Good Health
READ THE STORIES: Health Systems Resilience through Local Solutions in DRC | Universal Health Coverage on the Horizon in Namibia | Evidence Informed Response to Infectious Diseases in the U.S. | Modernized Access to Dietary Supplement Information in the U.S. | Millions Protected from Malaria
Health Systems Resilience through Local Solutions in DRC
Two provinces in the Democratic Republic of Congo (DRC) are trying to bridge the yawning gap between potential wealth and the nation’s critical health needs. Haut-Katanga and Lualaba provinces are doing it through their approach to localization—too often a platitude, not a practice. How? By making wise use of tax money from the controversial mining industry, which faces pressure from DRC collaboration with donors, civil society, and the private sector to improve its practices.
“No matter if we are here or not, these communities are finding solutions for their own problems.” says Dr. Diarra Houleymata, Abt Global’s chief of party for the U.S. Agency for International Development (USAID)-funded Integrated Health Project (IHP) in the DRC. “We need to really build on the systems they have already, not bring something external, which is not working for them at all.”
The country has always possessed two major reservoirs of potential: a diverse and vibrant population, which now totals nearly 105 million people, with deep cultural legacies, entrepreneurial spirit, and resilience; and vast mineral wealth, including significant deposits of cobalt, copper, diamonds, gold, tantalum, and tin. The DRC recently has seen a surge in mining investment. “Local revenues are not very considerable compared to the revenues from our mineral resources,” says Sebastien Mwape Kabinda, chief of the Bukanda sector in the Haut-Katanga province.
Mining company taxes provided funding in both Haut-Katanga and Lualaba, mostly for local development projects such as infrastructure, schools, and other local projects. Everything but health, it seemed. Yet “health is the priority of priorities for us,” Kabinda notes.
So, the Abt-led IHP program developed advocacy partnerships with provincial health divisions to persuade local governing bodies called Decentralized Territorial Entities to shift a larger chunk of spending to healthcare. The initial commitment in 2020 came to $684,500. Then the momentum picked up. Between late 2022 and 2023, a series of 18 advocacy meetings with local officials aimed to convince them of the pressing needs of the health zones and to rally even more support for addressing health coverage gaps. At the end of the meetings, the officials invited the chief medical officers of the health zones to take part in drawing up annual investment plans for each zone.
“This advocacy was of paramount importance,” says Dr. Claude Ngoikitenge, chief medical officer for the Kipushi health zone.
The IHP-supported advocacy partnership brought together local development committees for Kaponda and Bukanda to plan together. These efforts set in motion a plan to support health priorities in 2023 and 2024 and helped the funding for health in those health zones surge to $22.5 million in 2023. “USAID has helped us a lot by playing the role of facilitation,” Ngoikitenge says.
The money financed health infrastructure, drilling of water points for access to potable water, delivery of medicine, and provision of fuel to support mass campaigns in remote areas. The investments spanned 29 health centers and three health posts. Local officials bought medical equipment, medicine, five ambulances, two mortuary refrigerators, and 19 motorcycles for supervision and vaccine transportation. The funding also goes to helping people internally displaced by mining and DRC’s civil strife. In the last quarter of 2023, the Abt team and its local partner, Ambassadors for the Fight Against Tuberculosis, reached more than 15,000 people living in camps with health campaigns that raised awareness of communicable disease symptoms.
This approach for domestic resource mobilization may be replicable in other areas with large mining sectors. But mining revenue doesn’t exist everywhere, of course. There may be other sources like agriculture, fishing, or textiles that can enable a locality to replicate and scale a similar approach. And that’s the point. Strategies should be tailored to the local context. What should be the focus of strengthening local systems is local control of the revenue and decisions on how to spend it based on local needs.
Over the past six years, Abt and its partners have worked with the Ministry of Health to strengthen local health planning in several districts and foster coordination between health and other local officials. The goal is to expand access to and use of local funds to address local health needs.
