Baseline Report 1
The Impact of USAID’s 
Integrated Health Program in 
the Democratic Republic of 
the Congo: Baseline Report
November 2020
2 The Impact of USAID’s Integrated Health Program in the DRC
Data for Impact
University of North Carolina at Chapel Hill
123 West Franklin Street, Suite 330
Chapel Hill, NC 27516 USA
Phone: 919-445-9350 | Fax: 919-445-9353
D4I@unc.edu
http://www.data4impactproject.org
This publication was produced at the request of the United 
States Agency for International Development. It was 
prepared independently by David Hotchkiss, Janna 
Wisniewski, Paul-Samson Lusamba-Dikassa, Lauren Blum, 
Matt Worges, Charles Stoecker, and Eva Silvestre of Data 
for Impact.
This publication was produced with the support of the United 
States Agency for International Development (USAID) under 
the terms of the Data for Impact (D4I) associate award 
7200AA18LA00008, which is implemented by the Carolina 
Population Center at the University of North Carolina at 
Chapel Hill, in partnership with Palladium International, LLC; 
ICF Macro, Inc.; John Snow, Inc.; and Tulane University. The 
views expressed in this publication do not necessarily reflect 
the views of USAID or the United States government. 
TRE-20-28 D4I
ISBN 978-1-64232-246-0
The Impact of USAID’s 
Integrated Health Program in the 
Democratic Republic of the 
Congo: Baseline Report
David Hotchkiss, PhD
Janna Wisniewski, PhD
Paul-Samson Lusamba-Dikassa, MD, PhD
Lauren Blum, PhD
Matt Worges, MS
Charles Stoecker, PhD
Eva Silvestre, PhD
November 2020
Baseline Report 3
Abstract
Data for Impact (D4I), which is funded by the United States Agency for International Development (USAID), 
is conducting a performance and impact evaluation of the Programme de Santé Intégré de l'USAID en 
République Démocratique du Congo (PROSANI USAID), known in English as USAID’s Integrated Health 
Program (IHP) in the Democratic Republic of the Congo (DRC). The evaluation investigates the following 
issues:
1. Did the expected changes in outcomes and impacts occur?
2. If there were changes in healthy behaviors during the study period, to what extent were these 
attributable to USAID IHP?
3. Did the project contribute to gender equity in health services and in the health system?
4. What factors enabled or limited the success of USAID IHP? 
We report baseline data from three sources: (1) surveys of health facilities and households in USAID IHP￾supported areas; (2) routine data from the DRC’s routine health information system (RHIS) for USAID IHP￾supported areas and a matched control group; and (3) qualitative data collected from representatives of the 
government health system, implementing staff, and beneficiaries. To assess baseline health behaviors, we 
analyzed data from the DRC’s health information system (which is built on the District Health Information 
Software, version 2 [DHIS2]) for both USAID IHP provinces and provinces not receiving USAID support. 
Results suggest that the government health system faces multiple challenges to effectively plan, implement, 
and monitor services, including: lack of electricity, cellular communication, and Internet; wide variations by 
province in the availability of medicines and equipment; limited managerial autonomy; variations in the levels 
of external supervision; insufficient number of staff; and low levels of health worker satisfaction. 
Although many of the health system challenges identified through the study are outside the control of the 
project (and are the purview of the government), they are nonetheless critical constraints. Other challenges can 
be partially addressed through project-supported interventions.
Acknowledgments
The authors wish to thank the United States Agency for International Development (USAID) for supporting 
this work.
We acknowledge our partners at the Kinshasa School of Public Health who led the health facility survey:
Professor Patrick Kayembe, Professor Eric Mafuta, and Marc Bosonkie; and the provincial supervisors: Benito 
Kazenza, Moza Kiakese, Louise Kpanda, Gabriel Kyomba, Zarine Lutonamo, and Nickson Sonabo.
We also thank the medical anthropologists who collected qualitative data: Anicet Yemweni, Christelle 
Kasiama, Gerard Mbengo, Nadine Kamwang Kapend, and Fulgence Mwenze Mpanga.
Finally, we thank the knowledge management team of the Data for Impact (D4I) project for editorial, design, 
and production services. 
Cover
The lack of adequate roads and transportation means that young people must travel long distances in difficult 
conditions to sell their agricultural products. 2013 in Kasai Oriental Province in the Democratic Republic of the 
Congo. Photo: Alpha Luyoyo/USAID, courtesy of Flickr Creative Commons.
Suggested citation
Data for Impact. (2020). The Impact of USAID’s Integrated Health Program in the Democratic Republic of the 
Congo: Baseline Report. Chapel Hill, NC, USA: Data for Impact, University of North Carolina
Baseline Report 5 
Contents
Abstract.......................................................................................................................................................... 3
Acknowledgments .......................................................................................................................................... 4
Contents......................................................................................................................................................... 5
Figures ........................................................................................................................................................... 7
Tables............................................................................................................................................................. 9
Abbreviations ............................................................................................................................................... 11
Executive Summary...................................................................................................................................... 14
Evaluation Purpose and Evaluation Questions.......................................................................................... 14
Project Background .................................................................................................................................. 14
Evaluation Questions, Design, Methods, and Limitations.......................................................................... 15
Baseline Findings and Conclusions........................................................................................................... 15
Evaluation Purpose and Questions................................................................................................................ 19
Evaluation Purpose .................................................................................................................................. 19
Evaluation Questions................................................................................................................................ 20
Purpose of the Report ............................................................................................................................... 21
Project Background....................................................................................................................................... 22
Objective 1: Strengthen Health Systems, Governance, and Leadership at Provincial, Health Zone, and 
Facility Levels in Target Health Zones...................................................................................................... 22
Objective 2: Increase Access to Quality, Integrated Health Services in Target Health Zones ....................... 23
Objective 3: Increase the Adoption of Healthy Behaviors, including the Use of Health Services in Target 
Health Zones............................................................................................................................................ 23
Evaluation Methods and Limitations............................................................................................................. 25
Methods ................................................................................................................................................... 25
Limitations............................................................................................................................................... 26
Findings ....................................................................................................................................................... 28
Health Systems Governance and Leadership............................................................................................. 28
Access to Quality, Integrated Health Services............................................................................................ 49
Health Behaviors ...................................................................................................................................... 94
Key Informants’ Perspectives.................................................................................................................... 99
Qualitative Baseline Report, Health Zone of Bunkeya ..............................................................................121
Qualitative Baseline Report, Health Zone of Kasaji ..................................................................................154
Summary and Implications ..........................................................................................................................176
Summary ................................................................................................................................................176
Programmatic Implications......................................................................................................................178
Limitations..............................................................................................................................................179
6 The Impact of USAID’s Integrated Health Program in the DRC
References ...................................................................................................................................................179
Appendices..................................................................................................................................................180
Appendix 1. Evaluation Protocol.............................................................................................................180
Appendix 2. Data Collection Instruments ................................................................................................225
Appendix 3. Evaluation Team Members ..................................................................................................380
Appendix 4. Signed Disclosures of Conflicts of Interest ............................................................................382
Baseline Report 7
Figures
Figure 1.1 Electricity in health zone offices, by province ................................................................................ 28
Figure 1.2. Mean number of hours of functional electricity on a typical eight-hour day in health zone offices 
with a source of electricity, by province ......................................................................................................... 29
Figure 1.3. Cellular telephone and Internet connections at health zone offices, by province............................. 30
Figure 1.4. Mean number of hours of functional Internet on a typical eight-hour day in health zone offices with 
an Internet connection, by province............................................................................................................... 30
Figure 1.5. Health zone offices’ Participatory Institutional Capacity Assessment and Learning Index 
participation and score, by province .............................................................................................................. 32
Figure 1.6. Percentage of health workers who are not head of the facility who report being internally supervised 
in the past week ............................................................................................................................................ 33
Figure 1.7. Percentage of health centers that report having internal management meetings, community co￾management meetings, and meetings with CODESA presidents monthly or more often in the past 12 months, 
by province................................................................................................................................................... 37
Figure 1.8. Percentage of hospitals that report having internal management meetings, community co￾management meetings, and meetings with CODESA presidents monthly or more often in the past 12 months, 
by province................................................................................................................................................... 38
Figure 1.9. Percentage of health zone offices that send a representative to Comités de Gestion provincial 
meetings, by province ................................................................................................................................... 39
Figure 1.10 Data displayed at health centers, by type and location (n=328) .................................................... 40
Figure 1.11. Data displayed at hospitals, by type and location (n=110)........................................................... 41
Figure 1.12. Percentage of health centers that hold a monthly meeting to discuss SNIS data, and that made 
decisions based on SNIS data, by province .................................................................................................... 41
Figure 1.13. Percentage of hospitals that hold a monthly meeting to discuss SNIS data, and that make decisions 
based on SNIS data, by province................................................................................................................... 42
Figure 1.14. Percentage of health workers who reported that they have ever received their full government salary 
on time, by province ..................................................................................................................................... 46
Figure 1.15. Percentage distribution of health center workers by whether they were part of a performance-based 
financing scheme, by province ...................................................................................................................... 48
Figure 1.16. Percentage distribution of hospital workers by whether they were part of a performance-based 
financing scheme, by province ...................................................................................................................... 48
Figure 2.1. Percentage of hospitals with X-ray, ultrasound, and autoclave equipment, by province (MOH 
minimum package of complementary services).............................................................................................. 51
Figure 2.2. Percentage of health centers with electricity, by province .............................................................. 51
Figure 2.3. Percentage of hospitals with electricity, by province...................................................................... 52
Figure 2.4. Percentage of health facilities with improved sanitation, by province............................................. 53
Figure 2.5. Percentage of health facilities with a private delivery room, by province........................................ 53
Figure 2.6. Percentage of health facilities offering a package of comprehensive sexual- and gender-based 
violence services, by province........................................................................................................................ 57
Figure 2.7. Percentage of health facilities offering a long-acting or permanent method of FP, by province ....... 58
Figure 2.8. Percentage of health facilities with at least one health worker trained in youth-friendly FP services, 
by province................................................................................................................................................... 58
Figure 2.9. Percentage of health facilities with FP information and resources specific to youth, by province .... 59
Figure 2.10. Maternal delivery outcomes, among those for whom an outcome was recorded, by health facility 
type .............................................................................................................................................................. 66
Figure 2.11. Percentage of women who died during childbirth who experienced complications, by facility type
.................................................................................................................................................................... 67
Figure 2.12. Complications recorded for women who did not die during childbirth, by facility type ................ 67
8 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.13. Lengths of stay in health centers after normal delivery, by province............................................. 68
Figure 2.14. Lengths of stay in hospitals after normal delivery, by province .................................................... 69
Figure 2.15. Percentage of health workers who asked about aspects of medical history, by facility type ........... 70
Figure 2.16. Percentage of health workers who asked about aspects of social history, by facility type............... 71
Figure 2.17. Percentage of health workers indicating specific physical examinations, by facility type............... 72
Figure 2.18. Percentage of health workers who correctly identified bacterial dysentery/shigellosis as a likely 
diagnosis, by facility type and province.......................................................................................................... 73
Figure 2.19. Percentage of health center-based health workers who correctly mentioned metronidazole, fluids, 
or treatment for fever, by province (n=707).................................................................................................... 75
Figure 2.20. Percentage of hospital-based health workers who correctly mentioned metronidazole, fluids, or 
treatment for fever, by province (n=254)........................................................................................................ 75
Figure 2.21. Percentage of health workers who gave the correct diagnosis test (direct stool microscopy), and 
treatment (metronidazole) for bacterial dysentery/shigellosis, by facility type and province ............................ 76
Figure 2.22. Percentage of health workers who mentioned specific messages for counseling, by facility type.... 77
Figure 2.23. Percentage of health workers who asked questions related to health history, by facility type......... 78
Figure 2.24. Percentage of health workers who asked questions related to social history, by facility type ......... 79
Figure 2.25. Percentage of health workers who indicated that they would perform various physical 
examinations, by facility type........................................................................................................................ 80
Figure 2.26. Percentage of health workers who mentioned various diagnostic tests, by facility type ................. 81
Figure 2.27. Percentage of health workers who gave various recommendations, by facility type ...................... 83
Figure 2.28. Percentage of health workers who mentioned questions about aspects of medical history, by facility 
type .............................................................................................................................................................. 84
Figure 2.29. Percentage of health workers who mentioned questions about aspects of social history, by facility 
type .............................................................................................................................................................. 85
Figure 2.30. Percentage of health workers who would counsel the woman in choosing a contraceptive method, 
by facility type and province.......................................................................................................................... 86
Figure 2.31. Among health workers who indicated that they would not offer a contraceptive method, reasons 
given, by facility type .................................................................................................................................... 86
Figure 2.32. Among health workers who stated that they would offer a contraceptive method, counseling given, 
by facility type .............................................................................................................................................. 87
Figure 2.33. Among health workers who stated that they would offer a contraceptive method, criteria for 
determining the method to prescribe, by facility type ..................................................................................... 88
Figure 2.34. Among health workers who stated that they would offer a contraceptive method, response to the 
preferred method being unavailable, by facility type....................................................................................... 89
Figure 2.35. Among health workers who stated that they would offer a contraceptive method and their response 
to a request for confidentiality, by facility type............................................................................................... 89
Figure 2.36. Percentage of health centers that posted a standard fee schedule, had an indigent fee schedule, and 
posted an indigent fee schedule, by province.................................................................................................. 90
Figure 2.37. Percentage of hospitals that posted a standard fee schedule, had an indigent fee schedule, and 
posted an indigent fee schedule, by province.................................................................................................. 91
Figure 2.38. Percentage of health centers that accepted payment after treatment of emergencies and labor and 
delivery, by province..................................................................................................................................... 92
Figure 2.39. Percentage of hospitals that accepted payment after treatment of emergencies and labor and 
delivery, by province..................................................................................................................................... 92
Figure 3.1. Percentage of caregivers who sought care the last time their child under five had a fever, by province
.................................................................................................................................................................... 97
Figure 3.2. Percentage of HAs in which at least one woman reported that she used RECOs for care for herself or 
her children in the past three months............................................................................................................. 98
Figure 3.3. Percentage of women who participated in a community scorecard meeting in the past 12 months . 99
Baseline Report 9
Tables
Table 1.1. Degree to which health center directors report having autonomy in management (n=328).............. 31
Table 1.2. Degree to which hospital directors report having autonomy in management (n=110)...................... 31
Table 1.3. Status and role of respondents to health zone office survey, by province ......................................... 32
Table 1.4. Percentage of offices and health facilities that were visited in a supervisory capacity by a higher-level 
authority in the prescribed timeframe, by province......................................................................................... 33
Table 1.5. CODESA participation in health center management during the past 90 days, by province............. 34
Table 1.6. Percentage of health centers that received feedback from health zone offices in the past 90 days, by 
province ....................................................................................................................................................... 36
Table 1.7. Percentage of hospitals that received feedback from health zone offices in the past 90 days, by 
province ....................................................................................................................................................... 36
Table 1.8. Health zone offices’ oversight of health mutuelles, by province ...................................................... 36
Table 1.9. Frequency of health zone offices’ communication with CODESAs, by province............................. 38
Table 1.10. Frequency of health zone offices’ communication with other health zone offices, by province....... 39
Table 1.11. Frequency of provincial health offices’ communication and attendance at technical meetings, by 
province ....................................................................................................................................................... 40
Table 1.12. Timing of health zones’ reporting their most recent MAPEPI DHIS2 case, by province................ 42
Table 1.13. Barriers to a health zone submitting an immediate or weekly MAPEPI report on time, by province
.................................................................................................................................................................... 43
Table 1.14. Timing of provinces’ reporting their most recent MAPEPI DHIS2 case........................................ 43
Table 1.15. Barriers to a provincial health office submitting an immediate or weekly MAPEPI report on time, by 
province ....................................................................................................................................................... 44
Table 1.16. Percentage of health workers who reported attending a training on iHRIS, by facility type and 
province ....................................................................................................................................................... 44
Table 1.17. Percentage of health center workers who reported being generally satisfied with their job and with 
specific dimensions of their job, by province .................................................................................................. 45
Table 1.18. Percentage of hospital workers who reported being generally satisfied with their job and with 
specific dimensions of their job, by province .................................................................................................. 45
Table 1.19. Status of health workers’ salary payment for the last completed month, by province ..................... 46
Table 1.20. Percentage of health workers with sources of supplemental income, by province........................... 47
Table 2.1. Percentage of health centers that offered select MOH minimum package of preventive services, by 
province ....................................................................................................................................................... 49
Table 2.2. Percentage of health centers that offered select MOH minimum package of curative services, by 
province ....................................................................................................................................................... 49
Table 2.3. Percentage of hospitals with capacity to conduct specific laboratory tests on the day of the survey, by 
province (MOH complementary package of activities)................................................................................... 50
Table 2.4. Percentage of health centers that had selected tracer drugs in stock on the day of the survey, by 
province ....................................................................................................................................................... 54
Table 2.5. Percentage of hospitals that had selected tracer drugs in stock on the day of the survey, by province 54
Table 2.6. Percentage of health centers with all basic equipment on the day of the survey, by province............ 55
Table 2.7. Percentage of hospitals with all basic equipment on the day of the survey, by province ................... 55
Table 2.8. Percentage of health centers with adequate infection control equipment, by province...................... 56
Table 2.9. Percentage of hospitals with adequate infection control equipment, by province ............................. 56
Table 2.10. Percentage of health centers meeting minimum standards for essential staff, supplies, and equipment 
to support the provision of long-acting or permanent methods of contraception, by province .......................... 59
Table 2.11. Percentage of hospitals meeting minimum standards for essential supplies and equipment to support 
the provision of long-acting or permanent methods of contraception, by province .......................................... 61
10 The Impact of USAID’s Integrated Health Program in the DRC
Table 2.12. Percentage of health centers with adequate staffing numbers and mix according to government 
guidelines,* by province............................................................................................................................... 63
Table 2.13. Percentage of health center workers who reported agreeing with statements about their knowledge 
and attitudes, by province ............................................................................................................................. 64
Table 2.14 Percentage of hospital workers who reported agreeing with statements about their knowledge and 
attitudes, by province ................................................................................................................................... 65
Table 2.15. Total number of health workers who responded to the child health vignette, by facility type and 
province ....................................................................................................................................................... 69
Table 2.16. Percentage of health center-based health workers who ordered the correct tests for bacillary 
dysentery/shigellosis, by province ................................................................................................................. 73
Table 2.17. Percentage of hospital-based health workers who ordered the correct tests for bacillary 
dysentery/shigellosis, by province ................................................................................................................ 74
Table 2.18. Total number of health workers who responded to the ANC vignette, by facility type and province
.................................................................................................................................................................... 77
Table 2.19. Percentage of health center-based health workers who gave various assessments, by province ....... 81
Table 2.20. Percentage of hospital-based health workers who gave various assessments, by province............... 82
Table 2.21. Percentage of health center-based health workers who recommended various treatment options, by 
province ....................................................................................................................................................... 82
Table 2.22. Percentage of hospital-based health workers who recommended various treatment options, by 
province ....................................................................................................................................................... 82
Table 2.23. Total number of health workers who responded to the FP vignette, by facility type and province .. 84
Table 2.24. Health centers’ responses to patients who could not pay fees owed, by province ........................... 93
Table 2.25. Hospitals’ responses to patients who could not pay fees owed, by province................................... 93
Table 3.1. Pooled estimates from multiply imputed data ................................................................................ 95
Table 3.2. Percentage of women who sought care in a public facility who reported long wait times, by service 
and province................................................................................................................................................. 96
Table 3.3. Percentage of women who sought care in a public facility who reported that the services listed were 
unaffordable, by service and province............................................................................................................ 96
Table 3.4. Percentage distribution of reasons why care was not sought for fever (n=number of cases of fever for 
whom care was not sought)........................................................................................................................... 97
Table 3.5. Percentage of HAs in which at least one woman reported accessing the following services at a 
community care site...................................................................................................................................... 98
Table 3.6. Percentage of women who reported that they participated in a public or consultative meeting 
organized by the administrative/political authority or civil society at various levels in the past 12 months....... 99
Table 4.1. Background information collected from in-depth interviews and key informants in Bunkeya..........121
Table 4.2.Facility infrastructure, supplies, and medications for child health services based on observations in 
Bunkeya ......................................................................................................................................................123
Table 4.3. Results from observations of health provider-client interactions.....................................................139
Table 4.4. Background information collected from in-depth interviews and key informants in Kasaji .............154
Table 4.5. Facility infrastructure, supplies, and medications related to child care based on observations in Kasaji
...................................................................................................................................................................156
Table 4.6. Results from observations of health provider-client interactions.....................................................170
Baseline Report 11
Abbreviations 
AC animateur communautaire [community animator]
ACT artemisinin-based combination therapy
AG administrateur gestionnaire [health zone financial and administrative manager]
ANC antenatal care
ARI acute respiratory infection
BCC behavior change communication
BCZS Bureau Central de la Zone [central zonal office]
CAC Cellules d’Animation Communautaire [community animation cells]
CDR Centre de Distribution Régional [regional distribution center]
CHW community health worker
CODESA Comité de développement de l’aire de santé [health area development committee] 
COGE comité de gestion [management committee]
COR contracting officer’s representative
CPN prenatal care
CPON postnatal care
CPP Comité Provincial de Pilotage [Provincial Steering Committee]
CPS well-baby visits
CPS consultation préscolaire [preschool consultation]
CSO civil society organization
D4I Data for Impact 
DFSA Development Food Security Activities
DHIS2 District Health Information Software, version 2
DPS Direction Provincial de la Santé [provincial directorate of health]
DRC Democratic Republic of the Congo
EU European Union
FC Congolese franc
FFP Food for Peace
FP family planning
HA health area
HC health center
HCD human-centered design
HSS health systems strengthening
12 The Impact of USAID’s Integrated Health Program in the DRC
iCCM integrated community case management
IGA Integrated Governance Activity
IHP Integrated Health Program
IP implementing partner(s)
IPS Inspection Provincial de la Santé [provincial health inspector]
IRA Infection Respiratoire Aigue
IS Infirmier Superviseur [zonal nurse supervisor]
IT infirmière titulaire [head nurse]
ITA assistant infirmière titulaire [assistant head nurse]
IT information technology
LiST Lives Saved Tool
M&E monitoring and evaluation
MAPEPI maladies à potentiel épidémique [diseases with epidemic potential]
MCH maternal and child heath
MCZ Médecin Chef de Zone [health zone chief physician]
MOH Ministry of Health
MUAC mid-upper arm circumference
NGO nongovernmental organization
ORS oral rehydration solution
PAO Plan d’action opérationnel [operational action plan]
PARSS Projet d'Appui au Renforcement du Système de Santé [Health System Support and 
Strengthening Project]
PBF performance-based financing
PDSS Projet de Développement du Système de Santé [the DRC’s performance-based financing 
project]
PESS Programme des équipements pour les structures sanitaires [Equipment program for health 
facilities]
PEV Programme National de Nutrition [National Nutrition Program]
PICAL Participatory Institutional Capacity Assessment and Learning Index
PNDS Plan National de Développement Sanitaire [national health development plan]
PROSANI Programme de Santé Intégré [Integrated Health Program]
RECO relais communautaire [community relay]
RHIS routine health information system
SBC social and behavior change
SNIS Système national d'information sanitaire [national health information system]
Baseline Report 13
SRO Solution orale de réhydratation
TB tuberculosis
TIP Trafficking in Persons
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
USD United States Dollar
VAD Visite à domicile
VPO Vaccin antipoliomyélitique oral
VSAT very small aperture terminal 
WASH water, sanitation, and hygiene
WHO World Health Organization
14 The Impact of USAID’s Integrated Health Program in the DRC
Executive Summary
Evaluation Purpose and Evaluation Questions
Data for Impact (D4I), which is funded by the United States Agency for International Development (USAID), 
is conducting a comprehensive evaluation of the Programme de Santé Intégré de l'USAID en République 
Démocratique du Congo (PROSANI USAID), known in English as USAID’s Integrated Health Program 
(USAID IHP) in the Democratic Republic of the Congo (DRC). The evaluation is investigating the following 
issues:
• The progress of USAID IHP in achieving Objectives 1, 2, and 3: strengthened health systems, 
governance, and leadership at the provincial, health zone, and facility levels; increased access to 
quality, integrated services; and increased adoption of behaviors that improve health outcomes
(referred to as “healthy behaviors”).
