DRC: The health benefits of community engagement in the northeast
Angumu is a mountainous area in Ituri province, in northeast Democratic Republic of Congo (DRC), near the Ugandan border. It is a remote place and reaching the communities that live there can be challenging. The few roads that run through the mountain forest are reminiscent of dried river beds, uneven and full of loose stones that make driving difficult and slow, especially during the rainy season, when thick mud renders some of them impassable. In 2018, violence and natural disasters in neighbouring regions caused tens of thousands of people to move into Angumu. They found shelter in areas near villages and alongside roads, creating numerous camps for displaced people, each housing several thousand people. At the time, Doctors Without Borders/Médecins Sans Frontières (MSF) estimated that over 42,000 people had been forced to leave their homes in search for safety, and so decided to begin an emergency response. Since then the number of displaced people in Angumu has risen dramatically and currently stands at nearly 80,000.
If people cannot reach the healthcare facilities, then healthcare must be brought to the people
Frederic Manantsoa, MSF’s Country Director in DRC, recalls the beginning of the response: “Once we arrived, we immediately saw that there was a very high number of people with malaria, with very high mortality rates. We also noticed that it was very difficult for people to access the necessary healthcare services because the region is so remote and mountainous. We thought that if people cannot reach the healthcare facilities, then we must reverse the situation and bring healthcare services to the people.”
To do so in a sustainable way, MSF worked with the Ministry of Health (MoH) to put in place a project based on strong community engagement. “The project focuses on an advanced community approach aiming at giving community members ownership over their own health needs. There is extensive participation from both the Ministry of Health and the community. They are our partners, not beneficiaries that receive assistance. They are responsible for their own health and, as partners, they share responsibility in the project.”
This setup relies on three fundamental components. The first are the community relays (RECOs, for short). Their role is to educate community members on various health issues including: good hygiene and family planning; how to prevent diseases such as malaria and diarrhea and what to do in case someone becomes ill; and the medical services available to them in the area. The RECOs are also active eyes and ears in their community, monitor people’s needs and the general health situation. If someone needs medical attention, they are encouraged to see the community health site relays (RECOSITEs), the second component. The RECOSITEs have been trained in how to respond to cases of malaria, malnutrition and diarrhoea, and can either administer basic treatment on the spot or refer people to a more advanced health centre. The third component are the health site management committees (COGESITEs). These committees coordinate all practical and administrative aspects around the community health sites, such as work schedules and ensuring that services are free of charge. RECOs, RECOSITEs and members of the COGESITEs are volunteers elected by their own communities to carry out these important roles. They are trained, monitored and supported by MSF, in cooperation with the Ministry of Health.
Currently, in Angumu MSF provides supply, trainings and follow-up to supports the general regional hospital, along with seven health centres and 13 community health sites located near camps for displaced people. “When MSF arrived, we were confronted by a high number of severe cases because people arrived at the hospital when they were already very sick,” says David Mahomou Nyankoye, the MSF nursing activity manager in Angumu. “Now, community members are more aware and much quicker to seek care. They have become familiar with the community health sites system that we put in place. Now, they act early, before the disease becomes advanced, and this has caused a clear reduction in the number of deaths.” Currently, the community health centres perform about 7,000 consultations each month.
Focus on prevention
In an environment where malaria is endemic and living conditions are precarious, health prevention is extremely important. Since the beginning of the project, MSF has carried out large-scale preventative activities, such as a mass drug administration and indoor residual spraying, during which anti-malarial drugs are distributed to communities and homes and shelters are sprayed with insecticides, as well as distribution of mosquito nets. By raising awareness of malaria and other diseases, the RECOs also play an important role in their prevention.
Pascal lives in the Ugudo Zii displaced people site and was elected by his community to be a RECO. “I go door to door and show people good practices that can help prevent diseases. A lot of problems come from water that is not stored correctly, which then becomes a breeding ground for mosquitoes and can become contaminated and cause diarrhea and other health issues. Some other times, we gather people and talk to them about vaccinations, family planning and the admission criteria in the health centres. I am proud of what I do and my community appreciates it. Proper hygiene practices and the right knowledge make a big difference.”