Our integrated approach helps strengthen the capacity of local partners covering a broad spectrum of the DRC’s health needs: nutrition; malaria; family planning; reproductive, maternal, newborn, and child health; tuberculosis (TB); COVID-19; and water, sanitation, and hygiene (WASH) — all with a focus on health system sustainability. “We have strengthened their capacity to enable them to provide quality care even in remote places and places of insecurity,” says USAID IHP Deputy Director Narcisse Embeke. “Even after the program, they will be able to continue to provide care to the vulnerable population at all levels.”
Malaria, the DRC’s leading cause of maternal and child morbidity and mortality, is a particular challenge. Nearly all of the population lives in high malaria transmission zones. That’s why USAID IHP has made a big push on malaria treatment, including awareness campaigns that included screening and referrals for free care. From October 2022 to September 2023, the project supported local partners who provided care to nearly 4 million children under five in nine provinces, a 38 percent increase since 2017.
It’s impossible to overstate the importance of local community, person-to-person touches. Consider how Lomami Province dealt with COVID-19. Like most of the DRC, the province faced stubbornly persistent COVID-19 infections. Vaccination campaigns, which are relatively short, were relatively ineffective. What Lomami needed was a system of routine, ongoing vaccinations.
That’s what USAID IHP and its partners help provide. We supported the Lomami’s Macici Health Center by transporting vaccines, advanced vaccine strategies, management and awareness-raising tools, and materials and equipment for infection prevention and control. What made the difference, though, was strengthening grass roots community involvement in the vaccination effort. We regularly shared vaccination updates with health zone officials and providers while strengthening capacity in scores of facilities. As a result, 51,928 people achieved complete COVID-19 vaccination status, with 175 vaccination sites in seven provinces participating.
Local eyes and ears play a critical role in combatting TB, too. In the DRC, the stigma attached to TB makes people reluctant to seek care. It’s associated with HIV and poverty, and the risk of transmission is high. This makes it hard to detect, diagnose, and treat the disease.
But this is changing, even as cases of drug-resistant TB increase. The reason: our focus on communities through our collaboration with the National Tuberculosis Control Program. We focus on influencers such as pastors, teachers, traditional chiefs, and women’s and youth groups, who encourage people to get screening and treatment. We also provide integrated services such as nutrition kits to promote community engagement. In addition, the project awarded nearly $5 million in grants to nine local non-governmental organizations (NGOs) to identify potential TB patients and ensure follow-up treatment. The money has enabled NGO Batwa Bemba Oluwamie, for example, to expand its community connections. “The more you spend time with the community and understand the problem, the more you can find solutions,” says Biguette Bountouki-Lombouchi, national coordinator and founder of Batwa Bemba.
That’s the essence of locally driven solutions. Not every country or province has minerals to mine. But all of them can invest in another resource: their people—those with the local knowledge to design, tailor, and implement workable ways to address challenges—and will reap the benefits of the solutions.
LEARN MORE: USAID Integrated Health Program in the DRC
PROJECT: USAID Integrated Health Program
CLIENT: U.S. Agency for International Development (USAID)
Universal Health Coverage on the Horizon in Namibia
The Government of the Republic of Namibia can point to many strengths in its health system. Tax-funded, public health services cover over 80 percent of the population, with most services available for free or minimal charge. A well-developed private health system funded through voluntary insurance covers about 20 percent of people. And there is a large network of primary health care facilities spread across the vast but thinly populated country, with links to district and referral hospitals.
Nevertheless, there are gaps—notably in the quality and availability of care, both of which can vary—and until recently, there was little energy behind efforts to develop a policy to guide improvements. A draft universal health coverage (UHC) policy crafted by a Ministry of Health and Social Services (MoHSS) unit in 2019 received no external input and was never endorsed by ministry leadership.
Universal health coverage (UHC), as defined by the World Health Organization, means that “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.” Advancing UHC as a global priority was codified with the 2030 Sustainable Development Goals (SDGs): SDG Target 3.8 is to achieve universal health coverage. Unfortunately, progress has stagnated since 2015 in many countries. But in Namibia, efforts to make UHC a reality have regained momentum in the past two years.
In 2022, the Abt-led USAID Local Health System Sustainability Project (LHSS) began working with the government of the Republic of Namibia with renewed focus. And now, thanks to LHSS facilitation, the government is on the verge of approving a new draft UHC policy and a detailed roadmap to implementing it.
