ESSENTIAL HEALTH SERVICES: DEMOCRATIC REPUBLIC OF THE CONGO

Introduction and Key Takeaways

Public health emergencies such as the COVID-19 pandemic can profoundly disrupt the delivery of routine or essential health services  such as routine immunizations, antenatal care visits, or chronic care visits.¹ For instance, public health emergencies can reduce the supply of those services by redirecting health workers and resources toward the emergency response. Among other reasons, clients’ fear of infection in public places during a pandemic, especially in health care facilities, can also depress demand for essential health services and prevent people from receiving the care they need.

Why Did We Study the Democratic Republic of the Congo?

We selected the Democratic Republic of the Congo (DRC) for this study, alongside three other countries in sub-Saharan Africa (Nigeria, Senegal, and Uganda), because together they demonstrate a wide and variable spectrum of COVID-19 response and outcomes and because they have experience managing past public health emergencies. Also, the strong partnerships these four countries have established between researchers and health officials facilitate access to data and translation to action.

In general, DRC’s health system faced many challenges before the COVID-19 pandemic, including low coverage of health services, low quality of care, limited resilience of health facilities to emergencies, and low levels of community accountability. The COVID-19 pandemic exacerbated these issues. Despite the health system’s weaknesses, the country organized a COVID-19 preparation and response plan and carried out simulation exercises on case detection in January and February 2020, before the pandemic began in DRC. The country’s extensive experience with Ebola virus disease response enabled it to meet the challenges associated with this new pandemic and avoid some challenges that other countries had experienced. The committee coordinating DRC’s Ebola response also organized the COVID-19 response. Their experience in managing epidemics prevented a catastrophe in DRC despite the weaknesses of its health system.

Key Takeaways

Health crises such as the COVID-19 pandemic—and the response to them—can undermine demand and delivery of essential health services. However, countries can act to mitigate this threat by implementing new strategies or adapting older ones to new contexts. DRC’s health system showed weaknesses across key essential health services indicators even before COVID-19; the pandemic—and the interventions health officials implemented to control it, especially lockdowns—further undermined delivery of essential health services. Efforts to reverse this trend are under way, although most key indicators have yet to recover.

In DRC, these barriers (along with COVID-19 itself) had some initial effects on key public health indicators—especially in regions where public health and social measures to contain the spread of the novel coronavirus were concentrated. However, DRC’s experience with previous Ebola, cholera, and measles outbreaks that similarly undermined essential health services delivery gave national and subnational officials many tools and systems they could implement to boost the supply of, and demand for, essential health services during this pandemic emergency.² These interventions include: 

What Was the Pre-pandemic Context in DRC?

PRE-PANDEMIC HEALTH SYSTEM INDICATORS AND ESSENTIAL HEALTH SERVICES IN DRC

DRC’s public health system has a decentralized three-tier structure. The central level includes the offices of the national minister of health, the permanent secretary, directorates, and National Disease Control Programs. The intermediate level includes the offices of the provincial ministers of health. The local level is further divided into health zones with general referral hospitals and health areas with health centers, which are most clients’ initial point of contact with the health system.³ About 3 percent of local health areas do not have a primary care facility and nearly a quarter do not have a secondary care facility. Fewer than 1 percent of hospitals have a laboratory that can run polymerase chain reaction (PCR) tests to diagnose COVID-19 in emergency settings.³

DRC has a ratio of 1.2 health workers for every 1,000 people, below the World Health Organization (WHO) recommendation of 4.45 health workers for every 1,000 people. In 2006, DRC had eight hospital beds for every 10,000 people.⁶ A disproportionate number of the country’s health facilities and providers are located in Kinshasa, where less than 20 percent of the population lives.

According to estimates of universal health care effective coverage, DRC is in the eighteenth percentile of all countries, meaning that about 82 percent of all countries perform better in provision of universal health care (167 out of 204).⁷ Universal Health Care effective coverage measures a variety of indicators of delivery of essential health services like reproductive, maternal, newborn, and child health, and infectious and noncommunicable disease treatment, among others.

In DRC, total health expenditures—4.9 percent of gross domestic product (2020) and US$23 per capita⁸ —are far below the Abuja Declaration of 15 percent and below WHO recommendation of US$86 per capita. In 2020, out-of-pocket (private) health spending was 33 percent of the total,⁸ more than experts typically recommend.

In 2019, the UN Inter-agency Group for Child Mortality Estimation estimated that DRC had an under-five mortality rate of 85 deaths per 1,000 live births, higher than the average across sub-Saharan Africa of 76 deaths per 1,000 live births.⁹ In 2018, UNICEF estimated that 82 percent of pregnant women in DRC received prenatal care, which was the same as the average across sub-Saharan Africa in 2017.¹⁰ In 2019, the DTP3 (diphtheria, pertussis, and tetanus) vaccination coverage in surviving infants in DRC was 57 percent, which is markedly lower than the average across sub-Saharan Africa of 73 percent.¹¹

COVID-19 IN DRC

The first case of COVID-19 in DRC was identified on March 10, 2020. Between March 2020 and December 1, 2021, DRC confirmed over 58,000 cases of COVID-19, and over 1,100 confirmed deaths from COVID-19.¹² From September 2021 through December 2021, the case fatality rate from COVID-19 in DRC hovered around 1.9 percent.¹² DRC experienced a steady increase in the number of daily COVID-19 cases between March and June 2020. Case numbers declined between July and October, then increased steeply between November 2020 and January 2021 with the beginning of the pandemic’s second wave.¹² During this second wave, the hospitals were overwhelmed and the spike in deaths led the government to reinforce public health measures including a 9 p.m. curfew. Starting in May 2021, another wave of COVID-19 began that did not come back down until winter of 2021.¹²

Nonpharmaceutical interventions to limit the spread of COVID-19, including public health and social measures, have been a key part of DRC’s pandemic response, especially in the parts of the country most affected by the pandemic. These included:

• Movement restriction and physical distancing

On March 20, 2020, the president of DRC declared COVID-19 a public health emergency. This was accompanied by a lockdown of Kinshasa, the nation’s capital and largest city, including a ban on all movements by public transport or private vehicles into or out of the city, and a ban on most international flights into the country. On April 2, 2020, the government eased the lockdown in the Gombe area of Kinshasa—where many government offices and shopping centers are located—to mitigate the measure’s economic impact and allow sick people and pregnant women to seek health care.¹³ At the end of June, the government lifted the Gombe lockdown altogether, allowing shops, banks, telecommunications companies, offices, public establishments, public services, public administration, and commercial companies and industries to reopen and workers to return. On December 16, 2020, DRC’s government announced a new nationwide curfew from 9 p.m. to 5 a.m.

• Strategies to support mask wearing

On April 18, 2020, the governor of Kinshasa made face masking compulsory in public places in the city, fining those who failed to comply (5,000 Congolese francs or US$2.50).

• Precautionary measures in public places

On March 18, 2020, DRC’s president prohibited all gatherings of more than 20 people and closed schools and universities throughout the country for four weeks. Church services were also banned for four weeks, and nightclubs, bars, cafes, terraces, and restaurants were closed. People were also encouraged to stay at home if they had flu-like symptoms, but adherence to this decreased over time.¹⁴

Because of these pandemic response measures, mobility decreased sharply in the first months of the pandemic as shown in the following figure.

What Effect Did These Measures Have on the Maintenance of Essential Health Services in DRC?

Even before the COVID-19 pandemic began, DRC’s health system was overwhelmed by recurrent localized outbreaks of epidemic diseases such as Ebola virus disease, measles, and cholera, and endemic diseases such as malaria. The COVID-19 pandemic exacerbated these existing challenges, especially around resource mobilization at different health levels.

Early assessments of the health and socioeconomic impacts of the COVID-19 response in DRC showed that the implementation of nonpharmaceutical interventions, such as social distancing, had negative effects on education, employment rates, and the economy. Unemployment increased in both the formal and informal sectors; income fell; people reported difficulty in accessing food, education, and health care; and gender inequality increased.¹⁵

These precautionary measures also created supply- and demand-side barriers to the maintenance of essential health services, especially in the parts of the country most affected by COVID-19. One study found that use of health services declined in Kinshasa generally, but the decline was most pronounced in the Gombe health zone.¹⁵ Some health services (notably visits and tests for malaria and visits for new diagnoses of noncommunicable diseases) were more affected than others. For instance, maternal and child health services were relatively unaffected. When the lockdown measures were lifted, health service use rebounded but remained at levels lower than those observed pre-pandemic.

An analysis of routinely collected data in DRC showed similar findings: overall health service use declined early in the pandemic, as did the total number of people seeking outpatient services; and rates of outpatient use increased substantially when movement restrictions were lifted, but remained lower than they had been before the pandemic.¹⁵ Hospitals treating people with COVID-19 had a greater reduction in outpatient visits than hospitals without. According to DHIS2 data, consultation rates for common infectious diseases such as malaria dropped to 24 percent (typically around 80 percent for any given hospital in DRC) and to 30 percent for pneumonia. Consultation rates for noncommunicable diseases dropped as well; diabetes consultations dropped by 38 percent and hypertension consultations dropped by 16 percent, with incomplete levels of recovery. Unlike the aforementioned health services, maternal health service usage rates were not greatly affected in DRC. Maternal health service usage rates actually increased modestly at the start of the pandemic and did not fluctuate substantially over the course of the pandemic.

The COVID-19 pandemic and the response to it has particularly affected women’s sexual and reproductive health (though not maternal health). New care visits for women’s health in Kinshasa were reduced by 90 percent between May and July 2020 because of lockdowns, lack of transportation, and fear of a COVID-19 diagnosis and the job loss and financial problems that could result.¹⁶ In a study on Kenya, Burkina Faso, Nigeria, and DRC, data showed that between 9 to 14 percent of women changed their minds about becoming pregnant due to reluctance to interact with the health system (e.g., during antenatal care visits, delivery) for fear of contracting COVID-19.¹⁷ The study found that some women in Kinshasa were at increased risk of unintended pregnancy because lockdowns made contraceptives more difficult to obtain. Young women especially already face stigma when they seek contraceptive services, and pandemic-related closures of youth-friendly services likely made this problem worse.

The following findings are organized according to the Health Systems Building Blocks framework.¹⁸

Barriers to Maintenance and Delivery of Essential Health Services in DRC During the COVID-19 Pandemic

Supply-Side Barriers

Leadership and Governance

Although DRC has experienced many disease outbreaks during the last decade, it lacks policies and strategies for ensuring the maintenance of essential health services during a public health emergency. A large part of this was due to a lack of coordination and alignment across key stakeholders and partners at different levels of the health system in DRC. Documents, guidelines, and operations manuals have not been updated or finalized to account for changing contexts, and plans produced at all levels are poorly disseminated.

Finances

In general, because of very low levels of public funding, the health system in DRC relies heavily on user fees¹⁹ —but because more than 60 percent of the country’s population lives in poverty, these fees represent a major barrier to the utilization of health services. The COVID-19 pandemic exacerbated this problem. At the beginning of the pandemic, DRC’s government reallocated its small domestic health budget and mobilized international partners to help finance the pandemic response, further diverting resources such as personal protective equipment away from the maintenance and delivery of essential health services. While some of the funding specific to COVID-19 likely had secondary effects that benefited essential health services maintenance, such as through generalized risk communications, the government did not focus on essential health services continuity at the start of the pandemic.

DRC faced substantial challenges in mobilizing financial resources for COVID-19 response, and disbursing and allocating those funds once they were mobilized. During the pandemic, as resources were shifted, payment of health personnel was also affected, leading to disruption of essential health services. The allocation of the country’s budget for COVID-19 response grew from 6% of the health budget in April 2020 to 33% by October 2020.²⁰ DRC’s Ministry of Health ran a Resource Mapping and Expenditure Tracking (RMET) exercise with support from the Global Financing Facility, WHO, and World Bank to collect data on budgeting and disbursement.²⁰ This exercise highlighted resourcing requirements for geographies with the greatest level of need and provided insight into how funding should be allocated for an effective COVID-19 response without jeopardizing essential health service delivery.

Health Workforce

Before the COVID-19 pandemic, health worker distribution across DRC was substantially imbalanced, with most health workers concentrated in urban centers. In addition, only 3 provinces out of 26 (Kinshasa, Kongo Central, and Haut Katanga) met the international goal of 1 physician per 10,000 people.¹⁹

The pandemic made this problem worse. Across DRC, health facilities (secondary, tertiary, and university hospitals) were converted to COVID-19 treatment centers and their workers were redirected to pandemic response teams, further reducing the number of health care providers available to deliver essential health services. In addition, since most health facilities initially had inadequate stocks of personal protective equipment, health workers were reluctant to deliver health care and services due to fear of contracting the virus. This led health workers to avoid known COVID-19 patients. In addition, when mobility restrictions were introduced, health worker absenteeism rates increased.

