[Les médecins prestataires à la première ligne des soins dans la ville de Kisangani en République Démocratique du Congo : vers une typologie]

The first-line physicians' practice in Kisangani city in Democratic Republic of Congo: Towards a typology.

BACKGROUND

In the Democratic Republic of the Congo (DRC), for a number of years, there has been a spontaneous and growing phenomenon of physicians operating at the front line of the health system, while this role is traditionally devolved to nurse-practitioners. This phenomenon does not align with the current health policy.

AIM

The aim of this paper is to develop and discuss the main types of frontline physicians in the city of Kisangani.

SETTING

We conducted a descriptive cross-sectional study in two urban districts in the city of Kisangani.

METHODS

The study population consisted of all first-line health facilities that employed at least one physician. The construction of a typology of first-line physicians consisted of three stages: identification and definition of relevant dimensions of analysis; grouping cases based on empirical data; and analysis of significant relationships and establishment of the typology itself.

RESULTS

An involvement of physicians in healthcare delivery at the first line was observed in 60% of all first line facilities in the two urban districts. Two main types of first-line physicians were identified: firstly, and by large the most prevalent one (96% of cases), the 'hospital-like physician', and secondly, the much less frequent type of the 'supervision physician'.

CONCLUSION

The involvement of physicians in first line healthcare is today a growing phenomenon in the DRC, especially in urban areas. The most dominant expression of this phenomenon is a transposition of the hospital-based physician model to the first line healthcare services, which thereby jeopardizing the specificity of first line healthcare.

L’influence des prestations des médecins à la première ligne de soins sur le système intégré de district sanitaire à Kisangani, République Démocratique du Congo: une étude qualitative

INTRODUCTION

in the DRC, doctors, formerly absent, are increasingly being employed as primary care physicians, in particular but not exclusively in urban areas. This study describes and analyses the impact of primary care physician services on the integrated district health system in Kisangani, DRC.

METHODS

in the third quarter of 2018, we conducted 40 semi-structured interviews of health district stakeholders (population, nurses, doctors, managers) selected in a reasoned way. Questions focused on doctors' motivation, their package of activities and the perceptions of other district stakeholders on their front-line services. Data were analysed using the thematic content analysis.

RESULTS

the services of primary care physicians were a de facto but they were unplanned and unsupported. This derived largely from doctors' need for professional integration. This seemed to improve treatment acceptability but limited their financial accessibility. It was associated with an uncontrolled expansion of the activity packages and caused competition between first-line and second-line physicians.

CONCLUSION

physician services are a challenge and an opportunity to strengthen first-line care while preserving complementarity with second-line care. A (re)definition of first-line physicians' role and activity package is then required. Hence, the need to improve the dialogue between different health system actors in order to (re)define consensually a model of first-line care adapted to match physicians' needs.

Social and economic consequences of the cost of obstetric and neonatal care in Lubumbashi, Democratic Republic of Congo: a mixed methods study

Background

The aim of this study was to explore and measure the social and economic consequences of the costs of obstetric and neonatal care in Lubumbashi, the Democratic Republic of Congo.

Methods

We conducted a mixed qualitative and quantitative study in the maternity departments of health facilities in Lubumbashi. The qualitative results were based on a case study conducted in 2018 that included 14 respondents (8 mothers of newborns, 2 accompanying family members and 4 health care providers). A quantitative cross-sectional analytical study was carried out in 2019 with 411 women who gave birth at 10 referral hospitals. Data were collected for one month at each hospital, and selected mothers of newborns were included in the study only if they paid out-of-pocket and at the point of care for costs related to obstetric and neonatal care.

Results

Costs for obstetric and neonatal care averaged US $77, US $207 and US $338 for simple, complicated vaginal and caesarean deliveries, respectively. These health expenditures were greater than or equal to 40% of the ability to pay for 58.4% of households. At the time of delivery, 14.1% of women giving birth did not have enough money to pay for care. Of those who did, 76.5% spent their savings. When households did not pay for care, mothers and their babies were held for a long time at the place of care. This resulted in the prolonged absence of the mother from the household, reduced household income, family conflicts, and the abandonment of the home by the spouse. At the health facility level, the increase in length of stay did not generate any additional financial benefits. Mothers no longer had confidence in nurses; they were sometimes separated from their babies, and they could not access certain prescribed medications or treatments.

