Prediction Model with Validation for Polioseronegativity in Malnourished Children from Poliomyelitis Transmission High-Risk Area of the Democratic Republic of the Congo (DRC).

Background: Malnutrition is identified as a risk factor for insufficient polio seroconversion in the context of a vaccine-derived poliovirus (VDPV) outbreak-prone region. In the Democratic Republic of Congo (DRC), underweight decreased from 31% (in 2001) to 26% (in 2018). Since 2004, VDPV serotype 2 outbreaks (cVDPV2) have been documented and were geographically limited around the Haut-Lomami and Tanganyika Provinces. Methods: To develop and validate a predictive model for poliomyelitis vaccine response in malnourished infants, a cross-sectional household study was carried out in the Haut-Lomami and Tanganyika provinces. Healthy children aged 6 to 59 months (n=968) were enrolled from eight health zones (HZ) out of 27, in March 2018. We performed a bivariate and multivariate logistics analysis. Final models were selected using a stepwise Wald method, and variables were selected based on the criterion p < 0.05. The association between nutritional variables, explaining polio seronegativity for the three serotypes, was assessed using the receiver operating characteristic curve (ROC curve). Results: Factors significantly associated with seronegativity to the three polio serotypes were underweight, non-administration of vitamin A, and the age group of 12 to 59 months. The sensitivity was 10.5%, and its specificity was 96.4% while the positive predictive values (PPV) and negative (PNV) were 62.7% and 65.3%, respectively. We found a convergence of the curves of the initial sample and two split samples. Based on the comparison of the overlapping confidence intervals of the ROC curve, we concluded that our prediction model is valid. Conclusion: This study proposed the first tool which variables are easy to collect by any health worker in charge of vaccination or in charge of nutrition. It will bring on top, the collaboration between the Immunization and the Nutritional programs in DRC integration policy, and its replicability in other low- and middle-income countries with endemic poliovirus.

Area-specific covid-19 effects on health services utilization in the Democratic Republic of the Congo using routine health information system data.

BACKGROUND: Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas. METHODS: We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017-February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant. RESULTS: Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic. CONCLUSIONS: The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers.

"Zero Dose" Children in the Democratic Republic of the Congo: How Many and Who Are They?

(1) Background: The Democratic Republic of the Congo (DRC) is one of the countries with the highest number of never vaccinated or "zero-dose" (ZD) children in the world. This study was conducted to examine the proportion of ZD children and associated factors in the DRC. (2) Methods: Child and household data from a provincial-level vaccination coverage survey conducted between November 2021-February 2021 and 2022 were used. ZD was defined as a child aged 12 to 23 months who had not received any dose of pentavalent (diphtheria-tetanus-pertussis-Haemophilus influenzae type b (Hib)-Hepatitis B) vaccine (by card or recall). The proportion of ZD children was calculated and associated factors were explored using logistic regression, taking into account the complex sampling approach. (3) Results: The study included 51,054 children. The proportion of ZD children was 19.1% (95%CI: 19.0-19.2%); ZD ranged from 62.4% in Tshopo to 2.4% in Haut Lomami. After adjustment, being ZD was associated with low level of maternal education and having a young mother/guardian (aged ≤ 19 years); religious affiliation (willful failure to disclose religious affiliation as the highest associated factor compared to being Catholic, followed by Muslims, revival/independent church, Kimbanguist, Protestant); proxies for wealth such as not having a telephone or a radio; having to pay for a vaccination card or for another immunization-related service; not being able to name any vaccine-preventable disease. A child's lack of civil registration was also associated with being ZD. (4) Conclusions: In 2021, one in five children aged 12-23 months in DRC had never been vaccinated. The factors associated with being a ZD child suggest inequalities in vaccination that must be further explored to better target appropriate interventions.

Impact of a free care policy on routine health service volumes during a protracted Ebola virus disease outbreak in the Democratic Republic of Congo.

