Angumu is a mountainous area in Ituri province, in northeast of the Democratic Republic of Congo (DRC), near the Ugandan border. It is a remote place and reaching the communities who live there can be challenging. The few roads that run through the mountain forest are reminiscent of dried river beds, 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 natural 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 displaced people, each housing several thousand people.

At the time, our teams estimated that over 42,000 people had been forced to leave their homes in search for safety, and so decided to begin an emergency response. Since then the number of displaced people in Angumu has risen dramatically and currently stands at nearly 80,000.

If people can’t reach healthcare, we must bring it to them

“Once we arrived, we immediately saw that there was a very high number of people with malaria, with very high mortality rates,” says Frederic Manantsoa, MSF’s head of mission in DRC. “We also noticed that it was very difficult for people to access the necessary healthcare services because the region is so remote and mountainous.

“We thought that if people cannot reach the healthcare facilities, then we must reverse the situation and bring healthcare services to the people,” says Manantsoa. To do so in a sustainable way, our teams worked with the Ministry of Health (MoH) to put in place a project based on strong community engagement.

“The project focuses on an advanced community approach aiming at giving community members ownership over their own health needs,” says Manantsoa. 

“There is extensive participation from both the MoH and the community. They are our partners, not people that receive assistance. They are responsible for their own health and, as partners, they share responsibility in the project.”

This set-up relies on three fundamental components. The first is made up of the community relays (RECOs). Their role is to educate community members on various health issues including: good hygiene and family planning; how to prevent diseases, and what to do in case someone becomes ill; and the medical services available to them in the area.

If someone needs medical attention, they are encouraged to see the community health site relays (RECOSITEs) – the second component. The RECOSITEs have been trained in how to respond to cases of malaria, malnutrition and diarrhoea, and can either administer basic treatment on the spot or refer people to a more advanced health centre.
 
The third component is made up of the health site management committees (COGESITEs). These committees coordinate all practical and administrative aspects around the community health sites. All of the community health workers are volunteers elected by their communities. They are trained, monitored and supported by MSF, in cooperation with the MoH.

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

“Now, community members are more aware and much quicker to seek care. They act early, before the disease becomes advanced, and this has caused a clear reduction in the number of deaths.” 

Focus on prevention

In an environment where malaria is endemic and living conditions are precarious, health prevention is extremely important. 

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

“Sometimes, we gather people and talk to them about vaccinations, 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,” says Pascal. 

The RECOs are supported in their work by our health promoters (HPs), who train them and monitor their work.  Another added value of this approach is that it allows our teams to observe the spread of diseases at the community level.

“This allows us to have early surveillance and alerts, so that we can act in time to prevent outbreaks and other emergencies, or at least minimise as much as we can the need for emergency responses,” says Manantsoa. 

Support to health facilities

At the health centres and Angumu general regional hospital, our medical teams account for around 35 per cent of the staff and support the local MoH medical staff in their work. We offer malaria treatment for all age groups, mental health services, reproductive healthcare services including family planning, and management of moderate malnutrition cases. 

In addition, we offer support to survivors of sexual violence. This is done in cooperation with the protection committees present in each site for displaced people, which support survivors of sexual violence. 

Virginie fled conflict in the Musongwa area and arrived in Ugudo Zii seven months ago. She is a member of the site protection committee. “In a densely populated displaced people camp, women are very vulnerable and incidents of sexual violence are frequent,” she says. 

“We work in close cooperation with the RECOs and together direct survivors to the RECOSITEs, who in turn contact MSF so that 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.”

Community engagement needs to happen at all levels

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

“When we began our response, MSF was doing everything, even the transportation of water in the community,” says Abdurakhman Bodian, MSF HP manager 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,” says Bodian. 

MSF is now working to further build community resilience and to help them become more independent when it comes to the management of all aspects their health.

“When we compare the data collection that we did at the start on the number of deaths in Angumu with the latest data, we really see a difference,” says Frederic Manantsoa. “If it wasn’t for this system that we put in place, the situation would not have changed.

“Collaboration between MSF, the Ministry of Health and the community in Angumu has become very close and stable. I think that this type of project has a future. We need to develop it and build on all that we learned because I believe that it is one of the best approaches for MSF in DRC,” says Manantsoa.

“We should not forget that around 80 per cent of the population lives in rural areas with very limited access to healthcare. Therefore, this type of community approach seems to be the most suitable to tackle people’s health needs.”