Remote research in the DRC shows the benefits of methodological pragmatism and community-insiders

In regions where the COVID-19 pandemic meets violent conflict, research projects face novel challenges. By adopting adaptive programming and remote organisation of data collection, a project in northeastern DRC was not only successful in obtaining findings but gained unforeseen benefits: local researchers, as a part of the community, developed a trust that drew different ethnographic responses

Strengthening the midwifery workforce in fragile contexts: a mixed methods study from Ituri province, Democratic Republic of Congo

Skilled and motivated health workers are important to delivering quality healthcare. Ensuring their availability and equitable distribution is a key priority. Low- and middle-income countries are experiencing challenges in relation to the maternal health workforce. This situation is worse in fragile and conflict affected states. The Democratic Republic of Congo (DRC) has very high maternal mortality rates and a serious shortage of qualified skilled birth attendants. Ituri Province, in North-Eastern DRC is a fragile setting which faces conflict, Ebola outbreaks, the current COVID-19 pandemic and many challenges in attracting and retaining midwives in rural districts. This thesis aims to identify appropriate strategies to attract and retain midwives and related cadres in rural Ituri. I analysed the availability, distribution and trends relating to doctors, nurses and midwives in Ituri Province from 2013 to 2017 using secondary staffing data within three categories of districts (rural, peri-urban and urban). The analysis revealed an oversupply of doctors and nurses, and a serious shortages of midwives, particularly in rural districts, requiring further analysis to explore this situation in depth. Hence using a life history approach, I then explored midwives’ work experiences and challenges in rural Ituri Province. Midwives face immense challenges in their work, including severe shortages of qualified health workers, poor working conditions due to lack of equipment, supplies and professional support, and no salary from the government. These challenges were all exacerbated by fragility, conflict and rurality. Midwives showed bravery and resilience in navigating the interface between under-resourced health systems and poor marginalized communities. Finally, through a workshop methodology, I engaged with stakeholders in Ituri Province, to review data from these two studies, in order to identify context-specific strategies to improve staffing. Key strategies embedded in the realities of rural fragile Ituri province included: organizing midwifery training in nursing schools located in rural areas; recruiting students from rural areas; and lobbying NGOs and churches to support the improvement of midwives’ living and working conditions. Midwives are key skilled birth attendants managing maternal and newborn health care. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. Developing a holistic picture of the midwifery workforce using both quantitative and qualitative data is critical. Engaging stakeholders with this data, can facilitate the development of context-specific, feasible and potentially effective strategies to address the challenges of attraction and retention of midwives. Trusting relationships are critical to this co-production of knowledge. By implementing these strategies, only then will midwives, playing the interface between health systems and the communities, be able to provide the critical services that women and their families need, and therefore contribute to achieving Universal Health Coverage

Being a midwife is being prepared to help women in very difficult conditions”: midwives’ experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo

Introduction: Maternal and neonatal health is a core focus area in fragile and conflict-affected states and midwives are key actors. But there is currently very little evidence on midwives’ experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri region in the North-Eastern Democratic Republic of Congo. This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives’ work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, North-eastern DRC. Methods: A qualitative approach using life history interviews with 26 midwives and 6 ex-midwives, and 3 focus group discussions with 22 midwives in 3 health districts of Ituri Province (Bunia, Aru and Adja) was conducted in 2017. Purposive sampling was used to recruit research participants. The transcripts were digitally recorded, and thematically analyzed using NVivo. A lifeline framework was deployed in the analytical process. Results: Problem solving, child aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses resulting in different levels and training experiences of midwives. Midwives face many work challenges: serious shortage of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation is worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives want to continue working as midwives or follow further midwifery studies. Family related reasons were the main reasons for most ex-midwives to leave the profession

Using a human resource management approach to support community health workers: experiences from five African countries

Background Like any other health worker, community health workers (CHWs) need to be supported to ensure that they are able to contribute effectively to health programmes. Management challenges, similar to those of managing any other health worker, relate to improving attraction, retention and performance. Methods Exploratory case studies of CHW programmes in the Democratic Republic of Congo, Ghana, Senegal, Uganda and Zimbabwe were conducted to provide an understanding of the practices for supporting and managing CHWs from a multi-actor perspective. Document reviews (n = 43), in-depth interviews with programme managers, supervisors and community members involved in managing CHWs (n = 31) and focus group discussions with CHWs (n = 13) were conducted across the five countries. Data were transcribed, translated and analysed using the framework approach. Results CHWs had many expectations of their role in healthcare, including serving the community, enhancing skills, receiving financial benefits and their role as a CHW fitting in with their other responsibilities. Many human resource management (HRM) practices are employed, but how well they are implemented, the degree to which they meet the expectations of the CHWs and their effects on human resource (HR) outcomes vary across contexts. Front-line supervisors, such as health centre nurses and senior CHWs, play a major role in the management of CHWs and are central to the implementation of HRM practices. On the other hand, community members and programme managers have little involvement with managing the CHWs. Conclusions This study highlighted that CHW expectations are not always met through HRM practices. This paper calls for a coordinated HRM approach to support CHWs, whereby HRM practices are designed to not only address expectations but also ensure that the CHW programme meets its goals. There is a need to work with all three groups of management actors (front-line supervisors, programme managers and community members) to ensure the use of an effective HRM approach. A larger multi-country study is needed to test an HRM approach that integrates context-appropriate strategies and coordinates relevant management actors. Ensuring that CHWs are adequately supported is vital if CHWs are to fulfil the critical role that they can play in improving the health of their communities

