DRC Context and Challenges
DRC gained independence in 1997 and has received United States President’s Emergency Plan for AIDS Relief (PEPFAR) funding since PEPFAR’s inception in 2003 [2, 3]. DRC is a country of over 2 million square kilometers that borders seven sub-Saharan African countries. Decades of violent conflict and instability have taken a devastating toll on the country’s economy, human resources, and infrastructure, and, coupled with a largely rural population, present several challenges to providing healthcare .
DRC has a generalized HIV epidemic with an estimated prevalence of 1.2 percent among adults aged 15 to 49. HIV infection is more prevalent in urban settings (1.6 percent) compared to rural areas (0.9 percent). An estimated 404,894 people are living with HIV, and around 10,535 people die from AIDS-related conditions each year . The HIV epidemic has drastically impacted two of DRC’s most populous provinces, with general population prevalence estimates of 1.6 percent in Kinshasa and 2.6 percent in Haut Katanga .
ICAP at Columbia University (ICAP) initiated a comprehensive program of support for HIV care and treatment (C&T) services in DRC in 2010. Since then, ICAP has worked hand-in-hand with the Programme National de Lutte contre le SIDA (PNLS) to expand the availability, quality, and uptake of adult and pediatric HIV care and treatment in DRC with an emphasis on expanding prevention of mother-to-child transmission (PMTCT) activities, development of a laboratory network for disease monitoring, integration of HIV and tuberculosis (TB) services, improvement of infrastructure, prevention among key populations (KP) in Kinshasa and Haut Katanga provinces, and epidemic control. In partnership with DRC Ministry of Health (MoH) and donors, ICAP has rapidly expanded its support for PNLS activities from just 10 sites in 2010 to 240 public and private hospitals, health centers, and TB clinics as of September 2014. ICAP currently supports 199 sites.
ICAP and HRSA Engagement in Nursing in DRC
With PEPFAR funding through the United States Health Resources and Services Agency (HRSA), in 2017, ICAP was awarded the Resilient and Responsive Health Systems (RRHS) project to continue strengthening HRH in DRC. Using the World Health Organization (WHO) conceptual framework for HRH development, the first two years of the RRHS project built on extensive HRH capacity building and infrastructure improvements for student nurses and midwives through HRSA funding the Nursing Education Partnership Initiative (NEPI) as a follow-on to the previously funded Global Nursing Capacity Building Program (GNCBP) [6, 7]. Since nurses are the largest HRH component in DRC, this NEPI-focused work centered on nurses’ readiness for clinical practice through curricula reform and development of innovative pedagogy including use of skills labs and simulation-based training. Over the past two years, HRSA and ICAP have leveraged these pre-service strengthening efforts to shift focus to in-service capacity building and addressing wider HRH limitations affecting epidemic control.
Given the volume of people living in rural areas and HIV service needs therein, a collaborative effort between the MoH, Ministry of Education (MoE), ICAP and HRSA has yielded a RR program to increase nursing student and community health worker (CHW) exposure to rural health needs, rural health care, as well as rural clinical practice and community engagement prior to graduation, entry to practice, and employment.
The Challenge: Getting Nursing Students to Understand the Importance of—and to Participate in—Rural Healthcare
An increase in the use of telemedicine globally has expanded access to quality healthcare services regardless of a patient’s proximity to physical medical care/clinic services [8, 9], diminishing healthcare disparities in rural settings. However, many countries, including those in sub-Saharan Africa, still struggle with gaps in healthcare access for rural populations. Common themes seen among the extant literature include lack of funds to enhance rural healthcare, lack of medical professionals among rural populations, and lack of technology available for use in rural areas . Current scholarship identifies various issues faced in attempting to close these gaps between rural and urban health settings and describes various interventions that have been used on a global scale, in sub-Saharan Africa, and more specifically in DRC. In particular, the evolving role of nurses in supporting—and advancing—rural healthcare in such contexts is explored in-depth as is the need to actively recruit nurses to areas by demonstrating the advantages that such experiences and expertise will bring to their careers. This, exposure, in turn, will be valued more by student nurses and will, as a result, increase their willingness/interest in rural placement .
