemia. Odds ratio (OR) and their 95% confidence interval (95% CI) were computed.

RESULTS

After adjustment for season, children with severe stunting (height for age Z score<-3) were at lower risk of malaria parasitemia greater or equal to 5000 trophozoits/μL of blood as compared to those in with a better nutritional status (height for age Z score≥-2) (OR=0.48, 95% CI: 0.25-0.91).

CONCLUSION

Severely stunted children are at a lower risk of high-level malaria parasitemia.

[Supporting the intermediate level of health care in urban health areas in Kinshasa (1995-2005), DR Congo]

As a result of the decentralization of health systems, some countries have introduced intermediate (provincial) levels in their public health system. This paper presents the results of a case study conducted in Kinshasa on health system decentralization. The study identified a shift from a focus on regulation compliance assessment to an emphasis on health system coordination and health district support. It also highlighted the emergence of a?managerial (as opposed to a bureaucratic) approach to health district support. The performance of health districts in terms of health care coverage and health service use were also found to have improved. The results highlight the importance of intermediate levels in?the health care system and the value of a more organic and managerial rationality in supporting health districts faced with the complexity of urban environments and the integration of specialized multi-partner programs and interventions.

[Impact of mid-level management and support on the performance of a district health system in the Democratic Republic of the Congo]

INTRODUCTION

The aim of this study was to assess the contribution of mid-level management and support practices to the overall performance of a district healthcare system.

METHODS

This case study was carried out in the North Kivu Province of the Democratic Republic of the Congo. It was based on analysis of (i) preventive and curative healthcare services and (ii) management and support practices provided from 2000 to 2008.

RESULTS

In response to recurring sociopolitical unrest since 1992, the mid-level health system (provincial level) in North Kivu has strengthened management and support practices. The main goals have been to optimize allocation of interventions by external emergency organizations and integration of specialized program activities, to harmonize intervention techniques implemented by external partners, to standardize supervision of sanitary districts with regard to care provider skills, and to adapt strategic options defined by the Ministry of Health to the provincial level. Using this comprehensive approach, the performance of the North Kivu Province in terms of curative and preventive care has exceeded the national average since 2001. Between 2001 and 2008, use of curative services progressed from 0.36 to 0.50 new cases/capita/year. Positive results have also been recorded for infrastructure coverage, essential medicine stock, health information system, and emergency preparedness.

CONCLUSION

Stronger mid-level management and support practices have improved care activities in the health district while protecting the population from unstructured interventions by emergency organizations or specialized programs. A comprehensive management approach has also improved the resilience of the district and increased its contribution to Millennium Development Goals.

The role of hospitals within the framework of the renewed primary health care (PHC) strategy

This article summarizes a presentation made at the IHF Leadership Summit held in Chicago, USA in June 2010, by Denis Porignon from the World Health Organization (WHO) and Reynaldo Holder from the Pan American Health Organization (PAHO/WHO). It focuses on the role of hospitals within the framework of the renewed PHC strategy.

La carte sanitaire de la ville de Lubumbashi, République Démocratique du Congo Partie II : analyse des activités opérationnelles des structures de soins

Les structures de santé dans la ville de Lubumbashi tentent d’offrir à la population des soins de santé en réponse à ses besoins ressentis. Cet article présente et analyse la nature et le volume des soins offerts par les différents prestataires institutionnels aux différents niveaux du système de santé pour l’ensemble de l’année 2006. Pratiquement toutes les structures offrent des soins curatifs. Le taux d’utilisation moyen pour l’ensemble de la ville est de 0,37 nouveaux cas par habitant par an. La population utilise plus souvent l’hôpital que les structures intermédiaires et celles de première ligne. Des maternités sont disponibles dans près de 2/3 des structures de première ligne, dans toutes les structures intermédiaires et dans tous les hôpitaux. Neuf accouchements sur dix sont assistés avec un taux de césarienne de moins de 2%. La vaccination est réalisée dans 2/3 des structures de première ligne avec un taux de couverture de la 3ème dose du vaccin trivalent contre la diphtérie, le tetanos et la coqueluche (DTC3) de 49%. Seulement quelques structures de première ligne dépistent les cas de tuberculose pulmonaire à microscopie positive avec un taux de dépistage de 44%. La présente étude, basée sur une mesure quantitative, met en évidence une discordance entre l’offre et la demande. Elle contribue à une meilleure compréhension de l’offre de soins à Lubumbashi même si les questions de la qualité des soins et de l’accessibilité financière aux soins restent encore en suspens.

