Bibusi, 4, holds the PCIME health kit, which helps his family treating minor infections or diseases thay may affect him. UNICEF / Benoit Almeras-Martino, 2014.

HEALTH BEGINSAT HOME

Introducing Family Health Kits in the province of Bas-Congo

Despite achieving some progress since the early 2000s, the Democratic Republ ic of the Congo wil l not reach the Mil lennium Development Goals in 2015 for reducing chi ld mortal ity (MDG 4) and maternal mortal ity (MDG 5).

At its current pace, the country wil l not even achieve these targets by 2035, as evaluations studies have highl ighted major bott lenecks preventing the enhancement of the health system1.

In order to hasten mortal ity reduction among chi ldren and mothers, the Congolese government has developed a MDG accelerat ion framework for the period 2013 -2015 which specif ical ly targets MDG4 and MDG5.

This accelerat ion framework aims to extend (a) treatment of 1 ( i ) lack of medicines ; ( i i ) lack of f inancial access to healthcare faci l i t ies ; ( i i i ) Remoteness of healthcare fa-ci l i t ies ; ( iv) lack of qual if ied personnel ; (v) low qual ity of healthcare ; (vi) low qual ity of health zones manage-ment

ser ious chi ldrens diseases and infections2; (b) access to safe water, hygiene and sanitat ion; (c) access to routine vaccination; (d) access to appropriate maternal health; (e) access to family planning; (f) the promotion of key family practices3.

Mbanza Ngungu health zone was the f irst to benefit from this init iat ive with the support of UNICEF.

2 Fever / malar ia, acute respiratory infections, diarrhoea, severe acute malnutr it ion and postnatal infections.3 Exclusive breastfeeding, Food supplementation, Use of LLITN, hands cleaning, use of hygienic latr ines, birth registrat ion.

A child is being vaccinated against the wild poliovirus during the 2014 National Immunzation Days campaign in Mbanza Ngungu.

CONTEXT

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PROVIDING MEDICAL INPUTSFamilies directly receive health kits aimed at:1) Treating diseases and infection affecting children under five (PCIME kit)2) Facilitating antenatal care for pregnant women (CPN kit)3) Easing childbirth for mothers (delivery kit).

These kits include medicines, vitamins and essential health materials. Healthcare facilities receive and store medicines and tools in order to provide appropriate care for complicated cases (including C-sections).

The medical inputs are distributed by a regional distribution platform, which supplies the health facilities on a quarterly basis (based on their expected needs).

At the health area level, the Development and Health Committees (CODESA) check and approve inputs delivery. The CODESA distribute the health kits to the families through Community Animation Cells and Community Health Workers (see below).

INTRODUCING FLAT RATE PRICING AND THIRD-PARTY PAYMENTAfter 1) conducting an analysis of child healthcares intervention costs in the medical facilities of the health zones, 2) analyzing households ability (and will) to pay for

child healthcare, Mbanza Ngungu health zone harmonized child healthcares costs by establishing flat rate pricing for every major interventions involving children or expecting mothers.

Households only pay a fraction of the child healthcares costs, based on the production of an intervention sheet at the health center. The third-party payer pays for the remaining costs1.The same logic applies for complicated medical interventions (C-Sections), performed at the health zones main hospital (HGR), provided that patients have been referred by their local health center.

PERFORMANCE-BASED FINANCINGHealth facilities receive the third-party payment based on the quality of care they offer: it is the main principle of the performance-based financing in Mbanza Ngungu Health Zone.

Quality of care is assessed through the use of indicators and objectives, which are identified by contract (signed between the third-party payer and the health facilities), and checked2 by technical verification teams hired by the third-party payer.

At community level, local community-based 1 UNICEF currently act as the third-party payer, through Caritas.2 actual number of medical interventions, respect of interven-t ions standards

organizations check the satisfaction of health facilities users and report back to the third-party payer.

INVOLVING COMMUNITY STAKEHOLDERSThe MDG Acceleration Framework also aimed at revitalizing social cohesion within the communities through:

- The election of Community Health Workers (1 CHW per 50 households): The relays are in charge of the initial census of beneficiaries (households with children under 5 and pregnant women). Relays update the census data on a monthly basis and monitor births, deaths, migration. The relays also ensure the distribution of the health kits to families. The relays sensitize the household members on the use of the health kits and on key family practices.

- Community Animation Cells (CAC) compile the data gathered by the Community Health Workers and report back to the Development and Health Committees (CODESA).

- Development and Health Committees presidents participate in the health area monthly reviews in order to monitor the activities of the health facilities.

DESIGN: HOW IT WORKS The MDGs Accelerat ion Framework is based on several pr inciples, family health kits being one of the key elements of its implementation:

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INSIDE P.C.I.M.E. KITS

Paracetamolearly fever treatment

Zincdiarrhoeatreatment

Micronutrients*prevents malnutrition

* only for children aged 6-23 month

Oral Rehydration Saltsdiarrhoea treatment

The PCIME kit contains medicines, vitamins and food supplement to help parents caring for their children at home. The kit also contains intervention sheets that reduce the cost of childrens treatment at the health center (1000 FC), thanks

to the flat-rate pricing and third-party payment system.

PROGRESSIVE DEPLOYMENTFrom a pilot experiment in one health area (November 2013), the experiment was extended to four additional areas (February 2014), before covering the twelve health areas of Mbanza Ngungu health zone (April 2014). 26 health facilities (51) are now involved. Nearly 50,000 PCIME kits were distributed to families between November 2013 and July 2014.

COMMUNITIES REVITALIZATIONCommunities elected 203 Community Animation Cells (1 CAC per neighborhood or village) and 660 Community Health Workers (1 CHW per 50 households on average).

