Profiles of Community Care Sites and provider Community Health Workers: A Case study at Gombe Matadi, Kenge and Kisantu Rural Health Zones in the Democratic Republic of Congo

doi:10.21203/rs.3.rs-3347654/v1

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Profiles of Community Care Sites and provider Community Health Workers: A Case study at Gombe Matadi, Kenge and Kisantu Rural Health Zones in the Democratic Republic of Congo

https://doi.org/10.21203/rs.3.rs-3347654/v1

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Background: In sub-Saharan Africa, the DRC is ones of countries with high infant and child mortality. To solve this problem, the Ministry of Public Health has set up a new program: IMCI-C at the level of Community Care Sites managed by non-health professionals who are provider CHWs. Since its implementation, there have not yet been many studies that concretely describe the operation of CCS. It’s why we have chosen the Realist Evaluation Approach to analyze CCS functionality in the DRC.

Methods: To carry out this study which is a mixed method case study (qualitative and quantitative); we applied the fundamental principles of a realist evaluation which come down to Context – Mechanisms – Effects in the conceptual framework model that we developed with an emphasis on Mechanisms. Provider CHWs profile and CCSs functionality were defined after data collection through documentary review, CCS direct observation, in-depth interview with registered nurses and health zone team members using an interview guide with semi-structured questionnaire and a survey using a quantitative questionnaire with provider CHWs.

Results: CCS functionality was measured through the standards enacted for the implantation of CCS as well as the profile of provider CHWs which manage them. At the significance level (p=0.039) has been in place for 3 years or more increases by 7 times chance that it is functional (OR = 6.7; p = 0.000), has household is located less than 5 km from the CCS increases by 4 times chance that the CCS is functional (OR = 7.04; p = 0.034), has provider CHW is regularly trained and supervised increases by 10 times chance that the CCS is functional (OR = 10.01; p = 0.031), provider CHW participation in CAC meetings (OR = 4.34; p = 0.009) and CCS Management Team leads the management of CCS increase by 4 times chance that this CCS is functional (OR = 3.6; p = 0.002). Finally, if there is an initiative for funding CCS increases by 8 times CCS functionality (OR = 8.69; p = 0.009).

Conclusion: CCS are functional in the three RHZs. Their organization, establishment and operation are directly linked to the provision of services to populations living mainly in health areas with difficult access, the availability of inputs of three IMCI-C diseases management, namely uncomplicated malaria, diarrhea and pneumonia as well as building provider community health workers capacity to ensure their management. This study shows an effective contribution of provider CHWs on CCS functionality in health areas with difficult access.

Community Care Sites

functionality in the Democratic Republic of Congo with provider Community Health Workers involvement

Although the global decline in the annual number of infant deaths from 1990 to 2013 is encouraging, this reduction was slow to emerge before stagnating and sometimes even reversing in many countries around the world, including India, China, Pakistan, Indonesia and particularly in sub-Saharan Africa. (1) Currently, ten countries with the highest infant and child mortality rates are all in sub-Saharan Africa where most deaths of children under five are from preventable and treatable causes. (2) Indeed, in 2013, malaria, diarrhea and pneumonia accounted for 1.3 million (or 40%) of deaths on children under five in sub-Saharan Africa. (3) Among those ten countries, DRC is one of the first 5 followed by Nigeria and Uganda to hold the highest infant and child mortality. Malaria is responsible for more than 400,000 deaths per year, most of which are children under five and pregnant women (WHO: WMR 2016). In the DRC, 31% of children suffer from malaria and 19% die before their 5th birthday (DHS 2013–2014).

According to a study conducted in Africa in 2009 on 6,000 children suffering from severe malaria at the community level, about 23% reached a referral health facility between 6 to 15 hours of walking and 22% had still not arrived after more than 15 hours of walking. (4) One of the strategies to control these diseases is the Integrated Case Management of Childhood Illnesses at the Community Level (IMCI-C) which is a strategy based on the principle of equity which aims to improve the access to essential services for children that goes beyond the reach of health care facilities. (5) In 2012, through a joint statement, UNICEF and WHO supported the IMCI-C strategy with the aim of training, equipping and supervising community health workers (CHWs) to enable them to treat children for malaria (in malaria-affected countries), diarrhea and pneumonia using artemisinin combination therapy (ACT), oral rehydration salts (ORS), zinc tablets and oral antibiotics. (6)

IMCI-C strategy uses organization, establishment and operation of Community Care Sites in rural areas with difficult access. (7)

The Community Care Site is a space located in a house that covers a locality or one or more villages within which households located more than 5 km walk from a Health Center (HC) or separated following a natural barrier have access to first aid before referral to a HC or home care monitoring offered to children under five years of age by a Provider Community Health Workers (PCHW). (8)

The PCHW is a community health worker of the village and not a health professional who is given training on symptoms management of the following IMCI-C diseases: uncomplicated malaria, diarrhea and pneumonia. (9)

In 2017, 6,789 community care sites were identified and are operational in 402 HZs out of the 516 in the DRC. Actually, in the DRC, out of the 516 HZs 404 HZs have CCS (78%). (PNECHOL-MD Annual Report 2019).