La carte sanitaire de la ville de Lubumbashi, République Démocratique du Congo Partie I : problématique de la couverture sanitaire en milieu urbain congolais

Cet article fait l’inventaire physique de toutes les structures de soins existantes dans la ville de Lubumbashi en 2006, étudie l’évolution de leur apparition dans le temps, détermine leur répartition géographique et identifie les différents prestataires institutionnels et opérationnels qui y travaillent. Une enquête de terrain a permis de collecter des informations se rapportant à ces objectifs pour l’année 2006. Les résultats révèlent une augmentation annuelle du nombre des structures de soins et leur concentration vers le centre-ville ; une grande diversité institutionnelle des prestataires (Etat, confessions religieuses, ONG locales, entreprises paraétatiques et privés indépendants) ; une évolution exponentielle du nombre de structures de première ligne et une croissance de la pratique médicalisée dans ces structures ; une marginalisation de l’Etat comme prestataire de première ligne (moins de 10% de l’offre) mais qui reste néanmoins prestataire majoritaire dans l’offre de soins hospitaliers (51% de lits d’hospitalisation). Ces résultats plaident pour une évolution dans les rôles de l’Etat : celui-ci devrait se concentrer en priorité sur l’offre de soins hospitaliers, ensuite sur son rôle de démonstration des bonnes pratiques en première ligne et enfin sur la régulation de l’offre privée de soins de première ligne.

The contribution of primary care to health and health systems in low- and middle-income countries: a critical review of major primary care initiatives

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.

Linking programmes and systems: lessons from the GAVI Health Systems Strengthening window

OBJECTIVES

To analyse the first four rounds of country applications to the GAVI Alliance Health Systems Strengthening (GAVI-HSS) funding window; to provide valuable insight into how countries prioritize, articulate and propose solutions for health system constraints through the GAVI-HSS application process and to examine the extent to which this process embodies alignment and harmonization, Principles of the Paris Declaration.

METHODS

The study applied multiple criteria to analyse 48 funding applications from 40 countries, submitted in the first four rounds, focusing on the country analysis of health systems constraints, coordination mechanisms, alignment with national and sector planning processes, inclusiveness of the planning processes and stakeholder engagement.

RESULTS

The applications showed diversity in the health systems constraints identified and the activities proposed. Requirements of GAVI for sector oversight and coordination, and the management of the application process through the Ministry of Health's Planning Department, resulted in strong alignment with government policy and planning processes and good levels of stakeholder inclusion and local technical support (TS).

CONCLUSION

Health Systems Strengthening initiatives for global health partnerships (GHPs) can provide a link between the programmatic and the systemic, influencing policy alignment and harmonization of processes. The applications strengthened in-country coordination and planning, with countries using existing health sector assessments to identify system constraints, and to propose. Analyses also produced evidence of broad stakeholder inclusiveness, a good degree of proposal alignment with national health plans and policy documents, and engagement of a largely domestic TS network. While the effectiveness of the proposed interventions cannot be determined from this data, the findings provide support for the GAVI-HSS initiative as implementation continues and evaluation begins.

Nutritional Monitoring of Preschool-Age Children by Community Volunteers during Armed Conflict in the Democratic Republic of the Congo

Background

The coverage of preschool preventive medical visits in developing countries is still low. Consequently, very few children benefit from continuous monitoring during the first 5 years of life.

Objective

To assess community volunteers' effectiveness in monitoring the growth of preschool-age children in a context of endemic malnutrition and armed conflict.

Methods

Community volunteers were selected by village committees and trained to monitor children's growth in their respective villages. Community volunteers monitored 5,479 children under 5 years of age in the Lwiro Health Sector of the Democratic Republic of the Congo from January 2004 to December 2005 under the supervision of the district health office. Children's weight was interpreted according to weight-for-age curves drawn on the growth sheet proposed by the World Health Organization and adopted by the Democratic Republic of the Congo.

