Routine Health Care in the Time of Ebola

Health centers in Equateur province, Democratic Republic of Congo, use canoes to deliver vaccines and other health products to the millions of people they serve. (Photo by Freddy Nkosi, VillageReach)

Back in January, I sat in a cramped boat heading down the Congo River, into the heart of Equateur province, Democratic Republic of Congo (DRC). Among my boatmates were the Honorable Health Minister Oly Ilunga Kalenga, his cabinet, and some of their financial and technical partners—folks from the World Health Organization, UNICEF, and Gavi, the Vaccine Alliance. We were headed toward a collection of remote, riverside villages to see improvements in the primary health care infrastructure first-hand. Four months later Minister Kalenga would return to these villages to oversee crisis response teams. It would become ground zero in the fight to control a fast-moving Ebola epidemic.

Many of the rural communities of Equateur province rely heavily on the Congo River and its tributaries to connect its small villages to health centers. For local residents, the river can be the first barrier to access basic health services. If they can overcome geographical barriers, they may find another: a health center without vaccines and essential medicines. The DRC Ministry of Health is addressing these challenges head-on, prioritizing the accessibility and quality of basic health services for people living in remote villages across the country.

Last year, the DRC Ministry of Health turned to VillageReach, an NGO that aims to improve access to quality health care, which in this case meant supporting health centers in Equateur get the vaccines they needed, when they needed them. Ten years ago, the Mozambique Ministry of Health worked with us to set up a reliable supply of vaccines in rural villages, an effort that increased the number of fully vaccinated children by 25 percent in a five-year period.

Raj Panjabi, CEO of Last Mile Health, calls the health care access disparities in rural areas the “tyranny of distance.” That tyranny can be lethal. “Residents of remote communities are too often deemed not meaningful enough as consumers to garner private sector support, too expensive for nonprofit support, and too difficult for public sector support,” says Panjabi. “One billion people worldwide have no physical access to care due to distance from the health facility.”

Since proving the model in Mozambique, we’ve partnered with other governments to replicate our supply chain program. Our work isn’t wizardry—we build systems to get products to people. This requires discipline, usable data, trained professionals, and reliable transportation, which is no mean feat in an under-resourced health system. Investing in these systems builds resilient health systems and can help avert—or at least more quickly address—dangerous outbreaks. When the Ebola outbreak struck the DRC’s Equateur Province last May, it was within the first nine months of our work there, and we didn’t have infrastructure to dive headfirst into a life-or-death emergency response situation. What we did have, though, was expertise and strategic support for the hardest-to-reach areas. The Ebola response presented a high-stakes opportunity for the people we trained to demonstrate the immediate value of a strengthened supply chain to support essential health care delivery. In the end, these workers moved 30 tons of medicine to 57 health centers that serve more than half a million people.

Whether working in smallholder agriculture, girls’ education, or remote health care delivery, success in global development is measured by impact at scale. Our experience in the DRC during this recent wave of Ebola outbreaks gave me pause and made me take stock of the most useful lessons we’ve gathered over the years. Six stand out as broadly applicable to the leaders of NGOs working toward systems change in any region or sector.

• Governments must be at the center. It’s not always easy to partner with the government. Find those in government who can be trailblazers and take calculated risks. Government leadership inspires donors, technical partners, local organizations, and even individuals to coordinate actions with urgency. In DRC, Minister Kalenga’s vision to strengthen primary health care systems has aligned all partners around common priorities and investments, setting the stage both for long-term change and rapid response to emergencies.
• Embrace change. Almost as soon as the May Ebola outbreak was declared over, another more-deadly one started in August. Whether it’s a disease outbreak, a flood due to climate change, or a shift in political power, change is a constant. As organizations and individuals, we must decide to embrace and even shape the changes that confront us in daily work.
• Know your role. At VillageReach, we have found that bolstering government leaders and larger implementation partners can be the more-effective path to change at scale, even if it places VillageReach behind the scenes. When the May Ebola outbreak happened in an area where we had capacity, relationships, and resources, we decided not to respond directly to the emergency. Instead, we applied our supply-chain expertise to organize the distribution of essential and generic medicines in health districts affected by the outbreak and surrounding areas.
• Start with the hardest communities to create a resilient model. We often begin our work in the most geographically or socially difficult-to-reach communities. This helps us develop a resilient model that we can readily adapt to other, less challenging areas. In high-need, resource-constrained environments, you need to move quickly to put in place contextually appropriate systems. In DRC, we implemented a direct-delivery model, bringing medicines and supplies to health workers rather than having them leave patients for days to retrieve them from the provincial warehouse.
• Drive toward systems change. Technical solutions are necessary but not sufficient. Only when you recognize the political, operational, and financial constraints can you build strong systems that sustainably support the last mile. The latest Ebola outbreak is the ninth in DRC. We must connect programs to policies, as we are doing in partnership with the DRC government, to reliably deliver health services even in the face of crises.
• Replicate what works. Our work in the DRC builds on years of refining our model in Malawi and Mozambique—optimizing supply chains and health care delivery logistics and handing over those innovations for ownership by local and national governments. An innovative solution is a great start, but there is dire need for successful replication of solutions with impact in new geographies.

On the Congo River back in January, Minister Kalenga told me he planned to visit a province every month for a first-hand look at the realities of health service in remote areas. While we motored through the Ingende health zone of the Equateur province, villagers paddled by in wooden pirogues—a handcrafted canoe, hollowed out from the large trees that line the forested river banks. Every 10 to 15 minutes we passed a small village—a few wooden structures on stilts built high above the water line to guard against floods.

Rural health workers here routinely travelled more than 100 kilometers by canoe or on foot to collect vaccines—trips that can last three days. Now, health workers receive vaccine deliveries at their facilities, saving them these monthly journeys. This keeps health providers where they’re needed most—in rural, underserved communities. They have greater capacity to provide critical primary health services. These services are the foundation for good health: immunization, pre- and post-natal care, family planning, nutrition, treatment, and referrals.

Even during a worsening Ebola crisis that could have paralyzed operations, supply chain workers have successfully executed the same distribution of essential medicines every two months. We’ll continue to build health delivery resilience with the government in DRC to withstand Ebola, and the next crisis when it hits.

On that trip down the Congo I met Richard Molango, who manages a health center in Equateur. The lapping river comes up to the door of his tiny center, and even higher during floods. Still, the fridge and pharmacy were well organized, consumption and stock levels neatly posted on the wall.

“I used to travel on a monthly basis to the Lolanga health district office to collect vaccines,” he told me. “That 24-mile journey takes 9 hours on a canoe. I can now use that time for outreach activities.” Richard has more than doubled the outreach sessions per month, finding and vaccinating more children in the 11 rural villages his health center serves.

Read more stories by Emily Bancroft.