Improving financial access to health care in the Kisantu district in the Democratic Republic of Congo: acting upon complexity

Developing a clinical prediction model to modify empirical antibiotics for non-typhoidal Salmonella bloodstream infection in children under-five in the Democratic Republic of Congo

BACKGROUND

Non-typhoidal Salmonella (NTS) frequently cause bloodstream infection in children under-five in sub-Saharan Africa, particularly in malaria-endemic areas. Due to increasing drug resistance, NTS are often not covered by standard-of-care empirical antibiotics for severe febrile illness. We developed a clinical prediction model to orient the choice of empirical antibiotics (standard-of-care versus alternative antibiotics) for children admitted to hospital in settings with high proportions of drug-resistant NTS.

METHODS

Data were collected during a prospective cohort study in children (> 28 days-< 5 years) admitted with severe febrile illness to Kisantu district hospital, DR Congo. The outcome variable was blood culture confirmed NTS bloodstream infection; the comparison group were children without NTS bloodstream infection. Predictors were selected a priori based on systematic literature review. The prediction model was developed with multivariable logistic regression; a simplified scoring system was derived. Internal validation to estimate optimism-corrected performance was performed using bootstrapping and net benefits were calculated to evaluate clinical usefulness.

RESULTS

NTS bloodstream infection was diagnosed in 12.7% (295/2327) of enrolled children. The area under the curve was 0.79 (95%CI: 0.76-0.82) for the prediction model, and 0.78 (0.85-0.80) for the scoring system. The estimated calibration slopes were 0.95 (model) and 0.91 (scoring system). At a decision threshold of 20% NTS risk, the prediction model and scoring system had 57% and 53% sensitivity, and 85% specificity. The net benefit for decisions thresholds < 30% ranged from 2.4 to 3.9 per 100 children.

CONCLUSION

The model predicts NTS bloodstream infection and can support the choice of empiric antibiotics to include coverage of drug-resistant NTS, in particular for decision thresholds < 30%. External validation studies are needed to investigate generalizability.

TRIAL REGISTRATION

DeNTS study, clinicaltrials.gov: NCT04473768 (registration 16/07/2020) and TreNTS study, clinicaltrials.gov: NCT04850677 (registration 20/04/2021).

Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis

Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.

Challenges of Antibiotic Formulations and Administration in the Treatment of Bloodstream Infections in Children Under Five Admitted to Kisantu Hospital, Democratic Republic of Congo

Severe bacterial infections in children need prompt, appropriate antibiotic treatment. We report challenges observed within a prospective, cohort study on antibiotic efficacy in non-typhi Salmonella bloodstream infection (NCT04850677) in Kisantu district hospital (Democratic Republic of Congo). Children (aged > 28 days to < 5 years) admitted with suspected bloodstream infection (August 1, 2021 through July 31, 2022) were enrolled and followed until day 3 or discharge for non-typhi Salmonella patients. Antibiotics were administered to 98.4% (1,838/1,867) of children, accounting for 2,296 antibiotic regimens (95.7% intravenous, 4.3% oral). Only 78.3% and 61.8% of children were, respectively, prescribed and administered antibiotics on the admission day. At least one dose was not administered in 3.6% of children, mostly because of mismatch of the four times daily cefotaxime schedule with the twice-daily administration rounds. Inappropriate intravenous administration practices included multidose use, air-venting, and direct injection instead of perfusion. There was inaccurate aliquoting in 18.0% (32/178) of intravenous ciprofloxacin regimens, and thus administered doses were > 16% below the intended dose. Dosing accuracy of oral suspensions was impaired by lack of instructions for reconstitution, volume indicators, and/or dosing devices. Adult-dose tablets were split without/beyond scoring lines in 84.4% (27/32) of tablets. Poor availability and affordability of age-appropriate oral formulations contributed to low proportions of intravenous-to-oral switch (33.3% (79/237) of non-typhi Salmonella patients). Other quality issues included poor packaging, nonhomogeneous suspensions, and unsafe water for reconstitution. In conclusion, poor antibiotic products (no age-appropriate formulations, poor quality and access), processes (delayed prescription/administration, missed doses), and practices (inaccurate doses, [bio]safety risks) must be urgently addressed to improve pediatric antibiotic treatment.

Making health insurance responsive to citizens: the management of members' complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo

INTRODUCTION

In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members' needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal.

METHODS

Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l'Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa.