BACKGROUND: In response to the DRC's 10th Ebola Virus Disease (EVD) outbreak, the government subsidized routine health services in select health zones with the goal of maintaining routine service volumes. We assess the impact of the initial and revised Free Care Policies (FCP) on total clinic visits, uncomplicated malaria, simple pneumonia, fourth antenatal care clinic visits, and measles vaccinations, testing the hypothesis that routine services would not significantly decrease during the FCP. METHODS AND FINDINGS: We used data from the DRC's national health information system spanning January 2017 to November 2020. Intervention facilities were those that were initially and secondarily enrolled in the FCP, which occurred in August 2018 and November 2018, respectively. Comparison facilities were limited to the North Kivu Province and were from health zones that recorded at least one case of Ebola. A controlled interrupted time series analysis was conducted. The FCP appeared to have a positive effect in increasing overall clinic attendance rates, uncomplicated malaria case rates, and simple pneumonia case rates in those health zones where the policy was enacted relative to comparison sites. The longer-term effects of the FCP were mostly non-significant or, if significant, relatively modest in nature. Rates for measles vaccinations and fourth ANC clinic visits appeared to be unaffected or minimally affected, respectively, by the implementation of the FCP and relative to comparison sites. We did not observe the decrease in measles vaccinations that has been observed elsewhere. The study is limited in that we were unable to account for health facility bypassing and service volumes at private health facilities. CONCLUSIONS: Our findings provide evidence that FCPs can be used to maintain routine service provision during outbreaks. Additionally, the study design demonstrates that routinely reported health information from the DRC are sensitive enough to detect changes in health policy.

Improving the quality of maternal and newborn health outcomes through a clinical mentorship program in the Democratic Republic of the Congo: study protocol.

BACKGROUND: The Democratic Republic of the Congo (DRC) boasts one of the highest rates of institutional deliveries in sub-Saharan Africa (80%), with eight out of every ten births also assisted by a skilled provider. However, the maternal and neonatal mortality are still among the highest in the world, which demonstrates the poor in-facility quality of maternal and newborn care. The objective of this ongoing project is to design, implement, and evaluate a clinical mentorship program in 72 health facilities in two rural provinces of Kwango and Kwilu, DRC. METHODS: This is an ongoing quasi-experimental study. In the 72 facilities, 48 facilities were assigned to the group where the clinical mentorship program is being implemented (intervention group), and 24 facilities were assigned to the group where the clinical mentorship program is not being implemented (control group). The groups were selected and assigned based on administrative criteria, taking into account the number of deliveries in each facility, the coverage of health zones, accessibility, and ease of implementation of a clinical mentorship program. The main activities are organizing and training a national team of mentors (including senior midwives, obstetricians, and pediatricians) in clinical mentoring, deploying them to mentor all health providers (mentees) performing maternal and newborn health (MNH) services, and providing in-service training in routine and Emergency Obstetrical and Newborn Care (EmONC) to the mentees in health facilities over an 18-month period. Baseline and endline assessments are carried out to evaluate the effectiveness of the clinical mentorship program on the quality of MNH care and the effective coverage of key interventions to reduce maternal and neonatal mortality. Findings will be disseminated nationwide and internationally, as scientific evidence is scarce. A national strategy, guidelines, and tools for clinical mentorship in MNH will be developed for replication in other provinces, thus benefitting the entire country. DISCUSSION: This is the largest project on clinical mentorship aimed to improving the quality of MNH care in Africa. This program is expected to generate one of the first pieces of scientific evidence on the effectiveness of a clinical mentorship program in MNH on a scientifically designed and sustainable model.

Facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care in 72 rural health facilities in the Democratic Republic of the Congo: A cross-sectional study.

Background: Current facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care (EmONC) were assessed in the Kwango and Kwilu provinces of the Democratic Republic of the Congo (DRC). Methods: This is an analysis of the baseline survey data from an ongoing clinical mentoring program among 72 rural health facilities in the DRC. Data collectors visited each of the facilities and collected data through a pre-programmed smartphone. Frequencies of selected indicators were calculated by province and facility type-general referral hospital (GRH) and primary health centers (HC). Results: Facility conditions varied across province and facility type. Maternity wards and delivery rooms were available in the highest frequency of rooms assessed (>95% of all facilities). Drinking water was available in 25.0% of all facilities; electricity was available in 49.2% of labor rooms and 67.6% of delivery rooms in all facilities. Antenatal, delivery, and postnatal care services were available but varied across facilities. While the proportion of blood pressure measured during antenatal care was high (94.9%), the antenatal screening rate for proteinuria was low (14.7%). The use of uterotonics immediately after birth was observed in high numbers across both provinces (94.4% in Kwango and 75.6% in Kwilu) and facility type (91.3% in GRH and 81.4% in HC). The provision of immediate postnatal care to mothers every 15 minutes was provided in less than 50% of all facilities. GRH facilities generally had higher frequencies of available equipment and more services available than HC. GRH facilities provided an average of 6 EmONC signal functions (range: 2-9). Conclusions: Despite poor facility conditions and a lack of supplies, GRH and HC facilities were able to provide EmONC care in rural DRC. These findings could guide the provision of essential needs to the health facilities for better delivery of maternal and neonatal care.

Surveying the knowledge landscape in sub-Saharan Africa: methodology.

OBJECTIVE: To describe in detail the methods followed in each of the qualitative and quantitative surveys of national health information, research and knowledge systems and research institutions. DESIGN: Cross-sectional surveys. SETTING: National health information and research systems, and 847 health research institutions in 42 countries in the World Health Organization (WHO) African Region. PARTICIPANTS: Key informants from health research institutions, ministries of health and statistical offices. MAIN OUTCOME MEASURES: Stewardship, financing, ethics, human and material resources and output of health information and research systems. RESULTS: Key informants were used to collect data to assess national research systems in 44 countries in the Region. The same method was followed in assessing national information systems in 17 countries and knowledge systems for health in 44 countries. These assessments included a detailed review of the state of data sources in the Region and their effect on measuring progress on the health-related Millennium Development Goals. A concurrent survey employed a structured questionnaire (the WHO Health Research Systems Analysis Questionnaire) to assess the capacity of 847 health research institutions in 42 countries. Stewardship, financing, ethics, human and material resources and research output were assessed. CONCLUSIONS: The logistics and resources involved in surveying the knowledge landscape in the 42 countries were substantial. However, the investment was worthwhile as the results of the surveys can be used to inform policy-making and decision-making, as well as to establish a regional database of national health information, research and knowledge systems.

Health information systems in Africa: descriptive analysis of data sources, information products and health statistics.

OBJECTIVE: To identify key data sources of health information and describe their availability in countries of the World Health Organization (WHO) African Region. METHODS: An analytical review on the availability and quality of health information data sources in countries; from experience, observations, literature and contributions from countries. SETTING: Forty-six Member States of the WHO African Region. PARTICIPANTS: No participants. MAIN OUTCOME MEASURES: The state of data sources, including censuses, surveys, vital registration and health care facility-based sources. RESULTS: In almost all countries of the Region, there is a heavy reliance on household surveys for most indicators, with more than 121 household surveys having been conducted in the Region since 2000. Few countries have civil registration systems that permit adequate and regular tracking of mortality and causes of death. Demographic surveillance sites function in several countries, but the data generated are not integrated into the national health information system because of concerns about representativeness. Health management information systems generate considerable data, but the information is rarely used because of concerns about bias, quality and timeliness. To date, 43 countries in the Region have initiated Integrated Disease Surveillance and Response. CONCLUSIONS: A multitude of data sources are used to track progress towards health-related goals in the Region, with heavy reliance on household surveys for most indicators. Countries need to develop comprehensive national plans for health information that address the full range of data needs and data sources and that include provision for building national capacities for data generation, analysis, dissemination and use.

Overview of national health research systems in sub-Saharan Africa: results of a questionnaire-based survey.