Reaching this pivotal point was made possible by LHSS’s ability to re-engage working groups and strengthen the MoHSS’ capacity to engage with multi-sectoral stakeholders on health financing reform. First, the LHSS team took a multi-faceted approach to capacitate the MoHSS to lead these national reform processes. This included the establishing multisectoral UHC governance structures including platforms for engagement at both technical as well as political levels, as well as creating and staffing a dedicated health financing division, which helped the MoHSS manage more consistent and extensive stakeholder engagement. There were trainings to help staff understand the governance structures, and continuous mentoring of key ministry staff.
LHSS then facilitated UHC consultations with key stakeholders, including MoHSS directorates, other Ministries, parliamentarians, private sector, academia, civil society, and development partners. This stakeholder engagement approach to formulating the policy was a stark contrast to the Ministry’s well-meaning but isolated efforts in the past. The result was the development of a comprehensive health financing policy brief, draft UHC policy framework, and a list of prioritized services for possible inclusion in the Essential Health Services Package, which were presented to key stakeholders at a UHC technical meeting in August 2023. The last step is to gain approval from MoHSS leaders and the Cabinet of the Government of the Republic of Namibia, expected in 2024.
“One of the remarkable aspects of the drafting process was its inclusivity,” said L’Oreal Tjiueza, Manager of Insurance & Medical Aid Funds for the Namibia Financial Institutions Supervisory Authority. “Involving health care professionals, policymakers, regulators, medical aid funds, civil society organizations, and representatives from diverse organizations ensured a comprehensive understanding of the challenges and opportunities in health care.”
The draft UHC policy lays out four priority areas:
- Remedying gaps in quality of care, such as reducing wait times and providing patient-centered care
- Addressing persistent health disparities associated with limited access to health services for people in certain geographic areas and socioeconomic groups
- Ensuring widespread availability of preventive and promotive health services at the community level and specialized care at the national level
- Strengthening domestic public health sector financing to sustain and improve access to equitable, quality services for those who rely on public health services.
Likewise, the roadmap contains specifics of how the government will address these issues, reach its goal of UHC, and improve the health of its people.
The prominence of the UHC agenda has increased substantially over the years and UHC reform efforts are receiving substantial support from senior management and political leadership. The private sector had initially been very skeptical about the UHC reforms due to concerns about their own financial sustainability and continued profitability. However, the reiterative and consultative engagement approach has laid many of those fears to rest and has brought some of these stakeholders on board as key partners in the reform process.
Like his counterpart Ms. Tjiueza, Albert Tjaronda of the Ministry of Health’s Policy and Planning Directorate praised the broad stakeholder engagement that revitalized the UHC policymaking effort. He said:
Collaborating with partners and stakeholders to develop our country’s universal health coverage policy offers the advantages of shared expertise, increased access to resources, and a more comprehensive and sustainable healthcare system that ensures better health outcomes for all citizens.
The momentum behind the UHC agenda motivated other MoHSS directorates to also focus their efforts on the goal of improving equity in access to care, with a particular focus on healthcare at the community level where access to health is often limited due to the vast distances to health facilities. And so, LHSS engaged stakeholders to accelerate progress towards a robust social contracting policy. This policy, fundamental to advancing the UHC agenda, secured Cabinet approval quickly and launched in late 2023. This marked a pivotal moment for the sustainability and responsiveness of Namibia’s health system, allowing the Ministry to contract civil society organizations, who are often closest to the communities they serve, to provide health and HIV services.
Achievements like these are not rare on LHSS, USAID’s global flagship initiative for integrated health systems strengthening. Collaborating with diverse health system partners is core to our approach to strengthen local capacity to finance, provide equitable access to, and ensure the quality of essential health services. In 2022-2023, we worked to strengthen health systems in 27 countries in partnership with 720 local collaborators, grantees, contractors and technical assistance recipients.
LHSS’ goal is to support countries’ transition to sustainable, self-financed health systems on the path to expand universal health coverage. And countries like Namibia are on the road to success.
