DRC health system

Community level

Across DRC’s 26 provinces, currently 402 out of 516 health zones have 6,968 functional community care sites which cover a population of 10,179,461. [1] The CHWs in DRC provide an integrated package of services in their communities. The National Guide for Implementation of Community Care Sites (2016) defines the package of services to include referral of severe malaria cases and treatment of uncomplicated malaria cases in children under five. [1] It also allows that treatment of malaria in children over five years and adults can be provided as needed.

At the community level, integrated community case management (iCCM) is provided at community care sites (sites de soins communautaires). According to national guidelines, two volunteer community health workers (relais communautaires) are identified for each community care site:

• One CHW is responsible for providing diagnosis, treatment, and referral services.
• The other CHW focuses on health promotion, communication, and community mobilization.

CHWs are unpaid. Criteria for selection include a minimum level of education as well as having an established source of income, separate from their unpaid health activities. Both CHWs are to be trained approximately every 2–3 years in malaria, pneumonia, and diarrhoea diagnosis and treatment; this includes administration of rapid diagnostic tests (RDTs), artemisinin-based combination therapies (ACTs), and ARC for severe cases of malaria. [1]

Reference hospitals

Only 393 of the 516 health zones have a general reference hospital. Faith-based organizations run 34% of these hospitals, which are integrated into the public health system. [1]

Private sector

Care-seeking and treatment in the private sector (including non-profit and faith-based facilities, for-profit clinics, pharmacies, and drug shops) is widespread. According to the 2013-2014 Demographic and Health Survey (DHS), among children with fever, 49 percent report seeking care in the public sector and 47 percent in the private sector. [1]

The non-profit/faith-based facilities often function much like the public-sector facilities in that they report into the routine health information system and abide by the national policies. But there are important differences in treatment availability in public and private outlets. A research project supported by ACTwatch from 2013 to 2015 in Kinshasa and Katanga provinces included representative ‘outlet surveys’ that assessed availability of malaria diagnostics and treatment at service delivery points, including public facilities and CHWs, private non-profit and for-profit facilities, regulated pharmacies, and unregulated drug shops and retailers. [1] The last survey in 2015 found that drug shops represented 69 percent of outlets in Kinshasa and 59 percent in Katanga. [1] In Kinshasa, 87 percent of public sector outlets stocked quality-assured ACTs; in Katanga 92 percent did. In the private sector, however, only 22 percent of private outlets stocked quality-assured ACTs in Kinshasa while 53 percent stocked them in Katanga. [1]

Supply chain

The Democratic Republic of the Congo’s supply chain system works through a series of regional independent private non-profit warehouses with whom donors typically contract for storage and distribution to health zone services.

In addition to ensuring the availability of high quality antimalarial medicines and related products across all levels of the health system, the DRC 2016-20 National Malaria Strategic Plan highlights the importance of coordination among the key malaria procurement and supply chain management stakeholders. [2] It also highlights the importance of regular logistics data to inform supply planning and forecasting and establishing an electronic logistics management information system.

As all antimalarial medicines and related products are procured by donors, coordination between donors is critical.

In 2019, stocks of RDTs, ACTs, sulfadoxine-pyrimethamine (SP) and injectable artesunate at the central (regional depot) level were more stable and fell more consistently within the minimum and maximum stock window than in the previous year. [2]

However, the functionality of the DRC supply chain system is unpredictable due to a number of factors including the cost and distances to transport commodities, lack of appropriate infrastructure (road networks, warehousing, nascent LMIS, etc.) and challenges with lead times due to lengthy and complex customs clearing procedures. [2]