Democratic Republic of Congo’s Looming Measles Crisis: Public-Private Partnerships as a means of Prevention

This publication will focus on the role of the public and private health sectors in meeting current health sector demands and discuss the feasibility of public-private partnerships as a means of preventing an impending measles crisis. It posits that stronger inter-sectoral public-private partnerships are required for the DRC to effectively control a measles outbreak. The publication will explore the nature of such partnerships and provide recommendations that the DRC government may employ to possibly utilize the model’s potential in mitigating and preventing a widespread measles outbreak in the country.

Introduction

On September 1, 2015, Doctors without Borders (MSF) published an article about the growing measles epidemic that had infected upwards of 20,000 people and claimed the lives of more than 300 in Katanga province, Democratic Republic of Congo (DRC).[1] Al Jazeera estimated the infected number to be much higher at 30,000 and cited efforts by the United Nations (UN) to intervene, releasing $2.4 million to the DRC government and humanitarian efforts in the region to attempt to curtail the spread of this highly infectious and yet easily preventable disease.[2] Measles, a viral infection characterized by high fever, runny nose, blotchy red skin rashes and inflamed eyes, is most common in children under the age of 5 and is easily preventable through a standard vaccine.[3] Left untreated, the disease can lead to complications like blindness, encephalitis, severe diarrhea, and respiratory infections like pneumonia, making it one of the leading causes of death among young children.[4] According to the World Health Organization (WHO), measles is particularly deadly in developing countries recovering from natural disasters or conflict where there are particularly weak health infrastructures and overcrowding in camps.[5] According to the WHO, 95% of measles deaths occur in low income countries without routine immunization and/or poorly nourished children; the cost of vaccinating a child against measles is USD$1 yet in 2013 alone, the disease claimed 145,700 lives.[6]

As the continent’s second most populous country, estimated at 71 million, the health care system of DRC is under immense pressure to deliver services. Years of civil and political conflicts following independence, and the subsequent economic collapse, have resulted in the further deterioration of hospitals and clinics particularly in the remote regions.[7] While infant mortality has fallen from 148 per thousand to 104 per thousand in the last five years, other challenges remain.  Malaria and Diarrheal Diseases are the top causes of death among children, despite having a large number of trained midwives and assisted deliveries being at 80 percent, the maternal mortality rate is very high at 846 deaths per 100,000 births, which suggests poor quality services. MSF have described the various disease epidemics in the country as a “permanent emergency,” having responded to infectious diseases such as malaria, measles, cholera, TB and HIV/AIDS in all 11 of the country’s provinces.[8] The 2015 measles epidemic is the second in the DRC in the last 5 years. From 2010 – 2013, the country experienced a measles epidemic with more than 262,000 recorded cases and 800 deaths.[9] The “endemic” nature of the measles epidemic in the country has brought into question the state of the country’s health system and its suitability to withstand another measles epidemic in 2015. The region’s remote geography, poor infrastructure and costly private health care continue to impede the provision of necessary healthcare solutions to curtail the outbreak. Drawing on the country’s response to a measles outbreak in 2011-2013, this publication will focus on the role of the public (government-funded health services) and private (non-governmental, often charity-based health services) health sectors in meeting current health demands and discuss the feasibility of public-private partnerships as a means of preventing an impending health crisis. The publication will explore the nature of such partnerships in Congo and provide recommendations to increase the efficacy of these partnerships in mitigating and preventing the further spread of measles. It posits that stronger inter-sectoral public-private partnerships are required for the DRC to effectively control a measles outbreak.

The current status of healthcare services in the DRC

After nearly two decades of protracted conflict, the health system in DRC, like many other sectors of the country, is vastly underdeveloped. With a life expectancy of 49.96 years and a health expenditure of only 8% of GDP, the country is ranked as second to last on the Human Development Index.[10] Access to its cost recovery public health sector, is difficult for a majority of the population. Statistics show that 63% of the population live below the poverty line,[11] while the health care system is only able to provide 0.4 hospitals per 100,000 people and 0.11 physicians per 1,000 people.[12] As such, the existing health care services are largely dependent on international organisations such as UNICEF, World Bank, WHO and the CDC for technical and financial assistance; Donor aid accounts for one third of the country’s total funding for health services.[13] Poignantly, the health sector is also the largest recipient of aid in the country with 46 out of the 103 developmental projects in the country dedicated to health-related development.[14]