Conclusion

The government of the DRC should implement a mechanism for subsidizing care and associate it with a cost-sharing system. This would place the country on the path to achieving universal health coverage in improving the physical, mental and social health of mothers, their babies and their households.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03765-x.

Hospital detention of mothers and their infants at a large provincial hospital: a mixed-methods descriptive case study, Lubumbashi, Democratic Republic of the Congo

Background

The practice of detaining people who are unable to pay for health care services they have received is widespread in many parts of the world. We aimed to determine the proportion of women and their infants detained for inability to pay for services received at a provincial hospital in the Democratic Republic of the Congo during a 6-week period in 2016. A secondary objective was to determine clinical and administrative staff attitudes and practices about payment for services and detention.

Methods

This mixed-methods descriptive case study included a cross-sectional survey and interviews with key informants.

Results

Over half (52%) of the 85 women who were in the maternity ward at Sendwe Hospital and eligible for discharge between August 5 and September 15, 2016 were detained for 1 to 30 days for outstanding bills of United States dollars (USD) 21 to USD 515. Women who were detained were younger, poorer, and had more obstetric complications and caesarean sections than other women. In addition, over one quarter of the infants born to these women had died during delivery or in the first three days of life. Key informant interviews normalized detention as an unfortunate but inevitable consequence of patient poverty and health system resource constraints.

Conclusions

Detention of women and their infants is common at this hospital in the DRC. This represents a violation of human rights and a systemic failure to ensure that all people have access to essential health services and that they not suffer financial hardship due to the price of those services.

Incidence of catastrophic expenditures linked to obstetric and neonatal care at 92 facilities in Lubumbashi, Democratic Republic of the Congo, 2015

Background

In the Democratic Republic of the Congo (DRC), more than 93% of users must pay out of pocket for care. Despite the risk of catastrophic expenditures (CE), 94% of births in Lubumbashi are attended by skilled personnel. We aimed to identify risk factors for CE associated with obstetric and neonatal care in this setting, to document coping mechanisms employed by households to pay the price of care, and to identify consequences of CE on households.

Methods

We used mixed methods and conducted both a cross-sectional study and a phenomenological study of women who delivered at 92 health care facilities in all 11 health zones of Lubumbashi. In April and May 2015 we followed 1,627 women and collected data on their health care and household expenses to determine whether they experienced CE, defined as payments that reached or exceeded 40% of a household’s capacity to pay. Two months after discharge, we conducted semi-structured interviews with 58 women at their homes to assess the consequences of CE.

Results

In all, 261 of 1,627 (16.0%) women experienced CE. Whether a woman or her infant experienced complications was an important contributor to her risk of CE; poverty, younger age, being unmarried, and delivering in a parastatal facility or with more highly trained personnel also increased risk. Among a subset of women with CE interviewed 2 months after discharge, those who were in debt or who had lost their trading income or goods were unable to pay their rent, their children’s school fees, or were obliged to reduce food consumption in the household; some had become victims of mistreatment such as verbal abuse, disputes with in-laws, denial of paternity, abandonment by partners, financial deprivation, even divorce.

Conclusions

We found a higher proportion of CE than previously reported in the DRC or in other urban settings in Africa. We suggest that the government and funders in DRC support initiatives to put in place mutual-aid health risk pools and health insurance and introduce and institutionalize free maternal and infant care. We further suggest that the government ensure decent and regular payment of providers and improve the financing and functioning of health care facilities to improve the quality of care and alleviate the burden on users.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7260-9) contains supplementary material, which is available to authorized users.

Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: it is time to improve regulatory mechanisms

Background

The Demographic and Health Survey 2013–14 indicated that the Democratic Republic of the Congo (DRC) is still challenged by high maternal and neonatal mortality. The aim of this study was to assess the availability, quality and equity of emergency obstetric care (EmOC) in the DRC.

Methods

A cross-sectional survey of 1,568 health facilities selected by multistage random sampling in 11 provinces of the DRC was conducted in 2014. Data were collected through interviews, document reviews, and direct observation of service delivery. Collected data included availability, quality, and equity of EmOC depending on the location (urban vs. rural), administrative identity, type of facility, and province. Associations between variables were tested by Pearson’s chi-squared test using an alpha significance level of 0.05.

