In a Complex Country, What’s Working for Better Health

The statistics are head-turning: The Democratic Republic of Congo (DRC) has an estimated $24 trillion¹ in untapped mineral deposits, yet the sixth highest poverty rate² in the world. Its health outcomes are similarly out of line with its wealth: 

• Second highest number of malaria deaths in the world in 2019³
• 8th highest rate of new tuberculosis cases⁴
• 11th worst maternal mortality rate in 2020
• 22nd worst neonatal mortality rate in 2021

Despite its reservoirs of wealth, DRC is expected to have a $1.8 billion annual deficit for health spending through 2030—equal to 20 percent of the government’s budget.⁵

Good Governance is the Game Changer

The DRC’s vast mineral wealth includes significant deposits of copper, diamonds, gold, tantalum, and tin—plus the world’s largest cobalt reserves, making it a crucial player in the battery and electric vehicle industries. The DRC also gets sizable international donor assistance that fills in budget gaps.

But without proper precautions, both private investment and foreign aid aggravate corruption and power imbalances—stifling progress that would improve the lives of all Congolese.

Health supports multiple dimensions—food, housing, education, work and opportunity, making reliable healthcare essential. Governance is the linchpin for effective service delivery by institutions and their non-governmental counterparts, so the right governance structure is critical.

As the DRC uses mineral wealth and foreign aid to improve its healthcare system, it is decentralizing management and decision-making from central authorities and international donors to local power structures while integrating services to be more person-centered and community-driven.

“We need to really build on the systems they have already,” says Dr. Diarra Houleymata, a pediatrician from Mali and Abt Global’s chief of party for the U.S. Agency for International Development (USAID)-funded Integrated Health Program (IHP) in the DRC. “Not bring something external, which is not working for them at all.”

Before joining USAID IHP, Dr. Houleymata worked in multiple global health areas: maternal and child health, family planning, human resources for health, nutrition, and health system financing. She saw where they overlapped and developed ideas about how to integrate them to achieve a multiplier effect. USAID IHP was the chance to put her vision into practice.  

Many health programs work in vertical siloes. USAID IHP offers a one-stop shop with a comprehensive suite of services in nutrition; malaria; family planning; tuberculosis; COVID-19; water, sanitation, and hygiene; reproductive, maternal, newborn, and child health. Underpinning all these, it also facilitates improvements to health systems through better governance structures and policies, synced to the DRC’s recent decentralized institutions.

Localization has been crucial to this program’s near-term successes and long-term impact. Strategies must reflect the assets, structures, and relationships already in place—yet abide by common principles, including local control of revenue and decisions on how to spend it based on local needs.

“When you talk about localization, you need to think about two trends,” Dr. Houleymata says. “The first is working with local partners, including local NGOs and local associations, women's groups, youth groups, et cetera. But the other part of localization should be focused on how we can build the capacity of the local government so that they can take leadership and ownership of their system, and they can provide support so that the system is functioning.” 

To center the community in its activities, USAID IHP built a network of local collaborative partners. These include government officials as the architects of provincial health plans who then work closely with regional and local non-governmental organizations and community groups like revitalized health planning committees and volunteer health workers. Mobilizing community members supports a structure that feeds information back up the system to the higher levels of government so that planning and training reflect local community needs for health services.

“Doing the work in term of integrated health services is really to bring the health closer to the population and make sure that this population can get the quality services based on their need in different settings,” Dr. Houleymata said. “In DRC, this project was designed in the way that we can provide the communities with the knowledge, the skill, the support for their health, and for the quality of the health required in the health centers.”

The approach has elevated localization from engaging local actors in program design to the next level: embedding community-led interventions in local power structures. Grassroots entities analyze local challenges and develop and manage solutions, including public-private partnerships.  

Accountability and transparency are essential to make systems work. A new anonymous hotline has given individuals a voice to report suspected fraud or mismanagement, which then goes to provincial governments to investigate. Just having the hotline is prompting behavior change by medical staff and officials, as observed by USAID IHP staff. 

“DRC is a complex environment, but therefore we were able really to make some of the biggest results,” said Dr. Houleymata. 

“No matter if we are here or not, these communities are finding solutions for their own problems. So we need to build on the culture. We need to build a catalytic solution provider, so that we accompany these communities.”

Footnotes

¹Responsible Minerals Trade | Democratic Republic of the Congo | Fact Sheet | U.S. Agency for International Development (usaid.gov)   
²Poverty Rate by Country 2024 (worldpopulationreview.com)   
³World Malaria Report 2020 (who.int)   
⁴Further analysis of tuberculosis in eight high-burden countries based on the Global Burden of Disease Study 2021 data - PMC (nih.gov)   
⁵R3_Lettre2 - Version EN - Mars2021_A4_GFF_RDC.indd (worldbank.org)

Other resources

• Good Health | Abt Global
• Mining Royalties Fueling Improved Health Coverage in DRC | Abt Global
• Community Focus: How the DRC Is Reducing TB | Abt Global
• The Gateway to Inclusive Health Systems? Localization | Abt Global
• abt-approach-localization-brochure-version-2-copy.pdf (abtglobal.com)
• Local Health System Sustainability Project (LHSS) | Abt Global