OBJECTIVE: To assess the state of national health research systems of countries in the World Health Organization (WHO) African Region. DESIGN: A questionnaire-based survey METHODS: Structured questionnaires were used to solicit health research systems' relevant information from key informants in each country. SETTING: Forty-six Member States of the WHO African Region. PARTICIPANTS: Key informants from the ministry of health in each country, with the support of WHO Country Offices. MAIN OUTCOME MEASURES: Presence of national health research policy or strategy, priority setting and ethical review of research. RESULTS: Of the 44 responding countries, 39 (89%) reportedly had an official national health policy and 37 (84%) had a strategic health plan. A total of 16 (36%) countries reportedly had a functional national health research governance mechanism, nine of which had clear terms of reference; nine (20%) countries had a functional national health research management forum. Functional ethical review committees were reported in 33 countries (75%). CONCLUSIONS: National health research systems were weak in the countries assessed. Significantly more resources should be allocated to strengthening these systems.

Research and its governance in health research institutions in sub-Saharan African countries: results of a questionnaire-based survey.

SUMMARY: Objective: To describe governance and stewardship of research in health research institutions in the World Health Organization (WHO) African Region. Design: A structured questionnaire was used to solicit information on governance and stewardship from health research institutions. Setting: Forty-two Member States of the WHO African Region. Participants: Key informants from the respondent health research institutions in the respondent sub-Saharan African countries. Main outcome measures: Institutions' participation in setting the national health research agenda. Institutional research priorities, scientific reviews and governance structure. Results: During the previous 12 months, the heads of 49% of respondent health research institutions participated in the setting or coordination of national research priorities. The most frequently cited priorities for contributing to or performing research were improving health programmes, producing new knowledge, influencing health policies and conducting operational research. For 78% of respondent institutions, scientific review was required for research funded directly by the institution, and for 73% of respondent institutions, scientific review was required for research not funded by the institution. However, most respondent institutions did not have written policies or guidelines, either for the scientific review of proposals (70%) or regarding conflict of interest on scientific review committees (80%). Conclusions: Some health research institutions demonstrate good practice in terms of the establishment of structures and processes for governance and stewardship, many others do not. There is a need for the strengthening of the stewardship capacity of research institutions in the Region.

Expenditures on health research in sub-Saharan African countries: results of a questionnaire-based survey.

OBJECTIVE: To estimate the sources of funds for health research (revenue) and the uses of these funds (expenditure). DESIGN: A structured questionnaire was used to solicit financial information from health research institutions. SETTING: Forty-two sub-Saharan African countries. PARTICIPANTS: Key informants in 847 health research institutions in the 42 sub-Saharan African countries. MAIN OUTCOME MEASURES: Expenditure on health research by institutions, funders and subject areas. RESULTS: An estimated total of US$ 302 million was spent on health research by institutions that responded to the survey in the World Health Organization (WHO) African Region for the biennium 2005-2006. The most notable funders for health research activities were external funding, ministries of health, other government ministries, own funds and non-profit institutions. Most types of health research performers spent significant portions of their resources on in-house research, with medical schools spending 82% and government agencies 62%. Hospitals spent 38% of their resources on management, and other institutions (universities, firms, etc.) spent 87% of their resources on capital investment. Research on human immunodeficiency virus/tuberculosis and malaria accounted for 30% of funds, followed by research on other communicable diseases and maternal, perinatal and nutritional conditions (23%). CONCLUSIONS: Research on major health problems of the Region, such as communicable diseases, accounts for most of the research expenditures. However, the total expenditure is very low compared with other WHO regions.

Human resources in health research institutions in sub-Saharan African countries: results of a questionnaire-based survey.