LEARN MORE: Local Health System Sustainability Project | Empowering Namibia’s Health Care Future | LHSS Work in Namibia | LHSS Year 4 Annual Report
PROJECT: Local Health System Sustainability Project (LHSS)
CLIENT: U.S. Agency for International Development (USAID)
Evidence Informed Response to Infectious Diseases in the U.S.
It’s what they had long trained for—and hoped never to experience: a global COVID-19 pandemic that would cost millions of lives. When COVID-19 emerged on the world stage, Abt Global researchers tracked SARS-CoV-2 transmission for the Centers for Disease Control and Prevention (CDC) using, among other techniques, polymerase chain reaction (PCR) testing at a time when little was known about COVID-19. We used a network of prestigious clinical organizations established in 2013 to monitor novel flu viruses and eventually also tracked vaccine effectiveness.
Our rigorous data gathering produced a score of oft-cited journal articles that had a huge impact on national policy and science. More importantly, we assessed how COVID-19 operates in real world settings. And through regular testing of participants, we were able to track asymptomatic and mild cases that didn’t require a doctor’s visit and so weren’t necessarily entered in health records. Many studies rely on health records for data and miss what Abt detected.
On September 30, 2023, Abt ended its six COVID-19 studies, including Research on the Epidemiology of SARS-CoV-2 in Essential Response Personnel (RECOVER) and Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT). The RECOVER study was the first to validate, in March 2021, the effectiveness of the mRNA vaccines in real-world conditions. The study received front-page media coverage in both the New York Times and Washington Post and more than 500 other news outlets. Ongoing research through the PROTECT study validated the effectiveness of the vaccines in children.
Both study platforms confirmed waning effects of vaccines over time and against the Delta and Omicron variant and measured real-world effectiveness of boosters. These findings were among the key data sources used by CDC’s Advisory Committee on Immunization Practices to inform vaccination recommendations. The findings also contributed to CDC guidance on vaccinations and boosters. The studies were the only CDC-funded large multi-site study in the U.S. that included weekly PCR testing for COVID-19, which is both accurate and reliable, regardless of whether participants had symptoms. This made our results among the few windows into COVID-19 infection incidence regardless of symptoms and acted as an early indicator for new waves and variants. CDC and the White House COVID-19 task force used these indicators to inform other guidance such as masking during the public health emergency.
Over the three years of the studies, the Abt team along with CDC and study partners published 20 research articles in major scientific journals, including the New England Journal of Medicine, which have jointly been cited 1,800 times, and analyses continue. While rapid interim data deliveries to the CDC occurred weekly during peak periods, in the last two weeks of September 2023, Abt ultimately delivered final RECOVER and PROTECT datasets consisting of over 500,000 records and 429 million data points for use in ongoing and future analysis.
More than 300 news organizations, including CBS and Forbes, quoted Abt Principal Investigator Lauren Olsho explaining the scientific contribution of PROTECT:
Other pediatric vaccine effectiveness studies relied on lab testing data or health records and generally captured only cases where a child had symptoms and received health care. With increased use of home rapid testing, studies like ours are needed to provide more comprehensive information on rates of infection and vaccine effectiveness.
Given the prospective and longitudinal nature of RECOVER and PROTECT, the studies were an important resource for the early evaluation of COVID-19 vaccine effectiveness and directly informed national policy during the public health emergency. They informed CDC guidance on masking and recommendations for primary and booster COVID-19 vaccine doses. Abt routinely delivered complete, processed data files to CDC within three days of data collection and on request we accelerated deliveries to within 24 hours in response to urgent policy needs. This enabled CDC to capture emerging trends in near-real time and act on it.
Background on the COVID-19 RECOVER and PROTECT Projects
Abt led RECOVER study data collection under a contract with CDC since April 2020, shortly after SARS-CoV-2 began actively circulating in the U.S. RECOVER was originally designed to estimate the incidence of symptomatic and asymptomatic SARS-CoV-2 infection among health care workers in the U.S. and later included first responders and other essential and frontline workers. After emergency use authorization of Moderna and Pfizer-BioNTech COVID-19 vaccines in late 2020, study objectives expanded to include assessment of the effectiveness of COVID-19 vaccination. RECOVER evolved to provide scientific evidence to address new problems as they emerged during the pandemic, such as the impact and presentation of additional variants, antibody response to vaccine or natural infection, and long COVID. In April 2021, in anticipation of the pending availability of pediatric COVID-19 vaccines, RECOVER expanded to include PROTECT, which collected data from children aged 6 months to 18 years.