• The impact of USAID IHP on several proxy indicators of healthy behaviors, including treatment for 
childhood illnesses, maternal healthcare use, and contraceptive method use.
• The factors that enabled or limited the success of USAID IHP, including the design and scope of the 
project, implementation factors, and external and contextual factors.
This evaluation helps fill previous knowledge gaps by supplying critical information about the impact of 
USAID IHP, a large, complex health systems strengthening (HSS) project. It contributes to the country’s 
evidence base of successful HSS activities, and those that are not successful. Experience from this evaluation
can be used to help design future projects intended to deliver high-quality healthcare and family planning (FP)
services that meet the needs of the Congolese people.
This report documents the functioning of the health system and select health outcomes immediately before the 
implementation of USAID IHP-supported activities in the targeted provinces. We report baseline data from 
three sources: (1) surveys of health facilities and households in USAID IHP-supported areas; (2) routine data 
from the DRC’s RHIS for USAID IHP-supported areas and a matched control group; and (3) qualitative data 
collected from representatives from the government health system, implementing staff, and beneficiaries.
The key audiences for the evaluation include officials and relevant personnel of the DRC’s Ministry of Health 
(MOH), USAID, and other international health organizations and agencies. We expect that the results of this
evaluation will inform the design and implementation of future HSS activities in the DRC.
Project Background
As part of its strategy to improve health outcomes in the DRC, USAID funded the USAID IHP in 2018. The 
program began operations in July 2018 and is being implemented by Abt Associates and several partner 
organizations. The purpose of USAID IHP is to strengthen the capacity of Congolese institutions and 
communities to deliver quality, integrated health services to sustainably improve the health status of the 
Congolese population. The project focuses on the following specific health, population, and nutrition areas:
maternal health; neonatal, infant, and child health; tuberculosis (TB); malaria; child nutrition; water, 
sanitation, and hygiene (WASH); and FP. 
USAID IHP seeks to reach its goal through the achievement of the following overall performance objectives:
• Strengthen health systems, governance, and leadership at the provincial, health zone, and facility levels 
in target health zones (Objective 1).
• Increase access to quality, integrated health services in target health zones (Objective 2).
Baseline Report 15
• Increase the adoption of healthy behaviors, including the use of health services, in target health zones 
(Objective 3).
USAID IHP will work in nine contextually diverse provinces in the regions of Eastern Congo, Katanga, and 
Kasai, and will include a wide array of interventions. 
Given the breadth and depth of the planned interventions, the USAID/DRC Mission requested that D4I 
conduct an independent third-party evaluation of the performance and impact of USAID IHP on key health 
systems-related outcomes: the uptake of FP and healthcare services; health systems functioning (i.e., improved 
disease surveillance, the availability of essential commodities, and health worker motivation); and the practice 
of key healthy behaviors. 
Evaluation Questions, Design, Methods, and Limitations
The evaluation questions for the overall study, along with the methods and sources of data, are presented 
below.
Evaluation Question Method Source of Data
Did the expected changes in 
outcomes and impacts occur?
Quantitative analysis of changes 
over time in USAID IHP health 
zones
Baseline, midline, and endline 
surveys of provincial health offices, 
health zone offices, and health 
facilities.
Baseline, midline, and endline 
surveys of households.
RHIS data (DHIS2)
If there were changes in healthy 
behaviors over the course of the 
study period, to what extent were 
these attributable to IHP?
Doubly robust model that combines 
difference-in-differences with 
propensity score matching
RHIS data (DHIS2)
Did the project contribute to gender 
equity in health services and in the 
health system?
Quantitative analysis of changes 
over time in USAID IHP health 
zones
Baseline, midline, and endline 
surveys of provincial health offices, 
health zone offices, and health 
facilities
Baseline, midline, and endline 
surveys of households
What factors enabled or limited the 
success of IHP? 
Qualitative methods Baseline, midline, and endline 
qualitative data collection from key 
informant interviews, in-depth 
interviews, and focus group 
discussions
This report includes a discussion of the limitations of the evaluation and threats to carrying out the evaluation 
as planned. 
Baseline Findings and Conclusions 
Summary of Empirical Results
To assess baseline levels of health governance and leadership, service readiness, and service quality, we 
administered surveys of provincial health offices (n=6), health zone offices (n=113), health centers (n=328),
16 The Impact of USAID’s Integrated Health Program in the DRC
hospitals (n=110), and health workers (n=1,213). The results suggest that the government-run health system 
faces myriad challenges to effectively plan, implement, and monitor services. These challenges include
problems with electricity, cellular communication, and Internet connectivity; wide variations by province in 
the availability of medicines and equipment; limited managerial autonomy with respect to resource generation 
and budgeting practices; wide variations in the levels of external supervision of hospitals and health centers
(HCs); insufficient number of staff at health facilities; and low levels of health worker satisfaction. The specific 
results for these and other types of indicators are presented in the report. The results are disaggregated by 
province. 
We assessed health workers’ level of essential knowledge to provide high-quality healthcare services (as a 
factor enabling USAID IHP’s success) by presenting a sample of health workers with three vignettes describing 
hypothetical cases of diarrhea, antenatal care (ANC), and FP. We then asked a series of questions about
diagnosis, testing, and treatment. In response to the vignette on diarrhea, about half of the hospital health 
workers and 58 percent of the HC workers were unable to correctly diagnose the problem, and there were 
substantial numbers of personnel who did not prescribe standard tests and recommended treatments. 
Responses to the vignettes for ANC and FP also suggest that a significant proportion of health workers had 
problems identifying key elements of the standards of care. 
To assess baseline health behaviors, we analyzed District Health Information Software, version 2 (DHIS2)
data for both USAID IHP provinces (the “treatment” group) and provinces not receiving USAID support (the 
“control” group). Randomization of USAID IHP interventions for HSS between control and treatment sites 
was not an option, owing to budgetary, operational, and ethical factors. We used propensity score weighting to 
select an appropriate pool of control sites against which to measure changes in the treatment group—a process 
that helps control for selection bias. In effect, the propensity weights adjust the control group so that its 
pretreatment covariate distributions match those of the treatment group. We used a common pool of DHIS2 
data elements (e.g., live births, malnutrition, breastfeeding, ANC, vaccination, modern contraceptive method 
use, insecticide-treated net distribution, and case management of malaria, pneumonia, and diarrhea) for the 
propensity score weighting procedure, which produced a group of control sites that did not show an 
appreciable level of bias compared with the treatment sites.
We also used data from Abt Associate’s baseline household survey to characterize the care seeking 
experience and level of participation in health services among women of reproductive age. Most (82.2%) 
children under five with a fever received care. Among the caregivers who reported that they did not seek 
care for a child with a fever, the reason most frequently cited was lack of money. Overall, more than 
one-half (56.7%) of the health areas (HAs) appeared to have functioning relais communautaires
(community health workers). Rates of civic participation among women were low. 
Summary of Key Informant Results
We interviewed 20 key informants at central and provincial levels. Key informants were MOH representatives 
(7), USAID IHP senior staff (6), USAID staff overseeing USAID IHP (3), and collaborating partners (4). The 
key informants had a wealth of experience in health service delivery program development and 
implementation, and HSS. Informants consistently described the national health system strategy as well￾conceived and organized, and stated that it encompassed key elements. However, there was universal 
agreement that many facets of the health system were not being implemented as planned. The primary 
obstacles mentioned related to underfinancing, mismanagement of resources, and poor governance, which 
informants reported contributed to the low use and low quality of health services.
USAID IHP uses an integrated approach to implement six technical programs—malaria, maternal and child 
health (MCH), FP, nutrition, TB, and WASH, with a focus on HSS. Malaria programs will be executed across 
all 178 target health zones. Implementation of the other programs will vary according to the availability of 
resources, local needs, and ongoing activities of implementing partners (IPs). Specifically, USAID IHP will 
Baseline Report 17
partner with other organizations to attempt to piece together a cohesive approach that covers all six technical 
programs in the nine target provinces. There are also cross-cutting approaches (such as strengthening health 
systems, providing medications, improving information systems, developing finance systems, engaging in 
community development, accommodating youth, and provisions regarding gender) with separate funding 
allocated for each approach. The project will concentrate efforts on geographical areas to increase synergy with 
other USAID programs and improve overall project impact, which may cause inequities in the quality and 
consistency of health service delivery. 
USAID IHP is funded through a contractual agreement between USAID and Abt Associates, giving USAID 
ultimate decision-making power and technical oversight regarding project development and implementation,
and the use of funds. Abt Associates is responsible for executing activities and ensuring that indicators are 
followed and results are achieved. Some informants raised concerns that the restrictive nature of the contract 
and USAID IHP’s approach will limit the ability of government personnel to lead project development and 
implementation and to take ownership of HSS. 
Informants described USAID IHP as a complex project comprising many interventions and actors, with 
several informants reporting that the project is overly ambitious in relation to the myriad challenges plaguing 
the DRC’s health system. Commonly cited problems include poor health information systems affecting data 
quality and reporting, irregular provision of quality medications, low motivation of health workers linked to 
poor remuneration and work conditions, and rampant corruption and mismanagement of funds that infiltrate 
all levels of the health sector. 
Summary of Qualitative Field Results
We carried out an in-depth, qualitative investigation in two health zones in the Lualaba province. One health 
zone had received extensive support from the USAID IHP predecessor project, whereas the second health 
zone had received support for specific activities, such as integrated community case management (iCCM). In 
each health zone, we administered a mix of qualitative research methods, including key informant and in￾depth interviews, observations, and focus group discussions. Data collection involved in-depth interviews with 
HC nurses (4), members of the health development committee (4), community health workers (4), village 
chiefs or village chief representatives (4), reference hospital physicians (2), hospital or Bureau Central de la 
Zone de Santé (BZCS [central health zone office]); BZCS managers (2), and an acting health zone medical 
officer; key informant interviews with the Médecin Chef de Zone (MCZ [health zone chief physician]) (2); 
observations of health infrastructures (6) and health worker-client interactions (40); and focus group
discussions with caregivers of children under five years of age (4). 
Findings show that MCZs are frequently physically absent from their posts. Staffing of health personnel does 
not meet government standards, with HCs often using untrained workers to provide medical care. HCs are 
often small, and facilities are frequently poorly constructed, in disrepair, and lack key equipment and supplies. 
Stockouts of essential medications are common, forcing health workers to restock often with unregulated drugs 
or to give patients prescriptions to purchase drugs from local pharmacies. There is a growing number of private 
pharmacies selling unregulated drugs, which allows people to self-treat before seeking professional care. 
Community members often seek treatment from traditional healers, who provide remedies that can interfere 
with medical care and cause harmful health effects. 
Health workers rely primarily on monthly facility revenue for compensation, although performance-based 
financing activities are providing important bonuses to facilities that meet standards. Despite low and irregular 
remuneration, health providers expressed gratitude for being employed. Informants described health workers 
as respectful of and courteous toward clients, which was confirmed during health worker-client observations. 
Observations indicated that health workers fail to follow components of treatment protocols during patient 
consultations, which often take place in unclean, noisy environments, where privacy is not maintained. 
18 The Impact of USAID’s Integrated Health Program in the DRC
According to the people interviewed, no community-based organizations involved in health existed in the 
zones studied. Community outreach activities are not functioning according to the national strategy. 
Community health workers (CHWs) require training, supervision, and supplies to their fulfill roles. The lack of 
oversight and supplies do not allow iCCM sites to operate as planned. Poor motivation causes high attrition of 
CHWs. CHWs are predominantly male, with men controlling positions of leadership. 
Programmatic Implications
Although many of the health system challenges identified through the study—such as limited access to 
electricity and phone connectivity for health workers and problems with health worker remuneration—are 
outside the control of the project and in the hands of the government, they are critical constraints that must be 
considered when designing and implementing USAID IHP-supported interventions. Obvious examples are the 
lack of electrical power and limited phone and Internet connectivity and Internet credit, which can affect 
efforts to improve service readiness and data collection and reporting for the Système national d'information
sanitaire (SNIS [national health data collection and reporting system]). 
However, other challenges identified can be partially addressed through project-supported strategies and 
interventions. The following are recommendations based on the study results:
• The design of both facility- and community-based service delivery interventions should be based on 
formative research on community perceptions and needs. This recommendation reflects the qualitative 
research findings that highlight the importance of geographical and cultural differences in the DRC, 
and the need to design program approaches to better coincide with contextual conditions. More 
experimental interventions should also be tested to assess the role of cultural context on their 
effectiveness. 
• The program should explore alternative approaches to improve the remuneration of health workers—
possibly through coordination with the MOH’s Projet de Développement du Système de Santé (PDSS
[the DRC’s performance-based financing project])—to improve health worker motivation and, in turn, 
service quality and availability. This recommendation is based on both quantitative and qualitative 
research findings, suggesting that a large percentage of health workers do not receive a salary. We 
found that this affects health workers’ motivation and leads to a heavy reliance on income received 
from household out-of-pocket payments.
• The program should place more emphasis on supervision of local health officers and health workers to 
improve (a) service quality and (b) the collection, availability, and use of routine data, beyond the data 
that are available in the DHIS2. This recommendation is based on survey findings indicating that
external supervision is not carried out as frequently as MOH guidelines stipulate, and a finding that 
providers need support in adhering to provider practice guidelines.
• More emphasis should be placed on continuous education programs to improve adherence to provider 
practice guidelines, which can improve adherence to standards of care. Again, this is based on the 
finding from the clinical vignettes, indicating that providers often did not have the knowledge to 
correctly diagnose and treat certain health problems.
• Stockouts of essential medications plague health facilities, undermining health services and their use, 
and jeopardizing the revenue needed for health facilities to function. Stockouts force health workers to 
use unregulated drugs and provide prescriptions to sick patients. To ensure the provision of regular and 
quality care, efforts are needed to guarantee that medications meet drug orders and are delivered in a 
timely and routine fashion.
• Community health activities are not functioning as described in the national community health 
strategy. CHWs require ongoing training, supervision, and materials to successfully carry out activities, 
Baseline Report 19
including their roles in the execution of iCCM activities. Community activities would benefit from 
oversight by and the support of community-based organizations and development committees. 
Mechanisms to motivate and retain CHWs should be explored. 
Evaluation Purpose and Questions
Evaluation Purpose
Despite the need for a more responsive health system, the evidence base for improved policy decision making 
in the Democratic Republic of the Congo (DRC) is weak, due to limited research capacity, lack of 
transportation and communications infrastructure, security challenges, and limited funding for health systems 
research. Beyond the DRC, there is a general paucity of information about low-income countries, especially 
fragile states, regarding the efficacy of interventions to address system-level gaps and capacity shortcomings. In 
a 2012 systematic literature review of evaluations of health system strengthening (HSS) programs, few 
evaluations were found to be comprehensive across multiple health system building blocks, and few included 
evaluation designs that considered the complex nature of the programs (Adam, Hsu, and de Savigny et al., 
2012).
This evaluation helps fill the previous knowledge gaps by supplying critical information about the impact of 
the Programme de Santé Intégré de l'USAID en République Démocratique du Congo (PROSANI USAID), 
known in English as USAID IHP, a large, complex HSS project. By contributing to the country’s evidence 
base of successful and unsuccessful HSS activities, this evaluation provides lessons to help design future 
projects intended to deliver high-quality healthcare and family planning (FP) services that meet the needs of 
the Congolese people.
D4I designed this evaluation to investigate the following:
• The progress of USAID IHP over time in achieving Objectives 1, 2, and 3, as follows: strengthened 
health systems, governance, and leadership at the provincial, health zone, and facility levels; increased 
access to quality, integrated services; and increased adoption of healthy behaviors. 
• The impact of USAID IHP on several proxy indicators of healthy behaviors, including treatment for 
childhood illnesses, maternal healthcare use, and contraceptive method use.
• The factors that enabled or limited the success of USAID IHP, including the design and scope of the 
project, implementation factors, and external and contextual factors. 
Achieving these evaluation objectives requires both a performance evaluation and an impact evaluation. The 
performance evaluation incorporates several study components based on data from USAID IHP provinces 
only, including District Health Information Software, version 2 (DHIS2) data; population-based household 
survey data; health facility, health zone office, and provincial health office survey data; and qualitative data. 
