Democratic Republic of Congo

The Democratic Republic of Congo (DRC) is a sub-Saharan African country with more than 50 million inhabitants. The socio-economic situation in DRC is especially problematic due to widespread armed conflict and monetary inflation. Government employees, including health care workers, contend with low and erratically paid salaries in certain regions of the country. Inflation has appeared to stabilize and armed conflict has abated following the ratification of a new constitution in 2005 and elections held in 2006.  

DR Congo is one of the 22 high-burden countries targeted by Stop-TB Partnership for achieving the 70% case-detection rate and 85% treatment success rate. In 2004, the burden of tuberculosis in DR Congo was 94,000 cases (all forms), which reflects a case-detection rate of just over 70% - using the WHO criterion. In the same year, the NTP reported a treatment success rate of 83% for new ss- patients registered in 2003. Given the vast size of the country and the extremely difficult infra-structure conditions this is an enormous achievement for one of the poorest countries in the world.

The political situation is currently volatile in this USAID declared fragile state, which poses a great challenge to the NTP and its partners.  In spite of almost achieving the global targets for TB control, the NTP is faced with significant challenges and is still very vulnerable because of its extreme dependency on external funding. The growing TB/HIV epidemic and the presence of well documented patients with MDR-TB pose a serious threat to the achievements of NTP.

Due to the vastness of the country and the weak national health system coordination and supervision in various areas of the country is weak. This also poses a threat to the reliability of the drugs supply system, which is almost entirely dependent on aerial transportation.

TBCTA Project 1 (2000-2006)

Objectives

• Contribute to the implementation of the 2001-2005 strategic plan, whose objectives were the following:
• Detect at least 70 percent of infectious TB cases through positive microscopy.
• Cure at least 85 percent of newly detected infectious TB cases.
• Reach 90 percent of the population with the DOTS strategy.
• Increased TB/HIV collaborative and MDR-TB activities
• Strengthen the capacity of the NTP Central Unit and TB control activities in eight poor-performing regions: Maniema, Sankuru, Kasa ï Oriental Sud, Kasa ï Occidental, Equateur Nord, Orientale Est, Orientale Centre and Sud Kivu.

Major TBCTA Accomplishments

• DOTS coverage in the eight regions covered by TBCTA ranged from 72 percent (in Orientale Est) to 92 percent (in Sankuru), for an average of 85 percent DOTS coverage nationwide.
• Case detection rates of smear-positive cases increased from 58 percent in 2001 to 77 percent in 2005, exceeding the global TB target of 70 percent. Treatment success rates also reached the global TB target of 85 percent in 2005.
• Capacity and performance of the national and regional staff was increased with participation in a number of trainings. Central Unit doctors (including two women) and regional coordinating doctors participated in the Cotonou International TB Course. The administration manager took a management class in Brussels, while Central Unit doctors took classes in planning, operational research, and managing TB/HIV collaborative activities.
• In addition to renovation and stocking (with supplies and microscopes) of the National Reference Laboratory, the laboratory network was strengthened through an investment in training for laboratory staff at all levels. Several biologists participated in the International Medical Mycobacteriology Course held at the Institut Pasteur in Algiers, two biologists from the National Reference Laboratory effected internships on bacteriology and other subjects in Antwerp. The head of the National Reference Laboratory participated in a course on Advanced Microscopy in Dakar and regional laboratory technicians effected internships at the National Reference Laboratory. Moreover, TBCTA assistance contributed to the establishment of an external quality assurance system and National Reference Laboratory supervision of regional laboratories.
• World TB Day activities were implemented throughout all 20 regions of the country, beginning in year two of the project, as well as TB-related radio and television programs in Kinshasa. These activities contributed to raising awareness about both TB among the general population and NTP-implemented control and care activities.
• A TBCTA-supported pilot project on TB/HIV collaboration enabled the NTP to establish a working group for the NTP and National AIDS Program, in addition to other partners. TBCTA support was also instrumental in the development of a TB/HIV co-infection care guide, the training of training of 45 nurses and laboratory technicians, and the availability of cotrimoxazole preventive TB treatment.

TB CAP Highlights DR Congo

Supervision visits for better management
In DR Congo, the NTP and Leprosy programs are combined at the intermediate (provincial) level and are supported by different international NGOs such as Action Damien and The Leprosy Mission International (TLMI). TLMI focuses its main activities on leprosy and is not involved with TB.

South Kivu is one of the provinces where TB/Leprosy activities are supported by TLMI. Years ago, South Kivu had no detailed TB action plan. It just had some TB activities diluted in many and diversified leprosy activities.

When TB CAP financial and equipment support started, communication (e-mail and telephone) between South Kivu province and the NTP central unit improved and frequent supervisory visits were conducted. Those visits were conducted for several purposes as outline below;

• Discuss issues regarding low performance of TB indicators: detection rate (36%) and success treatment rate (80%) in 2007;
• Emphasize on the high risk of continuing to spread TB and potential development of MDR TB on the general population because it is insufficiently detected and inadequately treated;
• Find out possible ways to improve the situation;
• Train the TB/Leprosy staff to set up a combined action plan for both TB and Leprosy;
• Elaborate a calendar for TB activities on a quarterly basis for better monitoring.

The final result is the incorporation of TB activities by South Kivu TB /Leprosy team which has now been translated into an action work plan for TB including the main problems with their causes, and indication of which health districts are concerned, the strategies and activities to put in place to solve the problems, the indicators and the budget to accomplish these activities.

The big challenge is now to integrate TB activities in four health districts (Minembwe, Itombwe, Hauts Plateaux and Mulungu) where there are problems related to insecurity, high staff turnover, inaccessibility due to environmental constraints (bad roads, high mountains) and insufficient or lack of training of health workers.

To reduce inaccessibility, TB CAP is in talks with the provincial MOH and NTP to create 2 sub co-ordination centers in the southern (Uvira) and the western parts (Shabunda) of South Kivu. Each sub co-ordination centre will be under the responsibility of a supervising nursing officer and a laboratory technician whose activities will be to regularly supervise 3 or 4 health districts around them and to procure drugs and laboratory reagents.

Training is scheduled at the end of November 2008 for all health workers (doctors, nurses and laboratory technicians). Meanwhile, at the end of June 2008, Minembwe district has started the integration of TB activities after the laboratory technician has been trained and the microscope and laboratory reagents procured. As a result, 12 TB patients have been detected. TB CAP submitted the problems related to insecurity and destroyed roads to the provincial council for development.

TB CAP Project Period (2005-2010)

Expected output(s)

• Increase the case-detection rate from 67% to 70% and the treatment success rate from 78 – 85% in South Kivu province
• Increase the case-detection rate from 67% to 70% and the treatment success rate from 78 – 85% in Maniema province
• Publish and distribute PATI 4 guide book and information supports
• Conduct training on TB/HIV care
• Conduct training for project coordinators on TB/HIV activities
• Reinforce laboratory capacity
• Reinforce supervision at the National level
• Reinforce the drugs management
• Follow up and evaluation
  

Current Status

The approval of DR Congo work plan did not occur until August 2006, so the implementation of above components began in project Year 2 (October 2006 – September 2007).