Results

A total of 1,555 health facilities (99.2%) were surveyed. Of these, 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across the provinces and urban vs. rural areas; it was more available in urban areas, with the provinces of Kinshasa and Nord-Kivu being favored compared to other provinces. Caesarean section and blood transfusions were provided by health centers (6.5 and 9.0%, respectively) and health posts (2.3 and 2.3%, respectively), despite current guidelines disallowing the practice. None of the facilities provided quality EmOC, mainly due to the lack of proper standards and guidelines.

Conclusions

The distribution and quality of EmOC are problematic. The lack of regulation and monitoring appears to be a key contributing factor. We recommend the Ministry of Health go beyond merely granting funds, and also ensure the establishment and monitoring of appropriate standard operating procedures for providers.

Characterization of pharmaceutical medication without a medical prescription in children before hospitalization in a resource-limited setting, Cameroon

Introduction

The use of different therapeutic approaches is common among sick children in Cameroon. The main objective of this study was to characterize the use of non-prescription drugs and describe the therapeutic itineraries of sick children before admission to the hospital.

Methods

A cross-sectional and prospective study was conducted from January to May 2017. A closed-ended questionnaire (CEQ) consisting of one or several response options was administered to the parents/guardians of the children on admission to the hospital in the pediatric ward of the Laquintinie Hospital in Douala (LHD) and the Cité des Palmiers District Hospital (CPDH) of the city of Douala. Inclusion of participants was made consecutively for adolescents who gave their consent and parents or guardians who signed the informed consent for all children. The confidentiality of the data was ensured by the replacement of the names by codes.

Results

Overall, 295 hospitalized children were included with an average age of 3.1 (SD: 3.3) years in the study. More than half of these children (58.6%) came from LHD. More than 90% of parents had at least one therapeutic recourse (TR). The ratio of boys to girls 3/1. Self-medication (74.1%) and medical consultation (16.9%) were the main therapeutic paths in 1^st recourse. The medical consultation (80.2%) and the pharmaceutical advice (16.9%) were used frequently in 2^nd recourse. The mean lapse time to see a medical professional was 2.7 days (min-max: 0-14 days). The main symptoms associated with TR were fever (76.6%), vomiting (24.7%) and diarrhea (22.7%). The most frequently used drugs were Analgesics/antipyretics (47.6%), antimalarials (15.0%) and antibiotics (10.2%) and the family medicine box was the highest source of drugs.

Conclusion

Self medication remains the first therapeutic path, followed by medical consultation as second therapeutic path taken when the disease is perceived as serious.

[External anthropometric measurement and pelvimetry among nulliparous women in Lubumbashi: risk factors and predictive score of mechanical dystocia]

Introduction

Maternal and perinatal morbi-mortality is higher in most of sub-Saharan Africa compared to the rest of the world. All women at risk for mechanical dystocia should be screened before labor and referred to a better equipped Hospital for childbirth. This would reduce morbi-mortality. This study aims to develop a predictive score of mechanical dystocia during childbirth among nulliparous Congolese women.

Methods

We conducted a cross-sectional study of nulliparous women with single pregnancy in 7 Maternity Units in the city of Lubumbashi (DRC). Women' size, weight, and external pelvimetry results were collected and analyzed. Univariate and multivariate analyses were performed. Discrimination score was assessed using the ROC curve.

Results

We included in the study 535 nulliparous women, of whom 126 (23.55%) had given birth by cesarean section due to mechanical dystocia. After logistic modelling, three criteria emerged as predictive factors for mechanical dystocia: maternal height <150 cm (adjusted OR=2.96 [1,49-5,87]), bi-ischiatic diameter <8 cm (adjusted OR =15.96 [3,46-73,56]), and Trillat's pre-pubic diameter <11 cm (adjusted OR =2.34 [1,36-4,01]). The area under the ROC curve of the score was 0.6549 with a sensitivity of 23.81%, a specificity of 97.80% and a positive predictive value of 76.92%.

Conclusion

It has been observed that 10th percentile of the three maternal anthropometric measures was predictive of mechanical dystocia. When they were used together, these three values allowed for the development of lowest-cost screening score for use in low income settings.