This component of the evaluation investigates whether USAID IHP achieved targets for all three of its
performance objectives—strengthened health systems, governance, and leadership; increased access to high￾quality, integrated services; and increased adoption of healthy behaviors. To the extent possible, we will 
triangulate empirical data with qualitative data to explore whether changes over time in the adoption of 
healthy behaviors are associated with changes in strengthened health systems and increased access to high￾quality, integrated services, and to determine why expected changes are or are not observed. Last, to explore 
the health impacts of the changes in intervention coverage, we used the Lives Saved Tool (LiST) to estimate 
how changes in the adoption of healthy behaviors translate to changes in the number of lives saved. The LiST 
20 The Impact of USAID’s Integrated Health Program in the DRC
analysis will be conducted at midline and endline; therefore, no methods or results related to that analysis are 
presented in this report.
The impact evaluation component of the study compares DHIS2 data of several proxy indicators of healthy
behaviors in project areas and non-project areas using a difference-in-differences with propensity score 
matching approach. Because it was not possible to administer the population-based household surveys and the 
health facility, health zone office, and provincial health office surveys outside of the nine USAID IHP 
provinces areas, it is not feasible to assess the impact of USAID IHP on population-based service coverage 
rates, or on indicators of strengthened health systems, leadership and governance, and increased access to 
high-quality, integrated services. 
The key audiences for this evaluation include officials and relevant personnel of the Ministry of Health 
(MOH), USAID, and other international health organizations and agencies. We expect that the results of the 
evaluation will be used to inform the design and implementation of future HSS activities in the DRC.
Evaluation Questions
1. Did the expected changes in outcomes and impacts occur?
a. Strengthen health systems, governance, and leadership at provincial, health zone, and facility 
levels in target health zones
i. Outcome: Enhanced capacity (institutional and individual) of provincial health 
offices, health zones, and facilities to plan, implement, monitor, oversee, and 
supervise services
ii. Outcome: Strengthened capacity of civil society organizations (CSOs) and 
community structures to provide health systems oversight
b. Increase access to high-quality, integrated health services in target health zones
i. Outcome: Increased availability of high-quality, integrated facility-based health 
services and commodities
ii. Outcome: Increased availability of high-quality, integrated community-based health 
services
iii. Outcome: Improved affordability of integrated health services
c. Increase adoption of healthy behaviors, including health service use, in target health zones
i. Impact: Proportion of children under five for whom treatment or advice was sought 
for acute respiratory infection (ARI), diarrhea, and fever
ii. Impact: Proportion of children under five who slept under an insecticide-treated net
iii. Impact: Proportion of married women using any modern method of contraception
iv. Impact: Proportion of children who received all eight basic vaccinations
v. Impact: Proportion of pregnant women who attended four antenatal care (ANC) visits
2. If there were changes in healthy behaviors over the course of the study period, to what extent were 
these attributable to USAID IHP?
3. Did the project contribute to gender equity in health services and in the health system?
Baseline Report 21
4. What factors enabled or limited the success of USAID IHP? 
a. Design and scope
b. Implementation and management
c. External environment and contextual factors 
d. Government decentralization
Purpose of the Report
This report documents the functioning of the health system and select health outcomes immediately before the 
implementation of USAID IHP-supported activities in the targeted provinces. We report baseline data from 
three sources: surveys of health facilities and households in USAID IHP-supported areas; routine data from 
the DRC’s routine health information system (RHIS) for USAID IHP-supported areas and a matched control 
group; and qualitative data collected from representatives from the government health system, implementing 
staff, and beneficiaries.
22 The Impact of USAID’s Integrated Health Program in the DRC
Project Background
As part of its strategy to improve health outcomes in the DRC, USAID funded the USAID IHP program in 
2018. The program began operations in July 2018 and is being implemented by Abt Associates and several 
partner organizations. The purpose of USAID IHP is to strengthen the capacity of Congolese institutions and 
communities to deliver high-quality, integrated health services to sustainably improve the health status of the 
Congolese population. The specific health, population, and nutrition areas of focus for the project are maternal 
health; neonatal, infant, and child health; tuberculosis (TB); malaria; child nutrition; water, sanitation, and 
hygiene (WASH), and FP. 
USAID IHP seeks to reach its goal through the achievement of the following overall performance objectives:
• Strengthen health systems, governance, and leadership at the provincial, health zone, and facility levels 
in target health zones (Objective 1).
• Increase access to high-quality, integrated health services in target health zones (Objective 2).
• Increase the adoption of healthy behaviors, including the use of health services, in target health zones 
(Objective 3).
USAID IHP will work in nine contextually diverse provinces in the regions of Eastern Congo, Katanga, and 
Kasai, and will include a wide array of interventions. 
Given the breadth and depth of the planned interventions, the USAID/DRC Mission requested Data for 
Impact (D4I) to conduct an independent, third-party evaluation of the performance and impact of USAID IHP 
on key health systems-related outcomes, including the uptake of FP and healthcare services; health systems 
functioning (i.e., improved disease surveillance, the availability of essential commodities, and health worker 
motivation); and the practice of key healthy behaviors. 
The project team works closely with government health officials at the central, provincial, zonal, and health 
facility levels to build government capacity and leadership, and to increase the sustainability and local 
ownership of the interventions. The USAID IHP’s components will address three program objectives, as 
follows.
Objective 1: Strengthen Health Systems, Governance, and Leadership at Provincial, Health Zone, and Facility 
Levels in Target Health Zones
The programmatic approaches related to Objective 1 aim to support provinces, health zones, and communities 
to become empowered stewards and effective managers of health system functions, via tailored needs-based 
interventions guided by results of Participatory Institutional Capacity Assessment and Learning Index 
(PICAL) evaluations and human-centered design (HCD) techniques. 
The PICAL tool will be applied at provincial and health zone levels to foster a culture of self-assessment, 
enhance institutional capacity building, and guide the development and implementation of performance 
improvement action plans to support improved governance, leadership, and accountability. The capacity￾building needs identified during PICAL assessments will also be used to facilitate targeted technical assistance, 
coaching, and leadership training in (1) public financial management; (2) analysis and use of data for improved 
disease surveillance and facility-level data reporting; (3) management of human resources for health, taking
gender into consideration in the recruitment and deployment of staff; and (4) use of the performance 
dashboard tool to equip provincial and health zone managers with real-time, data-driven, decision-making 
capabilities. Moreover, USAID IHP will: optimize the use of existing methods, such as results-based 
financing; employ mobile phone-based surveillance technologies; and strengthen supply chain activities to 
support quantification, forecasting, and timely inventory replenishment.
Baseline Report 23
At the community level, USAID IHP will use the recently developed MOH community dynamics strategy to 
improve stakeholder coordination and oversight functions. By facilitating collaboration among provincial, 
health zone, and community stakeholders, this strategy aims to strengthen the capacity of Comités de 
Développement de l’Aire de Santé (CODESAs [health area development committees]), CSOs, and community￾based organizations to be true partners in addressing social and behavior change (SBC), and mobilizing the 
demand for and uptake of improved health services. Activities to support community-level monitoring of 
health system performance will include streamlining community scorecard approaches; launching a toll-free 
fraud and complaints hotline number for reporting corruption, abuse, or similar allegations; and providing 
rights-based education to communities. Capacity-building of CODESAs, select CSOs, or community-based 
organizations will also take place through a Grant under Contract program. Together, this enhanced 
coordination capacity and multi-level collaboration will support more effective community stewardship of the 
health system, while demanding accountability of both local and provincial authorities.
Objective 2: Increase Access to Quality, Integrated Health Services in Target Health Zones
The programmatic approaches related to Objective 2 focus on increasing health service demand, access, and 
quality in the program regions. A primary component entails scaling up health facilities that can provide 
essential, integrated, and high-quality health services. Facility-based activities include renovating health 
infrastructures; equipping health facilities with drugs and medical supplies; and building knowledge and 
capacity among health workers so that health personnel can provide a package of integrated services for
maternal, neonatal, and child health; nutrition; FP and reproductive health; WASH; malaria; and TB. 
The interventions will also focus on improving health worker attitudes and interpersonal communications. As 
part of this approach, the project will implement a fraud and complaints hotline and reporting system to 
enhance health worker accountability. Using a cluster model strategy, the project will first prioritize building 
capacity in a high-performing facility in a health zone, and once strengthened, use that health structure to 
provide support and outreach to facilities in the same health zone. The project aims to strengthen other 
facilities located in more remote locations over the course of the project. 
Community-based health activities are considered critical to increasing the use of facility services and 
improving the provision of essential health services, especially in remote localities. Interventions designed to 
strengthen community-based health services will include recruitment of new community health workers 
(CHWs), especially women; training CHWs on health promotion (with a focus on WASH) and integrated 
community case management (iCCM); and training facility-based health workers on community outreach and 
the provision of health services at the community level. Community activities will be scaled up over time, with 
an initial focus on remote communities with access to supported health facilities. Interventions will also 
involve strengthening referrals from community platforms and HCs to referral hospitals. A general emphasis 
will involve building collaboration with government health structures, the United States Government, and 
other donors by supporting and actively participating in central-level meetings during which learning 
experiences, needs, and priorities can be jointly identified and discussed, and policy influenced.
Objective 3: Increase the Adoption of Healthy Behaviors, including the Use of Health Services in Target 
Health Zones
The interventions related to Objective 3 are meant to increase the adoption of healthy behaviors and use of 
health services in the targeted provinces. The strategy aims to raise community awareness and knowledge of 
healthcare services and address barriers to optimal healthcare-seeking, and to strengthen community 
engagement and social support to enable healthy behaviors. Specific interventions will include a “healthy 
family” campaign composed of a multipronged educational program involving a family drama series focusing 
on common health problems and issues related to accessing facility and community-based health services, the 
care received, and satisfaction derived. Storylines disseminated through radio and text messaging will highlight 
24 The Impact of USAID’s Integrated Health Program in the DRC
sociocultural barriers that inhibit access to services and the practice of healthy behaviors, and ways these 
barriers can be overcome. Radio listening sessions will be organized to facilitate community discussions and 
reactions to scenarios presented during the drama series at the local level. The messages conveyed through the 
drama series will be complemented by interpersonal communication carried out by CHWs and CODESAs,
and supported by women’s organizations and other community-based groups through mobilization events. 
Open houses will be held to showcase improvements in health facilities and encourage use. 
The Champion Community model will be implemented to prioritize HAs and target audiences, and develop 
workplans and monitor activities in the targeted areas. Mini campaigns focused on addressing health problems 
will also be carried out according to specific and immediate needs. Efforts will be made to share lessons 
learned, harmonize strategies, and improve approaches by collaborating and coordinating with other groups 
involved in SBC, including the following: key government institutions working on communications; 
government officials, implementing agencies, and other stakeholders participating in coordination meetings 
(clusters, Médecin Chef de Zone [MCZ], head nurse) at the central, provincial, and zonal levels; and USAID staff 
and partners. 
The project aims to share SBC activity results with international audiences during academic conferences and 
through peer-reviewed, scientific manuscripts. At the more local level, coordination of SBC approaches will be 
carried out in conjunction with the health zone office, CODESAs, and Cellules d’Animation Communautaire
(CAC [community-level organizations that engage in health communication]), with assistance provided to 
health zones during the development of their operational action plans to ensure the overall goal of scalability 
of sound and effective messaging and activities that align with and contribute to the achievement of agreed on 
health goals. 
The project started in July 2018 and will be implemented over a four-year period, with the possibility of a 
three-year extension. The project is led by Abt Associates, with the International Rescue Committee and 
Pathfinder International as core partners. Seven niche partners with expertise in health programming, 
designing innovative approaches, and research in fragile states—including DRC—are participating.
Baseline Report 25
Evaluation Methods and Limitations
Methods
D4I will carry out two types of evaluation components for this study: a performance evaluation and an impact 
evaluation. As defined by USAID Evaluation Policy, performance evaluations incorporate before and after 
comparisons, but generally lack a rigorously defined counterfactual to control for factors other than the project 
or intervention that might account for the observed change. Impact evaluations assess the extent to which 
changes in health outcomes or service use over time are attributable to an intervention. The performance 
evaluation aspect of the study will address: Research Question 1, which investigates changes over time in 
USAID IHP areas; Research Question 3, which examines the extent to which the project addressed issues of 
gender equity; and Research Question 4, which investigates factors that enabled or limited the success of the 
project. Data for this component of the study will come from multiple sources, including: the DRC’s RHIS
(DHIS2); household surveys; surveys of healthcare facilities, health zone offices, and provincial health offices; 
and key informant and in-depth interviews, observations of patient-health worker interactions, and focus group 
discussions. The impact evaluation aspect of the study will address Research Question 2, which investigates 
the extent to which changes in healthy behaviors are attributable to USAID IHP. The impact of USAID IHP 
will be based on a difference-in-differences with propensity score matching model, a nonexperimental design, 
based on data from the DHIS2. Ethical approval for this work was given by the Institutional Review Boards of 
Tulane University and the Kinshasa School of Public Health.
Analysis of Impact Using a Difference-in-Differences Model
Model description: A doubly robust model that combines difference-in-differences with propensity score 
matching will be used to estimate the impact1 of USAID IHP on the provision of maternal and child 
healthcare services and FP services (as identified in Research Question 2). The unit of analysis will be at the 
facility level. The treatment arm includes facilities in health zones in USAID IHP provinces (based on data 
from both hospitals and HCs) in the pre-intervention (January 2018 to June 2019) and post-intervention (July
2019 to 2023) periods. The control arm includes facilities in comparable health zones without USAID IHP 
support. The data used for this analysis come from the health management information system.
Analysis of Changes in Project Areas 
Facility-, health zone office-, and provincial health office-level changes. To evaluate the progress of USAID 
IHP-supported areas on service readiness, service quality, and service use, a separate analysis component will 
use data from provincial health offices, health zone offices, and health facilities (HCs and hospitals), which we 
will collect, plus data from baseline, midline, and endline facility and household surveys that USAID IHP is 
collecting independently. This is the performance evaluation component of the overall study. Because USAID 
IHP is operating in all health zones in its nine provinces, it is not feasible to identify and survey a comparable 
control group of health zones in these same provinces. Comparisons will be made in selected indicators 
between baseline (Year 1), midline (Year 4), and endline (Year 7). To conduct the comparisons, the absolute 
changes for each indicator value will be compared between survey waves using t-tests or Chi2 tests, both 
overall and for the three regional sub-groups. We will also stratify results by sex and age when applicable. 
1 It should be noted that, in the health evaluation research literature, the term “impact” typically refers to the effects on health 
outcomes, such as lives saved, or disability-adjusted life years averted. In the HSS evaluation literature, “impact” is also often used to 
refer to the effects on service delivery or other aspects of health systems functioning (Adams et al., 2012). For the purposes of this 
evaluation, we use “impact” in the latter way, unless otherwise noted. 
26 The Impact of USAID’s Integrated Health Program in the DRC
Household-level changes. The population-based household surveys that USAID IHP administered at baseline 
included data on the healthcare services and behaviors that the project is supporting, including FP, ANC, 
skilled-delivery assistance, immunization, and treatment of childhood illnesses. Questions on exposure to the 
various interventions that will be supported by USAID IHP were also included in the household surveys. As 
with the facility- and health-worker data, changes will be analyzed for the entire sample and by the three 
regional sub-groups. 
Analysis of Enabling or Limiting Factors
To assess the perceptions of various stakeholders on the implementation of USAID IHP-supported 
interventions, qualitative research involving a mix of methods will be carried out during the baseline, midline,
and endline evaluations, with the aim of complementing the quantitative data analysis. During the baseline 
evaluation, we carried out research at the central level (Kinshasa) and in one province in the Katanga Region 
to assess the status of health systems and to understand details of the USAID IHP interventions and plans for 
implementation. 
Limitations
There are several limitations of the evaluation and threats to carrying it out as planned. 
First, due to the data limitations described in the previous section, the impact evaluation component of the 
study will only investigate the impact of USAID IHP on proxy indicators related to service provision, 
including treatment of childhood illnesses, contraceptive use, vaccinations, and ANC. Because data on health 
outcomes, service quality, and health systems governance and leadership are not available from non-project 
areas, impacts on these aspects cannot be rigorously assessed. However, to descriptively explore these aspects, 
a performance evaluation is being carried out using both quantitative and qualitative data collected in the nine 
USAID IHP provinces2 to explore changes in proxy indicators for all three USAID IHP objectives—HSS, 
quality, integrated health services, and healthy behaviors—and the factors that enabled or limited the success 
of the project. 
Second, the impact evaluation of the study is based on routine data from the DHIS2. Although it is expected 
that using a research design based on DHIS2 data (i.e., numerous, repeated health zone observations over 
extended periods and the real-time indicators of service coverage) provide power and cost advantages over a 
research design based on intermittent population-based surveys, poor data quality remains a threat due to 
inaccurate data on counts of services provided (numerators) and the populations that are served 
(denominators). These disadvantages could lead to two consequences. First, poor data quality could add 
spurious variability to the dependent variable. If it is a random measurement error, it will add to the variation 
of the random error in the model, with the consequence of larger standard errors in the estimated coefficients 
increasing the chances of not finding significant effects when there is impact. This is a common problem in 
research studies based on data from management information systems, and there is little that the evaluator can 
do to address the issue. Second, the measurement error could potentially evolve over time as data quality 
improves with improvements made to data reporting systems. Because USAID IHP aims to improve DHIS2 
data quality, these improvements could be different in treatment and comparison areas, which will create a 
type of endogeneity3 in the program variable of the model that varies over time, so it is not controlled by the 
fixed effects. This heteroskedasticity4 will be accounted for through the estimation of robust standard errors. 
Third, the D4I and USAID IHP surveys used as the source of baseline data were administered several months 
after USAID IHP started operations (in July 2018). This timing would be problematic if USAID IHP’s 
2 Qualitative data will be collected in three provinces and Kinshasa. 3 A model in which the explanatory variable is correlated with the error term.
4 A case in which the standard errors of a variable are not constant over time.
Baseline Report 27
implementation activities had already begun because it would bias the performance evaluation component of 
the study. However, based on previous meetings with USAID and the USAID IHP management teams, one of 
the key purposes of the USAID IHP surveys is to provide evidence that can be used to comprehensively assess 
the health systems needs in the nine provinces and, therefore, USAID IHP will withhold most of its 
interventions until after the survey data have been analyzed. 
Fourth, the DRC is an unstable environment and there is a possibility that both the implementation of USAID 
IHP, and D4I and USAID IHP survey activities, could be affected by political and social unrest during the 
project period. This is not likely to affect the impact evaluation component of the study, which relies on RHIS
data, but it could affect future surveys if the data collection teams cannot safely travel to sampled provinces, 
health zones, and facilities affected by unrest, should that occur.
28 The Impact of USAID’s Integrated Health Program in the DRC
Findings
Health Systems Governance and Leadership
Capacity to Plan, Implement, and Monitor Services
Electricity enables efficient work and regular communication. Not all health zone offices had a source of 
electricity. Overall, 44.3 percent of health zone offices had any source of electricity, and slightly less (37.7 
percent) had electricity functioning at the time of the survey (Figure 1.1). There was substantial variation
among the provinces. The availability of electricity in health zone offices ranged from 6.3 percent in Kasai 
Oriental to 74.1 percent in Haut Katanga.
Figure 1.1 Electricity in health zone offices, by province
Figure 1.2 shows the mean number of hours of electricity during a typical eight-hour day in health zone offices 
that had a source of electricity. Sankuru had the lowest number of hours, at an average of 3.3 hours per day 
(among the 20% of offices that had any electricity). Although Kasai Oriental had the lowest coverage of 
electricity, the lone health zone office that had a source of electricity also reported the longest duration, with 
uninterrupted service during an eight-hour day.
50.0
40.0
6.3
20.0
74.1
50.0
44.3 42.3
20.0
6.3
20.0
66.7
41.7
37.7
0
20
40
60
80
100
Sud Kivu (n=26) Tanganyika
(n=10)
Kasai Oriental
(n=16)
Sankuru (n=15) Haut Katanga
(n=27)
Lualaba (n=12) Overall (n=106)
Eastern Congo Kasai Katanga
Facility has electricity Electricity currently functioning
Baseline Report 29
Figure 1.2. Mean number of hours of functional electricity on a typical eight-hour day in health 
zone offices with a source of electricity, by province
A reliable means of communication is critical for health zone offices to carry out their oversight and reporting 
functions. Figure 1.3 displays the percentage of health zone offices that had a cellular telephone or an Internet
connection (either provided by the office or employees’ personal devices). Overall, there were cellular 
telephones at roughly one in four health zone offices and an Internet connection at slightly less than one-half. 
Health zone offices in Lualaba appeared the least connected, with 75 percent of the offices having no cellular 
telephone or Internet connection.