An interesting healthcare paradox exists in rural settings, compared to urban ones, no matter where one looks in the world: rural communities in which some of the most numerous, complex, and diverse healthcare needs exist are precisely those served least by HRH. Despite the prevalence of unmet healthcare needs in rural areas, healthcare providers tend to remain in the wealthier, better resourced, urban areas . A recent retrospective review of 174 nations and the rural “deficits” in health coverage showed that four basic inequities exist when comparing rural versus urban healthcare: lack of rights to healthcare (i.e., fewer entitlement programs in rural areas), shortages of rural HRH, unequal funding for rural health protection (and for preventative healthcare), and high out-of-pocket costs for rural populations forced to pay for their own health services . These deficits were seen in very poor rural areas throughout regions of Africa including countries such as Zambia, Nigeria, South Africa and Kenya.
These inequities, alone, however, are not the only reasons for higher incidence and prevalence of some infectious diseases (e.g., malaria), malnutrition, and less preventative care in rural areas. Social determinants of health also come into play including access to education, food and social support . Given social and economic inequities, few rural areas send students to medical and nursing schools; thus, fewer return to serve these areas . Yet where a medical professional student comes from is highly correlated with where that student will practice upon graduation . Attempts to improve recruitment from rural areas—via incentives and increased access to education—have resulted in mixed, or at best only short-term results and improvements . In addition, poor road networks and physical distances from patients to care centers—as well as the social factors and pressures in some rural communities—also prevent patients from seeking health care early or often. Social exclusion from urban areas, not to mention the social pressures to seek guidance from local/rural “healers,” are strong forces that may keep patients from seeking life-saving care .
These rural determinants of health can result in relatively lower health indicators and indices; for example: greater numbers of stillbirths and higher infant mortality in Central Africa , greater child malnutrition and inequitable distribution of food among families across most low-income countries , and larger family sizes . If rural determinants of health are not addressed proactively, poor rural health outcomes can pose serious health risks to urban areas—and their healthcare systems and populations, especially after conflict and/or national disasters when (rural) healthcare services are often depleted and rural urban migration ensues . For example, when an Ebola patient traveled from a small Liberian town to an urban center to seek better care during civil unrest and to escape pressures to utilize local healers, this patient’s travels resulted in a number of downstream infections closer to an urban center .
Other obvious negative effects from failing to adequately address rural healthcare staffing and care provision include underreporting of diseases, such as Buruli Ulcer in DRC , lack of appropriate and basic diagnostic services such as radiology in across Sub-Saharan Africa , and inadequate communication networks and sharing of best practices from urban to rural settings—from healthcare providers and thought-leaders in DRC . While several interventions have been proposed—including e-health information sharing and application deployment through smartphones in Ghana , e-health solutions for rural clinics in South Africa , Ghana, Tanzania, and Burkina Faso , and improved clinic leadership training for rural healthcare clinic leaders in South Africa , none appear to have been more effective than recruiting both rural and urban practitioners, nurses, and CHWs to serve these rural health centers even if only on a rotational basis .
In 2019 with support from HRSA, ICAP launched a telementoring program in DRC to help address some of the disparities and lack of knowledge transfer from urban to rural settings . While successfully launched and currently being scaled up to assist and build capacity of rural clinicians, telementoring does not address insufficient supply of health care workers in rural areas. Therefore, a combination approach to strengthening rural service delivery is necessary.
Engaging students in rural contexts while increasing their familiarity and understanding of rural health needs also allows students to experience the breadth of health services provided in rural areas and opportunities to expand knowledge and skills. Under the mentorship and supervision of experienced rural clinicians, students can be exposed to a broader array of healthcare challenges than may be seen in urban settings where care is divided between many units and specialized services. This level of exposure to health issues, symptomatology, and engagement in all aspects of care from health history, point of care laboratory investigations, diagnosis and follow up can rapidly build clinical understanding. Students also live in and absorb more varied cultural environs, and, in many cases, establish early career leadership and managerial success on a scale more demonstrable than in urban settings where they might become “lost in the crowd” of the larger healthcare workforce. Exposing nursing students to the opportunities in (secure) rural settings, on a rotational basis, can create more HRH who are willing to work in rural settings after graduating .