Infrastructure and Commodities

The COVID-19 pandemic and subsequent interventions to control it amplified DRC’s preexisting infrastructural deficiencies across sectors.²¹ Just 12 percent of primary health care facilities (1,006 out of 8,266) and 54 percent of secondary health care facilities (212 out of 393) in the DRC are built and equipped in accordance with international standards.¹⁹ In 2019—before the COVID-19 pandemic led to global supply shortages—fewer than half of outpatient departments in DRC health facilities had disinfectants, sterilizing equipment, masks, trash bins for infectious waste, and protective glasses. DRC also received donations of beds for intensive care, ventilators, oxygen concentrators, pulse oximeters, and other supplies from the World Bank, US Agency for International Development, PATH, and other international donors.

Overall, only about half of health facilities in DRC had access to water from an improved source—a critical tool for preventing infection—and just 20 percent were equipped with ambulances or other emergency modes of transportation.²² Health facilities in the hinterland also experienced disruptions in the drug supply following the restriction of traffic between Kinshasa and the provinces. In general, the pandemic response in DRC has exposed long-standing weaknesses in the country’s health care system, such as a deficit of resuscitation beds and medical ambulances, and the absence of an organized system for the production and transport of oxygen to health facilities.

According to one study, even before the COVID-19 pandemic, health facilities in Kivu struggled to find and retain skilled personnel; obtain basic materials and equipment; and obtain sufficient financial resources to pay for operating costs, essential supplies, and regular salaries for health workers.²³ The COVID-19 pandemic has magnified these challenges.

Health Information Systems

The health information system in DRC is not yet able to provide real-time, high-quality data for decision making and planning of health interventions. Its three main weaknesses are:

• Low completeness, timeliness, and correctness of data collected due to the low availability of standard data collection and reporting tools at the health facility level, low use of electronic tools (such as tablets, computers, and internet), and low integration of the data from the private health facilities.
• Weak analysis and use of health information due to the lack of skilled health workers and poor data quality.
• Low dissemination of health information due to the lack of sustainable financing and poor coordination.²⁴

Demand-Side Barriers

A 2020 survey of health care providers identified key demand-side barriers to health service delivery in DRC during the COVID-19 pandemic. People feared being infected with COVID-19 in a health care facility, and rumors and misinformation about the disease added to the overall atmosphere of fear. Other factors prevented access to essential health services, especially mobility restrictions such as lockdowns.¹⁵ The result was an overall decrease in use of health services during the COVID-19 pandemic, especially for maternal, newborn, and child health; sexual and reproductive health; and case management for measles, malaria, and cholera.³

In 2018, DRC’s Social Sciences Analytics Cell conducted several surveys to identify key barriers to health service delivery during an Ebola virus disease outbreak. They found that people feared being sent to an Ebola treatment center, because they believed it was a place where people went to die; they also found that important motivators for care seeking included positive messaging about Ebola treatment centers (including the number of Ebola virus disease patients who survived) and the importance of seeking treatment early for the disease.²⁵ This sentiment likely affected client hesitancy to visit health facilities and COVID-19 treatment centers during the pandemic.

Reductions in health-seeking behaviors proved to be another major barrier to the delivery of essential health services in DRC during the COVID-19 pandemic. Research findings from the Partnership for Evidence-Based Response to COVID-19 showed that among households whose members needed medical care in the first six months of the pandemic, nearly 40 percent did not seek medical attention or delayed seeking medical attention. By February 2021, it had dropped to about 30 percent and remained there through September 2021. According to the same survey, 33 percent of males were likely to delay seeking care during the pandemic compared with 23 percent of females. People living in urban areas (29 percent) were also more likely to skip care than those in rural areas (27 percent), and those from low-income backgrounds (39 percent) were more likely to skip care than those from high-income backgrounds (17 percent).

In DRC, COVID-19 had major economic impacts on households throughout the country, and cost was the most frequently cited reason for skipping health care visits not related to COVID-19 during the pandemic. Reduced household incomes in combination with the high cost of care likely played a role in undermining essential health services maintenance during the pandemic. For instance, one 2020 study reported that parents in Kinshasa and in Goma (North Kivu) prioritized buying food for their children instead of paying for health care services.¹⁵ Respondents also cited mobility restrictions and fear of contracting COVID-19 as major reasons for the reduction in seeking care. The most common type of care people skipped were routine or general visits, followed by care for diagnostic services, and reproductive and maternal health.

What Interventions Did DRC Put in Place to Ensure the Maintenance of Essential Health Services?

DRC’s Ministry of Health has implemented several interventions to overcome these supply- and demand-side barriers to essential health service delivery during the COVID-19 pandemic.

The following findings are organized according to the Health Systems Building Blocks framework.¹⁸

Leadership and Governance

• Guidelines for the maintenance of essential health services

In April 2020, DRC’s Ministry of Health and its partners developed guidelines for health service maintenance during the COVID-19 pandemic.³ These guidelines covered reproductive health; maternal, neonatal, and child health care and services; vaccine-preventable diseases; and nutrition. For instance, in May 2020, the permanent secretary issued a bill promoting the maintenance of childhood vaccination schedules (which may account for why immunization coverage did not fluctuate widely compared with two previous years).

For the most part, however, the guidelines DRC health officials issued focused on strengthening measures to prevent COVID-19 infections to guarantee safe service delivery for clients and health workers.³ At the same time, these guidelines—which were typically distributed on paper rather than electronically—were not sufficiently disseminated at all levels of the health system. In particular, they were not made available to the health workers at the health zone level who provide the essential health care services the guidelines cover.

• Risk communication and health promotion

The Ministry of Health, international partners, and civil society organizations in the private sector launched media campaigns to promote the continuity of essential health services such as the detection and treatment of diabetes, high blood pressure, and other noncommunicable diseases; adolescent sexual and reproductive health; and immunization. For example, WHO organized a campaign for diabetes and hypertension screening since October 2021 in Kinshasa.³

Finances

• Continued disbursement of essential health services funds

Informants reported that DRC’s government continued to provide some financial resources to health facilities and pay health workers throughout the pandemic. In June 2020, DRC’s government received a loan from the World Bank to help improve the utilization and quality of maternal and child health services in some parts of DRC.²⁷ The Global Fund to Fight AIDS, Tuberculosis and Malaria also announced a US$190 million COVID-19 Response Mechanism grant, known as C19RM, which is intended to support countries as they mitigate the pandemic’s impact on HIV, tuberculosis, and malaria programs. In addition, the World Bank has provided US$200 million in support of DRC’s immunization activities.

Health Workforce

• Platforms for support, supervision, capacity strengthening, and remote work

DRC’s government encouraged the continuity of essential health services by training health workers and community health workers, especially those in obstetrics and neonatal emergency care, on COVID-19 prevention and control. For instance, PATH and WHO organized infection prevention and control training sessions led by health workers from eastern DRC who were experienced in preventing Ebola virus disease infection in health facilities. Health facilities also used internet platforms such as Zoom and Google Meet for remote meetings with stakeholders. While remote meetings were helpful in higher-level facilities, electricity and internet connectivity posed challenges in some rural and remote areas of the country.

To strengthen capacity, the Technical Unit, coordinated by the DRC Ministry of Health and prime minister, developed training plans and supervision programs to ensure that health workers were trained at all levels of the health system. The Technical Unit also included partners outside of the DRC Ministry of Health, including WHO, PATH, and UNICEF, who provided support on training for data collection and communications. They also produced a manual for dissemination and implemented an accountability system for supervisors to provide feedback to health workers reporting to them.

• Task-shifting to community health workers

DRC’s Ministry of Health addressed the challenges associated with the health workforce shortage and its unequal distribution by training community health workers (and equipping them with necessary personal protective equipment) to provide essential health services free of charge. These included screening for and treating of minor conditions such as malaria, diarrhea, pneumonia; completing follow-up of child growth and immunization; nutritional services; and family planning services under close supervision of the nearest chief nurse of the health center. Community health workers also conducted client follow-up visits. However, these community health workers, especially those in Kinshasa, were not provided with any remuneration or incentives, and they went on strike from July through August 2020.²⁸ They returned from strike because they were promised incentives, both monetary and in the form of personal protective equipment.

