Innovations in Health Care Empowering communities to care for sick children in the DR of Congo The problem In the Democratic Republic of the Congo (DRC), the catchment area of a government health facility is established on the basis of population size. Though the goal is to serve 10,000 inhabitants per facility, many areas of the DRC have low population densities and as a result, health centers must cover very large areas. One health zone, Bena Dibele, covers 27,500 square kilometers but has only three inhabitants per square kilometer. Due to the poor quality of roads, limited transportation and insuffici t resources to pay for public transportation, most people -- especially pregnant women and children -- are unable to access health services. According to a 2007 study by the Congolese Ministry of Health and Macro International, almost 40% of mothers aged 15 to 49 in the province of Eastern Kasai claim they are unable to access health services because the nearest center is too far away. A joint project between CRS, Caritas and the Congolese Ministry of Health is active in six health zones in two of the DRCâ€™s least accessible districts, yet many centers treat as few as 20 children per month. This means not all children are benefiting f om the trained staff, equipment and supplies that the project -- the Kasai Child Survival Project (CSP) -- is making available.
An innovative solution Recognizing the barrier that distance was presenting to prompt care-seeking for sick children, the CSP decided to use an innovative new approach to bring the most essential curative services closer to the most remote communities. The goal was to empower local communities to be involved in ensuring that sick children gained access to life-saving health care. To do so, the project trained health facility staff as t ainers in integrated Community Case Management (iCCM). The trainers in turn trained two selected village health agents from each site to manage cases
A woman displays her healthy twin babies born at a hospital supported by the CRS Child Survival Project in Nyanza province. Photo: Elena McEwan
of diarrhea, pneumonia and malaria. In fi e of six health zones served by the project, a significa t percent of the population lives further than 5km from the nearest health facility. In these zones, the project team worked with local stakeholders including and members of affected communities to implement the iCCM approach at 56 Community Care Sites (CCS) where children are receiving quality curative integrated management of childhood illness (IMCI) closer to home. After the village health agents were trained, the project equipped the community care sites with basic equipment such as guidance cards, reporting forms, salter scales and stopwatches to time breathing. A supply chain was also developed to provide the sites with supplies such as paracetamol, cotrimoxizole, Artemisinin-based combination therapies (ACTs) against malaria, oral rehydration salts (ORS), and zinc. Once active, the new care sites received regular supportive supervision from the health facility staff, the health zone leadership team and the project team.
Happy mothers in line to receive vaccinations for their children.
Photo: Elena McEwan
Scale and impact At the beginning of the project, the idea of empowering communities to assess, diagnose and treat sick children was in its infancy in the DRC. Out of the 525 health zones in the country, only 80 -- or 15% -- had implemented community care case management at both the community and facility levels. In contrast, with the help of CRS and Caritas, 100% of the project-supported health zones reviewed their need for iCCM and all of the zones with populations further than 5km from the nearest facility -- or fi e out six health zones -- established iCCM community care sites. As of 2009, 130 volunteers at 56 sites were actively providing care for sick children. A total of 2,235 consultations were made at these sites up to September 2009, reaching roughly 5% of the children in the project area. In comparison, 21,211 consultations were provided in facilities, meaning that community care sites account for over 10% of all sick children receiving iCCM services through the project. In August 2008, an annual review meeting of the Community Care Sites strategy took place in Madagascar with the participation of Ministry of Health officials om 22 countries and the World Health Organization, USAID and UNICEF. In this meeting the iCCM activities implemented by the CSP were highlighted as best practices from the DRC. Discussions were also focused on the integration of malaria, pneumonia and
Families outside a local health center in Tshiamvi, Eastern Kasai. Photo: Elena McEwan
diarrhea indicators to be used for the monitoring and evaluation of the community care site information within the national health information system. The iCCM approach is part of a comprehensive Child Survival Project which will also include community engagement in Behavior Change Communication activities to promote exclusive breastfeeding, malaria and diarrhea prevention, support for Expanded Program of Immunization, and health system strengthening by improving the quality of care for sick children.
Looking ahead The success of community case management has shown that accessibility is a major barrier to care-seeking. CRS and its partners are making renewed efforts to fully implement this component of the Child Survival Project. Some sites throughout the project area continue to run out of key medications, so the project will focus on supply chain issues during its final ear of implementation. Sustainability is another main concern in the DRC, where the government health system remains unable to finan e even the basic functioning of health centers. To ensure sustainability, CRS has increased the technical and project management capacity at the field l vel. During the projectâ€™s final ear, CRS field staff will ork increasingly closely with Caritas leaders to help transition capacity.
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