Malaria

Rapid Access Expansion Programme in the Democratic Republic of the Congo

April 2018

High rates of preventable child mortality

In 2015, the under-5 mortality rate in the Democratic Republic of Congo was 98.3 deaths per 1000 live births, which represents a 39% reduction since 2000. Approximately 55% of the under-5 deaths in 2016 were caused by malaria, pneumonia and diarrhoea, all of which are treatable.

Improving the quality and availability of child health services at the community level

Better quality and coverage of iCCM services

As of November 2017, Tanganyika Province had the country’s most extensive coverage for iCCM services. The RAcE programme was the only programme to integrate the diagnosis and treatment of malaria, pneumonia, and diarrhoea at the provincial level, and also the only one that aimed to meet specific epidemiological needs, rather than to simply provide a single community care site per health district.

Since the launch of the programme, the Ministry of Health recommended that single disease approaches be replaced with integrated strategies in order to accelerate the improvement of child survival rates.

Partners

The International Rescue Committee (IRC) was the implementing nongovernmental organization and the main grant sub-recipient. IRC and WHO supported the Ministry of Health in delivering and monitoring iCCM services in all 11 health zones in Tanganyika Province. ICF International provided support for strengthening improving data quality and conducting baseline and end line surveys. Specifically, these partners supported the Ministry of Health in:

  • effecting policy change for iCCM service expansion;
  • recruiting, training, and motivating community health workers and their supervisors;
  • strengthening the procurement and distribution of iCCM commodities;
  • improving data collection and quality; and
  • mobilizing communities to create demand for and support the provision of iCCM services.

Community health worker selection, training and compensation

Community health workers, known as relais communautaires or ReCos, are volunteers selected by community members. The volunteers must know how to read and write in order to correctly perform the diagnosis, treatment, and reporting functions. Under the RAcE programme, the relais received six days of iCCM training. Those who did not perform well at any point during their work received extra coaching and supervision. RAcE invested additional efforts to ensure that supervision and case management was both regular and adequately supported the community health workers.

Challenges

Tanganyika Province is large, and infrastructure can create logistical challenges. During the rainy season, supervisors conducted field visits by motorized canoe. The RAcE programme provided bicycles to all community health workers so that they could reach target populations within their localities more easily. The programme also mobilized communities to support their local workers and thereby increase motivation.

Challenges remained, however, with the referrals of more complex cases, as community members lack the means and motivation to transport their children to non-community based health facilities that are further away and that provide unaffordable and often low-quality services.

During the summer of 2016, Tanganyika Province experienced some inter-ethnic conflict, and iCCM activities were temporarily halted in some communities.

RAcE-supported operational research

Low levels of literacy and numeracy among health workers mean that they may have trouble following care protocols and filling in reporting forms.

Operational research activities conducted in several health zones demonstrated that pictorial tools and user-friendly training manuals could improve the accuracy, completeness and regularity of reporting. These tools also resulted in time saved in correct treatment and diagnosis for the relais and programme cost savings. The revised tools were accompanied by an improved training curriculum based on adult learning methodologies and practical exercises. This package was adopted by the Ministry of Health for nationwide use.

Policy changes

The Democratic Republic of the Congo adopted WHO policy recommendations for iCCM implementation, including revising national iCCM tools and data collection forms to increase usability.

Based on the evidence generated by the RAcE experience, national policy now recommends amoxicillin rather than cotrimoxazole for the treatment of pneumonia at the community level, and rectal artesunate for the pre-referral treatment of cases of suspected severe malaria.


The RAcE Programme in numbers
Catchment population Catchment under-five population CHW trained* CHW active* Total cumulative cases treated*
The RAcE Programme is providing health services to 955 027 inhabitants 152 804 1866 1475  • 1 012 074 malaria cases

 • 332 624 diarrhoea cases

 • 215 743 pneumonia cases
* Since the start of the programme
Data April 2018
Community health worker near Kalemie, DRC, disposes of her gloves after performing a malaria test on a young girl
Griff Tapper/ WHO
A relais communautaire near Kalemie, DRC, disposes of her gloves after performing a malaria test on a young girl.

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