OBJECTIVE: To describe human capacity and staff movement in national health research institutions in 42 sub-Saharan African countries. DESIGN: A structured questionnaire was used to solicit information on governance and stewardship from health research institutions. SETTING: Eight hundred and forty-seven health research institutions in 42 sub-Saharan African countries. PARTICIPANTS: Key informants from 847 health research institutions. MAIN OUTCOME MEASURES: The availability, mix and quality of human resources in health research institutions. RESULTS: On average, there were 122 females employed per respondent health research institution, compared with 159 males. For researchers, the equivalent figures were nine females to 17 males. The average annual gross salary of researchers varied between US$ 12,260 for staff with 5-10 years of experience and US$ 14,772 for the institution head. Of those researchers who had joined the institution in the previous 12 months, 55% were employed on a full-time basis. Of the researchers who left the institutions in the same period, 71% had a full-time contract. Among all those who left, those who left to a non-research sector and to another country accounted for two-thirds. CONCLUSIONS: The study revealed significant gaps in the area of human capacity development for research in Africa. The results showed a serious shortage of qualified staff engaged in health research, with a dearth of staff that held at least a master's degree or doctoral degree. Major efforts will be required to strengthen human resource capacity, including addressing the lack of motivation or time for research on the part of existing capable staff.

Resources, indicators, data management, dissemination and use in health information systems in sub-Saharan Africa: results of a questionnaire-based survey.

OBJECTIVE: To describe the status of health information systems in 14 sub-Saharan African countries of the World Health Organization African Region. DESIGN: A questionnaire-based survey. SETTING: Fourteen sub-Saharan African countries of the African Region. PARTICIPANTS: Key informants in the ministries of health, national statistics offices, health programmes, donors and technical agencies. MAIN OUTCOME MEASURES: State of resources, indicators, data sources, data management, information products, dissemination and use of health information. RESULTS: The highest average score was in the identification and harmonisation of indicators (73%), reflecting successful efforts to identify priority indicators and reach international consensus on indicators for several diseases. This was followed by information products (63%), which indicated the availability of accurate and reliable data. The lowest score (41%) was in data management, the ability to collect, store, analyse and distribute data, followed by resources - policy and planning, human and financial resources, and infrastructure (53%). Data sources (e.g. censuses, surveys) were on average inadequate with a score of 56%. The average score for dissemination and use of health information was 57%, which indicated limited or inadequate use of data for advocacy, planning and decision-making. CONCLUSIONS: National health information systems are weak in the surveyed countries and much more needs to be done to improve the quality and relevance of data, and their management, sharing and use for policy-making and decision-making.

Institutional facilities in national health research systems in sub-Saharan African countries: results of a questionnaire-based survey.

OBJECTIVE: To describe the current status of institutional facilities and the supporting research infrastructure of surveyed health research institutions in Africa, including information on communication technologies and connectivity, library resources, and laboratory operations and resources. DESIGN: A structured questionnaire was used to solicit information on institutional facilities at health research institutions. SETTING: Health research institutions in 42 sub-Saharan African countries. PARTICIPANTS: Key informants from 847 health research institutions. MAIN OUTCOME MEASURES: The availability of laboratory, information and communication, and library facilities in health research institutions. RESULTS: Less than half of the respondent health research institutions had computer laboratories (49%), network computers (50%) and information technology support (38%). More than two-thirds (67%) had a library. Electronic subscriptions to international journals were observed to be very low, with an average of three subscriptions per institution. Almost two-thirds of the surveyed institutions (69%) reported having laboratories, about half of which (55%) were accredited nationally. Linkages and research collaborations were generally weak, particularly those with other laboratories in the Region. Challenges included financial and human resource constraints and the inability to communicate effectively with partners. CONCLUSIONS: Health research institutions in the Region have insufficient access to essential facilities such as laboratories, libraries, computers and the Internet to generate, access and share information.

Research output of health research institutions and its use in 42 sub-Saharan African countries: results of a questionnaire-based survey.