RESULTS

The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided.

CONCLUSION

MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.

Social, Educational and Medical Aspects after Cataract Surgery of Bilaterally Blind Children in Kinshasa—Perception of Parents and Children

The study investigated the influence of bilateral cataract surgery on the social and educational development of previously bilaterally blind children in Sub-Saharan Africa (SSA), where the prevalence of blindness due to cataract is higher than in high-income countries. The views of both, parents and children, were evaluated with structured interviews based on a newly developed questionnaire related to surgery, follow-up, and family life after surgery. The mean age of the children at interview was 14.4 ± 8.1 years, with 27 females and 26 males. Satisfaction with the outcome of the surgery was reported by 91% of parents. Parents would recommend surgery, because of the children being happy and able to act more independently, with personal, educational and familial factors essentially contributing to the reported satisfaction. The results also showed that 85.0% of children did not wear eyeglasses. Reasons given were mainly cost-related, but also included limited communication between families and health institutions. Providing and maintaining a high-quality and accessible pediatric cataract surgery and healthcare service for follow-up is a major requisite to reduce childhood blindness in SSA. Our study proved the necessity and effectiveness of a community-based rehabilitation program that cares about each individual child, whatever his or her social background.

Perceptions and use of traditional African medicine in Lubumbashi, Haut-Katanga province (DR Congo): A cross-sectional study

In the Democratic Republic of Congo, the desire of the Ministry of Health to integrate Traditional African Medicine into the Official Health System remains limited by the lack of reliable data on several aspects of this medicine. This study aims to determine the perceptions of the Lubumbashi population towards Traditional African Medicine and the contexts of recourse to these therapeutic modalities. We conducted semi-structured interviews of population samples in each of the 7 Lubumbashi municipalities, which were semi-randomly selected in proportions to each population size, from January to June 2017 and from February to July 2018. A total of 4278 people (average age, 32.1 ± 10.4 years; 36.5% of women) have been surveyed. Among them, 75.8% define "Traditional African Medicine" as "herbal-based treatments"; 79.4% have resorted to traditional medicine, for several pathologies and social problems. This medicine was preferred for efficiency, speed of healing and low cost, as well as the presence of the diseases against which it would be the only one used. Most, (52.1%) have started with Conventional Medicine, then resorted to Traditional African Medicine, 34.7% started directly with Traditional African Medicine, while 13.2% combined these two medicines. From those who have resorted to Traditional African Medicine (n = 3396), 55% declare no concern towards traditional medicine, while 42.5% fear looseness, overdose, intoxication, and lack of hygiene; from those who have not resorted to Traditional African Medicine (n = 882), 78% are fearful of fear looseness, witchcraft, and fetishism. Traditional African Medicine remains an important health care resource for the Lubumbashi people. It is essential that decision-makers consider the importance of this health sector for the population, but also the reported fears and hindrances, and work towards the regulation, sanitization, and control of this medicine to ensure its safe use.

Improving lifestyle behaviours among women in Kisantu, the Democratic Republic of the Congo: A protocol of a cluster randomised controlled trial

Introduction

As the prevalence of obesity among women of reproductive age is increasing in sub-Saharan Africa, the burden of lifestyle-related conditions is expected to rise quickly. This study aims to develop and evaluate a multi-component health promotion programme for a healthy lifestyle to ultimately prevent the onset of type 2 diabetes and gestational diabetes among adult women in Kisantu, the Democratic Republic of the Congo.

Methods and analysis

This study is a cluster randomised controlled trial whereby two groups of three healthcare centres each, matched by population size coverage and geographical area, will be randomised to an intervention or a comparison group. Adult women of reproductive age (18–49 years), non-pregnant or first-trimester pregnant, will be recruited from the healthcare centres. 144 women in the intervention centres will follow a 24-month multi-component health promotion programme based on educational and motivational strategies whereas the comparison centres (144 participants) will be limited to a basic educational strategy. The programme will be delivered by trained peer educators and entails individualised education sessions, education and physical activity group activities, and focus groups. Topics of an optimal diet, physical activity, weight management and awareness of type 2 and gestational diabetes will be covered. The primary outcome is the adherence to a healthy lifestyle measured by a validated closed-ended questionnaire and secondary outcomes include anthropometric measurements, clinical parameters, diet diversity and the level of physical activity. Participants from both groups will be assessed at baseline and every 6 months by trained health professionals from the recruiting healthcare centres. Data will be summarised by measures of central tendency for continuous outcomes, and frequency distribution and percentages for categorical data. The primary and secondary outcomes will be quantified using statistical mixed models.