The Global strategy on human resources for health to 2030 (resolution WHA69.19 (2016) presents a series of strategic options to maximize the benefits that States member could derive from investing in human resources for health.

This means that in many countries community health workers are part of the interdisciplinary workforce. They have specific roles in primary health care and essential public health functions. The Global Strategy recognizes that community health workers and other categories of health personnel working at this level are effective in delivering a range of preventive, curative and promotional services, and they can contribute to reducing health inequalities and optimize health care access. (10)

The 2018 Astana Declaration outlines the desire to effectively address current and future health challenges by mobilizing all stakeholders, including health professionals, academic institutions, community health workers and patients. (11)

After a study carried out in Mosango Rural Health Zone, promotional Community Health workers contributed to the improvement of health indicators. (12)

From this group of promotional CHWs, some were recruited as Provider Community Health workers (PCHWs) to manage the Community Care Sites (CCS). It is the same in Gombe Matadi, Kenge and Kisantu RHZs.

If promotional CHWs have indeed contributed to improve health indicators in Mosango RHZ, our study hypothesis is that provider CHWs contribution on CCS functionality is effective in the health area with difficult access.

To this end, this study will answer the main question of knowing: What are the profiles of operational CCS in the DRC, mainly in HA with difficult access?

To achieve this, we conducted a mixed method study (qualitative and quantitative) in 3 RHZs from 2018 to 2019 based on the Realist Evaluation approach which takes into account the Context - Mechanisms - Effects. By looking at CCS profiles, we focus on the main Mechanisms that make up our conceptual framework model. (13)

This study general objective is to contribute to the extension of CCS coverage to all health zones in the DRC. The specific objectives are to: (i) describe CCS profiles in terms of organization, implementation and operation and (ii) determine provider CHWs profile that manage these CCS.

To achieve the objectives mentioned above, we used a conceptual framework model adapted from PAWSON and Tilley model in order to explain the succession of different mechanisms that interact to make CCS functional in different Health Areas (HA) with difficult access in Fig. 1 as follow:

It should be emphasized here that in this conceptual framework model, our study only dealt with the Mechanisms part and more precisely the actions highlighted in red, particularly the human resources involved, in order to see how these different mechanisms, starting from CCS organization, establishment and operation have been organized in the 3 RHZs mentioned above. The Context is represented by the 6 pillars of the health system. (14)

However, DRC health policy has integrated the IMCI-C CMAP into the MAP of HZs. This resulted in the identification and selection of provider CHWs among the promotional CHWs, capacity building, official installation of CCS and the provision of inputs to organize the 3 IMCI CMAP interventions management.

Once all these conditions have been met, the implementation of activities of the IMCI-C CMAP with the support of Technical and Financial Partners (TFP) through community sensitization by promotional CHWs aimed at behavior change in the community through social and behavior change communication. This sensitization also aimed at the involvement of communities in activities of the CCS through the orientation of children and the active participation in the meetings of the Community Animation Cell (CAC) and the CCS Management Committee (CMC) in the HA where they are located.

3.1. Study design

This is a cross-sectional study carried out in Gombe Matadi, Kenge and Kisantu RHZs for 2 years, from 2018 to 2019. The study combined a mixed method (qualitative and quantitative).

3.2. Study population

Our study includes two study populations. For the first specific objective, the study population is made up of all CCS, a total of 36 CCCs for the 3 RHZs. Provider CHWs were the study population from the second specific objective, we investigated a total of 72 provider CHWs.

To do this, it appears that we used a systematic sampling for all CCCs and all provider CHWs.

3.3. Data collection

Data was collected through the following techniques: Documentary review, direct observation at CCS level, in-depth interview with registered nurses and HZ Management Team members using an interview guide with semi–structured questionnaire and a survey using a quantitative questionnaire with provider CHWs.

A total of 30 registered nurses and 9 members of the HZMT were interviewed and a quantitative questionnaire was administered to 72 provider CHWs.

For all the people interviewed, we had previously obtained the signature of an informed consent form.

3.4. Variables definition and analysis

The dependent variable for this study is the CCS functionality. This functionality is measured through the standards enacted for the implementation of CCCs, their operating capacities and provider CHWs profile that manage them.

Thus, our study has two statistical units: CCS and provider CHWs.

Three indicators were measured to identify CCS functionality: (i) the % of CCCs whose implementation is justified in accordance with the standards; (ii) the % of CCCs functional in accordance with standards and (iii) the % of provider CHWs meeting the typical profile of a good provider CHWs.