RECOVER operated in six locations and enrolled 4,300 participants whose occupations placed them at high risk of exposure to COVID-19. PROTECT recruited nearly 1,000 pediatric participants. The studies collected survey data on participant demographics, medical history, and vaccination history at enrollment and throughout the study. Participants self-collected nasal respiratory specimens each week to be tested for SARS-CoV-2 infection and routinely provided blood, including after a SARS-CoV-2 infection or COVID-19 vaccination.
LEARN MORE: Abt Played a Key COVID-19 Role Providing CDC Needed Data | CDC COVID-19 Surveillance Project
PROJECT: Research on the Epidemiology of SARS-CoV-2 in Essential Response Personnel (RECOVER) and Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT)
CLIENT: U.S. Centers for Disease Control and Prevention
Modernized Access to Dietary Supplement Information in the U.S.
The majority of American adults take dietary supplements, and the $20.5 billion-a-year market for these products continues to grow. In the U.S., dietary supplements are regulated by the Food and Drug Administration (FDA) as food, not as drugs, and do not require approval or safety testing before they enter the marketplace.
That is why Congress called on the National Institutes of Health (NIH) Office of Dietary Supplements to create the Dietary Supplement Label Database (DSLD) for capturing and tracking the growing number of supplements and to help understand the constantly evolving landscape, product ingredients, and claims.
The DSLD brings all information printed on individual product labels into a single, searchable database, making it easier for researchers and others to find information they need to make informed decisions. For example, researchers can use the DSLD to inform studies on nutrients and supplements, while health care providers can better understand products their patients take. And consumers can learn more about supplements and their ingredients by searching for information in the DSLD.
Abt developed the original database prototype for NIH in 2008, and the DSLD went live in 2013. When it was initially launched, the database included just under 17,000 dietary supplement product labels. We refresh it monthly to include more products from the ever-expanding market. By early 2024, there were over 186,000 labels in the system, with nearly 2,000 new labels still being added each month.
Abt has supported DSLD modernization efforts in recent years to enhance the user experience, provide faster database searches, and enable better access to data. The DSLD now contains an updated directory of linked dietary supplement resources from federal agencies and other sources. We also made sure the database has an application programming interface (API) so that application developers and data scientists can directly access the dietary supplement label data. The modernized cloud-based platform is scalable to NIH’s future needs.
In addition to modernizing the web application, we have worked closely with NIH to broaden the way DSLD can be used in answering research questions. For example, in 2022, we started routine web-scraping of data from mega-retailers like Amazon and Walmart to identify in real time best-selling dietary supplements and maintain a record for investigation into specific research questions. The scraping helps NIH prioritize supplements to enter into the DSLD, plus gain insight on the types of ingredients (and their amounts) in consistently best-selling products across popular categories.
Abt’s data scientists assist NIH in publishing dietary supplement research and in increasing the interoperability of DSLD with other federal data sources to streamline research and analysis across the government.
With Abt’s support, the Office of Dietary Supplements closely monitors the use of the DSLD to identify and roll out new features and site enhancements. The number of DSLD users nearly doubled after the launch of the updated website in 2021. The API receives nearly 4.5 million hits each month (requests for individual labels or searches count as a “hit”), indicating that users access DSLD routinely and consistently. And as of April 2024, more than 200 publications have referenced or cited DSLD.
We also know that other federal agencies use the DSLD regularly. For example, the DSLD helps the U.S. Department of Defense determine if product labels list any ingredients that might positively or negatively affect the health and performance of service members. The DSLD assists the U.S. Food and Drug Administration in reviewing ingredients and the multitude of claims listed on product labels. And it helps guide the U.S. Department of Agriculture’s ongoing efforts to analyze how actual levels of ingredients found in common supplement types compare with levels printed on labels by manufacturers. DSLD is also used by the Centers for Disease Control and Prevention to understand the supplements that U.S. citizens report consuming in national-level dietary intake surveys.
