Conflict, epidemic and faith communities: church-state relations during the fight against Covid-19 in north-eastern DR Congo.

BACKGROUND: Understanding and improving access to essential services in (post)-conflict settings requires paying particular attention to the actors who occupy the space left 'empty' by weak or deficient State institutions. Religious institutions often play a fundamental role among these actors and typically benefit from high trust capital, a rare resource in so-called 'fragile' states. While there is a literature looking at the role faith organisations play to mobilise and sensitise communities during emergencies, our focus is on a different dimension: the reconfiguration of the relationship between religion and health authorities impelled by health crises. METHODS: We analyse observations, interviews, and focus group discussions with 21 leaders from eight different religious groups in Ituri province in 2020-2021. RESULTS: Faith institutions handled the Covid-19 lockdown period by using and redeploying structures at the grassroots level but also by responding to health authorities' call for support. New actors usually not associated with the health system, such as revivalist churches, became involved. The interviewed religious leaders, especially those whose congregations were not previously involved in healthcare provision, felt that they were doing a favour to the State and the health authorities by engaging in community-level awareness-raising, but also, crucially, by 'depoliticising' Covid-19 through their public commitment against Covid-19 and work with the authorities in a context where the public response to epidemics has been highly contentious in recent years (particularly during the Ebola outbreak). The closure of places of worship during the lockdown shocked all faith leaders but, ultimately, most were inclined to follow and support health authorities. Such experience was, however, often one of frustration and of feeling unheard. CONCLUSION: In the short run, depoliticization may help address health emergencies, but in the longer run and in the absence of a credible space for discussion, it may affect the constructive criticism of health system responses and health system strengthening. The faith leaders are putting forward the desire for a relationship that is not just subordination of the religious to the imperatives of health care but a dialogue that allows the experiences of the faithful in conflict zones to be brought to the fore.

Engaging faith communities in public health messaging in response to COVID-19: Lessons learnt from the pandemic in Ituri, Democratic Republic of Congo.

Purpose: To understand challenges faced by faith leaders in the Democratic Republic of Congo (DRC) in engaging with current public health strategies for the COVID-19 pandemic; to explain why long-standing collaborations between government, faith-based health services and leaders of faith communities had little impact; to identify novel approaches to develop effective messaging that resonates with local communities. Methods: A qualitative participatory research design, using a workshop methodology was deployed to seek opinions of an invited group of faith leaders in the DRC provinces of Ituri and Nord-Kivu. A topic guide was developed from data gathered in prior qualitative interviews of faith leaders and members. Topics were addressed at a small workshop discussion. Emerging themes were identified. Findings: Local faith leaders described how misinterpretation and misinformation about COVID-19 and public health measures led to public confusion. Leaders described a lack of capacity to do what was being asked by government authorities with COVID-19 measures. Leaders' knowledge of faith communities' concerns was not sought. Leaders regretted having no training to formulate health messages. Faith leaders wanted to co-create public health messages with health officials for more effective health messaging. Conclusion: Public trust in faith leaders is crucial in health emergencies. The initial request by government authorities for faith leaders to deliver set health messages rather than co-develop and design messages appropriate for their congregations resulted in faith communities not understanding health messages. Delivering public health messages using language familiar to faith communities could help to ensure more effective public health communication and counter misinformation.

Supporting community health workers in fragile settings from a gender perspective: a qualitative study.

OBJECTIVE: To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. SETTING: Two districts in three fragile countries. Sierra Leone-Kenema and Bonthe districts; Liberia-two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)-Aru and Bunia districts in Ituri Province. PARTICIPANTS AND METHODS: Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). RESULTS: While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. CONCLUSIONS: Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre.

Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Democratic Republic of Congo.

BACKGROUND: Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province. METHODS: A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12. RESULTS: The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives' living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges. CONCLUSION: Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

Using data to support evidence-informed decisions about skilled birth attendants in fragile contexts: a situational analysis from Democratic Republic of the Congo.