CAPACITY BUILDINGTrainings were first organized for the health zone management team. The management team then trained health facilities personnel. The latter trained the Development and Health Committees members, the Community Animation Cells members and the Community Health Workers. The CHW were specifically trained on 1) monitoring the health area population through census; 2) sensitizing families on key family practices and the use of the health kits.

HARMONIZING HEALTHCARES COSTS

Cost harmonization and flat-rate pricing led to a simpler, easy-to-understand childrens healthcare system:

- Childrens healthcare interventions cost FC 4,000, with households supporting only FC 1000 of the total cost.

- Antenatal consultations cost FC 4500. Households only pay FC 1,500 for the first consultation and FC 300 for each of the three subsequent consultations.

- Assisted deliveries cost FC 18,000, with households paying FC 7500 thanks to the third-party payer.

CENSUS OF POTENTIAL BENEFICIARIESFollowing Community Health Workers training, a census of the health zones population was conducted: in 2014, 121,250 inhabitants were counted by the CHWs. 22,917 of them were children under five; 4,850 were pregnant women.

CREATING A SOLIDARITY FUNDA fraction of the third-party payments are used to fund a solidarity fund at the health zone level. This solidarity fund partially cover the cost of the most expensive interventions (C-sections) at the health zones main hospital

DELIVER: WHAT HAS BEEN ACHIEVED

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AUTHORITIES INVOLVEMENTThe Congolese Ministry of Health has played a leading role in the adoption of the approach at national level and in its experimentation in Mbanza Ngungu; local authorit ies faci l i tated its effective implementation in the health zones neighborhoods and vi l lages.

COMMUNITY COMMITMENTCommunitys commitment is a key to the success of the MDG Accelerat ion Framework. The approach empowers community-based organizations that ensure that the activit ies are effectively implemented1.

DECREASE OF CHILDRENS DISEASESBased on routine data, there was a decrease in chi ldrens diseases. Actual results were made possible thanks to the avai labi l i ty of medicines. Famil ies can easi ly treat diarrhoea and fever cases. The lower cost of chi ldrens healthcare interventions also improved disease control at health area level.

REDUCED HEALTHCARE COSTBy introducing third-party payment and f lat-rate pr icing, households could benefit from better f inancial access to healthcare.

INCREASED USE OF THE HEALTH ZONES FACILITIESCompared to the f irst quarter of 2013, there is 16 points increase in the use of Mbanza Ngungus health faci l i t ies in the f irst quarter of 2014. This was fol lowed by a signif icant increase of the health faci l i t ies income. The completion of the ful l antenatal care cycle (four antenatal consultat ions) also increased signif icantly.

IMPROVED MANAGEMENT Mult iple training of the health faci l i t ies personnel and performance-based f inancing were key factors leading to a better management of the health zone in general.

1 activities include : beneficiaries census, health kits management and distribution, home visits to promote key family practices and data gathering.

Kiff KimfueteteSenior Health Zone Supervisor - Mbanza Ngungu

The approach has allowed us to reinforce our expertise, improve the quality of our data and plan our development. We have a better

organization now. Our health zone has become an example at the provincial level.

Abeti KukaNurse Loma Health Center

The positive change lies in the families ability to treat minor diseases or infections at home.

Consequently, the Health Center is less loaded, we have refilled our stock of medicines in order

to care for the most serious cases.

Steve MikemotoCODESA member Loma Health Area

CODESAs have become the bridge between the communities and the Health Center. The approach has helped many families to have access to healthcare, thanks to lower health

care costs. We now think about creating a health mutual.

In Mbanza Ngungu health zone, the main stakeholders demonstrate the positive effects of the MDGs Acceleration Framework to their work.

DISCOVER: WHAT IS WORKING

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The development of the MDGs Acceleration Framework is expected to save the lives of 430,000 children under 5 and 7,900 mothers throughout the Democratic Republic of the Congo. In Mbanza Ngungu, further progress should include the following elements:

CREATING HEALTH MUTUALthe MDGs Acceleration Framework currently relies on the contribution of external partners (UNICEF especially). Beneficiaries have already been sensitized to the creation of community health mutual that would make the approach sustainable.

MAINTAINING THE COMMUNITY-BASED ORGANIZATIONS WORKat a high level requires additional funding. This issue was raised during the health zone monthly reviews; the health zone management team considers remunerating the members of the main community-based organizations involved (CODESAs, CACs, CHWs) with a portion of the health facilities income.

HARMONIZING THE QUALITY OF CARE BETWEEN HEALTHCARE FACILITIESThe approach led to an increased use of health facilities. Yet some are more popular than others because of the difference of the quality of care. This could lead to serious dysfunctions within the health zones system. Emulation between health areas and training of the health facilities personnel could reduce this risk.

EXTENDING THE ACCELERATION FRAMEWORK TO THE NATIONAL LEVELThe lessons learned from the Mbanza Ngungu experiment has led the Congolese Ministry of Health to consider extending the approach to other health zones. An implementation guide has already been produced to help the health zones adapting the Acceleration Framework to their local situations.

I want my children to grow up without disease, so they can be educated and grow normally.- Ezeline Kilandamo, mother of 5.

My dream is to contribute to eliminating childrens

disease in our community.

- Dieudonn Luzitu, 40,Community Health Worker within Loma Health Area.

DREAM: VISION FOR THE FUTURE

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Loma Health Center in Mbanza Ngungu. This Health Center is involved in the Acceleration Frame since February 2014UNICEF DRC / Benoit Almeras-Martino, 2014