From Insecurity to Health Service Delivery: Pathways and System Response Strategies in the Eastern Democratic Republic of the Congo

Availability of the Health Care Workforce

The occurrence of attacks on health facilities or health care workers often forces health staff to leave the affected area. Partners may be forced to withdraw their presence from the affected area and interrupt activities until security is reestablished. The same is true when the health care workers live with the constant fear that they or their health facilities could be attacked.

Insecurity affects the availability and quality [of services]; with insecurity qualified health staff flee, we can no longer supply or provide quality care. —NGO worker

Increased Stress

When health care workers decide to stay and work in the insecure area, they report that they often work under stressful conditions comprising fear, restlessness, and instability. These weigh heavily on the psychological health of the staff who reported struggling to concentrate and focus:

We are not psychologically stable when we are scared; and if we are scared, this can disrupt the care. —Hospital health care provider

This can increase the risk of committing mistakes or having other lapses in judgment.

I do not know if there is anybody who has heard a firearm shot and who is in good health, I do not know if such a person exists. If there is insecurity, you will understand, this affects our mentality, it affects our behavior; when the behavior is concerned, are we going to provide quality care? The answer is no. —Health facility health care provider

When you know that there is no peace, you can be struck any time, you cannot care for someone, and even if you treat someone, it hits you somewhere … and it limits our actions, our normal reaction to save … you work and you say, “Oh my God, they are going to find me here…” you are somehow traumatized. —Health facility health care provider

Availability of Drugs and Equipment

Participants reported that attacks on health facilities had both direct and indirect consequences. An immediate consequence of the destruction and plundering of health facilities is the reduced availability of functioning equipment and medications.

… A health center has recently been burgled in [health zone xx] … all material has been plundered; with the plundering of all medicaments if a severe case arrives, there will be no medicament available to treat them, and they can die. This is an effect of insecurity I think. —FGD participant

In situations of chronic crises like the one in eastern DRC, respondents also reported a sort of “investment reticence,” as the willingness to invest in equipment or supply decreases as the next plundering is around the corner.

Better not to bring [inputs] as the beneficiaries will not benefit from it; … [the armed groups] will steal and sell it, and when the donor will see the inputs on the market, it will be the partner who will be incriminated. —NGO worker

It is not easy to go and look for medicines and (at the same time), we are worried about how to keep the drugs. We cannot buy in great quantity, because you are scared that you will buy for [the armed groups]. I buy in small amounts like a woman going to the market. If I buy in great quantity, they might come and loot. —Health facility health care provider

Availability of Health Care Workforce

Health care workers are hindered in reaching the health facilities due to ongoing insecurity either near the facility or along their access route to the facility.

If the security is threatened, we do not work during the night, we stay at home, and if someone calls you that there is a patient who is turning worse at the hospital, you have to understand that nobody will be available to treat her/him, nobody will put himself in the insecurity to treat a patient. —Health facility health care provider

If the facility is staffed by visiting clinicians, they may need to abbreviate their service provision hours to travel home before darkness:

I remember a health facility where they were obliged to close the structure at 3 pm and come back the following day at 8 am, as spending the night there… it meant taking a lot of risks… —Ministry of Health/Division Provincial de Santé

…like that Friday, when there were some gunshots in my health area, we started working at noon…—Health facility health care provider

The same case can be made if there is any form of curfew imposed, either by the government or by the agency providing logistical support.

Delays in Reaching Care

Respondents noted that in insecure settings, reaching health care providers can become challenging. Ambulances often struggle to reach patients, and when they do, the route to the health facility may be obstructed. Delays in reaching care also speak to individuals' mobility being limited, either because of the fear of violence or because of limited availability of financial means to pass checkpoints or access ambulance services.

…Pregnant women delivered under difficult conditions as they didn't have access to the health facilities anymore, thus they preferred deliver at home instead of running the risk of the journey to the health facility. —NGO worker

The population takes on a self-management policy with regard to health matters. —Health facility health care provider

In these scenarios, they tend to resort to home-based solutions such as home deliveries, self-medication, or traditional treatment.