Results

During the 2-year program, the volunteers weighed children under 5 years of age monthly. The median percentage of children weighed per village varied between 80% and 90% for children of 12–59 months, and 80% and 100% for children of less than 12 months even during the conflict period. The median percentage of children between 12 and 59 months of age per village ranked as highly susceptible to malnutrition by the volunteers decreased from 4.2% (range, 0% to 35.3%) in 2004 to 2.8% (range, 0.0% to 18.9%) in 2005.

Conclusions

The decentralization of weighing of children to the community level could be an alternative for improving growth monitoring of preschool-age children in situations of armed conflict or political instability. This option also offers an opportunity to involve the community in malnutrition care and can be an entry point for other public health activities.

Performance-based financing for better quality of services in Rwandan health centres: 3-year experience

In 2005, the Ministry of Health in Rwanda, with the support of the Belgian Technical Cooperation, launched a strategy of performance-based financing (PBF) in a group of 74 health centres (HCs), covering 2-m inhabitants. In 2006, PBF was extended to an additional group of 85 HCs, thus reaching 3.8-m inhabitants. This study evaluates the effect of PBF on HC performance from 2005 to 2007. Composite indicators for measuring quantity and quality of services were developed and evaluated through monthly formative supervisions by qualified and well-trained district supervisors. The strategy was based on a fixed fee per quality-approved service. The entire budget spent on the implementation of PBF amounted to $0.25/cap/year, of which $0.20/cap/year for subsidies and an estimated $0.05/cap/year for administration, supervision and training. A positive effect on utilization rates was only seen for activities that were previously less well organized; in this case, growth monitoring services and institutional deliveries. The quality of services, defined as the compliance rate with national and international norms, rose considerably for all services in both groups. A sustained level of quality between 80% and 95% was reached within 18 months in the first group. A similar result was reached in the second group in 8 months.

[The effectiveness of community volunteers in counting populations and assessing their nutritional vulnerability during armed conflict: district health in D.R. Congo, Central Africa]

The study assessed the ability of community volunteers, working with district health officials, to conduct a local census to count the population in their villages and assess their nutritional vulnerability. The study involved organizing community volunteers in village nutrition committee and assigning them to count the village population in a Kivu rural health district (D.R.Congo) and assess their vulnerability in terms of nutrition. The study took place in March and April 2003, during armed conflict in the region. Community volunteers supervised by district health officials collected data, presented here as median proportions (with their Max and Min), by age category. The results show that community volunteers were able to conduct this census with reliable results. The population distribution by age category was similar to the national model from a survey by experts. The community volunteers estimated a median of 22.2 % (6.2-100 %) of households in each village in the eastern DR Congo were vulnerable and required foreign aid. Community volunteers can contribute accurately to the collection of demographic data to be used in health programme planning, thus allowing these data to be followed even during instability and armed conflicts.

[Protein-energy malnutrition and malaria-related morbidity in children under 59 months in the Kivu region of the Democratic Republic of the Congo]

In the Kivu region located in east of the Democratic Republic of the Congo, malnutrition and malaria is a major cause of morbidity and mortality. The relationship between malaria and malnutrition is unclear and has never been studied in the Kivu region. This report presents an analysis of data from 5695 children aged 0 to 5 years, admitted to the paediatric ward of Lwiro hospital between November 1992 and February 2004. The weight/age (W/A) index and weight/height (W/H) index expressed with standard deviation in relation to the reference median were calculated (Z score). The association between protein-energetic malnutrition and malaria infection and nutritional indicators was measured based on prevalence ratios determined by univariate analysis and adjusted Odds Ratio (OR) derived using a multivariate model. The prevalence of malaria at the time of admission was 35.8 % (n=5695). The W/A and W/H indexes and serum albumin level were correlated with malaria-related morbidity. Logistic regression showed that high malaria OR was associated with both anthropometric nutritional indicators [WHZ > -2: OR (CI 95 %) 1.7 (1.4-2.2)] [WAZ > -2: OR (CI 95 %) 1.3 (1.1-1.6)] and biological nutritional indicators [serum albumin > or = 23 g/L: OR (CI 95 %) 1.6 (1.2-2.1)]. Our findings indicate that malnourished children at admission have a lower risk of malaria infection.