5.5
7.0
8.0
3.3
6.4
7.0
6.1
0
2
4
6
8
Sud Kivu (n=13) Tanganyika
(n=4)
Kasai Oriental
(n=1)
Sankuru (n=3) Haut Katanga
(n=20)
Lualaba (n=6)
Eastern Congo Kasai Katanga Overall (n=47)
30 The Impact of USAID’s Integrated Health Program in the DRC
Figure 1.3. Cellular telephone and Internet connections at health zone offices, by province
Among health zone offices that had an Internet connection, the mean total connectivity time was slightly less 
than half a day (3.7 hours) (Figure 1.4). Sud Kivu experienced the longest cumulative interruptions, with only 
2.6 hours of Internet connection per day. Connectivity was best in Sankuru, with a mean of 6 hours per day.
Figure 1.4. Mean number of hours of functional Internet on a typical eight-hour day in health zone 
offices with an Internet connection, by province
30.8
60.0
18.8
33.3
14.8
0.0
24.5
53.9
50.0 50.0
13.3
63.0
25.0
46.2
42.3
20.0
43.8
53.3
33.3
75.0
43.4
0
20
40
60
80
100
Sud Kivu (n=26) Tanganyika
(n=10)
Kasai Oriental
(n=16)
Sankuru (n=15) Haut Katanga
(n=27)
Lualaba (n=12)
Eastern Congo Kasai Katanga Overall (n=106)
Cellular reception Internet connection Neither
2.6
3.4
4.3
6.0
4.2
4.7
3.7
0
2
4
6
8
Sud Kivu
(n=14)
Tanganyika
(n=5)
Kasai Oriental
(n=8)
Sankuru (n=2) Haut Katanga
(n=17)
Lualaba (n=3)
Eastern Congo Kasai Katanga Overall (n=49)
Baseline Report 31
HC and hospital directors were asked whether they agreed with five statements about their autonomy in 
managing their facility (Tables 1.1 and 1.2). Directors at both HCs and hospitals reported the highest levels of 
autonomy in staff assignments and staff activities, and the lowest levels of autonomy in obtaining resources 
and allocating their budgets. 
Table 1.1. Degree to which health center directors report having autonomy in management 
(n=328)
Completely Somewhat Not at all Not applicable
Staff assignments 61.6 23.2 13.7 1.5
Assign activities to staff 60.1 24.1 13.7 2.1
Services provided 54.6 29.0 14.3 2.1
Authority to obtain resources 37.2 22.0 36.9 4.0
Budget allocation 36.9 20.7 35.7 6.7
Table 1.2. Degree to which hospital directors report having autonomy in management (n=110)
Completely Somewhat Not at all Not applicable
Staff assignments 66.4 25.5 6.4 1.8
Assign activities to staff 62.7 27.3 8.2 1.8
Services provided 48.2 28.2 21.8 1.8
Budget allocation 35.5 28.2 30.9 5.5
Authority to obtain resources 30.0 25.5 40.9 3.6
One aim of USAID IHP is to administer the PICAL at all supported health zone offices. At the time of the 
baseline survey, a small percentage of health zone offices in the two provinces surveyed in the Katanga region 
(Haut Katanga and Lualaba) reported having completed a PICAL (Figure 1.5). Most facilities that completed 
a PICAL had done so in the past six months. In Haut Katanga, most offices had received a PICAL score, but 
none knew their score. 
32 The Impact of USAID’s Integrated Health Program in the DRC
Figure 1.5. Health zone offices’ Participatory Institutional Capacity Assessment and Learning
Index participation and score, by province
Improved Transparency and Oversight in Health Service Financing and Administration
In health zone offices, data collectors administered the survey to the highest-ranking official present. Table 1.3
shows the status and role of the person interviewed. In nearly 60 percent of health zones, the data collector 
interviewed an official who identified him or herself as the head of the office. In slightly more than half of the 
cases, the Médecin Chef (chief physician) was present. 
Table 1.3. Status and role of respondents to health zone office survey, by province 
Eastern Congo Kasai Katanga
Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Head of the 
office
53.9 100.0 37.5 66.7 63.0 50.0 59.4
Médecin chef 34.6 100.0 31.3 66.7 51.9 58.3 51.9
N 26 10 16 15 27 12 106
Health workers were asked to report the last time that someone at their facility interacted with them in a 
supervisory capacity. Figure 1.6 shows the percentage of health workers who had internal supervision in the 
week preceding the survey. Across all provinces, recent supervision was more prevalent in HCs than in 
hospitals. The levels of supervision were quite low overall, with less than one-quarter of health workers 
reporting recent supervision.
14.8
8.3
4.7
11.1
8.3
3.8
11.1
0
2.8
0
5
10
15
20
Sud Kivu (n=26) Tanganyika
(n=10)
Kasai Oriental
(n=16)
Sankuru (n=15) Haut Katanga
(n=27)
Lualaba (n=12)
Eastern Congo Kasai Katanga Overall (n=106)
Ever completed PICAL assessment PICAL within last six months Received PICAL score Knows PICAL score
Baseline Report 33
Figure 1.6. Percentage of health workers who are not head of the facility who report being 
internally supervised in the past week
The government-run health system in the DRC is designed to have a cascade of supervision: the national level 
supervises the provincial health offices, which in turn supervise the health zone offices. The health zone offices 
are primarily responsible for supervising the hospitals and HCs. Four of the six surveyed provincial health 
offices reported that they were visited by national-level authorities in the prescribed six completed calendar 
months before the survey (Table 1.4). Both provincial health offices that were not visited were in Katanga 
(Haut Katanga and Lualaba).
Similarly, Table 1.4 shows the percentage of health zone offices that were visited by either national-level or 
provincial-level authorities. Overall, more than one-half of the health zone offices received supervision in the 
prescribed three-month timeframe. The rate was lowest in Sud Kivu at 38.5 percent. 
Hospitals are also supposed to receive in-person supervision at least once every three months. Overall, more 
than one-half of the hospitals were supervised by either the health zone or provincial health office. The
percentage ranged from 25 percent in Sankuru to 80 percent in Tanganyika.
By contrast, HCs are supposed to be supervised every month. Half of the HCs reported that they had been 
supervised by either the health zone or the provincial health office. Rates of supervision were highest in 
Lualaba (62.2%) and lowest in Sankuru (33.3%).
Table 1.4. Percentage of offices and health facilities that were visited in a supervisory capacity by 
a higher-level authority in the prescribed timeframe, by province
Eastern Congo Kasai Katanga
Overall Sud 
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Provincial health 
offices 1 1 1 1 1 1 6
National yes yes Yes yes no no 66.7
19.3
34.8 31.4
12.5
21.0
33.0
23.3
15.1
20.0
40.3
12.0
26.7 29.3
23.7
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health center (n=862) Hospital (n=351)
34 The Impact of USAID’s Integrated Health Program in the DRC
Health zone offices 26 10 16 15 27 12 106
Province 34.6 50.0 62.5 40.0 55.6 50.0 48.1
National 3.9 30.0 25.0 6.7 11.1 8.3 12.3
Either 38.5 60.0 62.5 46.7 59.3 58.3 52.8
Hospitals 29 10 17 16 26 12 110
Health zone 34.5 70.0 41.2 18.8 50.0 41.7 40.9
Province 31.0 70.0 35.3 12.5 19.2 25.0 29.1
Either 55.2 80.0 52.9 25.0 53.9 50.0 51.8
Health centers 86 30 47 45 83 37 328
Health zone 41.9 56.7 53.2 28.9 54.2 62.2 48.5
Province 5.8 3.3 10.6 6.7 8.4 5.4 7.0
Either 43.0 56.7 55.3 33.3 55.4 62.2 50.0
CODESAs function as liaisons between health facilities and the community. A component of their role is to 
provide support to and oversight of health facility operations. Table 1.5 reports the percentage of HCs for 
which a CODESA performed various management and oversight tasks in the 90 days preceding the survey. 
Overall, the most common function performed was developing health messaging for the community (94.4%), 
followed by two functions related to medicines: being present when medicines arrived at the facility (84.6%) 
and assisting with the inventory of medicines (79%). Functions of financial oversight tended to be less 
common, with auditing financial records, planning for monthly expenses, assisting with the expense report,
and examining the cash box being the least frequently performed tasks.
Table 1.5. CODESA participation in health center management during the past 90 days, by 
province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Developed health messaging 
for community
95.4 100.0 97.8 100.0 85.0 97.3 94.4
Present when medications 
arrived
88.4 96.7 93.5 95.6 62.5 89.2 84.6
Assisted with inventory of 
medicines
89.5 93.3 93.5 86.7 51.3 75.7 79.0
Discussed fee schedule with 
management
81.4 83.3 78.3 97.8 52.5 91.9 77.5
Completed medicine 
acceptance report
84.9 96.7 91.3 93.3 47.5 70.3 77.2
Assisted in calculating health 
indicators
62.8 86.7 89.1 55.6 77.5 51.4 70.1
Completed inventory analysis 
report
80.2 93.3 73.9 80.0 47.5 46.0 68.5
Baseline Report 35
Ensured that cold chain was 
respected
69.8 83.3 71.7 48.9 58.8 56.8 64.2
Presented health indicators to 
community
68.6 90.0 76.1 42.2 58.8 40.5 62.4
Equipment inventory 69.8 93.3 67.4 68.9 36.3 59.5 62.0
Audited financial records 58.1 83.3 58.7 26.7 33.8 51.4 49.4
Assisted with plan for monthly 
expenses
51.2 83.3 50.0 13.3 32.5 46.0 43.5
Assisted with expense report 50.0 76.7 54.4 8.9 30.0 48.7 42.3
Examined cash box 48.8 80.0 43.5 15.6 33.8 29.7 40.4
N 86 30 47 45 83 37 328
Health facility directors were asked whether they had received formal feedback from the health zone office in 
the past 90 days and, if so, in what format (Tables 1.6 and 1.7). If the director reported that the health zone 
office had provided written feedback, the surveyor asked to see the report to verify. Overall, 63 percent of HCs 
and 45.4 percent of hospitals had received feedback. Sankuru was a negative outlier, with more than 93 
percent of HCs and hospitals reporting that they had not received feedback in the past 90 days.
36 The Impact of USAID’s Integrated Health Program in the DRC
Table 1.6. Percentage of health centers that received feedback from health zone offices in the past 
90 days, by province
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Yes, verbal 36.1 23.3 27.7 4.4 35.4 8.1 26.0
Yes, written (verified) 20.9 33.3 25.5 2.2 35.4 32.4 25.1
Yes, written (not 
verified) 11.6 13.3 10.6 0.0 9.8 32.4 11.9
No 31.4 30.0 36.2 93.3 19.5 27.0 37.0
N 86 30 47 45 82 37 327
Table 1.7. Percentage of hospitals that received feedback from health zone offices in the past 90 
days, by province
Hospital
Eastern Congo Kasai Katanga
Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Yes, verbal 24.1 0.0 23.5 6.3 25.0 0.0 16.7
Yes, written (verified) 17.2 50.0 5.9 0.0 29.2 25.0 19.4
Yes, written (not verified) 27.6 0.0 5.9 0.0 4.2 0.0 9.3
No 31.0 50.0 64.7 93.8 41.7 75.0 54.6
N 29 10 17 16 24 12 108
Health mutuelles are health financing schemes that operate in some communities in the DRC. Twenty health 
zone offices in three provinces reported that at least one health mutuelle was operating in their zone (Table 
1.8). The majority (65%) kept a list of the health mutuelles, but only 15 percent kept a list of the mutuelle
members. In 40 percent of health zones, the health zone office must authorize fee reductions for health 
mutuelle members, and in 40 percent, the health zone office reported that they made visits specifically to 
supervise the health mutuelles.
Table 1.8. Health zone offices’ oversight of health mutuelles, by province
Eastern Congo Kasai Katanga
Overall
Sud Kivu Tanganyika Kasai 
Oriental Sankuru Haut Katanga Lualaba 
Health zone keeps list of 
health mutuelles
84.6 N/A 0.0 N/A 33.3 N/A 65.0
Health zone keeps list of 
members
15.4 N/A 0.0 N/A 16.7 N/A 15.0
Health zone must give 
permission for fee 
reductions
53.9 N/A 0.0 N/A 16.7 N/A 40.0
Health zone makes 
supervision visits
53.9 N/A 0.0 N/A 16.7 N/A 40.0
n 13 0 1 0 6 0 24
Baseline Report 37
Strengthened Coordination
Directors of HCs and hospitals were asked about the frequency of their facilities holding internal management 
meetings, co-management meetings with the community, and meetings with a CODESA president in the past 
12 months. Figures 1.7 and 1.8 show the percentage of facilities that reportedly had such meetings monthly or 
more often. Overall, more than 80 percent of HCs had each type of meeting monthly or more often. Rates 
were lowest among HCs in Haut Katanga. 
In half of the surveyed provinces, a higher percentage of HCs than hospitals reported having internal 
management meetings (Figure 1.7). The frequency of meetings with the community and the CODESA tended 
to be much lower in hospitals (Figure 1.8). 
Figure 1.7. Percentage of health centers that report having internal management meetings, 
community co-management meetings, and meetings with CODESA presidents monthly or more 
often in the past 12 months, by province
93 93
72
93
67
86 83
94 93 91
96
70
86 87
94
100
89
96
76
89 89
0
20
40
60
80
100
Sud Kivu (n=86) Tanganyika
(n=30)
Kasai Oriental
(n=47)
Sankuru (n=45) Haut Katanga
(n=83)
Lualaba (n=37)
Eastern Congo Kasai Katanga Overall (n=328)
Internal Community CODESA
38 The Impact of USAID’s Integrated Health Program in the DRC
Figure 1.8. Percentage of hospitals that report having internal management meetings, community 
co-management meetings, and meetings with CODESA presidents monthly or more often in the 
past 12 months, by province
Health zone offices may coordinate with various stakeholders, including CODESAs and other health zone 
offices, and may also attend province-level management committee meetings. Overall, health zone offices’ 
communication with CODESAs was high, with 88.7 percent communicating monthly (Table 1.9). 
Communication with other health zone offices occurred less frequently. Approximately 42 percent of health 
zone offices reported communicating with other health zone offices on a monthly basis, and one in four said
that this communication happened only irregularly (Table 1.10). However, participation in provincial-level 
management committee meetings was very high, with more than 98 percent of health zone offices sending a 
representative (Figure 1.9). 
Table 1.9. Frequency of health zone offices’ communication with CODESAs, by province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba Overall
Monthly 92.3 100.0 87.5 66.7 92.6 91.7 88.7
Quarterly 3.9 0.0 0.0 0.0 7.4 8.3 3.8
Twice a 
year
0.0 0.0 0.0 0.0 0.0 0.0 0.0
Annually 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Irregularly 3.9 0.0 12.5 33.3 0.0 0.0 7.6
n 26.0 10.0 16.0 15.0 27.0 12.0 106.0
90
80 76
88
77
92
84
38
20
35 38
42
25
35
25
100
50
0
55
25
48
0
20
40
60
80
100
Sud Kivu (n=29) Tanganyika
(n=10)
Kasai Oriental
(n=17)
Sankuru (n=16) Haut Katanga
(n=26)
Lualaba (n=12)
Eastern Congo Kasai Katanga Overall (n=110)
Internal Community CODESA
Baseline Report 39
Table 1.10. Frequency of health zone offices’ communication with other health zone offices, by 
province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba Overall
Monthly 8.3 40.0 50.0 66.7 40.7 75.0 42.3
Quarterly 8.3 30.0 12.5 6.7 33.3 8.3 17.3
Twice a 
year
4.2 0.0 12.5 0.0 0.0 0.0 2.9
Annually 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Irregularly 33.3 30.0 18.8 26.7 22.2 16.7 25.0
Don't know 45.8 0.0 6.3 0.0 3.7 0.0 12.5
n 24 10 16 15 27 12 104
Figure 1.9. Percentage of health zone offices that send a representative to Comités de Gestion
provincial meetings, by province
Provincial health offices may also coordinate with their health zone offices and with other provincial health 
offices. Some also participate in technical meetings with the MOH or nongovernmental organizations
(NGOs). Table 1.11 shows the frequency of provincial health offices reporting engagement in these activities. 
All provincial health offices communicated with health zone offices on a monthly basis. Communication with 
other provincial health offices was more mixed, ranging from irregularly (Sud Kivu) to monthly (Kasai 
Oriental, Haut Katanga, and Lualaba). All provincial health offices reported attending technical meetings at 
least annually.
100 100
93.75
100 96.3 100 98.1
0
20
40
60
80
100
Sud Kivu
(n=26)
Tanganyika
(n=10)
Kasai Oriental
(n=16)
Sankuru
(n=15)
Haut Katanga
(n=27)
Lualaba
(n=12)
Eastern Congo Kasai Katanga Overall
(n=106)
40 The Impact of USAID’s Integrated Health Program in the DRC
Table 1.11. Frequency of provincial health offices’ communication and attendance at technical 
meetings, by province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Health zone offices Monthly Monthly Monthly Monthly Monthly Monthly
Other provincial meetings Irregularly Quarterly Monthly Quarterly Monthly Monthly
Technical meetings Quarterly Annually Quarterly Quarterly Annually Quarterly
d. Improved Disease Surveillance and Strategic Information Gathering and Use
Data collectors were instructed to record whether data were displayed at HCs and hospitals, and if so, what 
types of data and where they were posted. Overall, 85.4 percent of HCs and 69.1 percent of hospitals displayed 
data, whether demographic data, service statistics, or disease surveillance statistics (data not shown). Figure 
1.10 shows the percentage of HCs displaying data. Demographics were the most common data displayed, at 
78.3 percent of HCs. Roughly one-half of the HCs posted service statistics and/or disease surveillance data. 
Data were more frequently posted in public areas where they could be viewed by both staff and patients.
Figure 1.10 Data displayed at health centers, by type and location (n=328)
Hospitals displayed demographic data less frequently compared with HCs but posted service statistics and 
disease surveillance data at roughly similar rates (Figure 1.11). Demographics and service statistics were more 
frequently posted in public areas, whereas disease surveillance data were more likely to be in staff-only areas of 
hospitals.
57.9
35.4
31.7
20.4
16.2 18.0
21.7
48.5 50.3
0
20
40
60
80
100
Demographics Service statistics Disease surveillance
Public area Staff-only area None displayed
Baseline Report 41
Figure 1.11. Data displayed at hospitals, by type and location (n=110)
Theoretically, all health facilities have access to the Système national d'information sanitaire (SNIS [national 
health data collection and reporting system]), which displays current data at the facility, health zone, 
provincial, and national levels. The majority of HCs (95.4%) reported holding monthly meetings in which 
SNIS data were discussed (Figure 1.12). Slightly fewer (90.2%) HCs provided documentation that decisions 
were made based on SNIS data. This rate was notably low in Sankuru, at 73.3 percent.
Figure 1.12. Percentage of health centers that hold a monthly meeting to discuss SNIS data, and 
that made decisions based on SNIS data, by province
23.6
28.2
20.9
15.5
24.6 26.4
60.9
47.3
52.7
0
20
40
60
80
100
Demographics Service statistics Disease surveillance
Public area Staff-only area None displayed
96.5 100.0 100.0 97.8
88.0
97.3 94.2 95.4 93.3
97.9
73.3
88.0
94.6
90.2
0
20
40
60
80
100
Sud Kivu (n=86) Tanganyika
(n=30)
Kasai Oriental
(n=47)
Sankuru (n=45) Haut Katanga
(n=83)
Lualaba (n=37)
Eastern Congo Kasai Katanga Overall (n=328)
Monthly SNIS meeting Decisions based on SNIS data
42 The Impact of USAID’s Integrated Health Program in the DRC
The percentage of hospitals that reported holding a monthly meeting in which SNIS data were discussed was 
also high, at 94.6 percent (Figure 1.13), but the percentage that used SNIS data in decision making was lower 
(87.3% overall). This rate was lowest in Kasai Oriental, at 70.6 percent.
Figure 1.13. Percentage of hospitals that hold a monthly meeting to discuss SNIS data, and that 
make decisions based on SNIS data, by province
When a disease of epidemic potential (maladie à potentiel épidémique [MAPEPI]) is detected in a health zone, 
the health zone office is supposed to report it to the provincial health office within 24 hours. Health zone 
offices were asked to recall their most recent case and the amount of time it took to report it (Table 1.12). 