You will see now, people are resorting to what? You will see people will turn to traditional medicine, they will take herbs, they will take them with the consequence of anemia, and community deaths… —Health facility health care provider

They will risk the journey to health facilities only in the case of complications or once symptoms of an illness or injury have become too great to bear:

This does affect us because we have many severe cases, given the security situation, clients arrive late, sometimes they do not arrive at all… this affects us…—NGO worker

Increased Cost of Transportation

When the standard means of accessing health care facilities for both patients and providers are cut off, the use of alternative but higher cost options may be necessary. It was reported that in certain cases, it has been necessary to circumnavigate the insecure areas and travel through Uganda to reach northern parts of North Kivu from Goma. Other times, clinicians needed to access facilities via chartered air services such as helicopters or humanitarian flight services; similarly, patients that require critical care needed to be evacuated by air; and medications, equipment, and material also needed to be transported in the same way. As these methods of transit come at increased costs and require specialized capacity, respondents reported that the number of possible transports is limited, meaning a reduced amount of materials and number of people that can be transported.

A box of nutrition products which will probably cover [the treatment] of 1 child weighs 15 kg. When you have to pay US$3–4 per kg you see how difficult it is to implement such activity. —UN agency staff

Reduced Training and Supervision

Respondents noted that health staff in conflict-affected areas also may lose access to ongoing training efforts and effective supervision. They highlight the fact that during periods of insecurity, visits from supervisors or training personnel tend to be considered as less essential for the ongoing operations of that health facility. These visits may be interrupted, postponed to more stable times, or conducted remotely. Without being able to directly observe conditions and practice as the health facilities, quality can be compromised:

It is true, we go there where there is instability, but when there is really insecurity, all what I just told you about our system of regular quarterly visits for the monitoring and monthly for the supervisions, to visit health facilities to ensure service quality, … now, if this is an area where the NGOs [.] can get nowhere, we won't be able to enter the health facility, we cannot really say that we will assure the quality of the provided service —NGO worker

Availability of Drugs and Equipment

In addition to mobility challenges for patients, clinicians, trainers, and supervisors, respondents also noted that access constraints limit their capacity to send necessary supplies and materials in conflict-affected areas. Delays in the delivery lead to increased risk of stock-out of drugs, vaccines, and other medical materials, compromising the capacity to provide treatment and care.

Yes, this affects the availability of medicines. This means that during insecurity the district office or whoever provides us with medicines cannot pass, how can they reach our position? Thus, there will be stock-outs in the health zone which can easily affect the health center. —Health facility health care provider

Delays in Implementation of Activities

Respondents noted that medical activities may be put on hold during periods of insecurity. Such is the case when mobile clinics are deployed or specialist services are available only at certain scheduled intervals. These activities are often postponed until sufficient levels of security can be assured again, though there is often no set date for the resumption of these services. This has consequences on the overall implementation of work, as well as on the achievement of funding objectives and milestones.

We need to reassure ourselves of the security conditions, we cannot expose our staff to the risk of death because they want to help. In short, the workplan will not be observed. —NGO worker

We have problems with our activity planning. For example, I can plan my visit [to the health facility] taken the inconvenient security context into account. This will delay [everything]… this has the consequence to extend the implementation of activities and even unjustly will influence the results. —NGO worker

Availability and Motivation of Health Care Workforce

Health facilities use the fees paid by patients to cover the premium for health care workers, which complements the meager salary paid by the government. As these complementary premiums are often what makes staff activity sustainable, payment shortfalls can impact the motivation of the staff to report and provide clinical care, affecting overall availability and quality of care. Retention of health care workers becomes difficult as staff need to look for alternative income sources and tend to look for positions with stable payment (usually those supported by TFP).

First of all, the system is poorly funded, which causes that if we look at what service providers earn, this does not suffice to cover their survival needs. There, you will find some service providers who are demotivated, and this generates instability of resources. Looking for better (opportunities) elsewhere, health [care] workers run away and desert as well. This means that you can invest in a health provider with training, capacity building, but after a while they will leave and go somewhere else. —FGD participant

We can well recruit a skilled health [care] worker, but if we cannot take care of them, at a certain point as we just said that this staff is demotivated, this staff will simply run away. You have to recruit appropriately and ensure an acceptable minimum to stabilize the staff. —Ministry of Health/Division Provincial de Santé official

Therefore, reduced resources have an immediate impact on service availability and quality but also a broader reduced return of investment of capacity-building activities as turnover risks are high.