Thus, with these variables, 4 criteria were taken into account for this analysis: (i)Containing: CCS geographical location with distance between the CCS and the HC of the HA, the village population with difficult access covered by the CCS; CCS physical condition in relation to its interior and exterior appearance; (ii) Content: the technical platform related to the IMCI-C MAP (Kit or equipment, inputs), the existence of CCS subsidy ; (iii) Operation: CCS conditions of implementation (origin of its creation), provider CHWs volume of work, schedule of activities and data reporting; (iv) Provider CHWs Qualification : Sociodemographic profile (profession, marital status, sex, level of education, etc.), specific training of provider CHWs.

The qualitative data were analyzed manually on an empirical basis by identifying the main themes sought through the hypothetico-deductive approach by pinning down the significant statements.

Quantitative data from provider CHWs survey were codified and recorded using CSPro-7 software and then exported to SPSS 23.0 and StataS-64 software for analysis.

These data were summarized in the form of proportions for categorical variables and in the form of means and standard deviation for numerical variables.

The association between categorical variables was tested using Wald's Chi-square test, Odds Ratio and Fisher's exact test.

A multiple logistic regression model using the top-down step-by-step approach was used to identify the explanatory factors of the dependent variable.

The statistical significance threshold was set at p = 0.039.

The independent variables selected for the logistic regression model were selected according to their significant values with respect to the significance level and the inclusion in the confidence interval. They include the socio-demographic characteristics of the provider CHWs as well as the characteristics of the services offered at the CCS level. They are essentially the following: The CCS has been established for more than 3 years; households are less than 5 km walk from the CCS; the CCS is supported by an NGO or technical and financial partners; the provider CHW is trained and advised by community members on the CCS functioning during formal CAC meetings with community leaders and after the care of sick children; provider CHW provides advice to parents on the application of key family practices followed by home visits.

The Summary of methodology is presented in the Table 1 below as follow:

Table 1

Methodology of the article Profiles of CCS and PCHWs in the DRC
SPECIFIC OBJECTIVES	METHOD	STUDY POPULATION	DEPENDENT VARIABLE	OUTCOME MEASUREMENT INDICATORS	DATA SOURCE	SAMPLING	DATA COLLECTION TECHNIQUES
Describe the main ccs characteristics in terms of implementation, organization and operation	Qualitative	Community Care Sites	Community Care Site functionality	% of CCSs whose implementation is justified in accordance with standards	Mapping of the Health Area; HC SNIS and DHIS2 report; CCS implementation report, CCS activities report	Systematic	Direct observation; Documentary review
	Qualitative	Registered Nurse, Community Animator of HZCO		% of CCSs functional in accordance with standards	Key informant interview questionnaire	Systematic RN and Community Animator of RHZs with CCSs in the HZs surveyed	Documentary review; In-depth key informant interview
Determine the provider CHWs profile in relation to their socio-demographic characteristics	Quantitative	Provider CHWs		% of provider CHWs meeting the typical profile of a good provider CHWs	Provider CHWs interview questionnaire	Systematic	Documentary review; provider CHWs survey using a questionnaire

3.5. Study sites description

Gombe Matadi RHZ is located in the Kongo Central Province. It had an estimated population of 101.855 inhabitants in 2018 spread over an area of 4.778 km² and a density of 21 inhabitants per km².

It has 15 HA and all 15 each have an CCS, 15 CCCs, 15 HC and 1 General Reference Hospital (GRH).

The furthest CCS from the HZCO is 146 km and 17 km from the nearest HC (CCS Luwanda in Kinkoni HA).

All 15 CCCs are geographically inaccessible has the particularity of the poor condition of the roads, several natural obstacles including rivers with sometimes non-existent or poorly built bridges, ravines, the only means of access being either the motorbike or the canoe in 90% of CCCs visited.

Kenge RHZ is located in Kwango Province and had an estimated population of 306.488 inhabitants in 2018 spread over an area of 5.558 km² and a density of 55 inhabitants per km².

It has 29 HA, including 16 with CCS, 29 HC and 1 RGH. The furthest CCS from the HZCO is 159 km and 33 km from the nearest HC (CCS Kitanda in Boko HA).

For the Kenge RHZ, geographical inaccessibility is characterized particularly by the presence of 4 large rivers in the 4 cardinal points namely Wamba, Inzia, Gobari and Boko as well as the poor state of roads.

Kisantu RHZ is located in the Kongo Central Province. It had an estimated population of 196.554 inhabitants in 2018 spread over an area of 3.968 km² and a density of 49 inhabitants per km².

It has 17 HA, including 12 with CCS, 17 HC, 1 RHC and 1 RGH.

The farthest CCS from the HZCO is 157 Km and 24 Km from the nearest HC (CCS Lemfu in Lemfu HA).

Geographical inaccessibility is characterized by several natural barriers: Inkisi and Boko rivers, Congo River, poor road conditions and ravines.