[Use and evaluation of the Belgian 3BT thesaurus adapted for Rwanda]

The Kigali university medical centre (CHUK) lacks visibility on its activities for many years. Institution management as well understanding the institution as the corner stone of the Rwandese health system and reinforcement of its visibility are all health policy major issues. Nevertheless, to this point no such tool has been developed nor implemented. The objective is to assess the feasibility of the use of the thesaurus 3BT as data collection tool in a Rwandese health institution. In august 2005, the thesaurus 3BT (Belgian, bilingual, biclassified ICD-10/ICPC-2) adapted to the CHUK has been implemented. Main issues: encoding quality and thesaurus operationality. Qualitative analysis has been performed on 899 coding of which 16 empty. Low occurrences (< or = 0.2%) of about 25% of codings of clinical diagnosis show the need for using a thesaurus but also to upgrade it. Near 45% of the empty codings could be fulfilled with a quick look to the original medical record. Some diagnoses are missing in the thesaurus 3BT. 66% of which have similar concepts in the thesaurus although not identifiable by a lay person. Finally, a clinical data blind coding test by a doctor used to classifications and by a lay person used to code clinical diagnosis from medical records of the hospitalised patients shows an exact similarity in 70% of the coding and a loss of coding precision in 20%. No coding error has been identified at this time. In conclusion, operationality of the thesaurus is quite acceptable in this study. The thesaurus makes easy the coding of clinical diagnosis even by lay people. Quality of data is enough to be able to interpret the quantitative results of the coding process. This study has to be repeated on a wider basis.

[The prepayment scheme in Rwanda (II): membership and use of services by beneficiaries]

In Rwanda, the Ministry of Health is rebuilding the health sector destroyed during the genocide while trying to guarantee the financial accessibility of the population to the services through the setting up of a prepayment scheme. Membership remains low in the three pilot districts where the prepayment scheme was introduced four years before (15,6%). In two of these districts, the curative consultation and maternity utilisation has increased appreciably. The members of the prepayment scheme make greater use of the services than the rest of the population. There is a significantly higher prepayment scheme membership among households with a relatively high income and those with a large family (more than 5 family members). Overall, non-members of the prepayment scheme spend more on health services than members do. There are indications that developing the prepayment scheme would be very useful for the people in Rwanda if specific strategies geared to the poor were set up.

[The prepayment scheme in Rwanda (I): analysis of a pilot experiment]

Rwanda has made the setting up of a prepayment scheme a priority in its health sector reform in order to make health services more financially accessible to the population. A pilot study was carried out in three districts. The yearly family subscription charge was fixed at 7.9 US dollars, which covers care delivered at Health Centre level as well as some services at the hospital. The beneficiaries and providers mention difficulties in order to mobilise the subscription charges all at a time, the insufficiency of the offer of services at the hospital and the absence of involvement of the political authorities in the process. The Ministry of Health did initiate the experiment but the choice of the privileged pilot districts prevents results from being extrapolated to the country taken as a whole with a view to a possible extension at a later stage. Given the relatively short time in which it has taken place, the population could neither understand the contingency and solidarity issues implied nor have the opportunity to feel personally involved in the system. As a conclusion, the study advocates the continuation of the experiment with a reinforcement of the coordination which should take the weak points identified into account.

[Referral and delivery outcomes in Kivu, Democratic Republic of Congo]

BACKGROUND

The process of referral between the first and the second level of the health system in the Democratic Republic of Congo is poorly understood. This report intends to study the association between the referral and the hospital perinatal outcomes.

METHODS

Delivery outcomes in a retrospective cohort of 1162 women admitted between June 95 and May 96, in two referral hospitals in Kivu were analyzed according to the referral status and the women's characteristics.