BACKGROUND: Most low- and middle-income countries are experiencing challenges in maternal health in relation to accessing skilled birth attendants (SBA). The first step in addressing this problem is understanding the current situation. We aimed to understand SBA's availability and distribution in Ituri Province, North Eastern Democratic Republic of the Congo (DRC) from 2013 to 2017. METHODS: We used available data on SBAs (doctors, nurses and midwives) from the Ituri Provincial Human Resource for Health Management Unit's database from 2013 to 2017. The current distribution across and within three categories of district (rural, peri-urban and urban) and characteristics of SBAs as well as 5-year trends and vacancy trends were identified. Data on training outputs for SBA cadres was collected from training schools in the province. Descriptive analysis, disaggregating by district, cadre and gender where possible, was conducted using Excel. RESULTS: The national ratio of SBAs per 1000 population is four times less than the Sustainable Development Goals threshold (4.45) while the Ituri Province ratio is one of the lowest in DRC. There are more doctors and nurses in urban and peri-urban districts compared to posts, and shortages of midwives in all district categories, particularly in rural districts. From 2013 to 2017, occupied posts for doctors and nurses in all three categories of districts increase while midwives decrease in peri-urban and rural districts. There is clear gender and occupational segregation: doctors and nurses are more likely to be male, whereas midwives are more likely to be female. The projections of training outputs show a surplus against authorised posts of doctors and nursing increasing, while the shortfall for midwives remains above 75%. CONCLUSION: This is the first study to use existing human resource data to analyse availability and distribution of SBAs in a DRC province. This has provided insight into the mismatch of supply and demand of SBAs, highlighting the extreme shortage of midwives throughout the province. Further investigations are needed to better understand the situation and develop strategies to ensure a more equitable distribution of SBAs throughout this province and beyond. Without this, DRC will continue to struggle to reduce maternal mortality.

How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo.

BACKGROUND: Community health workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings-Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre. METHODS: We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n = 37), life history interviews with CHWs (n = 15) and reviewed policy documents. RESULTS: Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs' scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery. CONCLUSIONS: This is the first study that has explored the management of CHWs in fragile settings. CHWs' interface role between communities and health systems is critical because of their embedded positionality and the trusting relationships they (often) have. Their challenges are aligned to those generally faced by CHWs but chronic fragility exacerbates them and requires innovative problem solving to ensure that countries and communities are not left behind in reforming the way that CHWs are supported.

'Being a midwife is being prepared to help women in very difficult conditions': midwives' experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo.

INTRODUCTION: Maternal and neonatal health are core focus areas in fragile and conflict-affected areas, and hence midwives are key actors. But there is currently very little evidence on midwives' experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri Province in the north-eastern part of the Democratic Republic of Congo (DRC). This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives' work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, north-eastern DRC. METHODS: As part of a qualitative approach, life history interviews with 26 midwives and 6 ex-midwives, and three focus group discussions with 22 midwives in three health districts of Ituri Province (Bunia, Aru and Adja), were conducted in 2017. Purposive sampling was used to recruit research participants. The transcripts were digitally recorded, and thematically analyzed using NVivo software. A timeline framework was deployed in the analytical process. RESULTS: Problem solving, childhood aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses, resulting in different levels and training experiences. Midwives faced many work challenges: serious shortages of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation was worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives wanted to continue working as midwives or follow further midwifery studies. Family-related reasons were the main reasons for most ex-midwives to leave the profession. CONCLUSION: Midwives play a critical role in supporting women to deliver babies safely in rural Ituri Province. They face immense challenges and demonstrate bravery and resilience as they navigate the interface between underresourced health systems and poor, marginalized rural communities. This situation requires a call to action: donors need to prioritize these contexts; and the government and other stakeholders in DRC need to invest more in improving security conditions as well as working conditions and professional support for midwives in rural Ituri Province. Only then will midwives be able to provide the critical services that women and their families need, and therefore contribute to achieving universal health coverage.