Health care in the DRC is divided into three levels: central/national, provincial and peripheral. The central/national government level sets policies and regulations, overseas health services run at the provincial level and provides tertiary care; the provincial level is divided into 11 provinces and 65 health districts and oversees local health care where primary health services are provided.[15] In 2010, the DRC spent a total of $1 billion on healthcare, 43% of which came from government spending, 36% from households, and 22% from other sources.[16] During the period, 2011 – 2013, the government spent approximately USD$5 million on routine immunization and $3 million on vaccines, about 7% of the total amount spent on both factors by all sources.[17] Despite high levels of spending both by the government and private actors on preventative measures against viruses like measles, such levels of spending on vaccines and routine immunization only covered 73% of children against measles in 2013, effectively leaving the remaining 27% vulnerable to outbreaks.[18] A study commissioned by the European Commission Humanitarian Office produced much lower estimates of 40% nationally, and 50% at visited sites.[19] Providing immunization in remote geographic regions such as Katanga province, are further challenged by poor infrastructure.[20]

These problems were particularly acute in the 2010-2013 measles crisis that claimed the lives of about 800 people and infected more than 200,000 people.[21] Several studies that examined the outbreak and subsequent response consistently found accessibility (to remote regions), lack of routine immunization, and logistics (availability of families for vaccinations and transportation of heat-sensitive vaccines) to have played significant factors in the failure to curtail and prevent measles outbreaks.[22] MSF particularly identified the lack of adequate infrastructure, in terms of roads to access remote villages, and breaks in the cold chain, “the logistical network” used to preserve vaccines, as major obstacles to attaining the vaccination coverage sufficient enough to isolate the outbreak.[23] The lack of free health care also prevented families from seeking medical help for their infected children.[24] These conditions were further exacerbated by underperforming national routine vaccination campaigns that would prevent an outbreak; the reactionary nature of these programs are costly to both the government and donors and fail to produce the required coverage in time to prevent further infections.[25] Underlying these problems are other systemic issues of instability and conflict, malnutrition, and extreme poverty.[26]

 

Despite all these aforementioned obstacles, the 2010-2013 measles crisis also highlighted the importance of private sector health initiatives to curtail a measles outbreak. As mentioned earlier, health in the DRC is the most heavily donor-funded sector, with UNICEF currently placing their funding projection for 2015 at $132 million.[27] In 2012, USD $56 million was spent nationally on immunization programs – 49% of those funds came from the GAVI alliance, a public-private partnership organization that works to make vaccines accessible for children in poor countries; the World Bank was the second largest donor at 25%, the UN Children’s Fund (UNICEF) contributed 9%, and the WHO 5%, whereas the DRC government contributed 8%.[28] The government contributed an even lower amount for immunization campaigns, accounting for only 2% of the USD$39 million spent on immunization campaigns, whereas the WHO and UNICEF contributed 56% and 41% respectively.[29] During the 2010-2011 measles crisis, private health care providers, such as MSF, were particularly instrumental in controlling the outbreak. MSF, for example, embarked on a mass campaign to vaccinate isolated communities in the north that were also harbingers of the crisis. In order to limit new infections, 95% of the target population (6 month to 15 year old children in this case) in the affected area had to be vaccinated; in order to meet such high rates in high risk areas, as many as 400 – 500 children were vaccinated in a 24 hour period to prevent new infections.[30] MSF also provided operational and technical support to local hospitals by treating infected patients and participating in the vaccination of over 4 million people the two year period after the epidemic in 2010.[31]

Private-Public Healthcare Partnerships: Possibilities for Progress

It is apparent that the current health public-private partnerships in DRC are characterized by a government that is largely dependent on the private sector for the provision of necessary medical services, including routine immunization and vaccination programs. GAVI, the largest funder of immunization programs in the country, also provides operational support to the government in terms of civil society organizing, strengthening the health system, and supporting immunization services, among others; The WHO and UNICEF provide further technical assistance with the integration of new vaccines into the national government’s routine immunization program to ensure the necessary targets are set and met.[32] Despite these contributions, the government’s Expanded Program for Immunization (EPI) still suffers from systemic failures of vaccine shortages, undertrained health workers, neglected cold chains, ill-functioning equipment, and unreliable data collection and management systems.[33] The private-public partnerships themselves also suffer from poor financial and operational coordination among donors and with the government that inhibit coherent, collective and effective responses when an epidemic arises.[34]