Overall, 58.9 percent reported the case immediately, and an additional 15.9 percent reported it within the 24-
hour window. Reporting was most timely in Sud Kivu (82.8% reported immediately or within 24 hours) and 
least timely in Tanganyika, where 55.5 percent reported on time and more than 40 percent took more than two 
days to report. 
Table 1.12. Timing of health zones’ reporting their most recent MAPEPI DHIS2 case, by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Immediately 75.9 33.3 68.8 28.6 70.4 33.3 58.9
24 hours 6.9 22.2 12.5 28.6 11.1 33.3 15.9
Next day 10.3 0.0 12.5 14.3 3.7 16.7 9.4
> 2 days 6.9 44.4 0.0 28.6 7.4 0.0 11.2
Don't know 0.0 0.0 6.3 0.0 7.4 16.7 4.7
n* 29 9 16 14 27 12 107
*MAPEPI data were collected in a separate module; therefore, the n’s vary slightly from the other health zone-level analyses.
Health zone offices were asked to list the reasons why a MAPEPI case may not be reported on time (Table 
1.13). The most commonly cited barrier was lack of telephones (34.6%), followed by lack of Internet (32.7%). 
93.1
100.0 100.0
93.8
88.5
100.0
94.6
100.0 100.0
70.6
81.3
76.9
100.0
87.3
0
20
40
60
80
100
Sud Kivu (n=29) Tanganyika
(n=10)
Kasai Oriental
(n=17)
Sankuru (n=16) Haut Katanga
(n=26)
Lualaba (n=12)
Eastern Congo Kasai Katanga Overall (n=110)
Monthly SNIS meeting Decisions based on SNIS data
Baseline Report 43
Table 1.13. Barriers to a health zone submitting an immediate or weekly MAPEPI report on time, 
by province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Overall
Kasai 
Oriental Sankuru
Haut 
Katanga Lualaba
Lack of telephones 41.4 66.7 12.5 42.9 33.3 16.7 34.6
Lack of Internet 41.4 0.0 25.0 42.9 33.3 33.3 32.7
Lack of transportation 13.8 33.3 50.0 42.9 22.2 25.0 28.0
Lack of service 10.3 11.1 0.0 50.0 3.7 25.0 14.0
Lack of electricity 6.9 0.0 25.0 7.1 14.8 0.0 10.3
Do not have correct form 6.9 0.0 12.5 7.1 11.1 16.7 9.4
Lack of credit 3.5 0.0 6.3 14.3 11.1 0.0 6.5
Terrain (distance, 
insecurity) 0.0 11.1 6.3 7.1 7.4 8.3 5.6
No time to complete 
reports 3.5 10.0 6.3 0.0 3.6 0.0 3.6
Unaware of submission 
deadline 0.0 0.0 0.0 7.1 3.7 0.0 1.9
No supervision visits 0.0 0.0 6.3 0.0 0.0 8.3 1.9
No staff to complete 
reports 0.0 11.1 0.0 0.0 0.0 0.0 0.9
n* 29 9 16 14 27 12 107
*MAPEPI data were collected in a separate module; therefore, the n’s vary slightly from the other health zone-level analyses.
When they receive a MAPEPI report from a health zone office, provincial health offices are supposed to report 
to the MOH. Timeliness of reporting the most recent case varied among the provinces, with four provinces 
reporting immediately, one reporting the next day, and one (Haut Katanga) taking more than two days (Table 
1.14). 
Table 1.14. Timing of provinces’ reporting their most recent MAPEPI DHIS2 case
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Immediately Immediately Next day Immediately >2 days Immediately
Provincial health offices were also asked to list the barriers to timely MAPEPI case reporting (Table 1.15). 
Four of six provinces cited a lack of Internet. Lack of telephones, and lack of phone or Internet credit were 
also mentioned by two provinces each.
44 The Impact of USAID’s Integrated Health Program in the DRC
Table 1.15. Barriers to a provincial health office submitting an immediate or weekly MAPEPI report 
on time, by province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Lack of Internet X X X X
Lack of telephones X X
Lack of credit X X
Improved Management and Motivation of Human Resources for Health
As part of its HSS approach, USAID IHP plans to provide support to improve the management and 
motivation of health workers in targeted provinces. This includes supporting the implementation of the iHRIS
(IntraHealth International’s open-source human resources information software), which is designed to 
rationalize staffing. Thus far, the iHRIS has been rolled out in parts of Équateur and both of the Kasai
provinces, and the World Bank has expressed interest in further expansion.
Table 1.16 provides results on the percentage of health workers who reported ever attending an iHRIS 
training. Overall, only 1.3 percent of HC staff surveyed, and 1.4 percent of hospital staff surveyed received any 
training in the iHRIS. Surprisingly, no staff sampled in either Kasai province, where the iHRIS had been 
introduced, had received such a training. 
Table 1.16. Percentage of health workers who reported attending a training on iHRIS, by facility 
type and province
Eastern Congo Kasai Katanga
Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Health center 1.3 0.0 0.0 0.0 4.1 0.0 1.3
n 228 69 137 136 195 97 862
Hospital 2.2 0.0 0.0 0.0 2.7 2.4 1.4
n 93 30 62 50 75 41 351
To assess health worker satisfaction, the health worker module included several questions on whether workers 
were “satisfied with,” “not satisfied with,” or “neutral” to various dimensions of their job, including their 
workload and the availability of medicines and equipment. Table 1.17 reports the results among HC workers 
who were sampled. Overall, the majority of health workers (57%) reported being satisfied with their workload. 
However, a much lower percentage of workers reported being satisfied with the other dimensions of their 
work, including management (36.5%), the condition of the facility (26.3%), and the availability of medicines 
and equipment (20.4% and 12.2%, respectively). In terms of the province-specific results, Sankuru in the Kasai 
region had especially low levels of satisfaction for most dimensions, and Haut Katanga and Lualaba had 
relatively higher levels of satisfaction for most dimensions.
Baseline Report 45
Table 1.17. Percentage of health center workers who reported being generally satisfied with their 
job and with specific dimensions of their job, by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Workload 44.7 59.4 67.2 76.5 50.8 54.6 57.0
Management 23.7 58.0 35.8 9.6 48.2 67.0 36.5
Facility 25.9 27.5 27.7 11.8 32.8 32.0 26.3
Medicines 14.0 5.8 21.2 11.8 31.8 34.0 20.4
Equipment 10.5 7.3 10.2 2.9 21.0 17.5 12.2
Salary 5.7 13.0 2.9 0.0 6.2 1.0 4.5
Generally satisfied 37.3 58.0 28.5 33.1 36.9 41.2 37.2
n 228 69 137 136 195 97 862
Table 1.18 shows the levels of health worker satisfaction among hospital staff sampled. Among the 328 
hospital workers sampled, the majority (53.6%) reported being satisfied with their workload, which was similar 
to the levels among HC workers. However, the percentage of workers who reported being satisfied with the 
availability of medicines (38.2%) and equipment (22.8%) was higher than the percentage reported among HC
workers. In the province-specific results, the two provinces in the Kasai region—Kasai Oriental and Sankuru—
exhibited low satisfaction levels for the availability of medicines and equipment relative to the levels among 
workers in the other sample provinces. 
Table 1.18. Percentage of hospital workers who reported being generally satisfied with their job 
and with specific dimensions of their job, by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Workload 36.6 53.3 61.3 76.0 56.0 48.8 53.6
Management 21.5 40.0 22.6 16.0 36.0 53.7 29.3
Facility 51.6 23.3 30.7 22.0 36.0 65.9 39.6
Medicines 36.6 16.7 43.6 24.0 45.3 53.7 38.2
Equipment 32.3 10.0 17.7 8.0 26.7 29.3 22.8
Salary 3.2 10.0 0.0 0.0 4.0 4.9 3.1
Generally satisfied 49.5 66.7 21.0 34.0 38.7 46.3 41.0
n 93 30 62 50 75 41 351
Workers were also asked whether they were “generally satisfied” with their job. Overall, 37.2 percent of 
sampled HC workers reported being generally satisfied, which ranged from a low of 28.5 percent in Kasai 
Oriental to a high of 58 percent in Tanganyika (Table 1.17). Among hospital workers, 41 percent were 
“generally satisfied.” This ranged from a low of 21 percent in Kasai Oriental to a high of 66.7 percent in 
Tanganyika (Table 1.18). 
Health workers in HCs and hospitals were asked whether their salary for the last completed month had been 
paid and, if so, whether it had been paid on time (Table 1.19). Overall, 15.7 percent of health workers were 
46 The Impact of USAID’s Integrated Health Program in the DRC
paid on time. Notably, no health workers were paid on time in Tanganyika. Overall, 52 percent were still 
waiting for their salary. This percentage was highest in Kasai Oriental, where more than 72 percent had not 
yet been paid. A substantial number of health workers (25.3% overall) chose not to respond to the question.
Table 1.19. Status of health workers’ salary payment for the last completed month, by province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba Overall
Paid on time 17.5 0.0 11.7 2.9 35.9 5.2 15.7
Paid late 4.4 4.4 6.6 6.6 14.4 2.1 7.1
Not yet paid 50.9 56.5 72.3 68.4 32.8 38.1 52.0
Don't know/No response 27.2 39.1 9.5 22.1 16.9 54.6 25.3
n 321 99 199 186 270 138 1,213
Health workers were also asked whether they had ever received their full government salary on time (Figure 
1.14). Overall, 8.7 percent could recall being paid in full and on time. This ranged from none in Tanganyika to 
21.9 percent in Haut Katanga. 
Figure 1.14. Percentage of health workers who reported that they have ever received their full 
government salary on time, by province
In addition to their positions in government health facilities, more than 40 percent of health workers reported 
engaging in other activities to supplement their income (Table 1.20). Health workers were most likely to 
generate supplemental income in the Katanga region (Haut Katanga and Lualaba) and least likely in Eastern 
Congo (Sud Kivu and Tanganyika). The most common source of supplemental income was agriculture 
(23.7%), followed by trade or business (9.3%), and working in the private health sector (8.7%).
7.8
0.0
6.0
3.8
21.9
2.2
8.7
0
5
10
15
20
25
Sud Kivu
(n=321)
Tanganyika
(n=99)
Kasai Oriental
(n=199)
Sankuru
(n=186)
Haut Katanga
(n=270)
Lualaba
(n=138)
Eastern Congo Kasai Katanga Overall
(n=1,213)
Baseline Report 47
Table 1.20. Percentage of health workers with sources of supplemental income, by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
No supplemental income 74.8 64.7 62.3 50.0 49.6 48.6 59.5
Agriculture 15.9 26.3 11.6 43.0 21.1 37.0 23.7
Trade/business 3.1 5.1 14.1 4.8 15.9 13.0 9.3
Private healthcare 5.6 6.1 9.1 7.5 15.2 5.8 8.7
Livestock 4.1 8.1 6.0 15.1 6.3 8.7 7.4
Rental income 1.3 1.0 1.5 0.0 3.0 2.2 1.6
Contributions from family 0.0 0.0 0.0 0.0 0.7 0.7 0.3
Other source 1.6 1.0 1.5 4.8 6.7 0.7 3.1
n 321 99 199 186 270 138 1,213
One mechanism that has been introduced in the DRC to improve health service quality and reach is 
performance-based financing (PBF), which is intended to improve health worker motivation at the facility, 
health zone, and provincial levels. With assistance from the World Bank, in 2016, the DRC introduced a 
major PBF project, Projet de Développement du Système de Santé (PDSS ), including in three provinces targeted by 
USAID IHP: Lualaba, Haut Katanga, and Haut Lomami. Figures 1.15 and 1.16 show the percentage of 
surveyed HC and hospital workers, respectively, who reported that they were part of a PBF scheme. Overall, 
23.6 percent of HC workers and 23.8 percent of hospital workers had received performance-based payments, 
with Sud Kivu and Lualaba being the provinces with the highest coverage levels. 
48 The Impact of USAID’s Integrated Health Program in the DRC
Figure 1.15. Percentage distribution of health center workers by whether they were part of a 
performance-based financing scheme, by province
Figure 1.16. Percentage distribution of hospital workers by whether they were part of a 
performance-based financing scheme, by province
59.6
97.1
85.0 89.8
75.1
48.8
73.6
4.6
2.9
3.8
3.7
2.8
35.9
15.0 10.2
21.1
47.6
23.6
0%
20%
40%
60%
80%
100%
Sud Kivu
(n=198)
Tanganyika
(n=69)
Kasai Oriental
(n=127)
Sankuru (n=88) Haut Katanga
(n=185)
Lualaba (n=82)
Eastern Congo Kasai Katanga Overall (n=749)
Received PBF bonus in past month
Supposed to receive PBF bonus but did not receive bonus in past month
Not supposed to receive PBF bonus
66.7
100.0
82.3 84.4
68.6
38.9
71.8
7.8 7.1
5.6
4.4
25.6
17.7 15.6
24.3
55.6
23.8
0%
20%
40%
60%
80%
100%
Sud Kivu
(n=90)
Tanganyika
(n=29)
Kasai Oriental
(n=62)
Sankuru (n=32) Haut Katanga
(n=70)
Lualaba (n=36)
Eastern Congo Kasai Katanga Overall (n=319)
Received PBF bonus in past month
Supposed to receive PBF bonus but did not receive bonus in past month
Not supposed to receive PBF bonus
Baseline Report 49
Access to Quality, Integrated Health Services 
Service Readiness
Surveyors assessed HCs to determine whether they offered eight select services that are part of the MOH’s
minimum package of services. More than 90 percent of facilities offered prenatal consultations, postnatal 
consultations, malaria intermittent preventive treatment, vaccination, and growth monitoring. FP, 
mebendazole supplementation, and zinc supplementation were less common. Overall, 27.1 percent of HCs 
offered all eight services. 
Table 2.1. Percentage of health centers that offered select MOH minimum package of preventive 
services, by province
Eastern Congo Kasai Katanga
Overall
Sud Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Prenatal consultations 100.0 96.8 100.0 100.0 96.4 100.0 98.8
Malaria intermittent 
preventative treatment 97.7 90.3 95.7 100.0 90.5 97.3 95.1
Postnatal consultations 85.9 93.6 95.7 97.7 91.7 100.0 92.7
FP 96.5 58.1 36.2 100.0 78.6 100.0 80.5
Vaccination 100.0 96.8 100.0 97.7 97.6 97.3 98.5
Growth monitoring 95.3 90.3 97.9 95.5 78.6 89.2 90.2
Zinc supplementation 43.5 32.3 42.6 6.8 51.2 54.1 40.6
Mebendazole 
supplementation 89.4 83.9 78.7 31.8 72.6 78.4 74.1
All select preventive services 32.9 19.4 17.0 4.6 33.3 46.0 27.1
n 86 30 47 45 83 37 328
Similarly, HCs were assessed for the degree to which they offered six services in the minimum package of 
curative services (Table 2.2). Although the majority of HCs (93.9%) reported that they performed normal 
deliveries, no more than one-half of the HCs offered each of the remaining services. 
Table 2.2. Percentage of health centers that offered select MOH minimum package of curative 
services, by province
Eastern Congo Kasai Katanga Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
HIV testing 56.5 22.6 46.8 34.1 67.9 32.4 49.1
HIV treatment (post-exposure 
prophylaxis kit) 44.7 32.3 12.8 11.4 14.3 5.4 22.3
TB testing 12.9 22.6 29.8 20.5 15.5 18.9 18.6
TB treatment 18.8 83.9 55.3 36.4 42.9 37.8 40.9
Minor surgery 7.1 3.2 6.4 2.3 20.2 2.7 8.8
Normal deliveries 85.9 100.0 95.7 100.0 92.9 100.0 93.9
All curative services 0.0 0.0 2.1 0.0 2.4 0.0 0.9
n 86 30 47 45 83 37 328
50 The Impact of USAID’s Integrated Health Program in the DRC
The MOH recommends that hospitals offer a minimum complementary package of services categorized into 
parasitology, hematology, bacteriology, and biochemical testing (Table 2.3). Overall, prevalence of these 
services was high, ranging from 99.1 percent (stool microscopic exam) to 56 percent (gram stain). Sankuru 
tended to have the lowest percentage of hospitals offering the complementary services.
Table 2.3. Percentage of hospitals with capacity to conduct specific laboratory tests on the day of 
the survey, by province (MOH complementary package of activities)
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Parasitology
Malaria microscopy 100.0 100.0 100.0 75.0 92.0 91.7 93.6
Stool direct microscopic exam 100.0 100.0 100.0 100.0 100.0 91.7 99.1
Hematology
Hemoglobin testing 100.0 100.0 100.0 87.5 100.0 91.7 97.3
White blood cell count 96.6 80.0 94.1 62.5 88.0 66.7 84.4
Leukocyte formula 89.7 70.0 88.2 56.3 84.0 75.0 79.8
Sedimentation rate 86.2 90.0 94.1 68.8 92.0 83.3 86.2
Blood type crossmatch 100.0 100.0 100.0 93.8 100.0 91.7 98.2
Bacteriology
Ziehl stain 96.6 100.0 94.1 93.8 92.0 91.7 94.5
Gram stain 65.5 80.0 23.5 6.3 84.0 66.7 56.0
Urine analysis 100.0 90.0 100.0 100.0 100.0 91.7 98.2
Biochemical
Blood glucose 96.6 90.0 82.4 50.0 84.0 91.7 83.5
HIV testing 100.0 100.0 100.0 93.8 100.0 91.7 98.2
Syphilis testing 96.6 100.0 94.1 87.5 96.0 75.0 92.7
Pregnancy testing 96.6 100.0 100.0 93.8 96.0 91.7 96.3
Hepatitis testing 96.6 90.0 88.2 93.8 96.0 91.7 93.6
n 29 10 17 16 26 12 110
The minimum package of complementary services also calls for hospitals to be equipped to provide x-rays, 
ultrasounds, and autoclaves. Figure 2.1 shows the percentage of hospitals in each province that had at least 
one of each piece of equipment. X-rays were the least common, being found in 58.7 percent of hospitals 
(ranging from 18.8% in Sankuru to 75% in Lualaba), and autoclaves were the most common (ranging from 
76.5% in Kasai Oriental to 100% in Tanganyika).
Baseline Report 51
Figure 2.1. Percentage of hospitals with X-ray, ultrasound, and autoclave equipment, by province 
(MOH minimum package of complementary services)
Surveyors assessed whether each HC had a source of electricity and if so, whether it was functioning at the 
time of the survey (Figure 2.2). The majority (76.2%) of HCs had no source of electricity, and fewer than 10 
percent of HCs had electricity in Tanganyika, Kasai Oriental, and Sankuru. Among those that had a source of 
electricity, approximately three of ten did not have functional electricity at the time of the survey.
Figure 2.2. Percentage of health centers with electricity, by province
58.6 60.0
70.6
18.8
68.0
75.0
58.7
100.0 100.0
82.4
43.8
72.0
83.3 80.7
89.7
100.0
76.5
87.5 88.0
91.7
88.1
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
X-ray Ultrasound Autoclave
18.8
0.0 2.1 2.3
36.9
18.9 17.1
7.1
3.2 2.1
0.0
14.3
5.4 6.7
74.1
96.8 95.7 97.7
48.8
75.7 76.2
0%
20%
40%
60%
80%
100%
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Yes, functioning Yes but not functioning None
52 The Impact of USAID’s Integrated Health Program in the DRC
Overall, more hospitals had electricity than did HCs, with slightly fewer than one-half having a source of 
electricity (Figure 2.3). As was the case with HCs, hospitals’ access to electricity was lowest in Tanganyika, 
Kasai Oriental, and Sankuru. Among those hospitals that had electricity, there were outages on the day of the 
survey in all provinces, except Lualaba.
Figure 2.3. Percentage of hospitals with electricity, by province
Figure 2.4 displays the percentage of health facilities with improved sanitation. Across provinces, more than 
80 percent of HCs and 90 percent of hospitals had improved sanitation, with the exception of Tanganyika,
where the percentages were much lower (48.4% of HCs and 70% percent of hospitals).
20.7
30.0 23.5 31.3
56.0 50.0
34.9
20.7 10.0
5.9
6.3
24.0
0.0
13.8
58.6 60.0
70.6
62.5
20.0
50.0 51.4
0%
20%
40%
60%
80%
100%
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Yes, functioning Yes but not functioning None
Baseline Report 53
Figure 2.4. Percentage of health facilities with improved sanitation, by province
There was wide variation among provinces in the prevalence of private delivery rooms in health facilities 
(Figure 2.5). Among HCs, the percentage ranged from 21.6 percent in Lualaba to 91.5 percent in Kasai 
Oriental. The percentage of hospitals having private delivery rooms ranged from a low of 25 percent in 
Lualaba to a high of 100 percent in Tanganyika. Sud Kivu had the biggest discrepancy, with only 28.2 percent 
of its HCs having private delivery rooms compared with 65.5 percent of its hospitals.
