Fulbert Nappa Kwilu’s research while affiliated with University of Kinshasa and other places

Background The National Expanded Program on Immunization in the Democratic Republic of the Congo implemented a program in 9 Provinces to generate georeferenced immunization microplans to strengthen the planning and implementation of vaccination services. The intervention aimed to improve identification and immunization of zero-dose children and overall immunization coverage. Methods This study applies a mixed-methods design including survey tools, in-depth interviews and direct observation to document the uptake, use, and acceptance of the immunization microplans developed with geospatial data in two intervention provinces and one control province from February to June 2023. A total of 113 health facilities in 98 Health Areas in 15 Health Zones in the three provinces were included in the study sample. Select providers received training on gender-intentional approaches for the collection and use of geospatial data which was evaluated through a targeted qualitative study. A secondary analysis of immunization coverage survey data (2020–2022) was conducted to assess the associated effects on immunization coverage, especially changes in rates of zero dose children, defined as those aged 12–23 months who have not received a single dose of Pentavalent vaccine. Results This research study shows that georeferenced microplans are well received, utilized, and led to changes in routine immunization service planning and delivery. In addition, the gender intervention is perceived to have led to changes in the approaches taken to overcome sociocultural gender norms and engage communities to reach as many children as possible, leveraging the ability of women to engage more effectively to support vaccination services. The quantitative analyses showed that georeferenced microplans may have contributed to a dramatic and sustained trend of high immunization coverage in the intervention site of Haut-Lomami, which saw dramatic improvement in coverage for 3 antigens and little change in Pentavalent drop-out rate over three years of implementation. Conclusion The overall study identified positive contributions of the georeferenced data in the planning and delivery of routine immunization services. It is recommended to conduct further analyses in Kasai in 2024 and 2025 to evaluate the longer-term effects of the gender intervention on immunization coverage and equity outcomes. Trial registration The study was registered and given BMC Central International Standard. Randomised Controlled Trial Number ISRCTN65876428 on March 11, 2021.

Background The National Expanded Program on Immunization in the Democratic Republic of the Congo started using geospatial data at scale in 8 Provinces to strengthen the planning and implementation of vaccination services with a focus on the identification and immunization of zero-dose children, children who have not received the first dose of diphtheria-tetanus-pertussis containing vaccine (DTP1). Methods The study used a mixed-methods research design including survey tools, in-depth interviews and direct observation to document the uptake, use, and perceived impact of georeferenced immunization microplans in the intervention provinces of Haut-Lomami and Kasai and in the control province of Kasai Central. A total of 113 health facilities in 98 Health Areas in 15 Health Zones in the three provinces were included in the study sample. A gender intervention in select Health Zones and Health Areas in Kasai Province was also evaluated through a targeted qualitative study. A secondary analysis of immunization coverage survey data was conducted to assess the associated effects on immunization coverage, especially for rates of zero-dose children. Results This research study shows that georeferenced microplans are well received, utilized, and led to changes in routine immunization service planning and delivery with perceived improvements in identification and reaching zero-dose children. In addition, the gender intervention is perceived to have led to a significant change in the approaches taken to overcome sociocultural gender norms and engage communities to reach as many children as possible, leveraging the ability of women to engage more effectively to support vaccination services. The quantitative analyses showed that georeferenced microplans may have contributed to a dramatic and sustained trend towards high immunization coverage in the intervention site of Haut Lomami, which rose dramatically from 8.9% in 2020 to 76.8% in 2021 and to 92% in 2022 for Pentavalent 3 antigen, while the DPT1-DPT3 drop-out rate changed little from 1% in 2020 to 1.7% in 2021 and 1.6% in 2022 after three years of implementation. Conclusion The overall study identified positive contributions of the georeferenced data in the planning and delivery of routine immunization services. It is recommended to conduct further analyses in Kasai in 2024 and 2025 to evaluate the effects of the gender intervention on immunization coverage and equity outcomes.