Ethics

This research was approved by the Institutional Review Board of the Institute of Tropical Medicine Antwerp in Belgium (IRB/RR/AC/137) and the Ethical Committee of the University of Kinshasa in the Democratic Republic of the Congo (ESP/CE/130/2021). Any substantial change to the study protocol must be approved by all the bodies that have approved the initial protocol, before being implemented. Also, this journal will be informed regarding any protocol modification. Written informed consent will be required and obtained for all participants. No participant may be enrolled on the study until written informed consent has been obtained.

Trial registration number

NCT05039307.

Field Experiences with Handheld Diagnostic Devices to Triage Children under Five Presenting with Severe Febrile Illness in a District Hospital in DR Congo

As part of a field study (NCT04473768) in children presenting with severe febrile illness to Kisantu hospital (DR Congo), we retrospectively compiled user experiences (not performance) with handheld diagnostic devices assisting triage: tympanic thermometer, pulse oximeter (measuring heart rate, respiratory rate and oxygen saturation), hemoglobinometer and glucometer. Guidance documents for product selection were generic and scattered. Stock rupture, market withdrawal and unaffordable prices interfered with procurement. Challenges at implementation included environmental temperature, capillary blood sampling (antisepsis, order of multiple tests, filling microcuvettes and glucose strips), calibration (environmental temperature, cold chain) and liability-oriented communication with a manufacturer. Instructions for use were readable and contained symbol keys; two devices had printed French-language instructions. Shortcomings were poor integration of figures with text and distinct procedures for the oximeter and its sensor. Usability interview revealed appreciations for quick results, visibility of the display and memory function (three devices) but also problems of capillary blood sample transfer, cleaning, too long of a time-to-results (respiratory rate) and size, fitting and disposal of thermometer probes. Pictorial error messages were preferred over alphanumeric error codes but interpretation of symbols was poor. Alarm sounds of the oximeter caused unrest in children and caretakers perceived the device as associated with poor prognosis.

Performance of Automated Point-of-Care Respiratory Rate Counting versus Manual Counting in Children under Five Admitted with Severe Febrile Illness to Kisantu Hospital, DR Congo

To improve the early recognition of danger signs in children with severe febrile illness in low resource settings, WHO promotes automated respiratory rate (RR) counting, but its performance is unknown in this population. Therefore, we prospectively evaluated the field performance of automated point-of-care plethysmography-based RR counting in hospitalized children with severe febrile illness (<5 years) in DR Congo. A trained research nurse simultaneously counted the RR manually (comparative method) and automatically with the Masimo Rad G pulse oximeter. Valid paired RR measurements were obtained in 202 (83.1%) children, among whom 43.1% (87/202) had fast breathing according to WHO criteria based on manual counting. Automated counting frequently underestimated the RR (median difference of -1 breath/minute; p2.5-p97.5 limits of agreement: -34-6), particularly at higher RR. This resulted in a failure to detect fast breathing in 24.1% (21/87) of fast breathing children (positive percent agreement: 75.9%), which was not explained by clinical characteristics (p > 0.05). Children without fast breathing were mostly correctly classified (negative percent agreement: 98.3%). In conclusion, in the present setting the automated RR counter performed insufficiently to facilitate the early recognition of danger signs in children with severe febrile illness, given wide limits of agreement and a too low positive percent agreement.

Direct association between rainfall and non-typhoidal Salmonella bloodstream infections in hospital-admitted children in the Democratic Republic of Congo

Non-typhoidal Salmonella (NTS) ranks first among causes of bloodstream infection in children under five years old in the Democratic Republic of Congo and has a case fatality rate of 15%. Main host-associated risk factors are Plasmodium falciparum malaria, anemia and malnutrition. NTS transmission in sub-Saharan Africa is poorly understood. NTS bloodstream infections mostly occur during the rainy season, which may reflect seasonal variation in either environmental transmission or host susceptibility. We hypothesized that environment- and host-associated factors contribute independently to the seasonal variation in NTS bloodstream infections in children under five years old admitted to Kisantu referral hospital in 2013-2019. We used remotely sensed rainfall and temperature data as proxies for environmental factors and hospital data for host-associated factors. We used principal component analysis to disentangle the interrelated environment- and host-associated factors. With timeseries regression, we demonstrated a direct association between rainfall and NTS variation, independent of host-associated factors. While the latter explained 17.5% of NTS variation, rainfall explained an additional 9%. The direct association with rainfall points to environmental NTS transmission, which should be explored by environmental sampling studies. Environmental and climate change may increase NTS transmission directly or via host susceptibility, which highlights the importance of preventive public health interventions.