The RECOs are supported in their work by MSF health promoters (HPs), who train them and monitor their work. “When someone asks me a difficult question that I don’t know how to answer, I go to the HPs so they can come with me and help give the right information to people. We organize our work and plan our activities together with the HPs.”
Another added value of this approach is that it allows MSF to observe the spread of diseases at the community level. According to Frederic Manantsoa, “This allows us to have early surveillance and alerts, so that we can act in time to prevent outbreaks and other emergencies, or at least minimize as much as we can the need for emergency responses. With the very early management of simple cases in the community, we considerably reduce the number of complicated and severe cases needing treatment at the health centres and hospital.”
Support to health facilities
At the health centres and Angumu general regional hospital, MSF medical teams account for around 35 percent of the staff and support the local Ministry of Health medical staff in their work. MSF teams treat children aged 0 to 15 years, malaria treatment for all age groups, mental health services, reproductive healthcare services including family planning, and management of moderate malnutrition cases. To help people reach health facilities, MSF has put in place a referral system with motorcycles and ambulances that can quickly transport patients from the community health sites to the health centres or the hospital.
In addition, MSF offers support to survivors of sexual violence. This is done in cooperation with the protection committees present in each site for displaced people, which support survivors of sexual violence. Virginie fled conflict in the Musongwa area and arrived in Ugudo Zii seven months ago. She is a member of the site protection committee: “In a densely populated displaced people camp, women are very vulnerable and incidents of sexual violence are frequent. We work in close cooperation with the RECOs and together direct survivors to the RECOSITEs, who in turn contact MSF so that the person can receive medical care and mental health support. All this is done confidentially and is very important because survivors tend to suffer from shaming and stigma. We are thankful for the support offered by MSF.”
Community engagement needs to happen at all levels
The collaboration with the community is not limited to awareness raising activities or to the management of patients with malaria, diarrhea and malnutrition. It also involves the construction of facilities and infrastructure, including the community health sites, latrines and wells, the distribution of essential items, such as soap and mosquito nets, and the management of drugs in community health sites.
Abdurakhman Bodian is the MSF HP manager in Angumu. He has witnessed the changes that this approach has brought: “When we began our response, MSF was doing everything, even the transportation of water in the community. That was not sustainable, especially since there are very few other organizations working in Angumu. Today we have managed to empower the community and we have arrived at the point where all construction and other logistical efforts are done in cooperation with them. MSF provides the necessary material and the community does the rest. The participation is inclusive from the start, from the building to the management of the health sites. Here we have found a very engaged and organized community, which made it all easier.”
MSF is now working to further build community resilience and to help them become more independent when it comes to the management of all aspects their health. The committees operating in the various displaced people sites represent a good opportunity for MSF to delegate certain aspects of the response and increase the level of community empowerment. “We are trying to create resilient mechanisms,” says Abdurakhman. “Water sources and their chlorination can be managed by the hygiene committee, for example. We have to analyze the various components of the community and their capacity, and see how best to delegate. Decentralizing as many activities as possible in the community will make it more likely that the mechanisms will stay in place the day after MSF leaves.”
Frederic Manantsoa is satisfied with the results so far: “When we compare the data collection that we did at the start on the number of deaths in Angumu with the latest data, we really see a difference. If it wasn’t for this system that we put in place, the situation would not have changed. Collaboration between MSF, the Ministry of Health and the community in Angumu has become very close and stable. I think that this type of project has a future. We need to develop it and build on all that we learned because I believe that it is one of the best approaches for MSF in DRC. We should not forget that around 80 per cent of the population lives in rural areas with very limited access to healthcare. Therefore, this type of community approach seems to be the most suitable to tackle people’s health needs.”