RESULTS

Forty-three percent (n=492)of women admitted, corresponding to 2.3% of expected pregnant women, were referred. Referred women had higher risks of obstetrical complications (OR=2.0; CI95%: 1.3-3.1) and intervention (OR=1.5; CI95%: 1.0-2.3) and similar risks of low birth weight and perinatal mortality. Women with complications during the antenatal period had a double risk of intervention and perinatal mortality. The risk of obstetrical intervention was lower when women had attended 2 visits (OR=0.5; CI95%: 0.3-0.8); the risk of low birth weight was lowest only for mothers who had attended one visit (OR=0.5; CI95%: 0.3-0.9). Distance > or =90 minutes walking from home to hospital raised the risk of obstetrical complication (OR=1.7; CI95%: 1.1-2.5), the risk of obstetrical intervention (OR=1.5; CI95%: 1.0-2.1), and the risk of perinatal mortality (OR=1.6; CI95%: 1.0-2.7). Late admission raised the risk of perinatal mortality (OR=1.8; CI95%: 1.2-2.9) and lowered the risk of obstetrical complication (OR=0.7; CI95%: 0.5-1.0). Part payment of care was associated with higher risks of low birth weight (OR=1.9; CI95%: 1.3-2.9), perinatal mortality (OR=2.2; CI95%: 1.4-3.5) and obstetrical intervention (OR=2.4; CI95%: 1.7-3.4).

CONCLUSION

These results suggest a deficit of referred cases considering that 15% of pregnant women in the area covered by the referral hospitals should have been referred. They confirm the negative influence of economic and geographic constraints on the delivery outcomes. They point out the relevance of making reorganization of the referral system a priority.

[Analysis of data routinely collected in the maternity ward of Rutshuru in the Democratic Republic of the Congo between 1980 and 1998. II. New-born deaths and low birth weights]

This second paper aims at deriving useful information allowing to improve the strategy applied for maternal health care.

MATERIAL AND METHODOLOGY

Between 1980 and 1998, data on 13,042 deliveries were collected. Characteristics, mortality, morbidity of mothers and new-born and obstetrical interventions were recorded. The present work describes the evolution of low birth weight (LBW), new-born deaths, and associated risk factors. The statistical analyses applied included khi2, t-test, and multiple logistic regression.

RESULTS

Eighteen percent of new-born weights below 2.5 kg and 7.9% died. The proportion of low birth weights remains globally constant. Low proportions of new-born deaths were observed in 1981, 1982, 1988 and 1998. At admission, 35% of the women presented at least one of the four risks defined by the factors used for reference; this proportion went up from 26.1 to 39.2%. The four reference factors were associated with low birth weight. Baudelocque diameter and age were not associated with new-born death. Education and BMI were associated with an increased risk of new-born death. Marital status was not associated with any of the two outcomes.

CONCLUSION

This analysis shows small variation of LBWs and perinatal deaths. It confirms the association between these two outcomes and most of the risk factors studied. The efficacy of the strategies implemented for improving perinatal health is questioned. The authors recommend that they be reassessed.

[Analysis of data routinely collected in the maternity ward of Rutshuru in the Democratic Republic of the Congo between 1980 and 1998. I. Maternal mortality and obstetrical interventions]

This report is the first of 2 papers that analyse data routinely collected in the maternity ward of Rutshuru (democratic Republic of Congo). The present work describes the evolution of caesarean section, maternal deaths and the associated risk factors.

MATERIAL AND METHODOLOGY

Between 1980 and 1998, data on 13,042 deliveries were collected. Characteristics, mortality, morbidity of mothers and new-borns and obstetrical interventions were recorded. The statistical analyses applied included khi2, t-test, simple linear and multiple logistic regression.

RESULTS

Fifteen percent had a caesarean section and 1.9% of women died. When referred to the expected births during the period, these numbers led to a ratio of 150 maternal deaths for 100,000 expected births and a ratio of caesarean section of 1.2%. At admission, 35% of the women presented at least one of the four risk factors used for reference. The proportion of women with at least one of the 4 risk factors went up from 26.1% to 39.5%. The proportion of caesarean sections went up from 1.9% to 34.1%. The proportion of maternal deaths remained constant except in 1988, 1994, 1995 and 1997. Three of the four reference factors, the Baudeloque diameter, parity and height were associated with caesarean section. Age only was associated with maternal death. Education and marital status were both associated with caesarean section and maternal death.

CONCLUSION

This analysis shows high levels of maternal mortality and caesarean section. The authors recommend to analyse on a larger scale the value of the reference factors used in antenatal services and to standardise indications for the different obstetrical interventions.

The unseen face of humanitarian crisis in eastern Democratic Republic of Congo: was nutritional relief properly targeted?

