After four and half years of activities on ever-shifting ground, we are finally able to report on the impact we have had on access to quality healthcare in Kasai Oriental province of the Democratic Republic of Congo. Our findings suggest a genuine impact on the coverage of essential services in a hugely challenging context. Overall, the results are mixed and the picture complex.
Our Signature Programme in DRC (which I’ve blogged about previously here and here) was the crown jewel of Save the Children’s partnership with GSK between 2013 and 2017 – with nearly £10m worth of initial investment – and was designed on the premise that strengthening health systems and making essential services available to all is good for everyone in the long term: communities, ministries of health, the private sector and international NGOs. This flagship programme was to bring this common belief to life by tackling and reducing maternal, neonatal and child mortality in three health zones of Kasai Oriental province and one health zone of the Kinshasa province.
Progress: maternal, newborn and child health
Over the past two years, as programme activities gradually increased across the four target health zones, significant gains have been achieved on key maternal and newborn health indicators:
- The effective coverage of skilled birth attendants has increased from 10% to 44%.
- Coverage of essential newborn care – including immunisation, early initiation of breastfeeding, resuscitation, management of prematurity and more – has jumped from just 7% to 31%.
These levels of effective coverage are still far too low. But the increases are substantial in the context of the Kasai Oriental province, where it’s still the norm for women to give birth at home and in extremely precarious conditions. We’ve also seen significant gains on several key indicators for child health:
- Full immunisation coverage stands at nearly 50% in the target zones, compared with just 31% two years earlier.
- Effective coverage of diagnostic care and treatment of pneumonia in health facilities saw a remarkable ten-fold increase, from 4% in 2016 to 40% in 2018.
These results suggest that the Signature Programme’s focus on safe deliveries, newborn care and the integrated management of childhood illnesses is paying off and improving both access and use of these key services.
Malaria and diarrhoea: an uphill battle
Malaria remains a significant danger for families here. While rates of effective coverage have increased markedly, they’re still very low. This is worrying, given that malaria is the largest cause of illness and death among children under five in the target health zones.
It’s important to note, though, that access to a health centre equipped for the management of malaria stands at 93%. It seems the issue is not availability but uptake of services – the number of cases actually managed is far lower than we’d expect, given the known caseload in the region. These findings are consistent across the health centre and community levels and suggest that a lot more work is needed to get people using these services.
There are clearly significant barriers to take-up that we need to break down. Some barriers are behavioural – caregivers aren’t taking their children to be seen as quickly or habitually as we’d hope – but there are also very significant financial barriers. Our household survey data shows that the take-up of relevant malaria services varied greatly with affluence, from 24% among the poorest caregivers interviewed to 55% among those who are better off.
Community practices: a good start
Our work to get communities changing their behaviour and taking up health services got off to a slow start but began ramping up from 2016. The effect of women’s groups and the deployment of community health advocates seems to have been positive on two behaviours crucial to reducing diarrhoea, pneumonia and malaria: exclusive breastfeeding for infants up to six months and handwashing with soap.
These family and community practices are notoriously difficult to promote and sustain. A lot more work is needed to improve the effective coverage of these critical practices, but progress so far has been encouraging. The programme is now reviewing the results of formative research commissioned earlier this year, which will be used to design and implement a more comprehensive and sophisticated social and behaviour change strategy in the second phase.
Health needs beyond the programme: a case for partnerships
There is still a huge amount of need in areas such as maternal health and antenatal care, as well as family planning and HIV. All have extremely low rates of effective coverage. It’s also a big concern for us that the effective coverage of severe and acute malnutrition has actually decreased from 32% to 25% over the past couple of years. This is another area we’ve been unable to directly support through the programme, and the evaluation shows that the main bottleneck relates to the supply of therapeutic foods, despite the support provided in this area by other partners, including UNICEF.
We believe this shows a need to form partnerships and seek out synergies with others working in the DRC and specifically in these two provinces. Malnutrition is a major underlying factor for most childhood illnesses, wiping out their ability to fight their way back to health. To protect families from illness for good it needs to be tackled. A boost to family planning provision is also sorely needed in this region. Women of reproductive age are having up to eight children on average in some parts, which is a key driver of maternal and child mortality.