The 2015 measles outbreak thus presents itself as an opportunity to learn from previous failures to ensure that the epidemic is curtailed before it claims more lives. While preventative vaccination campaigns in the wake of the 2010-2013 measles epidemic were successful in curtailing the crisis, their reactive nature is neither sustainable nor advisable as a long term solution; A more practical solution would be to ramp up routine immunization efforts in high risk areas prior to the confirmation of measles outbreaks. Given the difficulty that the government faces in providing routine immunization in remote regions like Katanga, where the measles vaccination rates was 51% in 2007, better coordination between public and private health providers is the only viable solution to reaching the requisite 93-95% immunization rate to prevent a measles crisis.[35] Technical information-sharing on vital components of preventative immunization efforts, such as cold chain maintenance, would significantly improve efforts to contain and eventually eradicate the virus. For example, MSF’s centralized cold chain system stores vaccines in insulated boxes at the requisite temperatures of between 2 and 8°C without refrigerators for up to 5 days, allowing them to transport vaccines to isolated regions that would otherwise be inaccessible and thus poorly immunized.[36] The adoption of such a simple and cost-effective solution by the national government in charge of routine immunization would address weaknesses in its EPI of neglected cold chains and ill-functioning equipment that contribute to poor immunization rates in poor countries.[37] Similarly, increased cross-sector investments to address confounding variables that contribute to measles outbreaks such as malnutrition and poor infrastructure from both the public and private sectors would go a long way in providing long-term solutions against measles outbreaks.

Measles, as an infectious disease, presents a significant threat to the health of individuals, their communities and the nation as a whole. Unmitigated health threats translate into health insecurities that have the potential to affect national and regional economic growth and stability. As such nations must prioritize the provision of adequate health care as both a national and regional concern. While adequate funding plays a significant role in positive health outcomes, preventative technical measures such as immunization, play a significant role in curtailing current and future health concerns. This paper has put forward recommendations to better utilise these private-public partnerships, as a means to provide much needed health services to the communities that require them. Effectively used, the current private-public healthcare partnerships can not only increase the efficacy of healthcare in the country but mitigate the effects of future outbreaks.

 

 

NOTES

[1] Medicins Sans Frontieres (MSF), “Democratic Republic of Congo: Katanga Measles Epidemic Keeps Worsening,” last modified September 1. 2015, http://www.doctorswithoutborders.org/article/democratic-republic-congo-katanga-measles-epidemic-keeps-worsening.

[2] Al Jezeera, “DR Congo Measles Epidemic ‘A Looming Crisis,” Al Jazeera, last modified September 3. 2015, http://www.aljazeera.com/news/2015/09/drc-measles-epidemic-halted-60-days-msf-150903073745198.html.

[3] Mayo Clinic, “Measles,” last modified on May 24, 2015, http://www.mayoclinic.org/diseases-conditions/measles/basics/definition/con-20019675.

[4] World Health Organization, “Measles Fact Sheet,” last modified November 2015, http://www.who.int/mediacentre/factsheets/fs286/en/.

[5] Ibid.

[6] Ibid.

[7] Democratic Republic of the Congo, Ministry of Health, “Health System Strengthening Strategy – June 2006.” Accessed September 30, 2015, http://www.who.int/management/country/cod/drcstrategy2006.pdf.

[8] MSF, “Democratic Republic of Congo: Condition Still Critical,” last modified Dec, 11, 2011, accessed on September 30, 2015, http://www.msf.org/article/democratic-republic-congo-condition-still-critical.

[9] Measles and Rubella Initiative Blog, “Democratic Republic of Congo,” last modified July 4, 2013, http://www.measlesrubellainitiative.org/democratic-republic-of-congo/.

[10] United Nations Development Programme, “Human Development Report: Congo,” accessed September 30, 2015, http://hdr.undp.org/en/countries/profiles/COD.

[11] Central Intelligence Agency, “The World Factbook: Congo, The Democratic Republic of The,” last modified November 19, 2015, https://www.cia.gov/library/publications/the-world-factbook/geos/cg.html.

[12] Sarah E. Boslaugh, “Congo: Democratic Republic of the,” in Health Care Systems Around the World: A Comparative Guide, 106 – 108. Thousand Oaks: Sage Publications Inc, 2013.  