4.1. COMMUNITY CARE SITES IMPLEMENTATION

All 36 CCCs visited location in the 3 RHZs was dictated by the following criteria: (i) the distance between the CCS and the HC of the HA, (ii) the coverage of villages population with difficult access by the CCS, (iii) the existence of premises to house the CCS, (iv) the availability of inputs and subsidies, as well as that of provider CHWs to work there.

In addition, these 3 RHZs have major problems in common: geographical inaccessibility in most of HA, the existence of several natural barriers as well as the very advanced state of disrepair of the road infrastructures.

Conditions for setting up Community Care Sites are summary in the Table 2 as follow:

Table 2

Conditions for setting up Community Care Sites
	Health Zones
	Gombe Matadi	Kenge	Kisantu	Total	Observation
Distance from households
Less than 5 km	100,0	100,0	100,0	100,0	36
More than 5 km	0,0	0,0	0,0	0,0	0
Existence duration
1–2 years	0,0	0,0	0,0	0,0	0
3 years and over	100,0	100,0	100,0	100,0	36
Distance with Health C
15–20 Km	40,0	50,0	30,0	40,0	14
More than 20 Km	60,0	50,0	70,0	60,0	22
Availability of inputs
Yes	100,0	100,0	100,0	100,0	36
No	0,0	0,0	0,0	0,0	0
Conservation of inputs
Good	90,0	80,0	80,0	87,0	31
Bad	10,0	20,0	20,0	13,0	5
Existence of a local Yes No	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	36 0

Comment:

This table shows that all CCS (100%) are located less than 5 km from households, established for more than 3 years and have appropriate premises with the necessary inputs for children care. 60% of them were located more than 20 km from the HA HC against 40% between 15 and 20 km.

In 95% CCS, the CCS local belongs to the provider CHW against only 5% CCS was in the residence of the village chief. 80% of CCSs were built in rammed earth and 20% in semi-durable; 95% of CCSs had a cabinet with a padlock for storing drugs, working tools and other inputs.

The provider CHW choice met the following criteria: be a member of the village with irreproachable morality, have a minimum education level of complete secondary school, be trained in IMCI-C, have inputs for IMCI-C diseases management, be regularly supervised by RN and actively participate in CAC and HADC activities.

Households location of healthcare sought is summary in the Table 3 as follow:

Table 3

Location of healthcare sought by households by health zone
Location of healthcare sought	Health Zones
Location of healthcare sought	Gombe Matadi	Kenge	Kisantu	Total
CCS	91,87	92,98	81,08	89,38
Health Center	4,07	3,51	18,02	7,65
Traditional healers	4,07	3,51	0,90	2,97
Total	100,00	100,00	100,00	100,00
Observation	200	200	200	600

Comment:

The Table 3 above shows us that regardless of the health zone, those responsible for children under 5 years of age use treatment sites in rural areas with difficult access. To this end, 89.38% of household heads use community care sites when the child is sick. However, a small proportion of parents still use traditional healers 3%. The health center being the second resort after having attended the CCS around 8%.

4.2. CCS OPERATING CAPABILITIES

Community care sites operating capabilities are summary in the Table 4 as follow:

Table 4

Assessment of CCS operating capacities
N°	FONCTIONAL STANDARDS	FINDING
1	CCS establishment: CCS establishment begins during a HADC meeting with the identification of provider CHWs by the HZTM members as well as the RN and the Village Chief among the community leaders (promotional CHWs) with the following criteria: being a member of the village, having moral probity, having at least a state diploma: having completed the complete secondary school cycle, having a professional occupation, having a room for CCS and having the time to take care of CCS. The count of children under 5 in villages dependent on the CCS and the strengthening of provider CHWs capacities for 3 IMCI-C diseases management.	-In all CCS, 100%, provider CHWs were above all promotional members of the village chosen during HADC meetings and had benefited from capacity building in IMCI-C MAP. - Among them 92% had a complete secondary education level against 8% of the complete primary level.
2	Installation / CCS official opening: CCS is officially installed during a meeting which all members of the Village. They are summoned to the residence of the Village Chief who presents provider CHWs, gives them all documents and inputs and presents the premises to CCS house in the presence of the RN and sometimes HZT members and ends with their official installation followed by a small cocktail.	In all CCS visited, for 95%, CCS premises belong to the provider CHWs only 5% are in the residence of the Village Chief (2 CCSs of which one of the providers CHW was the daughter of the village chief in the Kenge HZ).
3	Inputs: Immediately after the official installation, provider CHW checks and fills in the management tools and begins the actual treatment according to the algorithms made available to it for the 3 diseases. The inputs are kept in a cabinet with a padlock and the CCS have receptacles for storing waste. At the beginning of the following month, after supervision by RN, provider CHW receives a flat rate for his bonus.	-100% of CCSs had a cabinet for storing all inputs -100% of CCSs were supplied quarterly with medicines and other inputs from the RN of the HC after supervision of medicines management -27% of CCCs had experienced a stock-out of inputs in the 3 months preceding the survey -80% incinerate the waste then bury it in a hole a few meters from the CCS in the bush. -70% had a bicycle in good condition for monitoring home visits for children treated -70% of provider CHWs had received their bonus
4	Working tools: Case management kit, consultation register, case management algorithms, referral note for cases to the HC, supervision register, register for holding CAC and DHAC meetings	100% of CCSs visited had management tools. Only 80% of them had all the management tools up to date.
5	Management bodies: CCS is managed by the CMC composed of a few members of the previously chosen village (5) who meet once a month, in turn, report to the CAC and to the RN. Minutes of meetings are countersigned by all members and archived.	100% of CCSs are managed by CMC, but the frequency of meetings was based on the availability of all members. With an average of 80% holding of CMC meetings. However, it should be noted that at the time of our investigation, Gombe Matadi HZ had HADC but had not yet set up the CACs in all HA. Only the Kenge and Kisantu HZs already had them and were operational.

