Angumu is a mountainous area in Ituri province, in northeast Democratic Repub- lic of Congo (DRC), near the Ugandan border. It is a remote place and reaching communities there can be challenging. The few roads that run through the mountain forest are reminiscent of dried riverbeds, uneven and full of loose stones that make driving difficult and slow, especially during the rainy season, when thick mud renders some of them impassable.

In 2018, violence and environmental disasters in neighbouring regions caused tens of thousands of people to move into Angumu. They found shelter in areas near villages and alongside roads, creating numerous camps for people who have been displaced, each housing several thousand people. At the time, Doctors Without Borders/Médecins Sans Frontières (MSF) estimated that over 42,000 people had been forced to leave their homes in search of safety, and so decided to launch an emergency response. Since then, the number of people who have been dis- placed in Angumu has risen dramatically and currently stands at nearly 80,000.

“THE PROJECT FOCUSES ON AN ADVANCED COMMUNITY APPROACH AIMED AT GIVING COMMUNITY MEMBERS OWNERSHIP OVER THEIR OWN HEALTH NEEDS.”

Frederic Manantsoa, MSF country coor- dinator in DRC, recalls the beginning of the response: “Once we arrived, we immediately saw there was a very high number of people with malaria, with very high mortality rates. We also noticed it was very difficult for people to access the necessary healthcare services because the region is so remote and mountainous. We thought if people cannot reach the healthcare facilities, then we must reverse the situation and bring healthcare services to the people.”

To do so in a sustainable way, MSF worked with the Ministry of Health to put in place a project based on strong community engagement.

“The project focuses on an advanced community approach aimed at giving community members ownership over their own health needs,” says Manantsoa. “There is extensive participation from both the Ministry of Health and the community. They are our partners, not beneficiaries that receive assistance. They are responsible for their own health and, as partners, they share responsibility in the project.”

This setup relies on three fundamental roles. The first are the community relays (known as RECOs). Their role is to help inform community members on various health issues including good hygiene and family planning; how to prevent diseases such as malaria and diarrhea and what to do in case someone becomes ill; and the medical services available to them in the area.

The RECOs are also listening and watching in their community, monitoring people’s needs and the general health situation. If someone needs medical attention, they are encouraged to see the community health site relays (RECOSITEs), the second role. The RECOSITEs have been trained in how to respond to cases of malaria, malnutrition and diarrhea, and can either administer basic treatment on the spot or refer people to a more advanced health centre.

The third role, the health site management committees (COGESITEs), coordinate all practical and administrative aspects around the community health sites, such as work schedules and ensuring services are free of charge. RECOs, RECOSITEs and members of the COGESITEs are volunteers elected by their own communities to carry out these important roles. They are trained and supported by MSF, in cooperation with the Ministry of Health.

MSF also provides supplies, trainings and follow-up support to the Angumu general regional hospital, along with seven health centres and 13 community health sites located near camps for people who have been displaced.

“When MSF arrived, we were confront- ed by a high number of severe cases [of illness] because people arrived at the hospital when they were already very sick,” says David Mahomou Nyankoye, the MSF nursing activity manager in Angumu.

“Now, community members are more aware and much quicker to seek care. They have become familiar with the community health sites system that we put in place. Now, they act early, before the disease becomes ad- vanced, and this has caused a clear reduction in the number of deaths.” Currently, the community health centres perform about 7,000 consultations each month.

FOCUS ON PREVENTION

In an environment where malaria is en- demic and living conditions are precarious, health prevention is extremely important. Since the beginning of the project, MSF has carried out large-scale preventative ac- tivities, such as a mass drug administration and indoor residual spraying, during which anti-malarial drugs are distributed to com- munities, homes and shelters are sprayed with insecticides and mosquito nets are distributed. By raising awareness about malaria and other diseases, the RECOs also play an important role in their prevention.

“I go door to door and show people good practices that can help prevent diseases,” says Pascal, who lives in the Ugudo Zii site for displaced people and was elected by his community to be a RECO.

“A lot of problems come from water that is not stored correctly, which then becomes a breeding ground for mosquitoes and can become contaminated and cause diarrhea and other health issues. Sometimes we gather people and talk to them about vacci- nations, family planning and the admission criteria in the health centres. I am proud of what I do and my community appreciates it. Proper hygiene practices and the right knowledge make a big difference.”

The RECOs are trained and supported by MSF health promoters (HPs).

“When someone asks me a difficult ques- tion that I don’t know how to answer,” says Pascal, “I go to the HPs so they can come with me and help give the right informa- tion to people. We organize our work and plan our activities together with the HPs.”

Working in partnership with the communi- ty can help prevent disease outbreaks.

According to Frederic Manantsoa, “This allows us to have early surveillance and alerts, so we can act in time to prevent outbreaks and other emergencies, or at least minimize as much as we can the need for emergency responses. With the very early management of simple cases in the community, we considerably reduce the number of complicated and severe cases needing treatment.”

SUPPORT TO HEALTH FACILITIES

At the health centres and Angumu gener- al regional hospital, MSF medical teams account for around 35 per cent of the staff and support the local Ministry of Health. MSF teams provide pediatric care for children up to 15 years of age, offer malaria treatment for all age groups, provide men- tal health support, reproductive healthcare including family planning and manage moderate malnutrition cases. To help people reach health facilities, MSF has put in place a referral system with motorcycles and ambulances that can quickly transport patients from the community health sites to the health centres or the hospital.

In addition, MSF offers support to survivors of sexual violence in cooperation with the protection committees present in each site for people who have been displaced.

Virginie Ucida fled conflict in the Musongwa area and arrived in the Ugudo Zii site for displaced people seven months ago. She is a member of the site protection committee.

“In a densely populated [camp for dis- placed people], women are very vulner- able and incidents of sexual violence are frequent,” says Ucida. “We work in close cooperation with the RECOs and together direct survivors to the RECOSITEs, who in turn contact MSF so the person can receive medical care and mental health support. All this is done confidentially and is very important because survivors tend to suffer from shaming and stigma. We are thankful for the support offered by MSF.”

COMMUNITY ENGAGEMENT NEEDED AT ALL LEVELS

The collaboration with the community is not limited to awareness-raising activities or to the management of patients with malaria, diarrhea and malnutrition. It also involves the construction of facilities and infrastructure, including the community health sites, latrines and wells, the distri- bution of essential items, such as soap and mosquito nets, and the management of drugs in community health sites.

Abdurakhman Bodian is the MSF health promotion manager in Angumu. He has witnessed the changes this approach has brought.

“When we began our response, MSF was doing everything, even the transportation of water in the community,” says Bodian. “That was not sustainable, especially since there are very few other organizations work- ing in Angumu. Today, we have managed to empower the community and we have arrived at the point where all construction and other logistical efforts are done in cooperation with them. MSF provides the necessary material and the community does the rest. Their participation is inclusive from the start, from the building to the management of the health sites.”

MSF is now working to further build community resilience and to help people become more autonomous when it comes to the management of all aspects of their health. The committees operating in the various sites for displaced people represent a good opportunity for MSF to decentralize certain aspects of the response and increase the level of community empowerment.

“I am proud of what I do, and my community appreciates it.”

“We are trying to create resilient mecha- nisms,” says Bodian. “Water sources and their chlorination can be managed by the hygiene committee, for example. We have to analyze the various components of the community and their capacity. Decentral- izing as many activities as possible in the community will make it more likely that the mechanisms will stay in place the day after MSF leaves.”