STUDY OBJECTIVE

Comparison of children's nutritional status in refugee populations with that of local host populations, one year after outbreak refugee crisis in the North Kivu region of Democratic Republic of Congo.

DESIGN

Cross sectional surveys.

SETTING

Temporary and other settlements, in the town of Goma and surrounding rural areas.

SUBJECTS

Anthropometric indicators of nutritional status and presence or absence of oedema were measured among 5121 children aged 6 to 59 months recruited by cluster sampling with probability proportional to size, between June and August 1995.

RESULTS

Children in all locations demonstrated a typical pattern of growth deficit relative to international reference. Prevalence of acute malnutrition (wt/ht < -2 Z score) was higher among children in the rural non-refugee populations (3.8 and 5.8%) than among those in the urban non-refugee populations (1.4%) or in the refugee population living in temporary settlements (1.7%). Presence of oedema was scarcely noticed in camps (0.4%) while it was a common observation at least in the most remote rural areas (10.1%). As compared with baseline data collected in 1989, there is evidence that nutritional status was worsening in rural non-refugee populations.

CONCLUSIONS

Children living in the main town or in the refugee camps benefited the most from nutritional relief while those in the rural non-refugee areas were ignored. This is a worrying case of inequity in nutritional relief.

How robust are district health systems? Coping with crisis and disasters in Rutshuru, Democratic Republic of Congo

BACKGROUND

Since the eighties, the North Kivu Province socio-economic environment has been deteriorating. This province also faced an influx of Rwandan refugees in July 1994. The objective of the paper is to show how a rural health district has been able to adjust and maintain its medical activities under unfavourable conditions.

METHOD

Performances of the local health system were assessed through the analysis of routine medical data collected in the Rutshuru Health District (RHD) between 1985 and 1995. Specific data collected during the Rwandan refugee crisis measured the workload of RHD due to the refugees.

RESULTS

For 11 years, health infrastructures have remained accessible and functional in RHD. The curative utilization and preventive coverage rates increased. Obstetrical activities were intensified from a quantitative as well as from a qualitative point of view. Between July and October 1994, the RHD treated 65000 cases of various pathological conditions in Rwandan refugees settled outside the camps. This corresponds to 9.3% of consultations for Rwandan refugees settled on RHD's territory and represents a 400% increase in the curative workload for the RHD health services. Human and financial resources remained at a very low level, especially when compared with those available in the camps through relief agencies.

CONCLUSION

The RHD was severely affected by various stresses but its services managed to provide significant and efficient response to these crises. Health district systems may constitute an effective tool to provide health care under adverse conditions.

Prognostic indices for mortality of hospitalized children in central Africa

A hospital-based follow-up study was conducted between 1986 and 1988 at Lwiro (South Kivu Province, Zaire). Of 1,129 children in the study, three of four were severely malnourished, and 17.4% died. This study analyzes the mortality in hospital; its objectives are to evaluate the prognostic power of edema and anthropometric and biologic indicators and to seek indices that perform better. Receiver operating characteristic curves were established for each parameter under study and for each index constructed. Areas under receiver operating characteristic curves were highest for biologic indicators, and simple indices, obtained by counting the number of risk factors present, performed best. In the absence of biologic parameters, the authors suggest classifying children as at risk of dying when they present with edema and/or with arm circumference of less than 115 mm. When biologic measurements are possible, in addition to edema and arm circumference, the authors suggest taking serum albumin and transthyretin into account. For serum albumin and transthyretin, mortality risk is defined in terms of values of less than 16 g/liter and 6.5 mg/dl, respectively. Children will be classified as at risk of dying when they present with at least two of the four risk factors. The resulting diagnostic test has a high sensitivity (91.2%) and positive and negative predictive values of 40.8% and 97.9%, respectively.

The role of the Zairian Health Services in the Rwandan refugee crisis

In July 1994, a stream of Rwandan refugees entered the southern part of North Kivu Region, Zaire. The public health consequences of this crisis for the host population and health services have not been analysed up to now. The lack of human and financial resources did not prevent Zairian health structures and personnel from taking care of the many refugees settled outside the camps, following their arrival. The public health consequences of the crisis for the local population should be considered an integral part of the disaster.