Case management assessment criteria

Concretely during our visit to some CCS, the process of taking care of a child presenting one or more symptoms of one of 3 IMCI diseases is as follow in the Table 5:

Table 5

Case management assessment criteria
B	Welcome
O	Welcome
S	Symptoms assessment and child weighing
A	“Anamnesis” depending on the case plus paraclinical examination (RDT) if suspicion of uncomplicated malaria
N
T	Treatment administration according to the algorithm
E	Evaluation through the home visit

Algorithms of case management at CCS level:

If fever, take capillary blood to do the RDT, if positive, T3 with paracetamol and ACT then follow-up of the home visit, if no improvement refers to the HC with an orientation note
If diarrhoea, administer ORS plus ZINC followed by home visit, if no improvement refers to HC
If cough with rapid breathing, administer Antitussive plus Amoxicillin Co followed by home visit, if no improvement refers to HC.

He regularly benefits from supervision visits from the RN to whom he reports through the transmission of his monthly report which includes: cases treated number by age and by pathology, drugs and waste management and the HC-oriented cases number.

We noted that in Gombe Matadi and Kisantu HZs, the integration of the complete package of IMCI-C interventions at the CCS level was progressive: the first year the fight against uncomplicated malaria, the second year the 2 other interventions (fight against diarrhea and ARI).

Community care sites operating conditions are summary in the Table 6 as follow:

Table 6

Community Care Sites operating conditions
	Health Zones
	Gombe Matadi	Kenge	Kisantu	Total	Observation
Existence of support
Yes	100,0	100,0	100,0	100,0	36
No	0,0	0,0	0,0	0,0	0
Number of p CHWs 2 1	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	36 0
Volume of work
CCS fonct 7days a week	100,0	100,0	100,0	100,0	36
Less than 7 days	0,0	0,0	0,0	0,0	0
Existence of 3 IMCI interventions Yes No	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	36 0
Care cost Free Paid	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	36 0
Existence algorithms Yes No	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	36 0
Medicines supply Registered Nurse HZCO or Partner	100,0 0	76,0 24,0	100,0 0,0	92,0 8,0	33 3
Out of stock medicines Yes No	30,0 70,0	30,0 70,0	20,0 80,0	27,0 73,0	10 26
Waste management Yes No	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	36 0
CCS Supervision Yes No	80,0 20,0	100,0 0,0	80,0 20,0	87,0 13,0	31 5
CCS Mangement CMC State Partner Other	80,0 0,0 20,0 0,0	100,0 0,0 0,0 0,0	70,0 0,0 30,0 0,0	83,0 0,0 17,0 0,0	30 0 6 0
Total					36

Comment:

It appears from the Table 6 above that with regard to the organization, implementation, operation and management, all CCSs visited are 100% compliant with standards: they have been established for more than 3 years, there is support at the CCS, households are located less than 5 km walk from the CCS, 2 provider CHWs recruited by the community trained in IMCI-C work there every day of the week and benefit from motivation and free access to care with the use of case management algorithms.

Nevertheless, 27% of CCSs, declared having had a stock-out of inputs in the 3 months preceding the survey, 83% of CCSs are managed by CMC and 87% of them benefited from at least one supervision visit either of the RN or HZT members and the TFPs.

