Maternity clinic in Kabeya-Kamwanga, Kasai Oriental province, Democratic Republic of Congo.

How do you strengthen access to healthcare in a fragile state?

I’m just back from the depths of rural Democratic Republic of Congo. In what’s probably the most potent example of a fragile state today, I was struck by the sheer complexity of doing development work there. And inspired by the extraordinary work of our colleagues and partners in the field.

Here are my reflections on delivering the right to healthcare in a highly unstable region of DRC.

Landing in the regional airport of Mbuji-Mayi, the provincial capital of the Kasai Oriental province of DRC, in an old Bombardier operated by the recently ‘un-blacklisted’ Congo Airways company left me grappling with a multiplicity of feelings. Relieved to have made it in one piece. Excited by the privilege of going where few internationals have been in recent years. Dismayed by the airport’s shack of a terminal.  And anxiously wondering what lies beyond.

Diamonds are forever

It wouldn’t take long for anyone driving around this strangely unanimated city of a million souls to figure out what gets people out of bed in the morning: the hope of becoming rich overnight. To say that the diamond industry dominates the regional economy is an understatement. Signs of the presence of the MIBA – the national mining company exploiting diamonds in the region – are everywhere, and the extent of its influence and power over local affairs is evident even to the most credulous observer.

As you drive out of the city and venture into rural territory, the effects of what can only be described as a ‘diamond curse’ reveal an extraordinary sight: thousands of acres of incredibly fertile land, left completely uncultivated. While farmers in the Kivu provinces of eastern DRC have squeezed the potential of every plot of land available to grow maize, plantain or sweet potatoes, young villagers in Kasai dig the earth looking for a fortune. What makes this particularly tragic is that rates of malnutrition among children under five are through the roof, and are one of the most pressing public health issues in this part of the world. Addressing the distorted incentives caused by diamond mining and trade ought to be an absolute priority for development actors in Kasai.

Kasai – an island of stability no more

DRC has been a byword for instability, atrocious war crimes and ungovernability for the best part of half a century. Remarkably, however, the Kasai provinces had until recently managed to escape calamities such as the murderous civil wars of eastern DRC, the separatist conflict of Katanga or the deadly urban riots of Kinshasa. Sadly, the region’s immunity to violent conflict ended spectacularly in 2016, when the death of a local leader prompted a bloody insurgency and months of fighting between the army and the newly formed militias. The violence resulted in hundreds of thousands of internally displaced people, with many civilians caught in the conflict leaving everything to flee across the border to Angola.

The intensity of the conflict decreased noticeably earlier this year, but only after thousands of people had died across the region. The western parts of the Kasai Oriental province, where our programme areas are located, turned into a virtual warzone that needed a humanitarian response overnight. Our system strengthening work there was suspended for months on end, until the situation gradually improved and it was deemed safe enough to deploy staff once more. Instability, combined with frequent outbreaks of malaria or measles in different parts of the province needing immediate attention, creates a context of ongoing disruption, and diverts resources away from the long-term, laborious business of system strengthening.

Our Signature Programme in action

It’s in this politically volatile, geographically challenging, epidemiologically unpredictable and economically distorted environment that Save the Children, in a uniquely close partnership with the Ministry of Health and with support from GSK, ITV and DFID, has been battling on the frontline for the past four years to improve the quality of healthcare for all, and to bring services closer to the children who need them most.

Health systems strengthening is often done through the prism of its ‘six building blocks’:

  • service delivery
  • health workforce
  • health information systems
  • access to essential medicines
  • financing
  • leadership/governance.

Implicit in the above is the availability of physical premises where quality basic services can be delivered. But that’s a distant prospect for the rural communities of Tshishimbi, Cilundu or Kabeya-Kamwanga, where the rotten state of what cannot in all seriousness be described as health centres left me dumbfounded.