[Risk factors for maternal and perinatal mortality among women undergoing cesarean section in Lubumbashi, Democratic Republic of Congo II]

Introduction

L’objectif était d’analyser les facteurs de risque de mortalité maternelle et périnatale de la césarienne à Lubumbashi, République Démocratique du Congo (RDC).

Méthodes

Étude multicentrique de 3643 césariennes réalisées entre le 1er janvier 2009 et le 31 décembre 2013 sur un total de 34199 accouchements dans cinq formations hospitalières de référence à Lubumbashi (RDC). Les données sociodémographiques, les indications, l’environnement obstétrical et la morbi-mortalité maternelles et périnatales ont été analysés au logiciel Epi Info 2011. Les fréquences calculées sont exprimées en pourcentage et les moyennes avec leurs écart-types. Le test de Chi-carré et le test exact de Fisher lorsque recommandés ont été utilisés pour la comparaison des fréquences. L’odds ratio a été calculé avec l’intervalle de confiance de 95% de Cornfield grâce à un modèle de régression logistique pour déterminer la puissance de facteurs de risque. Le seuil de signification a été fixé à p < 0,05.

Résultats

La fréquence de la césarienne était de 10,65%. L'âge moyen des césarisées était de 28,83±6,8 ans (extrêmes: 14 et 49 ans). La parité variait de 1 à 16 avec une moyenne de 2,6. De ces opérées, une sur neuf (10,9%) était porteuse d’un utérus cicatriciel de césarienne antérieure et 22,3% étaient des évacuées obstétricales. Les taux de létalité maternelle et périnatale étaient respectivement de 1,4% et 7,07% lors de la césarienne. L’analyse des facteurs de risque montre que la grande multiparité (≥5), l’absence de surveillance de la grossesse, le caractère urgent de l’indication opératoire influent significativement sur la mortalité maternelle. A ces facteurs s’ajoutent pour la mortalité périnatale l’âge maternel avancé (> 35 ans), l’évacuation comme mode d’admission et l’immaturité fœtale.

Conclusion

Cette étude montre que la césarienne dans nos conditions de travail est couplée à une forte mortalité maternelle et périnatale. Les facteurs de risque identifiés sont en grande partie évitables, surtout à tort ou à raison imputés à l’opération masquant ipso facto les circonstances souvent irrationnelles de sa pratique.

Introduction

The objective was to analyze risk factors for maternal and perinatal mortality among women undergoing cesarean section in Lubumbashi, Democratic Republic of Congo (DRC).

Methods

We conducted a multicenter study of 3643 women undergoing cesarean sections between 1 January 2009 and 31 December 2013 out of 34199 women delivering in five general referral hospitals in Lubumbashi (DRC). Sociodemographic data, indications, obstetrical environment as well as maternal and perinatal morbi-mortality were analyzed using Epi Info 2011 software. Computed frequencies were expressed in percentage and mean values were expressed in terms of standard deviations. Chi-square test and Fisher’s exact test, when recommended, were used to compare frequencies. The odds ratio was calculated using Cornfield 95% confidence interval based on a logistic regression model in order to determine the strength of risk factors. Threshold significance level was set at p < 0.05.

Results

The frequency of cesarean sections was 10.65%. The average age of women undergoing cesarean section was 28.83 ± 6.8 years (with a range from 14 to 49 years). Parity ranged from 1 to 16 with an average of 2.6. 1 out of 9 (10.9%) women undergoing cesarean section were patients with previous caesarean section uterine scar on the anterior wall of the uterus and 22.3% of women were patients with previous obstetric evaquation. Maternal and perinatal mortality rate was 1.4% and 7.07% during cesarean section respectively. The analysis of risk factors shows that the great multiparity (≥5), the absence of monitoring during pregnancy, the urgent nature of emergency surgery significantly affect maternal mortality. Other factors for perinatal mortality included advanced maternal age (>35 years), patients referral from one facility to another as a mode of admission and fetal immaturity.

Conclusion

This study shows that cesarean section in our working condition is associated to a significant maternal and perinatal mortality. Identified risk factors are largely preventable, because they are rightly or wrongly ascribed to cesarean section glossing over, ipso facto, the often irrational circumstances of its practice.

Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011

Background

While emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi.

Methods

This cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards.

Results

The availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one.

In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities.

Conclusion

Audits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1224-9) contains supplementary material, which is available to authorized users.

Content, participants and outcomes of three diabetes care programmes in three low and middle income countries

AIMS

To improve access and quality of diabetes care for people in low-income countries, it is important to understand which elements of diabetes care are effective. This paper analyses three diabetes care programmes in the DR Congo, Cambodia and the Philippines.

METHODS

Three programmes offering diabetes care and self-management were selected. Programme information was collected through document review and interviews. Data about participants' characteristics, health outcomes, care utilisation, expenditures, care perception and self-management were extracted from a study database. Comparative univariate analyses were performed.

RESULTS

Kin-réseau (DR Congo) is an urban primary care network with 8000 patients. MoPoTsyo (Cambodia) is a community-based peer educator network, covering 7000 patients. FiLDCare (Philippines) is a programme in which 1000 patients receive care in a health facility and self-management support from a community health worker. Content of care of the programmes is comparable, the focus on self-management largest in MoPoTsyo. On average, Kin-réseau patients have a higher age, longer diabetes history and more overweight. MoPoTsyo includes most female, most illiterate and most lean patients. Health outcomes (HbA1C level, systolic blood pressure, diabetes foot lesions) were most favourable for MoPoTsyo patients. Diabetes-related health care expenditure was highest for FiLDCare patients.

CONCLUSIONS

This study shows it possible to maintain a diabetes programme with minimal external resources, offering care and self-management support. It also illustrates that health outcomes of persons with diabetes are determined by their bio-psycho-social characteristics and behaviour, which are each subject to the content of care and the approach to chronic illness and self-management of the programme, in turn influenced by the larger context.

Health-seeking behaviour in the city of Lubumbashi, Democratic Republic of the Congo: results from a cross-sectional household survey

Background

Concerns about the occurrence of disease among household members generally initiate treatment-seeking actions. This study aims to identify the various treatment-seeking options of patients in Lubumbashi, analyze their health-seeking behaviour, identify determinants for the use of formal care, and analyze direct health care expenditure.

Methods

A cross-sectional survey of households in Lubumbashi was conducted in July 2010. Information was collected from a randomly selected sample of 251 households with at least one member who had been ill in the 2 weeks preceding the survey.

Results

Frequently used initial treatment-seeking options consist of self-medication based on modern medicines (54.6%), the use of first-line health services (23.1%) and hospitals (11.9%), with a perceived effectiveness of 51%, 83% and 91% respectively. If people go for a second option, then formal health care services are most often preferred. The majority (60%) of patients’ spontaneous itineraries reflect the expected functioning of a local health care system, with a patient flow characterised by the use of a first line health facility prior to the use of hospital-based services. Chronicity of the disease is the main determinant of seeking formal care. Analysis of care expenditure reveals that drugs are the only line of expenditure in the informal system and the main source of expenditure in the formal system; costs do not discriminate between first-line health services and hospitals, and the payment system is regressive since the poorest patients pay the same amounts as the richest.

Conclusions

This study points to the importance of self-medication as the first therapeutic option for the majority of patients in Lubumbashi, whatever the nature of the health problem. There is a lot of room to rationalise this practice. Although formal care is not common initial therapeutic option, it is the source of care most patients turn to, especially when they believe having a chronic disease. Patients’ itineraries in this urban environment are complex; health managers should try and deal with this reality. Finally, our study indicates that poor patients face the same level of out-of-pocket payments as the more wealthy ones, hence the need for more equitable health care financing arrangements.

Exacerbation of vulnerability in a hospital setting in Lubumbashi (Democratic Republic of Congo)

This article presents an ethnographic study of the pseudonymous Saint Amand Hospital in Lubumbashi (Democratic Republic of Congo) and of the way in which struggles for control of the hospital's resources contributed to shape certain practices that were damaging to the institution. We examine how, following the disengagement of both the State and a large bankrupt mining enterprise, the 'atypical' governance of the hospital and the institutional instability it generated led to professional vulnerability among care providers. We also look at how, in turn, this situation exacerbated the vulnerability of the helpless and uneducated patients attending that hospital.