[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.

Ocular Morbidity-A Critical Analysis to Improve Outpatient Services in an Eye Department in a Sub-Saharan Megacity

The aim of this study was to analyse outpatient services in an ophthalmic clinic of a church-run hospital providing secondary level care in an African megacity, paying special attention to the poorest users of the services. The range of examination was reviewed from 500 patient records of all ages consecutively chosen on random days attending the outpatient department for the first time in order to optimize workflow and to analyse the offered treatment modalities. Mean age was 41.9 ± 21.9 years, and 53.6% of the patients were female. Of the patients, 74.8% presented with visual impairment. The most frequent findings were refractive errors (35.8%), presbyopia (21.2%), allergic conjunctivitis (14.0%), cataract (13.2%) and glaucoma (6.4%). Patient management consisted of optical treatment (49.6%), surgery (11.4%) and medical treatment (39.0%). These results show the importance of the demand in refractive services and the need to train specific service providers. Knowing the frequencies of common conditions enables more appropriate diagnostic and treatment strategies, e.g., the importance of refractive errors, and should lead to improvements in training, staffing, therapeutics and patient outcomes. This approach can be applied to many other outpatient services and should be evaluated in light of the city’s impoverished health outreach and educational situation.

Algorithm for the support of non-related (serious) adverse events in an Ebola vaccine trial in the Democratic Republic of the Congo

Implementing an Ebola vaccine trial in a remote area in the Democratic Republic of the Congo (DRC), and being confronted with a dysfunctional health care system and acute unmet health needs of participants, ethical considerations were made regarding the ancillary care obligations of the sponsor and researchers. Spurred by the occurrence of non-related (serious) adverse events (NR-SAEs), the Universities of Antwerp and Kinshasa jointly developed an algorithm, accompanied by an algorithm policy. The algorithm consists of a set of consecutive questions with binary response options, leading to structured, non-arbitrary and consistent support and management for each NR-SAE. It is the result of dialogue and collaboration between the sponsor (University of Antwerp) and the principal investigator (University of Kinshasa), consultation of literature, and input of research ethics and social sciences experts. The characteristics of the project and its budgetary framework were taken into account, as well as the local socioeconomic and healthcare situation. The algorithm and related policy have been approved by the relevant ethics committee (EC), so field implementation will begin when the study activities resume in November 2021. Lessons learnt will be shared with the relevant stakeholders within and outside DRC.

If NR-SAEs are not covered by a functioning social welfare system, sponsors and researchers should develop a feasible, standardised and transparent approach to the provision of ancillary care. National legislation and contextualised requirements are therefore needed, particularly in low/middle-income countries, to guide researchers and sponsors in this process. Protocols, particularly of clinical trials conducted in areas with ‘access to care’ constraints, should include adequate ancillary care arrangements. Furthermore, it is essential that local ECs systematically require ancillary care provisions to enhance the well-being and protection of the rights of research participants. This project was funded by the European Union’s Horizon 2020 research and innovation programme, European Federation of Pharmaceutical Industries and Associations, and the Coalition for Epidemic Preparedness Innovations.

Costs and Outcomes of Integrated Human African Trypanosomiasis Surveillance System Using Rapid Diagnostic Tests, Democratic Republic of the Congo

We integrated sleeping sickness case detection into the primary healthcare system in 2 health districts in the Democratic Republic of the Congo. We replaced a less field-friendly serologic test with a rapid diagnostic test, which was followed up by human African trypanosomiasis microscopic testing, and used a mixed costing methodology to estimate costs from a healthcare provider perspective. We screened a total of 18,225 persons and identified 27 new cases. Average financial cost (i.e., actual expenditures) was US $6.70/person screened and $4,464/case diagnosed and treated. Average economic cost (i.e., value of resources foregone that could have been used for other purposes) was $9.40/person screened and $6,138/case diagnosed and treated. Our study shows that integrating sleeping sickness surveillance into the primary healthcare system is feasible and highlights challenges in completing the diagnostic referral process and developing a context-adapted diagnostic algorithm for the large-scale implementation of this strategy in a sustainable and low-cost manner.

First recourse for care-seeking and associated factors among rural populations in the eastern Democratic Republic of the Congo

BACKGROUND

Access to quality healthcare is a global fundamental human right. However, in the Democratic Republic of the Congo, several parameters affect the choices of health service users in fragile, rural contexts (zones). The overarching aim of this study was to identify the first recourse of healthcare-seeking and the determinants of utilization of health centers (primary health care structures) in the rural health zones of Katana and Walungu.

METHODS

A cross-sectional survey was conducted from June to September 2017. Consenting respondents comprised 1751 adults. Continuous data were summarized using means (standard deviation) and medians (interquartile range). We used Pearson's chi-square test and Fisher exact test to compare proportions. Logistic regression was run to assess socio-determinants of health center utilization.

RESULTS

The morbidity rate of the sample population for the previous month was 86.4% (n = 1501) of which 60% used health centers for their last morbid episode and 20% did not. 5.3% of the respondents patronized prayer rooms and 7.9% resorted to self-medication principally because the cost was low, or the services were fast. Being female (OR: 1.51; p = 0.005) and a higher level of education (OR: 1.79; p = 0.032) were determinants of the use of health centers in Walungu. Only the level of education was associated with the use of health centers in Katana (OR: 2.78; p = 0.045).

CONCLUSION

Our findings suggest that health centers are the first recourse for the majority of the population during an illness. However, a significant percentage of patients are still using traditional healers or prayer rooms because the cost is low. Our results suggest that future interventions to encourage integrated health service use should target those with lower levels of education.

Establishing women's cancer care services in a fragile, conflict and violence affected ecosystem in Africa

BACKGROUND

The majority of the world's poorest women (income < $1.90/day) reside in fragile, conflict and violence (FCV)-affected countries, like the Democratic Republic of the Congo. Health services in these settings have traditionally focused on immediate relief efforts, communicable diseases and malnutrition. Recent data suggests there is need to widen the focus to include cancer, as its incidence and mortality rates are rising.

METHODS

Employing competency-based learning strategies, Congolese health professionals were trained to perform same-day cervical cancer screening and treatment of precancerous lesions of the cervix; same-day clinical breast examination and breast ultrasound diagnostics; surgical treatment of invasive cancers of the breast and cervix; and infusion of cytotoxic chemotherapy. Outpatient breast and cervical cancer care clinics, a chemotherapy suite and surgical theatres were outfitted with equipment and supplies.

RESULTS

Combining local and regional hands-on training seminars with wise infrastructure investments, a team of US and Zambian oncology experts successfully implemented a clinical service platform for women's cancers in a private sector health facility in the Democratic Republic of the Congo.

CONCLUSION

We forged a novel partnership between oncology health professionals from Africa and its Diaspora, international philanthropic organisations, a cancer medicine access initiative and an established African cancer centre to build women's cancer services in a FVC-affected African setting.

Current status of resistance to antibiotics in the Democratic Republic of the Congo: A review

A review of literature was conducted to assess the prevalence and mechanisms of antibiotic resistance to date, mainly to β-lactam antibiotics, cephalosporins, carbapenems, colistin, and tigecycline in the Democratic Republic of the Congo (DRC). English and French publications were listed and analysed using PubMed/Medline, Google Scholar, and African Journals database between 1 January 1990 and 31 December 2019. For the 30 published articles found: (1) bacterial resistance to antibiotics concerned both Gram-negative and Gram-positive bacteria; (2) multidrug resistance prevalence was the same in half of Streptococcus pneumoniae isolates; (3) a worrying prevalence of methicillin-resistant Staphylococcus aureus (MRSA) was noted, which is associated with co-resistance to several other antibiotics; and (4) resistance to third-generation cephalosporins was very high in Enterobacteriaceae, mainly because of bla_CTX-M-1 group and bla_SHV genes. Data on carbapenem and colistin resistance were not available in DRC until recently. Further work is required to set up a surveillance system for antibiotic resistance in DRC.

Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo

Background

In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people’s voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members’ needs and expectations.

Methods

In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members’ rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman’s exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) ‘exit’ or ‘voting with the feet’; (2) ‘co-producing a long voice route’ or imposing rules through strategic purchasing; (3) ‘guarding over the long voice route of accountability’ or pressuring authorities to regulate and enforce regulations; and (4) ‘strengthening the short voice route’ by transforming the power imbalance at the provider–patient interface.

Results

All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak.

Conclusion

On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people’s rights are heard.

Non-typhoidal Salmonella bloodstream infections in Kisantu, DR Congo: Emergence of O5-negative Salmonella Typhimurium and extensive drug resistance

BACKGROUND

Non-typhoidal Salmonella (NTS) are a major cause of bloodstream infection (BSI) in sub-Saharan Africa. This study aimed to assess its longitudinal evolution as cause of BSI, its serotype distribution and its antibiotic resistance pattern in Kisantu, DR Congo.

METHODS

As part of a national surveillance network, blood cultures were sampled in patients with suspected BSI admitted to Kisantu referral hospital from 2015-2017. Blood cultures were worked-up according to international standards. Results were compared to similar data from 2007 onwards.

RESULTS

In 2015-2017, NTS (n = 896) represented the primary cause of BSI. NTS were isolated from 7.6% of 11,764 suspected and 65.4% of 1371 confirmed BSI. In children <5 years, NTS accounted for 9.6% of suspected BSI. These data were in line with data from previous surveillance periods, except for the proportion of confirmed BSI, which was lower in previous surveillance periods. Salmonella Typhimurium accounted for 63.1% of NTS BSI and Salmonella Enteritidis for 36.4%. Of all Salmonella Typhimurium, 36.9% did not express the O5-antigen (i.e. variant Copenhagen). O5-negative Salmonella Typhimurium were rare before 2013, but increased gradually from then onwards. Multidrug resistance was observed in 87.4% of 864 NTS isolates, decreased ciprofloxacin susceptibility in 7.3%, ceftriaxone resistance in 15.7% and azithromycin resistance in 14.9%. A total of 14.2% of NTS isolates, that were all Salmonella Typhimurium, were multidrug resistant and ceftriaxone and azithromycin co-resistant. These Salmonella isolates were called extensively drug resistant. Compared to previous surveillance periods, proportions of NTS isolates with resistance to ceftriaxone and azithromycin and decreased ciprofloxacin susceptibility increased.

CONCLUSION

As in previous surveillance periods, NTS ranked first as the cause of BSI in children. The emergence of O5-negative Salmonella Typhimurium needs to be considered in the light of vaccine development. The high proportions of antibiotic resistance are worrisome.

Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection?

BACKGROUND

The goal of universal health coverage is challenging for chronically under-resourced health systems. Although household out-of-pocket payments are the most important source of health financing in low-income countries, relatively little is known about the drivers of primary health care expenditure and the predictability of the burden associated with high fee-for-service payments. This study describes out-of-pocket health expenditure and investigates demand- and supply-side drivers of excessive costs in the Democratic Republic of Congo (DRC), a central African country in the midst of a process of reforming its health financing system towards universal health coverage.

METHODS

A population-based household survey was conducted in four provinces of the DRC in 2014. Data included type, level and utilization of health care services, accessibility to care, patient satisfaction and disaggregated health care expenditure. Multivariate logistic regressions of excessive expenditure for outpatient care using alternative thresholds were performed to explore the incidence and predictors of atypically high expenditure incurred by individuals.

RESULTS

Over 17% (17.5%) of individuals living in sample households reported an illness or injury without being hospitalized. Of 3341 individuals reporting an event in the four-week period prior to the survey, 65.6% sought outpatient care with an average of one visit (SD = 0.0). The overall mean expenditure per visit was US$ 6.7 (SD = 10.4) with 29.4% incurring excessive expenditure. The main predictors of a financial risk burden included utilizing public services offering the complementary benefit package, dissatisfaction with care received, being a member of a large household, expenditure composition, severity of illness, residence and wealth (p < .05). The insured status influenced the expenditure level, with no association with catastrophe. Those who did not seek care when needed reported financial constraints as the major reason for postponing or foregoing care. Wealth-related inequities were found in service and population coverage and in out-of-pocket payment for outpatient care.

CONCLUSION

Burdensome expenditure for primary care and its key drivers are of utmost importance. Forthcoming health financing reform agendas must incorporate a strategy for getting data used in the design of financial risk protection. Realizing equitable and efficient access to outpatient care is a vital ingredient for sustainable health systems.