Years ago, a mother named Kilumba watched as her child grew sicker and sicker, knowing she could not afford her care and medication. She earned a meager income as a farmer in a rural province of the Democratic Republic of Congo, and her husband brought in about $1 per day from selling mats. In desperation, they set out for the health clinic. By the time they arrived, their child had died.
A decade ago when this took place, preventable and treatable conditions such as malaria, diarrhea, pneumonia and malnutrition were the leading causes of death in DRC. Children carried the heaviest burden of this epidemic — representing 47 percent of deaths across the country. Today, 1 in 7 children in DRC still die before the age of five. The United Nations Inter-Agency Group for Child Mortality Estimation reported in 2015 that the country was not estimated to meet the Sustainable Development Goal for child mortality even by the year 2050.
But new evidence from one of the poorest parts of the country indicates that there is hope. Our research indicates that giving community health workers simple tools and training can improve the efficacy of integrated Community Case Management, a strategy already proven to improve rates of child survival.
Tanganyika province, located in the southeastern region of the country, contains many of the challenges that drive this grim trend of child mortality. More than half of the province’s population of 2.5 million cannot access health care due to geographic or financial barriers. Until 2014, the majority of children in the province who died never made it to a health facility to receive treatment. And though not specific to Tanganyika region, we know that 82 percent of the population in DRC live on less than $1.25 per day.
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Since 2013, hundreds of thousands of children in Tanganyika have been receiving life-saving care in their own communities through an iCCM approach. The Rapid Access Expansion project, or RAcE, supported by Global Affairs Canada and the World Health Organization, has installed community health workers to provide free treatment for malaria, pneumonia and diarrhea for children under the age of five in their communities. With the collaboration of the Ministry of Health, more than 1,500 community health workers, or CHWs, have been elected by their communities and trained and equipped to provide treatment to children. Between January 2014 and November 2016, CHWs supported by the RAcE project have provided a total of 998,347 treatments to children between two to 59 months old.
One of the least glamorous but influential aspects of iCCM is the paperwork. Existing tools and training materials are often complex, rarely tailored for community health workers with little to no formal education. Simplifying tools for low-literacy individuals may not only improve performance, but potentially increase the opportunity for women to work as community health workers.
In DRC, the current Ministry of Public Health package contains seven tools to record information on sick child cases that must be completed by CHWs. These tools are complicated and often capture information that is redundant. The International Rescue Committee conducted operational research to determine whether simplifying for low-literate CHWs and reducing the overall number of tools could improve quality of care, as well as save time and money. As part of this research, pictorial tools were developed, including vivid images to help CHWs effectively carry out and document the assessment of a sick child. IRC’s research focused on the effectiveness of using the new package as compared to the existing Ministry of Public Health package.
This approach does not simply save time and improve quality. It saves money.
—The results were astonishing — ranging from improving quality, to saving time and reducing implementation costs. Children seen by CHWs using the simplified package were more than three times as likely to receive correct care. The assessment and documentation of a sick child took on average 10.6 minutes less time, representing 6 hours of time saved per month for each CHW examining approximately 35 children per month.
This approach does not simply save time and improve quality. It saves money. Because of the reduced number of tools in the simplified package, we estimate $338,745 will be saved over the life of a four-year program covering a population of up to 1 million people through 1,500 CHWs.
The results clearly highlight the direct impact that training and tools can have on the quality of care provided by community health workers and their workloads.
—The results from this research have implications that reach far beyond DRC. The results clearly highlight the direct impact that training and tools can have on the quality of care provided by CHWs and their workloads. In many countries, CHWs do not receive any remuneration for their services, so it is important to keep their workload to a minimum. In countries where iCCM is being implemented by low-literate CHWs, simplified pictorial tools and improved training materials could help improve the quality of care delivered, and reduce CHW workload.
The strategy is before us. The question is whether the global community will help to make sure it is sustained and scaled. After years of commitment from donors, international funding to improve the health of the population in the DRC has waned. Their presence — and absence — will shape the course of survival for thousands of children.
Recently, Kilumba’s youngest child recently fell ill with a fever, which appeared to be caused by malaria. She still did not have money to seek care from a health facility. But this time, she did not need it to keep her child alive. She walked to a nearby hut in her village, where her community’s health worker diagnosed her child with malaria and provided treatment. Her child has fully recovered.
There are a million more children waiting for the global community to expand this evidence-driven approach in sub-Saharan Africa, where mortality rates for children under five still remain unacceptably high. By 2050, we can expect that generations of children in DRC — and other countries facing similar challenges — have needlessly been lost to preventable diseases. We cannot wait for measurable progress to come decades from now. Our experience confirms that with creativity and commitment, it does not have to.
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About the author
Alison Wittcoff
Alison Wittcoff is a health technical advisor who has worked with IRC for the past five years. She recently served as health coordinator in Kalemie, DRC and prior to DRC, Alison worked as health coordinator in Rwanda. In both countries she was managing large iCCM projects. Before coming to IRC, she worked as a quality improvement specialist at University Research Co. providing support in Niger, Tanzania and Uganda. Alison has a master’s of international affairs from George Washington University and is fluent in French.