Availability of Drugs and Equipment

A related consequence of reduced facility revenue is an increased risk of drug stock-outs. Health facilities that are not supported by a TFP use part of the user fees for purchasing their medical supplies and medicines. Reduced revenue leads to less availability both in terms of quantity and variety.

When utilization decreases, the health facility does not yield, and when it does no longer yield anything, it is difficult to purchase medicines, it is difficult to pay staff, thus the facility has problems in its overall functioning. —Health facility health care provider

Addressing Lack of Human Resources

Respondents reported 4 strategies to compensate for reduced health care workforce.

1. Task shift from higher to lower level or from foreign to national staff. Respondents reported how community health workers are put in charge of needs assessments and management of additional diseases when external teams from the health zone office or the TFP cannot access a given area. Another example of task shifting is substituting a foreign staff person with national staff, who are considered to have easier access in insecure areas.

2. Implement a “self-supervision” model. Registered nurses in charge of a health facility are trained to temporarily take over a supervision role usually attributed to the health zone technical team.

We trained the chief nurses from each health center on supervision; each one is considered as an internal supervisor and if the Health Zone Central Office team doesn't arrive, the chief nurse acts officially as internal supervisor. Secondly, we trained the supervisors from the central offices of the health zone, so when the team from [NGO] is prevented from being there, the supervisors from the health zone do the supervision. Therefore, we have strengthened the system in such a way that if we cannot be there or are prevented from being there, we know they can still do something to ensure quality services. —NGO worker

• 3. Rapidly train agents, or nurses, who have been trained only for a specific task but are then given additional tasks but without having received complete training.

• 4. Train a pool of staff (instead of only 1 person) to anticipate the high turnover.

Addressing Lack of Access

Respondents described 4 strategies used to compensate for the reduced mobility and access.

1. Implement a contingency plan that limits field presence and movements and therefore the exposure of humanitarian staff to insecurity. This was mainly reported by NGOs, rather than government health care workers.

2. Use mobile clinics to bring a set of health services to communities when individuals have difficulties in reaching the health center.

3. Establish maternity waiting homes (known as "Binyolas") to allow close-term pregnant women to stay within the health facility while awaiting the onset of labor. Given the current pattern of armed conflict in the Kivu mostly characterized by one-off attacks or clashes between armed groups rather than prolonged military sieges, during phases/days of relative peace between armed clashes, a woman may decide to go to the nearest health facility with a maternity waiting area until the onset of labor.

4. Distribute preventive drugs both at the facility level and patient level. In certain cases (and specifically for chronic diseases), some organizations give out “security drugs,” (i.e., supply of medications for a longer period so that patients can go to the health facility less frequently).

For example, in our TB or HIV program, we give out “security medicines”: it is usually necessary for a patient to come every month to get drugs, but we give 3 months because of insecurity. This is specific when it is needed to flee, and you do not have the possibility to go back for medicines. —NGO worker

Addressing Insecurity

Besides operational challenges, organizations also implement activities to address overall security and acceptance at 2 levels. At the community level, organizations aim to strengthen acceptance and facilitate the implementation of activities through dialogues and engagement with different population groups. This entails working with community members to establish an appropriate way to gather, share, and use information about community needs and organization's activities and find an acceptable way to implement programs. Humanitarian organizations have also developed codes of conduct, agreements, and operational standards to ensure they are accountable to the population they serve.

For security, yes, the overall strategy that we use is to promote acceptance which is our trademark in our communities, and we ensure […] that our programs are [of] high quality; that the promises we make to our beneficiary population are kept; we provide information first to the population and to the partners; for each commitment, we sign a protocol and we make every effort to respect this protocol; […] we have codes of conduct for the staff, for our partners ensuring that we don't do anything foolish in the community, codes of conduct linked to sexual life, to protection, against exploitation and sexual abuse, code of conduct against fraud, fraud sensitivity, and all that, because there are stories like that which once started create problems down the road. —NGO worker

The second strategy is advocating and increasing awareness at national and international levels by tracking attacks on health care and advocating for safe humanitarian space. A specific human resource is usually appointed as security focal point or security advisor who monitors the situation, approves movements, and advises on risk-management strategies.