Figure 2.5. Percentage of health facilities with a private delivery room, by province
84.7
48.4
91.5
81.8
96.4
81.1 84.5
100.0
70.0
94.1
100.0
96.0
91.7 94.5
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health centers (n=328) Hospitals (n=110)
28.2
87.1
91.5
86.4
48.8
21.6
55.2
65.5
100.0
94.1 93.8
60.0
25.0
71.6
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health centers (n=328) Hospitals (n=110)
54 The Impact of USAID’s Integrated Health Program in the DRC
Surveyors assessed whether HCs had selected tracer drugs in stock on the day of the survey (Table 2.4). 
Oxytocin was most frequently in stock, being available in 80.9 percent of HCs overall, followed by artesunate￾amodiaquine, and oral rehydration salts. Iron sulfate, and rifampicin and isoniazid were most commonly out
of stock. Stock levels varied considerably among provinces. Overall, only 4 percent of HCs had all seven tracer 
drugs in stock.
Table 2.4. Percentage of health centers that had selected tracer drugs in stock on the day of the 
survey, by province
Eastern Congo Kasai Katanga Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Oxytocin 75.0 54.8 87.5 82.2 88.1 89.2 80.9
Artesunate-Amodiaquine 79.8 87.1 81.3 75.6 44.1 81.1 71.1
Oral rehydration salts 75.0 77.4 43.8 6.7 72.6 78.4 61.1
Depo Provera 73.8 22.6 20.8 86.7 57.1 83.8 59.9
Folic acid 61.9 38.7 52.1 53.3 58.3 67.6 56.8
Iron sulfate 27.4 22.6 31.3 13.3 39.3 35.1 29.5
Rifampicin and Isoniazid 13.1 38.7 29.2 31.1 31.0 27.0 26.4
All tracer drugs 2.4 0.0 2.1 0.0 8.3 8.1 4.0
n 86 30 47 45 83 37 328
Oxytocin was also the most commonly stocked tracer drug in hospitals, at 97.2 percent (Table 2.5). All tracer
drugs were available in at least 50 percent of the hospitals on the day of the survey although, again, stock levels 
varied widely among the provinces. For example, oral hydration salts were present in all hospitals in 
Tanganyika but in only 6.3 percent of hospitals in Sankuru. Overall, 14.2 percent of hospitals had all seven 
tracer drugs in stock.
Table 2.5. Percentage of hospitals that had selected tracer drugs in stock on the day of the 
survey, by province
Eastern Congo Kasai Katanga
Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Oxytocin 100.0 100.0 87.5 93.8 100.0 100.0 97.2
Rifampicin and Isoniazid 86.2 60.0 62.5 81.3 95.7 91.7 82.1
Artesunate-Amodiaquine 69.0 90.0 93.8 81.3 65.2 91.7 78.3
Oral rehydration salts 82.8 100.0 75.0 6.3 91.3 91.7 74.5
Folic acid 72.4 80.0 56.3 25.0 65.2 91.7 64.2
Depo Provera 72.4 20.0 31.3 93.8 69.6 66.7 63.2
Iron sulfate 55.2 60.0 37.5 18.8 65.2 75.0 51.9
All tracer drugs 10.3 0.0 0.0 0.0 30.4 41.7 14.2
n 29 10 17 16 26 12 110
Table 2.6 shows the percentage of HCs that had functioning basic equipment on the day of the survey (at least 
one functional piece of six types of basic equipment). Overall, more than one-half of the facilities had each 
type of equipment, and 37.4 percent had all six types. The percentage of HCs with all basic equipment was 
highest in Haut Katanga (54.8%) and lowest in Sankuru (2.2%). 
Baseline Report 55
Table 2.6. Percentage of health centers with all basic equipment on the day of the survey, by 
province
Eastern Congo Kasai Katanga Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Stethoscope 96.4 93.6 95.8 51.1 97.6 100.0 90.6
Thermometer 98.8 87.1 93.8 40.0 98.8 97.3 88.8
Blood pressure monitor 91.7 64.5 89.6 33.3 96.4 97.3 82.7
Adult scale 83.3 87.1 77.1 60.0 90.5 91.9 82.4
Infant scale 67.9 61.3 83.3 42.2 75.0 75.7 68.7
Light source (spotlight) 85.7 61.3 43.8 11.1 81.0 51.4 62.0
All basic equipment 46.4 29.0 29.2 2.2 54.8 37.8 37.4
n 86 30 47 45 83 37 328
Basic equipment was more prevalent in hospitals, with more than 80 percent of hospitals having each 
individual item and 77.4 percent having all six pieces of basic equipment (Table 2.7). The percentage of 
hospitals with all basic equipment was highest in Sud Kivu (93.1%) and lowest in Sankuru (50%).
Table 2.7. Percentage of hospitals with all basic equipment on the day of the survey, by province
Eastern Congo Kasai Katanga
Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut 
Katanga Lualaba
Infant scale 100.0 100.0 100.0 87.5 100.0 100.0 98.1
Thermometer 96.6 100.0 100.0 87.5 100.0 100.0 97.2
Blood pressure monitor 100.0 100.0 100.0 81.3 100.0 100.0 97.2
Adult scale 100.0 100.0 93.8 93.8 91.3 100.0 96.2
Stethoscope 100.0 100.0 100.0 81.3 95.7 100.0 96.2
Light source (spotlight) 96.6 90.0 68.8 56.3 95.7 58.3 81.1
All basic equipment 93.1 90.0 68.8 50.0 87.0 58.3 77.4
n 29 10 17 16 26 12 110
An inventory of equipment related to infection control was carried out at HCs (Table 2.8). Most HCs (89.7%) 
had a safe method of final disposal of biohazardous materials. Gowns and sharps boxes were also highly 
prevalent in HCs. The least prevalent types of equipment were eye protection (8.2%) and test strips (4.3%). 
Haut Katanga was the only province in which any HCs had all pieces of infection control equipment.
56 The Impact of USAID’s Integrated Health Program in the DRC
Table 2.8. Percentage of health centers with adequate infection control equipment, by province
Eastern Congo Kasai Katanga
Total
Sud Kivu Tanganyika
Kasai 
Oriental Sankuru
Haut 
Katanga Lualaba
Safe final disposal 89.3 96.8 97.9 77.8 88.1 91.9 89.7
Gowns 72.6 87.1 68.8 46.7 79.8 94.6 74.2
Sharps box 84.5 67.7 70.8 55.6 77.4 67.6 73.3
Gloves 51.2 61.3 87.5 53.3 72.6 83.8 66.9
Sink or basin 81.0 38.7 85.4 22.2 65.5 56.8 62.9
Clean water 77.4 48.4 62.5 11.1 54.8 29.7 52.3
Autoclave or steam 
sterilizer 46.4 32.3 27.1 48.9 42.9 37.8 40.7
Disinfectant 
(chlorine powder) 44.1 6.5 18.8 2.2 31.0 16.2 24.6
Masks 19.1 22.6 22.9 4.4 38.1 32.4 24.3
Eye protection 9.5 9.7 10.4 2.2 8.3 8.1 8.2
Test strip 6.0 0.0 2.1 4.4 7.1 0.0 4.3
All equipment 0.0 0.0 0.0 0.0 1.2 0.0 0.3
n 86 30 47 45 83 37 328
Similar to HCs, most hospitals (92.5%) had a safe method of final disposal of biohazardous materials (Table 
2.9). Although more prevalent in hospitals than in HCs, eye protection and test strips were still relatively rare, 
as was disinfectant. Hospitals in Sud Kivu and Haut Katanga were the only hospitals that had all infection 
control equipment.
Table 2.9. Percentage of hospitals with adequate infection control equipment, by province
Eastern Congo Kasai Katanga
Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Safe final disposal 96.6 90.0 100.0 81.3 95.7 83.3 92.5
Autoclave or steam 
sterilizer 89.7 100.0 81.3 87.5 87.0 91.7 88.7
Gloves 93.1 100.0 93.8 87.5 65.2 100.0 87.7
Sink or basin 82.8 100.0 81.3 68.8 95.7 91.7 85.9
Masks 96.6 90.0 68.8 87.5 69.6 75.0 82.1
Sharps box 93.1 80.0 81.3 50.0 82.6 91.7 81.1
Gowns 89.7 80.0 75.0 62.5 69.6 91.7 78.3
Clean water 82.8 80.0 87.5 31.3 82.6 66.7 73.6
Eye protection 72.4 30.0 37.5 18.8 43.5 58.3 47.2
Disinfectant 69.0 50.0 18.8 0.0 43.5 33.3 39.6
Test strip 37.9 0.0 12.5 0.0 13.0 8.3 16.0
Baseline Report 57
All equipment 10.3 0.0 0.0 0.0 4.4 0.0 3.8
n 29 10 17 16 26 12 110
The percentage of HCs and hospitals that offered a package of comprehensive sexual- and gender-based 
violence services is illustrated in Figure 2.6. Prevalence of services in HCs ranged from 9.1 percent in Sankuru 
to 45.9 percent in Sud Kivu. In all provinces, hospitals were more likely to have these services, ranging from 
50 percent of hospitals in Tanganyika to 94.1 percent in Kasai Oriental.
Figure 2.6. Percentage of health facilities offering a package of comprehensive sexual- and 
gender-based violence services, by province
Overall, the majority of HCs (55.5%) and hospitals (83.5%) offered a permanent or long-acting method of FP
(Figure 2.7). These services were least prevalent in both HCs and hospitals in Kasai Oriental. 
45.9
25.8
29.8
9.1
31.0
13.5
29.3
86.2
50.0
94.1
62.5
92.0
66.7
78.9
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health centers (n=328) Hospitals (n=110)
58 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.7. Percentage of health facilities offering a long-acting or permanent method of FP, by 
province
Figure 2.8 shows the percentage of health facilities that had at least one health worker trained in youth￾friendly FP services. No more than one-half of the HCs or hospitals in any province had such a health worker. 
In most provinces, hospitals had health workers trained in youth-friendly FP at higher rates than did HCs, 
with the exception of Tanganyika. 
Figure 2.8. Percentage of health facilities with at least one health worker trained in youth-friendly 
FP services, by province
Facilities are encouraged to have FP information and resources specific to youth. Again, fewer than one-half 
of the HCs and hospitals in any given province had these resources (Figure 2.9). 
68.2
45.2
21.3
47.7
60.7
75.7
55.5
93.1
80.0
58.8
93.8
84.0 83.3 83.5
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health centers (n=328) Hospitals (n=110)
30.6
25.8
10.6
27.3 23.8
40.5
26.2
41.4
20.0
29.4
37.5
44.0
50.0
38.5
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health centers (n=328) Hospitals (n=110)
Baseline Report 59
Figure 2.9. Percentage of health facilities with FP information and resources specific to youth, by 
province
Tables 2.10 and 2.11 list the essential staff, supplies, and equipment for administering long-acting or 
permanent methods of contraception. None of the surveyed HCs had everything necessary to administer any 
of the methods (Table 2.10). One of the major limiting factors in performing male and female sterilization in 
the HCs was the lack of trained health workers. Specific pieces of equipment (dissecting and ring forceps for 
male sterilization, and uterine elevators and Ramathibodi hooks for female sterilization) were also rarely 
present in HCs.
Table 2.10. Percentage of health centers meeting minimum standards for essential staff, supplies,
and equipment to support the provision of long-acting or permanent methods of contraception, by 
province
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Male sterilization
At least one trained health 
worker 2.4 0.0 0.0 0.0 0.0 2.7 0.9
Bucket 76.2 80.7 64.6 15.6 83.3 83.8 69.3
Chlorine powder 44.1 6.5 18.8 2.2 31.0 16.2 24.6
Sharps container 84.5 67.7 70.8 55.6 77.4 67.6 73.3
Lidocaine 75.0 54.8 37.5 71.1 70.2 78.4 66.3
Dissecting forceps 2.4 0.0 0.0 0.0 4.8 10.8 3.0
Ring forceps 1.2 0.0 0.0 2.2 2.4 5.4 1.8
All 0.0 0.0 0.0 0.0 0.0 0.0 0.0
25.9
16.1
23.4 20.5
14.3
21.6 20.4
34.5
10.0
29.4
43.8
48.0
16.7
33.9
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health centers (n=328) Hospitals (n=110)
60 The Impact of USAID’s Integrated Health Program in the DRC
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Female sterilization
At least one trained health 
worker 2.4 0.0 2.1 0.0 10.7 2.7 4.0
Bucket 76.2 80.7 64.6 15.6 83.3 83.8 69.3
Chlorine powder 44.1 6.5 18.8 2.2 31.0 16.2 24.6
Sharps container 84.5 67.7 70.8 55.6 77.4 67.6 73.3
Lidocaine 75.0 54.8 37.5 71.1 70.2 78.4 66.3
Uterine elevator 4.8 0.0 14.6 0.0 9.5 0.0 5.8
Ramathibodi hook 1.2 0.0 20.8 0.0 1.2 2.7 4.0
All 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Intrauterine device 
insertion and removal
At least one trained health 
worker: insertion 11.9 25.8 14.6 0.0 36.9 18.9 19.2
At least one trained health 
worker: removal 15.5 25.8 14.6 0.0 38.1 18.9 20.4
Bucket 76.2 80.7 64.6 15.6 83.3 83.8 69.3
Chlorine powder 44.1 6.5 18.8 2.2 31.0 16.2 24.6
Sharps container 84.5 67.7 70.8 55.6 77.4 67.6 73.3
Iodine 52.4 48.4 37.5 44.4 46.4 37.8 45.6
Uterine elevator 4.8 0.0 14.6 0.0 9.5 0.0 5.8
Ring forceps 1.2 0.0 0.0 2.2 2.4 5.4 1.8
All 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Implant (insertion and 
removal): Norplant, Jadelle, 
Sino-Implant II
At least one trained health 
worker: insertion 60.7 48.4 16.7 42.2 58.3 64.9 50.5
At least one trained health 
worker: removal 64.3 41.9 16.7 44.4 59.5 67.6 51.7
Bucket 76.2 80.7 64.6 15.6 83.3 83.8 69.3
Chlorine powder 44.1 6.5 18.8 2.2 31.0 16.2 24.6
Sharps container 84.5 67.7 70.8 55.6 77.4 67.6 73.3
Iodine 52.4 48.4 37.5 44.4 46.4 37.8 45.6
Trocar 14.3 3.2 8.3 0.0 19.1 8.1 10.9
Scalpel 6.0 0.0 6.3 0.0 17.9 0.0 7.0
Forceps 1.2 0.0 4.2 0.0 3.6 0.0 1.8
All 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Implant (insertion and 
removal): Implanon
Iodine 52.4 48.4 37.5 44.4 46.4 37.8 45.6
Implanon applicator 28.6 25.8 4.2 11.1 28.6 43.2 24.0
Baseline Report 61
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Scalpel 6.0 0.0 6.3 0.0 17.9 0.0 7.0
Forceps 1.2 0.0 4.2 0.0 3.6 0.0 1.8
All 1.2 0.0 0.0 0.0 0.0 0.0 0.3
n 86 30 47 45 83 37 328
By contrast, hospitals tended to have higher levels of readiness to provide FP services, although readiness in 
hospitals was still relatively low (Table 2.11). In three provinces (Tanganyika, Sankuru, and Lualaba), no 
surveyed hospitals had all personnel and equipment necessary to provide any method of permanent or long￾acting contraception. In hospitals, the limiting factor was not the lack of health workers trained to administer 
the methods, but rather the availability of equipment.
Table 2.11. Percentage of hospitals meeting minimum standards for essential supplies and 
equipment to support the provision of long-acting or permanent methods of contraception, by 
province
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Male sterilization
At least one trained health worker 20.69 10.0 12.5 6.25 8.7 8.33 12.26
Bucket 89.7 100.0 93.8 62.5 87.0 100.0 87.7
Chlorine powder 69.0 50.0 18.8 0.0 43.5 33.3 39.6
Sharps container 93.1 80.0 81.3 50.0 82.6 91.7 81.1
Lidocaine in stock on day of survey 96.6 80.0 81.3 100.0 91.3 83.3 90.6
Dissecting forceps 34.5 0.0 12.5 6.3 21.7 25.0 19.8
Ring forceps 31.0 0.0 6.3 6.3 13.0 8.3 14.2
All 13.8 0.0 0.0 0.0 8.7 0.0 5.7
Female sterilization
At least one trained health worker 72.4 20.0 37.5 56.3 52.2 75.0 55.7
Bucket 89.7 100.0 93.8 62.5 87.0 100.0 87.7
Chlorine powder 69.0 50.0 18.8 0.0 43.5 33.3 39.6
Sharps container 93.1 80.0 81.3 50.0 82.6 91.7 81.1
Lidocaine in stock on day of survey 96.6 80.0 81.3 100.0 91.3 83.3 90.6
Uterine elevator 37.9 0.0 43.8 6.3 43.5 16.7 29.3
Ramathibodi hook 31.0 0.0 43.8 25.0 17.4 0.0 22.6
All 20.7 0.0 6.3 0.0 8.7 0.0 8.5
Intrauterine device insertion 
and removal
At least one trained health worker: 
insertion 82.8 60.0 50.0 31.3 69.6 58.3 62.3
62 The Impact of USAID’s Integrated Health Program in the DRC
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
At least one trained health worker: 
removal 82.8 60.0 50.0 31.3 69.6 50.0 61.3
Bucket 89.7 100.0 93.8 62.5 87.0 100.0 87.7
Chlorine powder 69.0 50.0 18.8 0.0 43.5 33.3 39.6
Sharps container 93.1 80.0 81.3 50.0 82.6 91.7 81.1
Iodine* 52.4 48.4 37.5 44.4 46.4 37.8 45.6
Uterine elevator 37.9 0.0 43.8 6.3 43.5 16.7 29.3
Ring forceps 31.0 0.0 6.3 6.3 13.0 8.3 14.2
All 20.7 0.0 0.0 0.0 4.4 0.0 6.6
Implant (insertion and removal): 
Norplant, Jadelle, Sino-Implant II
At least one trained health worker: 
insertion 89.7 70.0 50.0 75.0 78.3 58.3 73.58
At least one trained health worker: 
removal 86.2 70.0 50.0 75.0 78.3 58.3 72.64
Bucket 89.7 100.0 93.8 62.5 87.0 100.0 87.7
Chlorine powder 69.0 50.0 18.8 0.0 43.5 33.3 39.6
Sharps container 93.1 80.0 81.3 50.0 82.6 91.7 81.1
Iodine* 52.4 48.4 37.5 44.4 46.4 37.8 45.6
Trocar 51.7 10.0 25.0 18.8 34.8 16.7 31.1
Scalpel 27.6 10.0 25.0 31.3 47.8 8.3 28.3
Forceps 31.0 30.0 18.8 31.3 26.1 33.3 28.3
All 17.2 0.0 6.3 0.0 8.7 0.0 7.6
Implant (insertion and removal): 
Implanon
Iodine* 52.4 48.4 37.5 44.4 46.4 37.8 45.6
Implanon applicator 51.7 30.0 0.0 25.0 26.1 66.7 34.0
Scalpel 27.6 10.0 25.0 31.3 47.8 8.3 28.3
Forceps 31.0 30.0 18.8 31.3 26.1 33.3 28.3
All 17.2 0.0 0.0 0.0 4.4 0.0 5.7
n 29 10 17 16 26 12 110
*Prevalence of iodine in facilities was collected in a different module and therefore has a different denominator from the other items in
Table 2.11.
Service Delivery
The MOH designates minimum staffing levels for urban and rural HCs. Table 2.12 shows the percentage of 
HCs found to have the minimum numbers of nurses, midwives, lab technicians, and maintenance technicians 
on staff. Overall, 23.2 percent of HCs had a sufficient number of nurses, whereas the percentage with a 
sufficient number of the other cadres was much lower. In ten cases, there were no HCs with the minimum 
numbers of health workers in a specific cadre.