Scepticism is justified when it comes to constructing health facilities in development programmes. As an activity it doesn’t exactly scream sustainability, and examples abound of white elephants left unused or degraded due to a lack of maintenance, rehabilitation or usage. Moreover, it’s not an activity that typically falls neatly within the mandate of an INGO, but is more naturally associated with that of the government or multilateral agencies such as the World Bank.

But the hard truth is this: training and deploying qualified health personnel in mud huts with no running water, no electricity and virtually no equipment, and expecting them to save lives by the dozen is an enterprise that is doomed to fail. That’s why part of our Signature Programme’s activities include the rehabilitation of health centres, and more often the construction of new ones, that fulfil the national quality standards of a primary healthcare facility, and ensure complicated pregnancies and severe cases of malaria have a fighting chance of making it through the week.

Let’s take it down one level: as an organisation we’re never content with supporting primary healthcare alone in rural parts of Africa, and evidence abounds on the huge impact community health can have on reducing child mortality. One of our flagship approaches for extending the reach of the health system to the most marginalised communities is the Integrated Community Case Management (ICCM) of childhood illnesses – something I have blogged about previously.

The programme has recruited, trained and deployed community health workers in ICCM sites in three health zones of Kasai Oriental to manage uncomplicated cases of malaria – which is still by far the largest cause of child morbidity in this part of the world – pneumonia and diarrhoea, directly within the communities they are from and have decided to dedicate their lives to help. This is a new approach in this province, and one which we hope will help an under-resourced health system reach more children at a relatively low-cost. The community health workers I met throughout the week certainly came across as knowledgeable, motivated and acutely aware of the importance of their role in reducing child mortality and promoting healthy and hygienic practices and behaviour.

Let’s now take it up one level from primary healthcare and look at secondary healthcare. Here the picture is not dissimilar. Our Signature Programme doesn’t directly intervene in general referral hospitals in the health zones, but it does exert a degree of influence over these structures through the support provided with drug supplies, motorcycles and bicycles for outreach sessions, etc. We use this ‘soft power’ to accompany improvements in the quality of care provided in three referral hospitals through a combination of technical support and local advocacy. Examples of things I came across during the visit include poorly managed pharmacy rooms, damaged equipment such as a broken obstetric table and defective oxygen concentrators for the treatment of pneumonia, and an observation room where the same beds were used for adult and paediatric health. These issues were flagged and logged in a health zone action plan that our field team has already started to address.

Supporting these three levels of care, strengthening the referral pathways between each level, ensuring they are coordinated and coherent as a health system, and improving the quality of the services they provide is the DRC’s best hope of shifting from the disastrous trajectory it’s been on for decades to one of rapidly decreasing maternal and child mortality. Strengthening a health system in a fragile state is about making it more resilient in the face of external or endogenous shocks, from conflict to disease outbreaks.

Building greater flexibility and adaptability into our programmes, and harnessing the different skills and capabilities Save the Children is able to deploy, is critical in achieving this. This is what we’re doing in the Kasai provinces of DRC: our Emergency Health Unit has set up impressive mobile clinics operating alongside our Signature Programme and is treating up to 150 patients a day in different parts of our target health zones. This model reflects the reality we are increasingly facing across a range of fragile states in Africa: the line between development work and humanitarian response is a blurred one. And the need to deal with emergencies doesn’t not preclude the long-term system-building we know is required to achieve sustainable change.


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  • Systems man

    What you wrote is interesting, but written from a certain angle. What would capture the reality better and make your argument stronger is to drop the ‘stronger health systems’ hat. It is a poorly defined concept and remains an entirely aspirational notion. Despite all the noise about stronger health systems, the concept does not translate into practice… not for lack of money, but because as a theoretical framework it does not work. Health systems needs systems thinking, which largely lacks in current thought and discourse on health systems. I hope this helps. Otherwise you are doing a good job.

  • I am touched by the work that you are doing over there. Can you please unable a Whatsup sharing option to allow large distribution for donation purposes.