In 2015, the under-five mortality rate in the Democratic Republic of the Congo was 98.3 deaths per 1000 live births, which represents a 39% reduction since 2000. Approximately 62% of the under-five deaths in 2013 were caused by malaria, pneumonia and diarrhoea, all of which are treatable.
The Rapid Access Expansion Programme (Race) was launched in Tanganyika Province in September 2013, with the aim of improving access to services for malaria, diarrhoea and pneumonia for children under five living in hard-to-reach areas. Using the integrated community case management (ICCM) approach, Race trains, supports and supplies local community-based workers to diagnose and treat children.
The programme also documents best practices to support the ministry of health’s expansion of iCCM coverage at the national level.
Better quality and coverage of ICCM services
Tanganyika Province now has the country’s most extensive coverage for ICCM services. The Race Programme is the only one to integrate the diagnosis and treatment of malaria, pneumonia and diarrhoea at the provincial level, and also the only one that aims to meet specific epidemiological needs, rather than to simply provide a single community care site per health district.
Since the launch, the ministry of health has recommended that single disease approaches be replaced with integrated strategies in order to accelerate the improvement of child survival rates.
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. They receive six days of ICCM training. Those who do not perform well at any point during their work receive extra coaching and supervision.
Tanganyika Province is large, and infrastructure can create logistical challenges. During the rainy season, supervisors conduct field visits by motorised canoe. The programme has provided bicycles to all community health workers so that they may more easily reach target populations within their localities. It is also mobilising communities to support their local workers and thereby increase motivation.
Challenges remain, 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 have shown that pictorial tools and user-friendly training manuals can improve the accuracy, completeness and regularity of reporting. These tools also result in time saved in correct treatment and diagnosis for the Recos and programme cost savings. The revised tools were accompanied by an improved training curriculum based on adult learning methodologies and practical exercises.
The Democratic Republic of the Congo has adopted WHO policy recommendations for ICCM implementation, including revising national tools and data collection forms to increase usability.
Additionally, national policy now recommends amoxicillin rather than cotrimoxazole for the treatment of pneumonia at the community level, as well as rectal artesunate for the pre-referral treatment of cases of suspected severe malaria.