• Exempting health workers from tax payments

In April 2020, the government suspended value-added tax payments on pharmaceutical products and essential goods for public health workers for three months to compensate for the lack of payment for overtime during the pandemic. Additionally, all DRC households received free water and electricity for two months and income tax payments were waived for one month. Officials also implemented a moratorium on evictions from March through June 2020, and food importation companies were exempted on paying import taxes for two months. ²⁹

• Staff redeployment and recruitment

The DRC Ministry of Health maintained access to essential health services by leveraging existing human resource capacity from schools and colleges. For instance, the National TB Control Program and some maternity hospitals deployed nursing trainees and students for patient care.

Infrastructure and Commodities

• Monitoring available stock of essential commodities

The Ministry of Health provided equipment (i.e., ambulances, oxygen extractors, and personal protective equipment) to 36 hospitals (19 in Kinshasa). Private companies and international organizations contributed essential health supplies such as water, disinfectants, medications, and personal protective equipment. However, the Kinshasa School of Public Health conducted an assessment after the pandemic started that showed that among health facilities visited, fewer than one in five had sufficient medical masks of different types (4.4 percent), disposable surgical masks (15.2 percent), eye protection (8.7 percent), and other equipment such as pulse oximeters. Oxygen cylinders were present in just 2 percent of facilities.

• Private sector engagement

DRC also worked with the private sector to provide continuity of certain essential health services. For example, Marie Stopes International, an NGO, distributed contraceptives during the COVID-19 pandemic to improve adolescent sexual and reproductive health.³⁰

Health Service Delivery

• Designation of facilities for COVID-19 treatment

Designation of specific facilities for COVID-19 treatment, especially in Gombe, enabled the continuity of essential health services in other facilities, although financial constraints blocked their widespread use across the country.

• Implementing disease-specific program adaptations

The DRC Ministry of Health implemented adaptations tailored to specific disease programs to enable the continuity of health services. For instance, the distribution of insecticide-treated mosquito nets along with other antimalarial services (i.e., for traceability, case management, quality of care, and biological diagnosis) continued. The Comorbidity-COVID-19 Project, funded by the Médecins du Monde organization, made drugs available for the management of diabetes and hypertension, and community health workers carried out community screening for those diseases. Health facilities in Kinshasa distributed antituberculosis drugs to clients' homes through funding by the Global Fund to Fight AIDS, Tuberculosis and Malaria, as this had been shown to be effective for AIDS treatment through antiretroviral drug distribution under the funding of the United States President’s Emergency Plan for AIDS Relief. While they have started this pilot program for antituberculosis home drug distribution in Kinshasa, there is no data on the efficacy of the initiative.

In September 2020, DRC’s diabetes control program and the cardiovascular disease control program set up a large-scale screening project for diabetes and hypertension at ten high-priority sites in Kinshasa. Between September 2020 and February 2021, health workers screened nearly 10,000 people. As a result, thousands of newly diagnosed hypertensive and diabetic people gained access to monitoring and free treatment.

• Initiating self-care

Self-care, such as client self-injection of subcutaneous contraceptives, made it possible to substantially reduce contact between care providers and clients, thus reducing health care provider workloads and maintaining service delivery. During the COVID-19 pandemic, the Ministry of Health accelerated scale-up of the self-injection DMPA-SC, and by July 2021, over 7,400 providers had been trained in self-injection, and DMPA-SC was available in 33 percent of public health facilities.³¹

• Multimonth prescribing

To reduce the frequency of client visits to health care facilities, care providers began to prescribe and distribute essential drugs to clients for longer periods of time (one to six months, depending on the person’s health condition). For example, in April 2020, DRC’s National AIDS Control Program instructed the managers and providers of AIDS treatment centers to provide three to six months of antiretroviral treatment for stable clients to minimize disruption of HIV/AIDS services. Before the COVID-19 pandemic, these clients typically received only one month of treatment at a time.³²

Health Information Systems

• Addressing reporting gaps

UNICEF, WHO, and Tulane University supported the development of tools and guidelines to monitor the implementation of health services and the continuity of health service delivery. Donors such as PATH also made investments to improve data reporting in DRC.

How Did DRC Perform Across Essential Health Service Indicators During the COVID-19 Pandemic?

In DRC, the COVID-19 pandemic and the response to it—particularly the lockdowns in Kinshasa in March and April 2020—temporarily disrupted some essential health services indicators, especially at the local level. However, since DRC’s health system showed weakness across key essential health services indicators before the COVID-19 pandemic, it is difficult to parse the effects caused by the pandemic—and likewise difficult to parse the effects of individual interventions to boost essential health services delivery.

Different indicators can reveal different patterns of disruption to essential health services. For example:

• DTP3 immunization

This indicator refers to the number of DTP3 vaccine doses given to children under one year old in a given month. In DRC, the number of infants receiving immunization services increased each year from 2018 to 2020. Between March and November of 2020, we expected to see a drop in vaccination rates due to the movement restrictions and other nonpharmaceutical interventions; however, this indicator shows no changes in access to essential health services because of the pandemic. WHO recommended pausing routine immunizations at the beginning of the pandemic, but due to ineffective dissemination of this guidance to the local health officials, there was no disruption in DTP3 coverage in DRC. However, according to DHIS2 data, with confirmation from WHO and Expanded Programme on Immunization officers, in December 2020 the number of children receiving DTP3 dropped compared with previous years. This drop was likely the result of a temporary vaccine shortage experienced during the second wave of COVID-19, and not mobility restrictions related to COVID-19.

• In-facility deliveries

This indicator refers to the total number of women who gave birth in a health facility in a given year. In DRC, the number of deliveries in health facilities rose between 2019 and 2020. Between March to July of 2020, in-facility deliveries rose by 3.6 percent compared with the same period in 2019. Between August to December of 2020, in-facility deliveries rose by 0.8 percent compared with the same period in 2019.

• Maternal deaths

According to national data, maternal deaths dropped in the first two months of the COVID-19 pandemic, then rose between May and August (appearing to coincide with the first wave of the pandemic in the country) before falling again.²⁵ An analysis of maternal deaths from ten hospitals in Kinshasa found that maternal deaths increased by about 30 percent in 2020, from 84 to 111. The fraction of maternal deaths due to eclampsia and anemia increased between 2019 and 2020, suggesting that conditions that might be screened for and treated in antenatal care visits were not being identified as frequently or effectively during the pandemic. Ten women were deceased upon arrival at hospitals in 2020 compared with two in 2019, suggesting a delay in health seeking. In general, we know that COVID-19 (and in particular the financial exigencies associated with it) pushed many women to change their behavior in ways that might have undermined their own health. For instance, some women reduced the number of meals they ate to provide as much food to their children as they could and skipped or delayed antenatal care and other health care visits because of their cost.¹⁶

What Are the Key Lessons From DRC’s Efforts to Maintain Essential Health Services During the COVID-19 Pandemic?

Nonpharmaceutical interventions such as movement restrictions, physical distancing in public places, and strategies to support mask wearing interfered with the supply of—and demand for—essential health services in the parts of DRC that applied them. DRC officials have produced guidelines for protecting clients and health workers, including masking and temperature screening in health facilities, that mitigate supply- and demand-side obstacles to care. They also emphasize innovations in treatment delivery that do not require as much in-patient contact. For instance, the DRC Ministry of Health’s HIV and tuberculosis programs introduced multiweek drug dispensing programs that enabled clients to avoid health facilities as much as possible.

Lessons learned From DRC’s efforts to maintain essential health services

Recommendations For Other Geographies Based on Learnings in DRC

• Establish and communicate clear and consistent guidance on the maintenance of specific essential services.
• Engage public and private partners to run communications and campaigns to promote use of essential health services.
• Leverage community health workers for client follow-up and dissemination of information on the availability of essential health services.
• Provide incentives for health workers such as waived taxes and free resources to better ensure service continuity.
• Designate specific COVID-19 treatment centers early so that people who need care for other reasons can feel safe in health facilities.
• Implement new service-delivery strategies such as multimonth drug dispensing and self-care.
• Use virtual platforms for meetings, trainings, and supervision.

Lessons Learned From Research Applicable to DRC COVID-19 Context

• Effectively disseminate clear guidelines on how to maintain essential health services across all health system levels.
• Implement systems to allow officials and facilities to collect and use real-time, high-quality data for decision making and planning.
• Improve coordination of financing for essential health services maintenance.
• Improve surge workforce capacities at all levels of health system; distribute health workers more equitably across regions instead of concentrating care in major urban centers.