Baseline Report 63
Table 2.12. Percentage of health centers with adequate staffing numbers and mix according to 
government guidelines,* 
by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Nurses 37.2 13.3 4.3 42.2 16.9 13.5 23.2
Midwives 3.5 0.0 0.0 0.0 4.8 5.4 2.7
Lab techs 0.0 0.0 0.0 0.0 2.4 0.0 0.6
Maintenance techs 1.2 0.0 4.3 0.0 9.6 2.7 3.7
n 86 30 47 45 83 37 328
*Rural HCs should have a minimum of four nurses (A1/A2), two midwives, one laboratory technician, and one maintenance 
technician. Urban HCs should have a minimum of eight nurses (A1/A2), four midwives, two laboratory technicians, and one 
maintenance technician.
To explore the factors that influence health worker behaviors, health workers were asked whether they agreed
with several statements about their knowledge and attitudes toward patients. The results for HC workers are 
presented in Table 2.13 and the results for hospital workers are presented in Table 2.14. Overall, more than
one-half of the HC workers (55.6%) agreed with the statement that “patients I care for are not educated 
enough to make good health decisions for themselves,” which is lower than the 60.7 percent of hospital 
workers who agreed with this statement. However, almost all HC and hospital workers agreed with the 
statement that “I consider patients to be worthy of my respect regardless of how poor or low status they are” 
(97.1% and 99.7%, respectively). Other findings of note were that most workers at both HCs and hospitals 
agreed that it was important to engage patients in discussions and to provide information to patients, as 
indicated through several indicators. Nevertheless, a substantial number of health workers (25.1% of HC
workers and 21.8% of hospital workers) agreed with the statement that “I was trained to provide clinical care; 
being respectful to every patient is not part of my job.”
64 The Impact of USAID’s Integrated Health Program in the DRC
Table 2.13. Percentage of health center workers who reported agreeing with statements about 
their knowledge and attitudes, by province
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Patients I care for are not 
educated enough to make good 
health decisions for themselves 
49.3 69.6 54.0 75.0 57.7 30.9 55.6
Patients I care for are not 
grateful for the efforts I make 
when I care for them 
35.2 46.4 37.2 51.5 40.2 28.9 39.4
I consider my patients to be 
worthy of respect no matter how 
poor or low status they are 
96.0 94.2 97.8 98.5 98.5 95.9 97.1
Patients often treat me without 
respect, so it is hard to treat 
them with respect 
11.5 10.1 5.1 5.2 4.6 3.1 6.9
Patients I care for make bad 
decisions regarding their health 
no matter what I tell them 
26.9 55.1 18.3 41.2 26.8 10.3 28.1
Engaging patients in 
discussions leads to better 
health outcomes than just telling 
them what is best for them 
91.6 68.1 92.0 89.0 90.2 93.8 89.3
My patients will work hard to 
improve their health when they 
are given the proper information
86.3 82.6 96.4 94.1 87.6 87.6 89.3
My role is to provide clinical 
care, not to teach patients about 
how to take care of themselves 
23.6 8.8 21.9 26.5 19.1 11.3 20.2
I do not spend a lot of thought 
about what patients may think 
about their experience at the 
clinic as I have other things to 
worry about 
9.7 10.3 13.1 16.9 8.9 7.2 11.0
An important part of my job is to 
communicate with patients to 
make sure they understand their 
care 
96.0 91.2 96.4 97.1 94.3 94.9 95.3
I try hard to think about the 
patients’ healthcare needs, not 
just solving their immediate 
problem 
86.3 77.9 94.2 91.9 80.0 82.5 86.0
I was trained to provide clinical 
care; being respectful to every 
patient is not my job 
29.7 32.4 15.6 41.9 13.7 21.7 25.1
When medicine is given, it is 
important that I explain well 
what it does for the patient and 
how it helps them 
97.8 92.7 95.6 99.3 96.8 94.9 96.7
n 228 69 137 136 195 97 862
Baseline Report 65
Table 2.14 Percentage of hospital workers who reported agreeing with statements about their 
knowledge and attitudes, 
by province
Eastern Congo Kasai Katanga
Overall Sud 
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Patients I care for are not 
educated enough to make good 
health decisions for themselves 
51.6 70.0 62.9 80.0 60.0 48.8 60.7
Patients I care for are not grateful 
for the efforts I make when I care 
for them 
34.4 40.0 30.7 60.0 41.3 26.8 38.5
I consider my patients to be 
worthy of respect no matter how 
poor or low status they are 
98.9 100.0 100.0 100.0 100.0 100.0 99.7
Patients often treat me without 
respect, so it is hard to treat them 
with respect 
8.6 0.0 3.2 4.0 6.7 2.4 5.1
Patients I care for make bad 
decisions regarding their health 
no matter what I tell them 
30.1 63.3 19.4 44.0 21.3 19.5 29.9
Engaging patients in discussions 
leads to better health outcomes 
than just telling them what is best 
for them 
89.3 73.3 93.6 94.0 89.3 90.2 89.5
My patients will work hard to 
improve their health when they 
are given the proper information
87.1 90.0 85.5 96.0 96.0 78.1 89.2
My role is to provide clinical care, 
not to teach patients about how to 
take care of themselves 
21.5 3.3 16.1 24.0 9.5 10.0 15.5
I do not spend a lot of thought 
about what patients may think 
about their experience at the 
clinic as I have other things to 
worry about 
9.7 16.7 11.3 12.2 1.4 7.5 8.9
An important part of my job is to 
communicate with patients to 
make sure they understand their 
care 
95.7 100.0 93.6 100.0 94.6 92.5 95.7
I try hard to think about the 
patients’ healthcare needs not 
just solving their immediate 
problem 
85.0 86.7 87.1 96.0 81.1 80.0 85.7
I was trained to provide clinical 
care; being respectful to every 
patient is not my job 
26.9 26.7 17.7 34.0 9.5 20.0 21.8
66 The Impact of USAID’s Integrated Health Program in the DRC
Eastern Congo Kasai Katanga
Overall Sud 
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
When medicine is given, it is 
important that I explain well what 
it does for the patient and how it 
helps them 
98.9 96.7 96.8 100.0 100.0 95.0 98.3
n 93 30 62 50 75 41 351
Medical Record Review
While on site at the facilities, the surveyors reviewed the facility registers and recorded the volume of specified 
types of cases and services for the last completed calendar month as a means of assessing the quality of care 
being delivered. Here, we provide results related to labor and delivery care. Overall, records were reviewed for 
3,300 deliveries at HCs and 1,090 deliveries at hospitals. At HCs, 71.4 percent (n=2,355) of the records 
included a delivery outcome (survival or mortality); at hospitals, 89.3 percent (n=973) of the delivery records 
included an outcome. Figure 2.10 shows maternal delivery outcomes separately for HCs and for hospitals,
where an outcome was recorded.
The registers showed that 93.6 percent of women who delivered in HCs survived childbirth with no 
complications, as did 88.4 percent who delivered in hospitals, which presumably have a higher percentage of 
high-risk deliveries. The percentage of women who had complications but survived was 5.5 percent at HCs 
and 10 percent at hospitals. The maternal death rate was recorded as 1 percent at HCs and 1.6 percent at
hospitals.
Figure 2.10. Maternal delivery outcomes, among those for whom an outcome was recorded, by 
health facility type
Health workers record certain delivery-related complications in the facility register, specifically, antepartum 
hemorrhage, postpartum hemorrhage, and postpartum infection. Among the women who died in childbirth at 
a HC, nearly 70 percent had no complication recorded (Figure 2.11). The only complication recorded for 
women who died in childbirth at a HC was postpartum hemorrhage, at 30.4 percent. A larger percentage of 
1.6
10.0
88.4
1.0
5.5
93.6
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
Deceased
Survived, complications
Survived, no complications
Health center (n=2,355) Hospital (n=973)
Baseline Report 67
women who died during childbirth in hospitals had an associated complication recorded. The most common 
was postpartum hemorrhage, followed by antepartum hemorrhage and postpartum infection.
Figure 2.11. Percentage of women who died during childbirth who experienced complications, by 
facility type
Most of the women who did not die in childbirth had no recorded complications (94.5% in HCs and 89.9% in 
hospitals) (Figure 2.12). The most common complication among women who survived childbirth was 
postpartum hemorrhage, followed by antepartum hemorrhage and postpartum infection.
Figure 2.12. Complications recorded for women who did not die during childbirth, by facility type
MOH guidelines indicate that a woman should remain in the health facility for at least 24 hours following a normal 
delivery. Facility registers contain delivery and discharge dates, but not times. Therefore, we present the number of 
6.3
37.5
25.0
43.8
0.0
30.4
0.0
69.6
0 10 20 30 40 50 60 70 80 90 100
Postpartum infection
Postpartum hemorrhage
Antepartum hemorrhage
None recorded
Health center (n=16) Hospital (n=23)
1.7
6.3
4.1
89.9
1.5
2.9
2.2
94.5
0 10 20 30 40 50 60 70 80 90 100
Postpartum infection
Postpartum hemorrhage
Antepartum hemorrhage
None recorded
Health center (n=2,355) Hospital (n=957)
68 The Impact of USAID’s Integrated Health Program in the DRC
calendar days that women remained in the facility. Overall, 13.5 percent of women who had a normal delivery in a HC
were discharged at two days and an additional 59.9 percent stayed three or more days (Figure 2.13). The lowest￾performing province was Sankuru, where 54.8 percent of women remained at least two days, and the highest 
performing was Lualaba, where 88.6 percent remained for at least two days.
Figure 2.13. Lengths of stay in health centers after normal delivery, by province
*Note: Maternal deaths and Caesarean sections are excluded from this analysis as guidelines pertain to discharges after a normal 
delivery.
Lengths of stay after normal deliveries in hospitals are shown in Figure 2.14. Overall, rates were similar to 
those in HCs, with 13.5 percent of women being discharged at two days and an additional 63.7 percent staying 
three days or more. In hospitals, the lowest performer was Tanganyika (where 64% remained for at least two 
days) and the highest was Lualaba, at 91 percent remaining for at least two days.
65.3
46.4
66.6
49.9 56.1
71.0
59.9
16.7
11.8
12.5
4.9
14.1
17.6
13.5
4.6
24.7
3.5
16.2
3.9
4.3
7.7
13.5 17.1 17.5
29.0 26.0
7.1
18.9
0
20
40
60
80
100
Sud Kivu
(n=846)
Tanganyika
(n=304)
Kasai Oriental
(n=464)
Sankuru
(n=445)
Haut Katanga
(n=817)
Lualaba
(n=369)
Total (n=3,245)
Three or more days Two days Next day Same day
Baseline Report 69
Figure 2.14. Lengths of stay in hospitals after normal delivery, by province
*Note: Maternal deaths and Caesarean sections are excluded from this analysis as guidelines pertain to discharges after a normal 
delivery.
Clinical Vignette 1: Child Health
A total of 961 health workers responded to a vignette describing a hypothetical case of a four-year-old boy with 
diarrhea who was brought to the clinic by his mother. The purpose of the vignettes was to assess providers’ 
knowledge and self-reported clinical practices. It should be noted, however, that clinical vignettes do not 
measure actual clinical practices.
The majority of respondents (92.5%) were nurses (77.9%) or physicians (14.6%). There were few midwives 
(4.2%) and CHWs (3.3%). The vignette gave a short description of the patient and his symptoms. It asked the 
health workers what questions they would ask to fully understand the condition of the patient. After the 
questions by the health worker about the condition of the patient were collected, more information was given 
about the patient. Then, the vignette asked how the health worker would conduct the physical exam and, after 
gathering this information, the data collector provided the results of the physical exam. Based on these results, 
the health worker was asked to give a differential diagnosis and order laboratory tests. The vignette provided 
the results of the laboratory tests. Based on those results, the health worker was asked to determine a final 
diagnosis, indicate the appropriate treatment, and describe the counseling to be given to the patient or their 
caregiver before leaving the clinic. Table 2.15 shows the respondents’ distribution, by facility type and 
province.
Table 2.15. Total number of health workers who responded to the child health vignette, by facility 
type and province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Health center 194 53 120 114 180 46 707
Hospital 59 22 53 39 62 19 254
n 253 75 173 153 242 65 961
69.2
51.2
68.1 61.2 56.2
75.8
63.7
17.5
12.8
4.4 14.3
14.9
15.2
13.5
2.6
26.7 0.6
4.1
3.4
2.0
4.8
10.7 9.3
26.9 20.4 25.5
7.1
18.0
0
20
40
60
80
100
Sud Kivu
(n=234)
Tanganyika
(n=86)
Kasai Oriental
(n=160)
Sankuru
(n=147)
Haut Katanga
(n=235)
Lualaba (n=99) Total (n=961)
Three or more days Two days Next day Same day
70 The Impact of USAID’s Integrated Health Program in the DRC
Questions Asked by Health Workers about the Patient
Figure 2.15 lists questions that a health worker should ask when assessing a patient with this clinical 
presentation. The questions most frequently asked by health workers were related to temperature (fever), 
frequency of stools, and treatment given before the child was brought to the clinic. We noted that some
respondents, ranging from 16.5 percent to 44.3 percent, missed these three questions. On the other hand, fewer
than one-half of the health workers asked questions about the consistency of stools, vomiting, progression of 
diarrhea, eating and drinking, and the presence of blood in the stool. The proportion of health workers missing 
those questions ranged from 57.1 percent to 80.2 percent. In general, relatively higher numbers of physicians 
asked most of these questions compared with nurses who asked them (results not shown).
Figure 2.15. Percentage of health workers who asked about aspects of medical history, by facility 
type
Information about the patient’s social environment is important for arriving at a diagnosis and planning care. 
However, fewer than 10 percent of health workers based in both hospitals and HCs asked specific questions 
about the social environment of the child, as shown in Figure 2.16.
0.4
14.2
18.5
18.1
24.0
28.0
25.6
42.9
50.4
56.3
76.4
83.5
0.3
11.9
15.3
15.8
19.8
22.9
29.4
35.8
42.4
55.7
68.2
71.2
0 20 40 60 80 100
No questions
Happened previously
Mucus in stools
Abdominal pain
Blood in stools
Eating and drinking
Progression of diarrhea
Vomiting
Consistency of stools
Treatment
Frequency of stools
Temperature
Health center Hospital
Baseline Report 71
Figure 2.16. Percentage of health workers who asked about aspects of social history, by facility 
type
Physical Examination
More than 50 percent of health workers correctly stated that, when performing the physical examination of a 
child with diarrhea, they would check for dehydration, observe the child’s affect or demeanor, check for fever, 
or perform abdominal palpation (Figure 2.17). However, between 9.8 percent to 49.2 percent of health 
workers did not mention these signs. The other important signs of skin turgor, heart rate, respiratory rate, 
weight, and capillary refill were missed by the majority of health workers. In general, higher proportions of 
hospital health workers mentioned that they would check most of the important physical signs than did their 
HC counterparts.
0.0
0.0
2.0
5.9
9.7
6.7
0.6
0.8
1.9
2.0
4.2
5.5
0 10 20
Religious affiliation
Caretaker's occupation
Mother's marital status
Household composition
Housing and WASH conditions
Anyone else in the household ill?
Health center (n=707) Hospital n=254)
72 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.17. Percentage of health workers indicating specific physical examinations, by facility 
type
Differential Diagnosis
Overall, only 52.4 percent of hospital health workers and 41.6 percent of HC health workers correctly 
indicated dysentery/shigellosis as part of the differential diagnosis. As shown in Figure 2.18, the proportions 
of correct differential diagnosis were variable across the provinces. The lowest proportions—13.2 percent and 
30.2 percent for HC and hospital health workers, respectively—were in Sankuru and Kasai Oriental. The 
highest proportions of correct differential diagnosis were observed among health workers in Lualaba.
0.0
21.3
22.4
44.5
46.5
38.2
60.2
61.8
72.1
90.2
0.2
11.5
23.3
27.0
27.4
28.2
50.8
61.5
62.8
82.6
0 20 40 60 80 100
No examination
Capillary refill
Weight
Respiratory rate
Heart rate
Skin turgor
Abdominal palpation
Temperature
Affect/demeanor
Dehydration
Health center Hospital
Baseline Report 73
Figure 2.18. Percentage of health workers who correctly identified bacterial dysentery/shigellosis 
as a likely diagnosis, by facility type and province
Laboratory Tests
Among health workers in HCs, 91 percent correctly mentioned direct microscopic examination of stool as the 
laboratory test to be ordered. However, only 15 percent of them mentioned conducting a stool culture. The 
proportion of those mentioning both tests was even lower (13.4%). As shown in Table 2.16, there was little 
variation in recommendations regarding laboratory tests across provinces. Table 2.17 shows that the 
proportions of hospital-based health workers who mentioned direct microscopic stool examination, stool 
culture, or both tests were slightly higher.
Table 2.16. Percentage of health center-based health workers who ordered the correct tests for 
bacillary dysentery/shigellosis, by province
Eastern Congo Kasai Katanga Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Direct microscopic 
stool exam 94.3 86.8 88.3 96.5 87.2 89.1 91.0
Stool culture 18.6 30.2 20.0 0.9 10.6 21.7 15.0
Both tests 17.0 24.5 15.8 0.9 10.6 21.7 13.4
n 194 53 120 114 180 46 707
50.0 52.8
32.5
13.2
46.1
69.6
41.6
71.2 68.2
30.2
41.0
46.8
79.0
52.4
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health center (n=707) Hospital (n=254)
74 The Impact of USAID’s Integrated Health Program in the DRC
Table 2.17. Percentage of hospital-based health workers who ordered the correct tests for 
bacillary dysentery/shigellosis, 
by province
Eastern Congo Kasai Katanga Total
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Direct microscopic 
stool exam 96.6 100.0 90.6 82.1 96.8 84.2 92.5
Stool culture 47.5 27.3 39.6 30.8 19.4 36.8 33.9
Both tests 45.8 27.3 30.2 18.0 19.4 26.3 28.7
n 59 22 53 39 62 19 254
Treatment
Overall, fewer than one-half of the HC-based health workers correctly mentioned fever treatment as part of the 
management of the sick child, but three-quarters of them correctly mentioned fluids for dehydration and 
metronidazole for Shigella dysentery. Across provinces, HC-based health workers in Tanganyika had the 
lowest proportions of correct treatment for fever and dehydration (26.4% and 32.1%, respectively), whereas
those in Haut Katanga had the lowest proportion (70%) of correct treatment for Shigella dysentery. HC health 
workers in Sankuru had the highest proportions of correct treatment for dehydration (82.5%) and Shigella
dysentery (82.5%) and those in Lualaba had the highest proportion for correct treatment of fever (60.9%), as 
shown in Figure 2.19.
By comparison, half of the hospital-based health workers correctly mentioned fever treatment as part of the 
management of the sick child, and 78.7 percent of them correctly mentioned fluids for dehydration. 
Metronidazole was mentioned by 70.1 percent of the hospital-based health workers for the treatment of 
Shigella dysentery. Across provinces, hospital-based health workers in Tanganyika had the lowest proportions 
of correct treatment for fever and dehydration (40.9% and 63.6%, respectively), whereas those in Sankuru had 
the lowest proportion of correct treatment for Shigella dysentery (46.2%). Hospital-based health workers in 
Lualaba had the highest proportions of correct treatment for fever (57.9%) and dehydration (94.7%). Hospital￾based health workers in Kasai Oriental had the highest proportion of correct treatment for Shigella dysentery 
(77.4%) (Figure 2.20).
Baseline Report 75
Figure 2.19. Percentage of health center-based health workers who correctly mentioned 
metronidazole, fluids, or treatment for fever, by province (n=707)
Figure 2.20. Percentage of hospital-based health workers who correctly mentioned metronidazole, 
fluids, or treatment for fever, by province (n=254)
If we combine diagnosis and treatment, as shown in Figure 2.21, we see a drop in the overall proportion of 
HC-based and hospital-based health workers who correctly mentioned direct microscopy and metronidazole, 
respectively, for the diagnosis and treatment of Shigella dysentery. This trend was also observed across the 
provinces.
70.1 71.7
80.8 82.5
70.0 71.7 74.1
81.4
32.1
73.3
82.5
76.7 78.3
75.1
43.8
26.4
58.3
42.1
50.0
60.9
47.4
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Metronidazole (Flagyl) Fluids (oral or IV) Treatment for fever
71.2
77.3 77.4
46.2
77.4
63.2
70.1
83.1
63.6
75.5
92.3
69.4
94.7
78.7
55.9
40.9
45.3
51.3 50.0
57.9
50.4
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Metronidazole (Flagyl) Fluids (oral or IV) Treatment for fever
76 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.21. Percentage of health workers who gave the correct diagnosis test (direct stool 
microscopy), and treatment (metronidazole) for bacterial dysentery/shigellosis, by facility type 
and province
Counseling
Figure 2.22 shows that hygiene and feeding emerged as the most frequently mentioned topics for counseling 
for both HC-based and hospital-based health workers. The other important topics for counseling, such as 
rehydration, how to take medicines, and mode of transmission, were mentioned less frequently.