OBJECTIVE: To describe and analyse research output from surveyed national health research institutions in Africa. DESIGN: The survey used a structured questionnaire to solicit information from 847 health research institutions in 42 countries of the World Health Organization African Region. SETTING: Eight hundred and forty-seven health research institutions in 42 sub-Saharan African countries. PARTICIPANTS: Key informants from the health research institutions. MAIN OUTCOME MEASURES: Volume, type and medium of publications, and distribution of research outputs. RESULTS: Books or chapters for books accounted for the highest number of information products published (on average 16.7 per respondent institution), followed by patents registered in country (8.2), discussion or working papers (6.5) and conference proceedings (6.4). Publication in a peer-reviewed journal constituted only a minor part of research output (on average about 1 paper per institution). Radio and TV broadcasts on health research accounted for the highest number of products issued by institution staff (on average 5.5 per institution), followed by peer-reviewed journals indexed internationally (3.8) or nationally (3.1). There were, on average, 1.5 press releases, 1.5 newspaper or magazine articles, and 1.4 policy briefs per institution. Over half of respondent institutions (52%) developed briefs and summaries of articles to share with their target audiences, 43% developed briefs for possible actions and 37% provided articles and reports upon request. Only a small proportion of information products produced were available in institutional databases. CONCLUSIONS: The research output of health research institutions in the Region is significant, but more effort is needed to strengthen research capacity, including human and financial resources.

Research ethics policies and practices in health research institutions in sub-Saharan African countries: results of a questionnaire-based survey.

OBJECTIVE: To describe the state of research ethics policies and practices in health research institutions in sub-Saharan African countries. DESIGN: A structured questionnaire was used to solicit information on research ethics from health research institutions. SETTING: Forty-two sub-Saharan African countries. PARTICIPANTS: Key informants from the health research institutions. MAIN OUTCOME MEASURES: Existence of institutional ethics review policies and mechanisms. RESULTS: About half (51%) of respondent institutions reported having policies on research ethics and 58% had written policies requiring that researchers obtain informed consent of research participants. About one-third of respondent institutions (34%) had established ethics review committees, 42% required that studies went through ethics review committees and 46% had linkages with national or regional ethics organisations. Regarding operating procedures for ethics review committees, 53% had adopted standard operating procedures. Less than one-quarter of respondent institutions reported having policies in place to monitor ongoing research. Of the institutions that monitored ongoing research, 34% did an annual ethical review and 74% required a periodic written report. Only 36% provided any type of ethics training for staff, including those conducting health research and those who were not members of the ethics review committee. CONCLUSIONS: There are substantial gaps in the capacity of health research institutions in the WHO African Region to undertake ethical review of studies before, during and after studies conducted. There is a need to strengthen such capacity in order to ensure the wellbeing of individuals enrolled in studies and that of communities that host these studies.

Knowledge systems in health in sub-Saharan Africa: results of a questionnaire-based survey.

OBJECTIVE: To describe the mechanisms and systems of knowledge acquisition, creation, diffusion, application and improvement of knowledge in two layers of the health system: health policy formulation and the provision of clinical services. DESIGN: A questionnaire-based survey. SETTING: Health research institutions in 46 countries of the World Health Organization (WHO) African Region. PARTICIPANTS: Key informants in ministries of health and health care institutions in 39 countries of the Region. MAIN OUTCOME MEASURES: Existence of knowledge management infrastructure or components of infrastructure in the countries of the Region. RESULTS: Central national bodies are always cited as having a major role in policy-setting. Non-national bodies most frequently provide advice and act in monitoring and evaluation, while decentralised entities are strongly involved in dissemination, implementation, and monitoring and evaluation. In general, ministries tend not to have an explicit knowledge management framework and do not map knowledge sources and flows for policy-making. The main sources of evidence are guidelines or recommendations from international or national agencies, although systematic reviews are rarely used. Routine monitoring and evaluation of quality and effectiveness of the process of policy development and its implementation was reported in 19 of the 39 respondent countries. In most respondent countries, electronic medical records were rarely used. CONCLUSIONS: As systematic reviews are rarely utilised as a source of evidence in policy development and few mechanisms exist to assess the performance of the policies, there are significant opportunities for improving policy development.