We have learned several lessons about how the DSLD can expand its value to users. By attending monthly federal workgroup meetings, Abt gains valuable insight into ways we can enhance the reach and impact of DSLD as a leading federal research tool. And, by regularly monitoring user inquiries and conducting user interviews, we learn about the various ways that researchers and the public use DSLD. The resulting insights inform the implementation of site enhancements.
Given the rapid pace of change in the dietary supplement market, continued updates and enhancements to the DLSD are imperative to expand its reach and value. It’s how DSLD can achieve its goal: being a recognized and valued resource to make information readily available to those who need it, when they need it.
LEARN MORE: Modernizing NIH’s Dietary Supplement Label Database | Dietary Supplement Label Database
PROJECT: Dietary Supplement Label Database
CLIENT: U.S. National Institutes of Health
Millions Protected from Malaria
Malaria, one of the world’s deadliest diseases, is transmitted by one of the world’s smallest insects—the mosquito. Bites from malaria-carrying mosquitoes resulted in about 249 million cases of malaria in 2022, with an estimated 608,000 people dying from the disease, according to the World Health Organization. Young children and pregnant women are among the most vulnerable to the disease, especially in Africa, which accounts for 96% of malaria deaths and 95% of illnesses. To reduce malaria transmission and ensure that fewer people become sick or die from this illness, vector control—activities that limit or prevent mosquitoes from spreading the disease—is essential.
Since 2006, the U.S. President’s Malaria Initiative (PMI) has protected millions of people from malaria, working with partner countries to scale up proven, life-saving interventions. Abt Global has contributed to this impact since 2011, beginning by leading the Africa Indoor Residual Spraying (AIRS) and PMI AIRS projects. In September 2017, the U.S. continued its commitment to tackling this deadly disease, awarding Abt the five-year PMI VectorLink Project. Working in 25 countries in Africa as well as Cambodia and Colombia, the PMI VectorLink Project conducted robust entomological monitoring and equipped countries to plan and implement IRS programs and other proven, life-saving malaria vector control interventions, including insecticide-treated nets (ITNs) and larval source management (LSM).
PMI VectorLink implemented safe, cost-effective, and sustainable vector control interventions while promoting gender equity in all facets of planning and implementation. The project strengthened the capacity of country governments to use epidemiological, entomological, and coverage data to support the optimal deployment of vector control tools based on each country’s context and needs. We developed a global database management system, VectorLink Collect, using the open source DHIS2 platform to improve the way data was captured, managed, and used across the project countries. Our work has informed global malaria best practices, guidelines, and policies.
Abt concluded its work on the PMI VectorLink Project in September 2023, with stunning results over the six-year period of implementation. Distribution of mosquito nets helped to protect nearly 24 million people against malaria. Year after year, indoor residual spray (IRS) campaigns protected millions more, reaching a high of more than 21 million people each year.
We have powerful stories of local capacity strengthening, reaching the unreached with malaria prevention, local health system resilience, and innovation from our years of work.
In 2023, Abt launched the PMI Evolving Vector Control to Fight Malaria Project, known as PMI Evolve, to continue to support PMI achieve its goal of ending malaria faster with renewed emphasis on strengthening local institutions to expand sustainability of this life-saving work. In its first year, PMI Evolve conducted IRS campaigns in four countries—Madagascar, Malawi, Rwanda, and Zambia—protecting 4.8 million people from malaria; and distributed 2.7 million ITNs in Zambia, protecting 5.4 million people, while supporting the country’s nationwide ITN campaign that distributed more than 11.5 million ITNs.
LEARN MORE: Advancing Malaria Prevention to Save Lives | PMI VectorLink Six Years of Malaria Vector Control Achievements | PMI Evolve Project
PROJECT: U.S. President’s Malaria Initiative VectorLink Project, U.S. President’s Malaria Initiative Evolving Vector Control to Fight Malaria Project
CLIENT: U.S. Agency for International Development (USAID)
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