Using a human resource management approach to support community health workers: experiences from five African countries.

BACKGROUND: Like any other health worker, community health workers (CHWs) need to be supported to ensure that they are able to contribute effectively to health programmes. Management challenges, similar to those of managing any other health worker, relate to improving attraction, retention and performance. METHODS: Exploratory case studies of CHW programmes in the Democratic Republic of Congo, Ghana, Senegal, Uganda and Zimbabwe were conducted to provide an understanding of the practices for supporting and managing CHWs from a multi-actor perspective. Document reviews (n = 43), in-depth interviews with programme managers, supervisors and community members involved in managing CHWs (n = 31) and focus group discussions with CHWs (n = 13) were conducted across the five countries. Data were transcribed, translated and analysed using the framework approach. RESULTS: CHWs had many expectations of their role in healthcare, including serving the community, enhancing skills, receiving financial benefits and their role as a CHW fitting in with their other responsibilities. Many human resource management (HRM) practices are employed, but how well they are implemented, the degree to which they meet the expectations of the CHWs and their effects on human resource (HR) outcomes vary across contexts. Front-line supervisors, such as health centre nurses and senior CHWs, play a major role in the management of CHWs and are central to the implementation of HRM practices. On the other hand, community members and programme managers have little involvement with managing the CHWs. CONCLUSIONS: This study highlighted that CHW expectations are not always met through HRM practices. This paper calls for a coordinated HRM approach to support CHWs, whereby HRM practices are designed to not only address expectations but also ensure that the CHW programme meets its goals. There is a need to work with all three groups of management actors (front-line supervisors, programme managers and community members) to ensure the use of an effective HRM approach. A larger multi-country study is needed to test an HRM approach that integrates context-appropriate strategies and coordinates relevant management actors. Ensuring that CHWs are adequately supported is vital if CHWs are to fulfil the critical role that they can play in improving the health of their communities.

Raising the profile of participatory action research at the 2010 Global Symposium on Health Systems Research.

By involving citizens and health workers in producing evidence and learning, participatory action research has potential to organize community evidence, stimulate action, and challenge the marginalization that undermines achievement of universal health coverage. This paper summarizes and analyzes results of two sessions on this research model convened by the authors at the First Global Symposium on Health Systems Research in Montreux Switzerland, November 16-19, 2010. In so doing, it reviews case studies and experiences discussed, particularly their contribution to universal health coverage in different settings. The paper also reflects on challenges faced by participatory action research, and outlines recommendations from the two sessions, including creation of a learning network for participatory action research.

Indicators of sustainable capacity building for health research: analysis of four African case studies.

BACKGROUND: Despite substantial investment in health capacity building in developing countries, evaluations of capacity building effectiveness are scarce. By analysing projects in Africa that had successfully built sustainable capacity, we aimed to identify evidence that could indicate that capacity building was likely to be sustainable. METHODS: Four projects were selected as case studies using pre-determined criteria, including the achievement of sustainable capacity. By mapping the capacity building activities in each case study onto a framework previously used for evaluating health research capacity in Ghana, we were able to identify activities that were common to all projects. We used these activities to derive indicators which could be used in other projects to monitor progress towards building sustainable research capacity. RESULTS: Indicators of sustainable capacity building increased in complexity as projects matured and included- early engagement of stakeholders; explicit plans for scale up; strategies for influencing policies; quality assessments (awareness and experiential stages)- improved resources; institutionalisation of activities; innovation (expansion stage)- funding for core activities secured; management and decision-making led by southern partners (consolidation stage).Projects became sustainable after a median of 66 months. The main challenges to achieving sustainability were high turnover of staff and stakeholders, and difficulties in embedding new activities into existing systems, securing funding and influencing policy development. CONCLUSIONS: Our indicators of sustainable capacity building need to be tested prospectively in a variety of projects to assess their usefulness. For each project the evidence required to show that indicators have been achieved should evolve with the project and they should be determined prospectively in collaboration with stakeholders.