Introduction In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members’ needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal. Methods Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l’Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa. Results The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided. Conclusion MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.

Background Catastrophic health expenditures are direct healthcare expenses that exceed 10% or 25% of total household income. The present study aims to measure the proportion of households that fall into catastrophic health expenditure, their socio-demographic and economic characteristics and the factors associated with catastrophic health expenditures. Methods We conducted a secondary data analysis of 205 households from a cross-sectional study in seven health zones in 2022 in DRC. A Clustered Lot Quality Assurance Sampling (LQAS) was used through a 3-stage sampling process. Data were entered into SPSS version 26 and analyzed using the same software. Descriptive analyses included frequencies and percentages, bivariate analyses were performed to see the association between catastrophic health expenditure at 10% and 25% and the independent variables (location, household size, household head occupation, health insurance coverage, and economic well-being). Binary logistic regressions were performed respectively at the 10% and 25% thresholds of income. The association was statistically significant if the p-value was strictly less than 0.05. Results Overall, the extent of catastrophic expenditure at the 10% threshold was 72%, and 47% at the 25% threshold of the monthly household income. Poor households were 1.87 (95% confidence interval, CI=1.06-3.28) times more exposed to catastrophic expenditure than rich households. Conclusions In Kongo Central’s port area, catastrophic health expenditure prevalence is significantly higher than in Sub-Saharan Africa. This exposes the majority to further poverty, highlighting the need for a healthcare coverage system in the country. Registration : ESP/CE/118/2022 of September 12, 2022

Background The number of patients on dialysis has significantly increased worldwide. However, prospective studies estimating the cost of hemodialysis (HD) in sub‐Saharan Africa remain scarce. The present study aimed to evaluate the direct cost of treating end stage renal disease. Determinants of additional direct cost were also assessed. Methods This study is an analytical, prospective study of cost performed at two HD centers in Kinshasa for a period of 3 months among HD patients enrolled consecutively. The cost analyzed includes only expenditures: consultation, HD session, drugs, comorbidities, laboratory tests, and imaging. Transportation, patient hospitalization, and indirect costs are not taken into account. The determinants of the additional direct cost of HD are identified by multivariate logistic regression analysis. P < 0.05 is the level of statistical significance. Findings The average quarterly direct cost of chronic HD in United States Dollars (US$) is$7070 (~US$28,280 annual cost) at a rate of US$287 per patient per HD session. This cost includes the HD session (US$237) and medicine (US$33) costs, which account for 82.5% and 11.3% of the direct costs, respectively. The presence of at least 4 comorbidities (OR adjusted 4.3, 95% CI [1.23–14.95], P = 0.022) and infection (adjusted OR 4.56, 95% CI [1.05–19.85], P = 0.043) emerged as independent determinants of additional direct cost. Conclusion The direct cost of HD is very high in Kinshasa, where more than 80% of Congolese people live on less than US$1.25 a day.

Contexte: Les mutuelles de santé sont retenues comme une des stratégies pour améliorer l’accès financier aux soins de santé en République Démocratique du Congo mais il existe peu d’évidence sur ses effets. Objectif : évaluer l’apport des mutuelles de santé sur l’utilisation des services de santé et la qualité de soins. Méthodes: Une étude évaluative post‐test comparant les ménages mutualistes et les ménages non mutualistes et combinant les données quantitatives et qualitatives portant sur 260 ménages et 8 formations sanitaires de la zone de santé de Kisantu a été réalisée. Les données en rapport avec les caractéristiques de ménages, l’utilisation de services de santé, la perception de difficulté financière pour accéder aux soins, la perception de la qualité de soins et la satisfaction par rapport aux soins ont été collectées. Les données collectées ont été analysées en utilisant le test de Khi‐carré pour comparer les proportions et le test t de student pour les moyennes. Les données de focus group ont été analysées par l’analyse du contenu. Résultats: L’étude a porté sur 130 ménages mutualistes et 130 ménages non mutualistes. La distribution des chefs de ménages par rapport à la profession (Employé 43,1% versus 30,0%) (p=0,026), au niveau d’études (Secondaire et plus : 82,3% vs 79,2%) (p=0,038) et au niveau de revenu mensuel (plus de 100$ : 16,9% vs 8,5%) (p=0,02) était différente entre les mutualistes et les non‐mutualistes. La perception des difficultés financières pour accéder aux soins était plus moindre auprès de mutualistes (14,6%) qu’auprès de non mutualistes (83,1%) (p=0,000). L’utilisation de services était plus importante pour les mutualistes sans être significativement différente (324± 178 vs 246± 145) (p=0,354). La continuité de la prise en charge financière des soins était plus importante auprès de mutualistes (79,2% vs 46,9%) (p=0,000). La qualité de services est différemment perçue par les mutualistes et les non‐mutualistes surtout liée à la disponibilité de médicaments (réception de tous les médicaments prescrits : 62,3% vs 24,6%) (p=0,000). La majorité des bénéficiaires de la mutuelle de santé (97,7%) étaient plus satisfaits de la qualité des services reçus (97,7% vs 88,4%). Ces données corroborent avec celles obtenues par les focus groups. Conclusion: Ces résultats suggèrent que la mutuelle de santé améliore l’accès financier aux soins et le recours aux services de santé par la population couverte. Elle garantit la qualité de soins à ses bénéficiaires par le biais d’une certaine influence exercée sur les prestataires de soins

Introduction: La République Démocratique du Congo a connu depuis plusieurs années une déstructuration de son système de santé. Plusieurs reformes ont été mises en oeuvre dont la politique pharmaceutique nationale et la stratégie de renforcement du système de santé. La politique pharmaceutique est basée sur la centralisation des achats et de la décentralisation de la distribution à travers les centrales de distribution régionale (CDR). Cette étude a pour objectif de déterminer les facteurs qui expliquent la sous‐utilisation de la CDR par les structures de santé de la ville de Kinshasa. Matériels et Méthode: Une étude des cas a été menée en Novembre et Décembre 2015 en combinant les approches qualitative et quantitative. Les structures de santé (Six Bureaux centraux de zone de santé, six hôpitaux généraux de référence et 12 centres de santé) ont été sélectionnées de manière raisonnée utilisant des cas contrastants. Les variables ont été élaborées en se basant sur la théorie de comportement planifié et la théorie de comportement des acheteurs institutionnels. Les données ont été collectées par interview semi‐structuré et par revue documentaire et ont été analysées en utilisant l’analyse inductive du contenu. Résultats: Les résultats obtenus ont montré que la plupart des structures de santé ne disposaient d’aucune procédure officielle à suivre pour les achats des médicaments. La majorité de structures enquêtées préférait s’approvisionner en médicaments auprès des fournisseurs privés au lieu de la CDR, à moins qu’il y ait une contrainte ou une exigence claire de partenaires d’appui. Bien que la raison affichée a toujours été le bas prix pratiqué par les fournisseurs privés et la diversité de l’offre de produits, le choix de fournisseurs était plus guidé par les intérêts individuels de personnes en charge d’acquisition de médicaments (remise, ristourne et rabais), souvent ciblées par la politique commerciale de fournisseurs privés non pratiquée par la CDR. La CDR semble ne pas être en mesure de pratiquer une politique commerciale proche des fournisseurs privés. La plupart des structures ne reçoivent pas de supervision. L’analyse de prix d’un panier de médicaments essentiels pratiqué montre que les prix de CDR sont meilleurs que ceux de fournisseurs privés, bien que ceux‐ci présentent des formes galéniques préférées. Conclusion: Les résultats de cette étude suggèrent qu’un effort soit mis dans la régulation et la supervision des structures de santé de manière à les encourager à utiliser la CDR sans pour autant imposer une politique monopolistique.