[13] Rossi et al., “Evaluation of Health, Nutrition, and Food Security Programmes in a Complex Emergency: The Case of Congo as an Example of a Chronic Post-Conflict Situation.” Public Health Nutrition 9 (2006): 551- 556, accessed September 30, 2015. doi: 10.1079/PHN2005928; Boslaugh, “Congo, Democratic Republic.”

[14] NGO Aid Map, “Democratic Republic of the Congo,” accessed September 30, 2015, http://www.ngoaidmap.org/location/28?category_id=8.

[15] Boslaugh, “Congo, Democratic Republic.”

[16] Ibid.

[17] Sabin Vaccine Institute, “Feedback on Financial Indicators 6470-6520, WHO/UNICEF – Joint Reporting Form (JRF),” last modified September 2014, http://www.sabin.org/sites/sabin.org/files/DR%20Congo%20Financial%20Report%202006-13%20%28EN%29.pdf.

[18] UNDP, “Human Development Report: Congo.”

[19] Rossi et al., “Evaluation of Health.”

[20] MSF, “DRC: Innovative Vaccination Strategies to Respond to the Measles Epidemic,” last modified September 23, 2013.  http://www.doctorswithoutborders.org/news-stories/field-news/drc-innovative-vaccination-strategies-respond-measles-epidemic.

[21] Measles and Rubella Initiative Blog, “Democratic Republic of the Congo.”

[22] Cuesta et al., “Measles Vaccination Coverage Survey in Moba, Katanga, Democratic Republic of Congo, 2013: Need to Adapt Routine and Mass Vaccination Campaigns to Reach the Unreached,” PLOS Currents: Outbreaks, last modified February 2, 2015, http://currents.plos.org/outbreaks/article/measles-vaccination-coverage-survey-in-moba-katanga-democratic-republic-of-congo-2013-need-to-adapt-routine-and-mass-vaccination-campaigns-to-reach-the-unreached/; MSF, “DRC: Innovative Vaccine Strategies.”

[23] MSF, “DRC: Innovative Vaccine Strategies.”

[24] MSF, “Katanga Measles Epidemic Keeps Worsening.”

[25] Ibid.

[26] Rossi et al., “Evaluation of Health.”

[27] United Nations Children’s Fund (UNICEF), “UNICEF is Requesting US$132 Million to Meet the Humanitarian Needs of Children in DRC in 2015,” last modified January 22, 2015, http://www.unicef.org/appeals/drc.html.

[28] GAVI, “GAVI Alliance Tailored Approach for the Democratic Republic of Congo, 2013 – 2017,” accessed September 30, 2015, http://www.gavi.org/country/drc/documents/cta/gavi-country-tailored-approach-for-the-democratic-republic-of-the-congo-2013—2017/.

[29] Ibid.

[30] MSF, “DRC: Innovative Vaccine Strategies.”

[31] Ibid.

[32] Ibid.

[33] Ibid.

[34] ibid; MSF, “Measles: ‘There Are Clearly Systemic Failures in Measles Prevention Programs,” last modified June 16, 2010, http://www.doctorswithoutborders.org/news-stories/voice-field/measles-there-are-clearly-systemic-failures-measles-prevention-programs.

[35] Mancini et al., “Description of a Large Measles Epidemic in the Democratic Republic of Congo, 2010 – 2013,” Conflict and Health 8 (2014): 1 – 8, accessed September 20, 2015, http://www.conflictandhealth.com/content/8/1/9.

[36] MSF, “DRC: Innovative Vaccine Strategies.”

[37] MSF, “DRC: Innovative Vaccine Strategies.”

RECOMMENDED GOV-ENHANCEMENTS

 

For the DRC to reach the requisite 93-95% immunization rate to prevent a measles crisis the government should:

• shift from reactive action to preventative by ramping up routine immunization efforts in high risk areas prior to the confirmation of measles outbreaks,

• better coordinate public and private health providers in order to provide routine immunization in remote regions,

• increase sharing of technical information on vital components of preventative immunization efforts, such as cold chain maintenance. This would significantly improve efforts to contain and eventually eradicate the virus to transport vaccines to isolated regions that would otherwise be inaccessible and thus poorly immunized,

• increased cross-sector investments to address confounding variables such as malnutrition and poor infrastructure from both the public and private sectors would go a long way in providing long-term solutions against measles outbreaks.