Provider CHWs sociodemographic characteristics and assessment of the effectiveness of their work are summary in Tables 7 and 8 as follow:

Table 7

Sociodemographic characteristics of Provider CHWs
	Health Zones
	Gombe Matadi	Kenge	Kisantu	Total	Observation
Sex
Male	76,9	75,0	81,8	77,8	56
Female	23,1	25,0	18,2	22,2	16
Age group
Under 45 years	65,4	54,2	59,1	59,7	43
45 years and over	34,6	45,8	40,9	40,3	29
Educational level
Complete primary	3,9	12,5	9,1	8,3	6
Complete secondary	96,1	87,5	90,9	91,7	66
Occupation Teacher Farmer	51,4 48,6	52,0 48,0	50,4 49,6	51,2 48,8	37 35
Marital status Married Single people	88,4 11,6	91,0 9,0	92,0 8,0	90,5 9,5	65 7
CHWs recruitment Community Registered Nurse	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	72 0
CHWs capacity build IMCI Yes No	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	72 0
Motivation of p CHWs Yes No	100,0 0,0	100,0 0,0	100,0 0,0	100,0 0,0	72 0
Religion Catholic Protestant Kimbanguist Revival church	15,5 20,0 64,0 0,5	67,0 19,8 12,0 1,2	68,5 20,5 10,0 1,0	50,3 20,1 27,0 0,6	36 15 19 2
Total					72

Comment:

It appears from the table above that among provider CHWs surveyed are more men (77.8%) than women (22.2%). The majority of provider CHWs surveyed are in the age group of less than 45 years (59.7%) with an average age of 30 years and followed by that of 45 years and over (40.3%). They have almost a complete secondary education level (91.7%) followed by those of complete primary level (8.3%). These global trends were also observed in all the study health zones. Regarding professional occupation, all provider CHWs surveyed, in addition to being CHWs, have a professional occupation: 55.7% teachers and the rest other professions mainly farmers 44.3%. This trend remains the same in Kenge and Kisantu health zones. Overall, almost all them were married 90% against 10% of single people. With regard to religion, almost half are Catholic 50%, except in Gombe Matadi HZ where 64% are Kimbanguists (the proximity to the Kimbanguists Church of Nkamba).

Table 8

Assessment of provider CHWs on the effectiveness of their work
N°	INDICATORS	Yes (%)	No (%)
1	Training received as promotional CHWs	100,0	0,0
2	Knowledge on promotional activities	86,7	13,3
3	Promotion of key family practices	85,6	14,4
4	Promotion of vaccination, LLINs and birth registration	84,7	15,3
5	Overall score on practices in accordance with IMCI-C MAP	90,0	10,0
6	Knowledge of uncomplicated malaria, diarrhea and ARI management	92,8	7,2
7	Home visits set up	93,0	7,0
8	Knowledge of stock shortages of inputs	27,0	73,0
9	Waste management	100,0	0,0
10	Data reporting	100,0	0,0
11	CCS supervision	82,0	18,0

Comment:

Overall, all provider CHWs interviewed acknowledged (being primarily promotional CHWs) that they had received basic CHWs training,100.0%. While 86.7% of them have good knowledge of promotional activities, their overall score on practices in accordance with the IMCI-C MAP is 90.0%. This level also justifies the fact that only 92.8% of provider CHWs have a good knowledge of the management of uncomplicated malaria, diarrhea and ARI. This is justified by the fact that only at Kenge HZ all 3 interventions were implemented at the same time (having served as a pilot HZ); in the 2 HZs (Gombe Matadi and Kisantu) we started with the implementation of the fight against uncomplicated malaria then the 2 other interventions followed 2 years later.

However, compared to the indicators of a few flagship activities of the IMCI-C MAP, including home visits to households, promotion of key family practices, waste management, data reporting and supervision of CHWs either by RN or other HZT members show an increasing trend, but 27% of provider CHWs reported experiencing a stock-out of inputs in the 3 months prior to the survey.

To improve community participation, indicators are summary in Table 9 as follow:

Table 9

Evolution of 2 community involvement indicators
HEALTH ZONES	Indicator	Base line	Obs Val 2017	Obs Val 2018	Obs Val 2019
GOMBE MATADI	Holding of HADC	50%	62%	90%	93%
GOMBE MATADI	Rate of implementation HADC decisions	30%	67%	75%	80%
KENGE	Holding of HADC	50%	90%	85%	80%
KENGE	Rate of implementation HADC decisions	30%	90%	80%	84%
KISANTU	Holding of HADC	50%	96%	97%	99%
KISANTU	Rate of implementation HADC decisions	30%	93%	90%	90%

Source: Activity report, DHIS2 data from 3 RHZs

Comment:

This table shows a significant improvement in the holding and implementation of the decisions taken by the community involvement bodies. This demonstrates a strong community involvement in the implementation of the CMAP at the CCS level.

Then, Community care sites functionality explanatory factors are summary in Table 10 as follow:

Table 10

Community Care Sites Functionality explanatory factors
Independent Variables	Modalities of variable	Chi-square	Odds Ratio	Standard deviation	p	Confidence interval
CCS uptime	1–2 years	47,19^***	Réf
CCS uptime	3 years and over		6,73^***	12,81	0,000	[3,29 ; 13,79]
Distance between CCS and household’s	More than 5 km	2,70	Réf
Distance between CCS and household’s	5 Km or less		7,04^**	0,83	0,034	[0,05 ; 0,14]
Out of stock of IMCI inputs	No break	2,68	Ref
Out of stock of IMCI inputs	More than a week		2,96^**	0,28	0,039	[0,04 ; 0,15]
CCS management	NGO and Partner	8,78^**	Réf
	State		1,10	0,59	0,855	[0,38 ; 3,19]
	CMC		3,64^**	1,54	0,002	[1,59 ; 8,36]
CCS supervision	No supervision	13,05^***	Ref
CCS supervision	Regular supervision in the last 3 months		10,01^***	0,13	0,031	[0,02 ; 0,82]
Method for collecting the Community's opinion on the CCS functioning	Formal meeting with community leaders	12,12^**	Réf
	Suggestion box		3,27^**	1,87	0,038	[1,07 ; 10,03]
	CAC meeting		4,34^**	2,47	0,009	[1,45 ; 13,00]
Provider CHW advice to parents on key family practices and home visit	Advised and visited	12,26^***	Réf
	Did not advise and visited		0,40^**	0,12	0,000	[0,22 ; 0,75]
% of those who think there is a CCS fundraising initiative	10–30%	16,18^***	Réf
	31–50%		3,54^**	1,88	0,037	[1,08 ; 10,04]
	More than 51%		8,69^***	4,69	0,009	[1,54 ; 12,00]
Constant			0,40^***	71,23	0,039	[0,003 ; 0,15]

Comment:

This table shows us that at the significance level (p = 0.039) has been in place for 3 years or more increases by 7 times chance that it is functional (OR = 6.7; p = 0.000), has household is located less than 5 km from the CCS increases by 4 times chance that the CCS is functional (OR = 7.04; p = 0.034), has provider CHW is regularly trained and supervised increases by 10 times chance that the CCS is functional (OR = 10.01; p = 0.031), provider CHW participation in CAC meetings (OR = 4.34; p = 0.009) and CCS Management Team leads the management of CCS increase by 4 times chance that this CCS is functional (OR = 3.6; p = 0.002). Finally, if there is an initiative for funding CCS increases by 8 times CCS functionality (OR = 8.69; p = 0.009).

This study follows the first 2 during which we laid the foundations for using the realist approach to assess the effectiveness of IMCI-C at the CCS level. (12)(13). It allowed us to analyze the profiles of CCSs and the human resources working there (provider CHWs) on the basis of the results obtained through a mixed approach (qualitative and quantitative). The conceptual model framework of the realistic evaluation approach of PAWSON and TILLEY (15) served as a basis for this analysis based on the pillars of the health system to justify the importance of put in place mechanisms to support the 3 components of IMCI-C and promote the accessibility of populations living in hard-to-reach environments to benefit from quality health care.

To achieve the two specific objectives of this study, we firstly analyzed the operating capacities of CCSs to deliver quality health care and services, and secondly determined the profile of provider CHWs who are responsible for the CCS management. The combination of the good CCS capacities which are organized according to the enacted standards and a good profile of their leaders allowed us to envisage a good level of CCS functionality established in the three RHZs selected for this study. This optimistic perspective makes it possible to effectively consider the extension of CCSs in other HZs not yet covered by these community structures which provide access to quality care for marginalized and hard-to-reach populations in the DRC. (16)

To achieve this, we have developed above a conceptual model framework adapted from the PAWSON and Tilley model which allowed us to identify the context of the integration of the C-MAP into the MAP of the HZs, the organization, implementation, operation and CCS management on the one hand and the contribution of human resources on the other hand which represent the mechanisms in the effective of CCS implementation.

All CCSs visited (100%), are operating in accordance with standards. This is confirmed in a study carried out in 2018 which presents similar results showing that 80% of the CCSs were functional after taking into account the following criteria: population coverage of villages with difficulty accessible, the CCS proximity with households to less than an hour's walk as well as the availability of IMCI-C and provider CHWs inputs. (17)

Provider CHWs surveyed are more men (77.8%) than women (22.2%). Almost surveyed are in the age group of less than 45 years (59.7%) with an average age of 30 years and followed by that of 45 years and over (40.3%). Provider CHWs surveyed have almost a full secondary education level either (91.7%) followed by those with a full primary level or (8.3%), in addition to being provider CHWs, all have a professional occupation either teacher or farmer; these results have been demonstrated by the DHS 2 which indicates that in the DRC 47% of adults have a level of secondary education, also the study conducted by Kadiri Mohammed and Wafae in Morocco in 2017 with 51%. [18–23]

98% provider CHWs were trained in IMCI-C, this corroborates with USAID's final report published in 2014 on the evaluation of cases management of uncomplicated malaria in the districts of Gahombo, Gashoho and Mabahi in Burundi with 67% of provider CHWs trained. In 2017 in Morocco, the study insists on the fact that this training made it possible to equip 62% of provider CHWs with the skills necessary to carry out certain universal coverage strategies through the census of beneficiaries as well as local communication for behavior change. (24)(25)(26)

However, the risk of abandonment of provider CHWs and indeed CHWs in general is very high in the DRC environment. Motivation issues are often at the root of these abandonments which require regular renewal of their training. (27)

Compared to the practice of IMCI-C MAP activities, 90% of provider CHWs do it correctly. WHO emphasizes that CHWs are an integral part of an interdisciplinary workforce, they have particular roles in primary health care and the essential public health function. The global strategy recognized that CHWs and other categories of CHWs working at this level are effective in providing a range of preventive, curative and promotional services and can help reduce inequities to care access. (28)

As for the supervision component; 98% of provider CHWs surveyed were trained in IMCI-C, of which 90% said they had received a supervision visit in the month preceding the survey. In 2017, a study conducted in Mozambique also demonstrated that regularly trained and supervised provider community health workers, regardless of their level of education, are able to ensure adequate first aid in their communities and provide the necessary services to hard-to-reach populations. They are confident in their abilities and are highly valued by the communities they serve and most of them are motivated to continue as volunteers without receiving regular compensation. (29)

In 2012, WHO and UNICEF issued a joint evidence-based statement that considers the use of IMCI-C by community health workers as an equity strategy to improve access to essential care children under 5 years old. Community health workers represent an effective investment solution to strengthen primary health care. (30)

Compared to the availability of inputs at the care recourse place, 80% of CCS visited had inputs for the management of 3 IMCI-C diseases.

A recent CCS Implementation Assessment Report conducted in 2022 by the Clinton Health Access Initiative with support of USAID, SANRU and PNECHOL-MD highlighted the key role of the three IMCI diseases management at the CCS level in the DRC which led to the development of the Plan for CCS extension in all of 112 DRC HZs. [31–35]

Community care sites are functional in the 3 RHZs. Their organization, establishment and operation are directly linked to the provision of services to populations living mainly in HA with difficult access, the availability of inputs for three IMCI-C diseases management namely uncomplicated malaria, diarrhea and pneumonia as well as the capacity building of provider Community Health Workers to ensure their management.

Provider Community Health Workers are first and foremost the promotional CHWs where, in addition to performing their tasks related to health promotion activities, they were able to organize the three IMCI-C interventions management in CCS level. This study shows an effective contribution of provider CHWs on the CCS functionality in HA with difficult access.

ACT : Artemisinin Combination Therapy

CAC : Community Animation Cell

CCS: Community Care Site

CHW: Community Health Worker

CMC : Community Care Site Management Committee

CME: Context-Mechanisms-Effects

DFID: Department for International Development

DHIS 2: Data Health Information System 2 software

DHS: Demographic and Health Survey

DRC: Democratic Republic of the Congo

HADC : Health Area Development Committee

HAFT: Health Area Framework Team

HC : Health Center

HZCO : Health Zone Central Office

HZMT : Health Zone Management Team

IMCI: Integrated Management Childhood Illness

LLIN : Long Light Insecticide Net

MAP : Minimum Activities Package

NGO : Non Government Organization

NHDP: National Health Development Plan

ORS : Oral Rehydration Salts

PCHW : Provider Community Health Worker

PNECHOL-MD : Programme National d’Élimination du Cholera et Lutte contre les Maladies Diarrhéiques

RDT : Rapid Diagnostics Test

RHZ : Rural Health Zone

SANRU : Sante en Milieu Rural

TFP : Technical Financial Partner

UNICEF: United Nations International Children’s, Emergency Fund

USAID: United States Agency for International Development

WHO: World Health Organization

Ethics Approval and Consent to Participate

Written informed consent was obtained from all study participants. The University of Kinshasa Ethic Committee approved all protocols (Reference number: ESP/VD/DIR/CE/223/KL/2018).

Availability of Data and Material

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Authors’ Contributions

JME contributed to the design of the evaluation protocol, the actual evaluation,

the analysis of findings and the writing of the manuscript,

DNB contributed to the protocol development and the writing of the manuscript,

JE contributed to the protocol evaluation, data analysis and writing of the manuscript

CNN contributed to the protocol evaluation and the writing of the manuscript.

Acknowledgements

The authors thank F. E. Meyer for English language editing of the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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No competing interests reported.

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Profiles of Community Care Sites and provider Community Health Workers: A Case study at Gombe Matadi, Kenge and Kisantu Rural Health Zones in the Democratic Republic of Congo

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Abstract

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1. INTRODUCTION

2. OBJECTIVES

3. METHODOLOGY

3.1. Study design

3.2. Study population

3.3. Data collection

3.4. Variables definition and analysis

3.5. Study sites description

4. RESULTS

4.1. COMMUNITY CARE SITES IMPLEMENTATION

4.2. CCS OPERATING CAPABILITIES

5. DISCUSSION

6. Conclusion

Abbreviations

Declarations

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