Conflict, epidemic and faith communities:Church-state relations during the fight against Covid-19 in north-eastern DR Congo

BACKGROUND: Understanding and improving access to essential services in (post)-conflict settings requires paying particular attention to the actors who occupy the space left ‘empty’ by weak or deficient State institutions. Religious institutions often play a fundamental role among these actors and typically benefit from high trust capital, a rare resource in so-called ‘fragile’ states. While there is a literature looking at the role faith organisations play to mobilise and sensitise communities during emergencies, our focus is on a different dimension: the reconfiguration of the relationship between religion and health authorities impelled by health crises. METHODS: We analyse observations, interviews, and focus group discussions with 21 leaders from eight different religious groups in Ituri province in 2020–2021. RESULTS: Faith institutions handled the Covid-19 lockdown period by using and redeploying structures at the grassroots level but also by responding to health authorities’ call for support. New actors usually not associated with the health system, such as revivalist churches, became involved. The interviewed religious leaders, especially those whose congregations were not previously involved in healthcare provision, felt that they were doing a favour to the State and the health authorities by engaging in community-level awareness-raising, but also, crucially, by ‘depoliticising’ Covid-19 through their public commitment against Covid-19 and work with the authorities in a context where the public response to epidemics has been highly contentious in recent years (particularly during the Ebola outbreak). The closure of places of worship during the lockdown shocked all faith leaders but, ultimately, most were inclined to follow and support health authorities. Such experience was, however, often one of frustration and of feeling unheard. CONCLUSION: In the short run, depoliticization may help address health emergencies, but in the longer run and in the absence of a credible space for discussion, it may affect the constructive criticism of health system responses and health system strengthening. The faith leaders are putting forward the desire for a relationship that is not just subordination of the religious to the imperatives of health care but a dialogue that allows the experiences of the faithful in conflict zones to be brought to the fore

Engaging faith communities in public health messaging in response to COVID-19:Lessons learnt from the pandemic in Ituri, Democratic Republic of Congo

PURPOSE: To understand challenges faced by faith leaders in the Democratic Republic of Congo (DRC) in engaging with current public health strategies for the COVID-19 pandemic; to explain why long-standing collaborations between government, faith-based health services and leaders of faith communities had little impact; to identify novel approaches to develop effective messaging that resonates with local communities. METHODS: A qualitative participatory research design, using a workshop methodology was deployed to seek opinions of an invited group of faith leaders in the DRC provinces of Ituri and Nord-Kivu. A topic guide was developed from data gathered in prior qualitative interviews of faith leaders and members. Topics were addressed at a small workshop discussion. Emerging themes were identified. FINDINGS: Local faith leaders described how misinterpretation and misinformation about COVID-19 and public health measures led to public confusion. Leaders described a lack of capacity to do what was being asked by government authorities with COVID-19 measures. Leaders' knowledge of faith communities' concerns was not sought. Leaders regretted having no training to formulate health messages. Faith leaders wanted to co-create public health messages with health officials for more effective health messaging. CONCLUSION: Public trust in faith leaders is crucial in health emergencies. The initial request by government authorities for faith leaders to deliver set health messages rather than co-develop and design messages appropriate for their congregations resulted in faith communities not understanding health messages. Delivering public health messages using language familiar to faith communities could help to ensure more effective public health communication and counter misinformation

Fragile and conflict affected states: report from the Consultation on Collaboration for Applied Health Research and Delivery

Fragile and Conflict Affected States present difficult contexts to achieve health system outcomes and are neglected in health systems research. This report presents key debates from the Consultation of the Collaboration for Applied Health Research and Delivery, Liverpool, June, 2014

Supporting community health workers in fragile settings from a gender perspective: a qualitative study

Objective To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. Setting Two districts in three fragile countries. Sierra Leone—Kenema and Bonthe districts; Liberia—two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)—Aru and Bunia districts in Ituri Province. Participants and methods Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). Results While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. Conclusions Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre