NEW YORK — If a patient arrives at a public health clinic in the Democratic Republic of the Congo with symptoms of a serious noncommunicable disease, they are rarely presented with options for further care, according to Jacques Sebisaho, a Congolese physician and the founder of the health care nonprofit Amani Global Works.
“If you go to a clinic, usually they say, in that case, ‘We cannot treat you.’ For pregnant women they will refer you to a hospital, but for other issues they just tell you, ‘There is nothing we can do,’” Sebisaho said.
“It costs us $18 per person for primary health care. The government is spending $40. It is cheaper because of the massive community involvement.”— Jacques Sebisaho, Congolese physician and Amani Global Works founder
The ongoing Ebola response has diverted doctors from primary health care to focus on the outbreak, weakening the country’s already fragile health care system, Médecins Sans Frontières warned last month.
Sebisaho is hoping that a model of referral systems and community health care he pioneered on the remote island of Idjwi — which sits on Lake Kivu, near Congo’s border with Rwanda — could help strengthen primary health care in the rest of Congo. His system is cheaper, and more efficient than the existing public health care across the country, according to Sebisaho.
“It costs us $18 per person for primary health care. The government is spending $40. It is cheaper because of the massive community involvement. We structure the community with health workers and they see people all the time. They wind up not having to refer many people to health clinics,” Sebisaho said. “For lots of them, disease is getting caught early, at the community level.”
Amani Global Works has an agreement with Congo’s health ministry and plans to begin replicating its model by 2021, Sebisaho said.
The population of Idjwi has ballooned since the late 1970s, when Sebisaho, 47, and his family left the island for the nearby city of Bukavu. Since then, the island has grown from 37,000 people to more than 300,000, according to Sebisaho — a result of a birth rate of more than 8 live births per woman, coupled with a historic lack of available family planning services.
Idjwi has one of the highest infant and maternal mortality rates in the world and a life expectancy of just 25 years. One main component of Amani’s work is family planning services, including offering birth control.
“They have gone gangbusters with family planning provisions, which was nonexistent before. They are hiring local staff to ensure that the patients are influencing the direction of the organization,” said Andy Bryant, executive director of the Segal Family Foundation, which funds Amani.
“The patient numbers are skyrocketing. They saw or touched 140,000 in 2018 with their work. Between the family planning work and the vaccine programming, they are hitting sort of big preventative measure pieces that can lead to a really healthy population,” Bryant said.
Malaria, intestinal parasites, and severe anemia are all common. But Idjwi has also been immune to the conflict that has played out in surrounding regions, making it an interesting case study for new models of health care, according to Sebisaho.
“Our model is set on integration of community health workers and health centers. Government ones are undersupplied and understaffed,” Sebisaho said in a recent sit-down interview with Devex in Harlem, a Manhattan neighborhood he calls home for half the year. He spends the other half working on Idjwi.
“The health centers and clinics are there [in the rest of the country], so we want to use the same approach for health workers and make sure that we integrate and put in place a supply chain system, which is missing,” Sebisaho continued.
Idjwi village chiefs lead their communities in selecting some of the most respected people — mainly women — to train as community health workers. Those women go through multiple rounds of testing and a 27-day intensive training course, where they learn how to use and read portable ultrasound machines and other health skills. The workers are each tasked with visiting about 150 households each month and ensuring that women have three prenatal care visits at the hospital. There is prestige to the position, and a high level of accountability among the health workers, Sebisaho said.
A new guideline from WHO looks to improve best practices and working conditions for community health workers.
In the past few years, Amani has trained nearly 200 community health care workers, who receive a monthly stipend of $30. And since its inception in 2010, it has also set up 12 satellite health clinics and one referral hospital, equipped with 50 beds.
“We believe we cannot build a health care system on volunteers. It doesn’t work. But our referral numbers have increased and the number of facility deliveries have been heightened,” Sebisaho said. “At the hospital, we now have about 70 deliveries a month. These are people who have never delivered in any facility before.”
The referral hospital, health care clinics, and community health care workers all coordinate to make referrals and conduct follow-up appointments. If a patient is discharged from the hospital, a community health worker will be alerted, for example, to follow up with them at home. And if a health worker finds someone has a high fever, they will give them medicine and then return the next day to see if a referral to a health clinic is necessary.
Amani will gain a better sense of its impact on health care early next year, after a team of Princeton University researchers conduct a follow-up study to the baseline demographics study it did with Harvard University that was published in 2015. The hopeful outcome would be major improvements in child mortality rates, according to Christopher Hale, a Ph.D. population studies student and researcher at Princeton. But demonstrated change in health awareness and behaviors might come faster, Hale said.
“It is a program that had a lot of resilience in that sense and is doing a lot of good without having a lot of resources. Health workers can be easily replicated and could have a lot of success in being able to do the low-cost program in low-resource areas,” Hale told Devex. “What will be harder is some of the things they have in Idjwi. One of the big advantages is that they have a lot of cooperation from the local leaders.”