27.7
32.7
19.5
5.7
29.8
5.7
22.8
9.1
25.0
17.5
6.9
27.4
0.0
17.5
0
20
40
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health center (n=707) Hospital (n=254)
Baseline Report 77
Figure 2.22. Percentage of health workers who mentioned specific messages for counseling, by 
facility type
Clinical Vignette 2: ANC
A total of 804 healthcare workers responded to a vignette presenting a 19-year-old woman making her first 
ANC visit. The woman was visibly pregnant and she estimated that she was at least 20 weeks into her 
pregnancy. She had not taken a pregnancy test and did not come for an ANC visit earlier because she lived far 
from the HC. Table 2.18 presents the distribution of health workers who responded to this vignette by 
province and facility type. The majority of health workers (78%) were based in HCs.
Table 2.18. Total number of health workers who responded to the ANC vignette, by facility type 
and province
Facility type Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Health center 166 52 118 88 168 35 627
Hospital 22 12 40 29 62 12 177
n 188 64 158 117 230 47 804
The vignette first asked the health workers what questions they would ask the woman before proceeding with a 
physical examination. Subsequently, the vignette gave the results of the physical examination and asked the 
health worker to order the most appropriate laboratory tests based on the physical examination results. The 
vignette then provided the results of the laboratory tests. Using the results of the physical examination and 
laboratory tests, the health worker was requested to assess the condition of the woman, prescribe a treatment,
and propose counseling messages.
0.4
5.5
16.1
15.0
17.3
22.8
36.2
60.6
92.9
0.3
3.4
11.3
12.7
13.7
20.4
35.6
58.3
90.7
0 20 40 60 80 100
No counseling
Diagnosis
How to monitor
When to follow up
How transmitted
How to take medicine
Hydration
Feeding
Hygiene
Health center (n=707) Hospital (n=254)
78 The Impact of USAID’s Integrated Health Program in the DRC
Questions Asked by Health Workers about the Patient
Most of the health workers (95%) asked a question about the timing of the last menstrual period, an important 
factor in confirming the duration of the pregnancy. However, fewer than one-half of them asked other 
important questions about her reproductive history, such as the number of pregnancies, live births, and 
miscarriages she had experienced and her disease history (Figure 2.23).
Figure 2.23. Percentage of health workers who asked questions related to health history, by 
facility type
Furthermore, small proportions of health workers, ranging from 0.6 percent to 30.5 percent, asked questions 
about the patient’s social history, as shown in Figure 2.24. The social history provides important context that 
informs a patient’s diagnosis and treatment.
0.0
9.6
11.3
10.2
11.9
24.9
37.9
41.2
42.4
39.6
44.6
94.9
0.3
6.9
8.3
9.3
10.5
16.9
31.9
34.9
38.0
38.6
42.1
95.2
0 20 40 60 80 100
No questions
History of diabetes
Family health history
Past illnesses
History of hypertension
Number of children who have died
Number of miscarriages
Number of children alive
Number of live births
Complaints during this pregnancy
Number of pregnancies
Timing of last menstrual period
Health center (n=627) Hospital (n=177)
Baseline Report 79
Figure 2.24. Percentage of health workers who asked questions related to social history, by 
facility type
Physical Examination
Figure 2.25 shows that more than 50 percent of health workers—with percentages ranging from 52.2 percent 
to 81.9 percent—correctly indicated that they should examine the fundal height, blood pressure, and fetal 
heartbeat, and check for the presence of edema. Fewer than one-half of the health workers mentioned other 
key elements of a physical examination, such as measuring the woman’s weight, height, and body 
temperature, checking for abdominal palpation, and carrying out a breast examination. There were negligible 
differences across facility types.
0.6
0.6
2.8
2.3
11.9
12.4
30.5
0.7
1.0
1.1
4.0
7.8
9.6
28.9
0 10 20 30 40
Support network
Religious affiliation
History of sexual/intimate partner violence
Education level
Sexual history
Occupation
Marital status
Health center (n=627) Hospital (n=177)
80 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.25. Percentage of health workers who indicated that they would perform various physical 
examinations, by facility type
Laboratory Tests
A higher proportion of hospital-based health workers than HC-based workers correctly indicated that they 
should order proteinuria, hemoglobin, and blood grouping tests. Nevertheless, among hospital-based health 
worker respondents, many failed to mention these tests: 31.6 percent (for proteinuria), 38.4 percent (for 
hemoglobin), and 68.9 percent (for blood grouping). In addition, more than one-half of both hospital-based 
and HC-based health workers failed to mention other key routine tests, such as tests for HIV, pregnancy, and 
syphilis, as shown in Figure 2.26.
0.0
23.2
28.8
31.1
31.1
41.8
48.0
45.8
63.8
63.8
80.2
81.9
0.2
13.9
17.9
20.6
33.5
35.1
48.5
51.2
52.2
68.4
69.5
79.1
0 10 20 30 40 50 60 70 80 90 100
No examination
Breast exam
Pulse
Respiratory rate
Height
Temperature
Abdominal palpation
Weight
Presence of edema
Fetoscope
Blood pressure
Fundal height
Health center (n=627) Hospital (n=177)
Baseline Report 81
Figure 2.26. Percentage of health workers who mentioned various diagnostic tests, by facility type
Assessment of Patient’s Condition
Tables 2.19 and 2.20 show the percentage of HC-based and hospital-based health workers’ assessments of the 
patient’s condition. Overall, a higher percentage of hospital-based health workers (83.6%) correctly assessed 
the patient’s condition as preeclampsia compared with 64.8 percent among their HC-based counterparts. 
Across the provinces, Sud Kivu scored highest (76.2%) among HC-based health workers, with Tanganyika 
scoring lowest (50%). Among hospital-based health workers, those in Kasai Oriental scored the highest (100%) 
and Tanganyika had the lowest score (70%) in correctly assessing the patient’s condition as preeclampsia.
Table 2.19. Percentage of health center-based health workers who gave various assessments, by 
province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Preeclampsia 76.2 50.0 57.1 75.9 50.0 55.8 64.8
Healthy pregnancy 8.3 18.6 2.9 12.1 22.7 21.2 14.0
Other/don't know 15.5 31.4 40.0 12.1 27.3 23.1 21.2
n 166 52 118 88 168 35 627
0.6
11.3
31.1
26.0
33.3
41.8
61.6
68.4
55.9
3.0
4.9
16.9
19.1
42.4
45.5
47.5
52.3
56.9
0 10 20 30 40 50 60 70 80 90 100
No tests
Hematocrit
Blood grouping
Syphilis
Pregnancy test
HIV
Hemoglobin
Proteinuria
Malaria
Health center (n=627) Hospital (n=177)
82 The Impact of USAID’s Integrated Health Program in the DRC
Table 2.20. Percentage of hospital-based health workers who gave various assessments, by 
province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Preeclampsia 87.1 70.0 100.0 81.8 89.7 83.3 83.6
Healthy pregnancy 6.5 15.0 0.0 9.1 10.3 8.3 9.0
Other/don't know 6.5 15.0 0.0 9.1 0.0 8.3 7.3
n 22 12 40 29 62 12 177
Treatment
Overall, fewer than one-half of the HC-based health workers (44.7%) indicated that they would refer a 
preeclampsia case to the hospital (which the DRC MOH guidelines recommend) (Table 2.21). Across the 
provinces, Sankuru had the highest percentage of referrals to a hospital (75.3%) and Sud Kivu had the lowest 
percentage (28%). Among hospital-based health workers, the administration of hypotensive drugs was 
indicated by 74 percent of the respondents (Table 2.22). Provincial comparisons showed that Sud Kivu scored 
the highest (87.1%) on hypotensive treatment and Haut Katanga scored the lowest (58.6%).
Table 2.21. Percentage of health center-based health workers who recommended various 
treatment options, by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Hypotensive drug 62.5 44.1 22.9 28.9 23.9 59.6 42.3
Transfer to hospital 28.0 34.8 57.1 75.3 31.8 36.5 44.7
Anticonvulsive drug 10.7 11.0 0.0 1.8 15.9 7.7 8.3
Induction of labor 1.2 2.0 0.0 0.6 1.2 0.0 1.0
No treatment 4.2 5.9 22.9 4.8 5.7 19.2 7.2
n 166 52 118 88 168 35 627
Table 2.22. Percentage of hospital-based health workers who recommended various treatment 
options, by province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Hypotensive drug 87.1 60.0 83.3 77.3 58.6 75.0 74.0
Transfer to higher level 
of care 9.7 7.5 16.7 22.7 6.9 0.0 10.2
Anticonvulsive drug 12.9 7.5 33.3 13.6 3.5 8.3 11.3
Induction of labor 3.2 0.0 0.0 0.0 0.0 0.0 1.2
No treatment 0.0 10.0 0.0 0.0 0.0 8.3 2.8
n 22 12 40 29 62 12 177
Baseline Report 83
Counseling
Figure 2.27 shows that the counseling most frequently given was the reduction of salt intake, which was 
mentioned by 56.6 percent of HC-based workers and 68.4 percent of hospital-based health workers—a 
treatment that is critical for women with preeclampsia. We noted that only 34 percent of HC-based health 
workers mentioned referral to a hospital among their counseling topics. Other important counseling topics, 
such as the reduction of physical activity, increasing water intake, taking medications correctly, and watching 
for danger signs signaling the need for emergency care, were mentioned by fewer than 25 percent of both HC￾based and hospital-based health workers.
Figure 2.27. Percentage of health workers who gave various recommendations, by facility type
Clinical Vignette 3: Family Planning
A total of 595 healthcare workers responded to a vignette presenting a 22-year-old woman who visited a clinic 
because she was interested in using contraceptives. The majority of respondents (70%) were HC-based health 
workers. The vignette first asked the health workers what questions they would ask the woman. The vignette 
then described the obstetrical history of the woman and provided some information on her marital status, 
parity, and sexual activity; notably, that she was married, had no children, and wanted to delay having 
children for at least three years. After that, the vignette asked whether the health workers would counsel the 
woman in choosing a contraceptive method and what information they would provide when counseling the 
woman about the FP method she was using. The vignette also asked the health workers how they would 
determine which FP method to recommend and what factors they would consider when making that decision. 
After counseling and discussion, the woman indicated her choice to use the implant method. However, this 
method was not currently being offered in the clinic. The vignette subsequently asked the health workers what 
0.6
11.3
9.6
8.5
23.2
23.7
32.8
24.3
5.7
50.9
68.4
1.8
4.5
7.3
9.6
12.6
17.5
21.9
23.6
34.0
40.7
56.6
0 10 20 30 40 50 60 70 80 90 100
No counseling
Signs that emergency care is needed
Causes, symptoms, risks
Increase protein intake
How to take medicine
Increase water intake
When to return for follow-up
Reduced physical activity
Referral to higher level of care
Bed rest
Minimize salt intake
Health center (n=627) Hospital (n=177)
84 The Impact of USAID’s Integrated Health Program in the DRC
they would do in that event. The woman emphasized that she did not want anyone to know that she was using 
contraception and asked that it be kept confidential. Last, the vignette asked how the health workers would 
respond to her concerns about confidentiality. Table 2.23 shows the distribution of the participants, by facility 
type and province.
Table 2.23. Total number of health workers who responded to the FP vignette, by facility type and 
province
Eastern Congo Kasai Katanga Overall
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Health center 141 22 39 77 111 27 417
Hospital 52 7 28 25 56 10 178
n 193 29 67 102 167 37 595
Questions the Health Workers Asked the Woman
As shown in Figure 2.28, fewer than one-half of both HC-based and hospital-based health workers stated that 
they would ask specific important questions about the medical history of the woman, such as information on 
her menstrual cycle, obstetrical and gynecological history, medications, FP methods used, recent intercourse, 
and other health conditions. The proportions of health workers reporting these questions ranged from 7.4 
percent to 38.9 percent. 
Figure 2.28. Percentage of health workers who mentioned questions about aspects of medical 
history, by facility type
Other questions asked were related to the social history of the client (Figure 2.29). Among those, the most 
frequently mentioned question was about the marital status of the client. However, both HC-based and 
hospital-based health workers demonstrated little interest in other important social information, such as 
contraceptive preference, length of marriage, pregnancy intentions, and sexual history.
0.6
9.0
11.2
31.5
41.6
38.2
1.0
7.4
15.1
21.6
33.6
38.9
0 10 20 30 40 50 60 70 80 90 100
No questions
Other health conditions
Recent intercourse
Medication/FP history
Ob/Gyn history
Menstrual history
Health center (n=417) Hospital (n=178)
Baseline Report 85
Figure 2.29. Percentage of health workers who mentioned questions about aspects of social 
history, by facility type
Counseling on Choosing a Contraceptive Method
Overall, fewer than one-half of both HC-based and hospital-based health workers responded that they would 
counsel the woman on choosing a contraceptive method. Figure 2.30 shows that the highest percentages of 
both HC-based and hospital-based health workers willing to provide counseling were in Tanganyika (86.4%
and 85.7%, respectively). The lowest percentages of health workers willing to provide counseling were found 
in Lualaba among HC-based health workers (29.6%) and in Kasai Oriental among hospital-based health 
workers (28.6%). 
1.2
0.6
5.6
10.1
11.2
6.2
12.4
9.6
28.1
73.6
1.0
2.0
6.0
6.2
8.2
8.6
9.4
10.1
26.6
68.6
0 10 20 30 40 50 60 70 80 90 100
History of S/IPV
Religious affiliation
Education level
Occupation (husband)
Occupation (self)
Sexual history
Pregnancy intentions
Length of marriage
Contraceptive preferences
Marital status
Health center (n=417) Hospital (n=178)
86 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.30. Percentage of health workers who would counsel the woman in choosing a 
contraceptive method, by facility type and province
Among both HC-based and hospital-based health workers, the most frequently mentioned reasons for not 
providing counseling on contraceptive methods were “no or not enough children” (64.3% and 81.1%,
respectively) and “husband not present” (54.9% and 53.3%, respectively). The other commonly reported
reason was “she is married” (36.2% of HC-based and 33.3% of hospital-based health workers) (Figure 2.31).
Figure 2.31. Among health workers who indicated that they would not offer a contraceptive 
method, reasons given, by facility type 
50.4
86.4
41.0
45.5
39.6
29.6
46.3
52.9
85.7
28.6
48.0 48.2
70.0
49.2
0
20
40
60
80
100
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba
Eastern Congo Kasai Katanga Overall
Health center (n=417) Hospital (n=178)
2.3
3.3
2.3
33.3
53.3
81.1
0.5
1.8
5.1
36.2
54.9
64.3
0 20 40 60 80 100
Provider's religious beliefs
Contraindicated
Condoms are sufficient
She is married
Her husband is not present
She has no/not enough children
Health center (n=224) Hospital (n=90)
Baseline Report 87
Topics for Counseling about Family Planning
Side effects and the availability of FP methods on the day of visits were the most frequently mentioned 
counseling topics by both HC-based and hospital-based health workers, with percentages ranging from 63.2 
percent to 72.4 percent (Figure 2.32). Other important topics, such as effectiveness, duration of protection, 
correct use, safety, and discomfort during use of the contraceptive method, were mentioned by fewer than one￾half of the health workers.
Figure 2.32. Among health workers who stated that they would offer a contraceptive method, 
counseling given, by facility type
Criteria for Determining Which Family Planning Method to Prescribe
Figure 2.33 shows the criteria mentioned by health workers for determining the method to prescribe. Of these, 
side effects and effectiveness of the method emerged as the most frequently mentioned criteria (percentages 
ranging from 47.1% to 54.9%). It is worth mentioning that the patient’s preference was mentioned by 36.8 
percent and 37.9 percent of HC-based and hospital-based health workers, respectively. 
0.0
9.9
9.9
7.4
18.4
19.5
33.3
20.7
32.2
40.2
72.4
65.5
0.0
6.6
7.1
7.7
15.5
22.3
29.5
29.5
39.9
43.5
63.2
64.3
0 20 40 60 80 100
No counseling
Cost
Provider's recommendation
Discomfort during administration
Safety
Effectiveness in preventing STI's
Methods available consistently
Correct use
Duration of protection
Effectiveness in preventing pregnancy
Methods available today
Side effects
Health center (n=193) Hospital (n=87)
88 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.33. Among health workers who stated that they would offer a contraceptive method, 
criteria for determining the method to prescribe, by facility type
What Health Workers Would Do Were the Preferred Method Unavailable
If the contraceptive method preferred by the client was not available at the clinic, the HC-based health workers 
indicated three options: (1) referring the client to another clinic (71.5%); (2) asking the client to choose another 
method (41.5%); or (3) ending the consultation (2.2%). The hospital-based health workers indicated two 
options: (1) referring the client to another clinic (54%); and (2) asking the client to choose another method 
(60.9%) (Figure 2.34). 
1.2
5.8
13.8
20.7
19.5
21.8
29.9
25.3
37.9
47.1
50.6
4.9
7.8
13.5
14.5
22.3
22.3
26.4
26.9
36.8
48.2
54.9
0 20 40 60 80
Competence of providers to administer
Peers' acceptance
Cost of method
Preferences regarding pregnancy/spacing
Patient's confidence in correct use
Husband's acceptance
Patient's medical history
Availability of method
Patient's preferred method
Effectiveness
Side effects
Health center (n=193) Hospital (n=87)
Baseline Report 89
Figure 2.34. Among health workers who stated that they would offer a contraceptive method, 
response to the preferred method being unavailable, by facility type
Confidentiality
The majority of health workers—more than 80 percent—stated that they would respect the request for 
confidentiality from the client when offering a contraceptive method. Moreover, one-third of them (38.9% of 
HC-based and 32.2% of hospital-based health workers) would encourage the client to inform her husband 
about her use of the contraceptive method. It is worth noting that 5.2 percent of HC-based and 4.6 percent of 
hospital-based health workers would refuse to provide a contraceptive method if the client did not inform her 
husband about her use of the contraceptive method (Figure 2.35).
Figure 2.35. Among health workers who stated that they would offer a contraceptive method and 
their response to a request for confidentiality, by facility type
Affordability of Services
Transparency in fee schedules enables patients to make informed decisions about their health services. Figure 
2.36 shows the percentage of HCs that had their standard fee schedule posted for patients to see. It also shows 
whether a facility had a reduced fee schedule for indigent patients and whether that fee schedule was posted. 
0.0
60.9
54.0
2.2
41.5
71.5
0 10 20 30 40 50 60 70 80 90 100
End consultation
Choose another method
Refer elsewhere
Health center (n=193) Hospital (n=87)
1.2
4.6
32.2
81.6
2.2
5.2
38.9
82.4
0 20 40 60 80 100
Encourage her to tell other people
Refuse to provide until she informs husband
Encourage her to tell her husband
Reassure that care is confidential
Health center (n=193) Hospital (n=87)
90 The Impact of USAID’s Integrated Health Program in the DRC
Overall, 64 percent of HCs had a posted general fee schedule. This ranged from 50.6 percent in Haut Katanga 
to 86.1 percent in Sud Kivu. Posted indigent fee schedules were less common. In some provinces, this was
because few facilities had an indigent fee schedule (e.g., Sankuru), whereas others had fee schedules but did
not post them (e.g., Tanganyika).
Figure 2.36. Percentage of health centers that posted a standard fee schedule, had an indigent fee 
schedule, and posted an indigent fee schedule, by province
There was a higher prevalence of posted fee schedules for general fees (74.1%) and indigent fees (50.9%) in 
hospitals (Figure 2.37). Lualaba was the most transparent, with 91.7 percent of facilities posting a general fee 
schedule, and 91.7 percent posting an indigent fee schedule (representing 100% of those that had an indigent 
fee schedule).
86.1
51.6 53.2 54.6
50.6
78.4
64.0 61.6
54.8
31.9
13.6
44.6
64.9
46.3
54.7
16.1 12.8
9.1
27.7
54.1
32.0
0
20
40
60
80
100
Sud Kivu (n=86) Tanganyika
(n=30)
Kasai Oriental
(n=47)
Sankuru (n=45) Haut Katanga
(n=83)
Lualaba (n=37)
Eastern Congo Kasai Katanga Overall (n=328)
Standard fee schedule is posted Facility has indigent fee schedule Indigent fee schedule is posted
Baseline Report 91
Figure 2.37. