Child health in the Democratic Republic of the Congo : exploring subnational disparities and inequities in illnesses and mortality

Background: Today, sub-Saharan Africa accounts for a disproportionally high burden of deaths in children, with the Democratic Republic of the Congo (DRC) being one of the countries with the highest mortality burden. Ample evidence exists on what protective, preventive, and curative services need to be in place to end preventable deaths in children. However, context-specific sub-national data that can effectively guide public health interventions is scarce for the DRC. This thesis first explored causes of death and coverage of preventive interventions to give a broad understanding of inequities around child mortality. Based on these findings, a case study approach was taken to look in depth at system factors that contribute to diarrhoeal deaths.

Methods: In Paper I, household survey and health facility data were used to compare child mortality rates and coverage of key indicators known to lower child mortality at the provincial level. Conflict event data was further used to classify provinces according to conflict intensity to explore conflict exposure as a predictor for child health. Paper II used demographic and verbal autopsy data to empirically estimate the causes of and circumstances around deaths. Papers III and IV used focus group discussions, health facility audits, and knowledge questionnaires to understand the health system’s capacity for cholera surveillance and diarrhoeal disease case management in cholera hotspots.

Results: Paper I identified large disparities in child mortality and indicator coverages. Conflict was found to be a poor predictor of child health. Provinces classified as conflict-affected had both the highest and lowest under-five mortality rates and indicator coverages. Paper II (manuscript) identified infectious diseases as the main cause of death in children and adolescents 1month to 19 years of age. Most deaths occurred at home; however, the majority sought care in the days preceding death. Papers III and IV found low capacity for diarrhoea surveillance and case management, and that health facility providers, drug shop vendors, and traditional health practitioners are perceived as important providers of care and should be considered in health policy plans.

Conclusions: Sustained, and more equitable, health system strengthening efforts are needed to decrease sub-national disparities and end preventable deaths in children in the DRC.

List of scientific papers

I. Schedwin M, Furaha AB, Kapend R, Akilimali P, Malembaka EB, Hildenwall H, Alfvén T, Tylleskär T, Mapatano MA, King C. Under-five mortality in the Democratic Republic of the Congo: secondary analyses of survey and conflict data by province. Bull World Health Organ. 2022 Jul 1;100(7):422-435.
https://doi.org/10.2471/BLT.22.287915

II. Fumwakwau JK & Schedwin M, Hildenwall H, Alfvén T, Mapatano MA, King C, Mavinga DP. Mortality in children and adolescents in Western Democratic Republic of Congo – Analysis of verbal autopsy- and demographic data. [manuscript]

III. Schedwin M, Furaha AB, Elimian K, King C, Malembaka EB, Yambayamba MK, Tylleskär T, Alfvén T, Carter SE, Okitayemba PW, Mapatano MA, Hildenwall H. Facility capacity and provider knowledge for cholera surveillance and diarrhoea case management in cholera hotspots in the Democratic Republic of Congo - a mixed-methods study. Glob Health Action. 2024 Dec 31;17(1):2317774.
https://doi.org/10.1080/16549716.2024.2317774

IV. Schedwin M, Furaha AB, Hildenwall H, Elimian K, Malembaka EB, Yambayamba MK, Forsberg BC, Damme WV, Alfvén T, Carter SE, Okitayemba PW, Mapatano MA, King C. Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis. PLOS Glob Public Health. 2024 Mar 19;4(3):e0002896.
https://doi.org/10.1371/journal.pgph.0002896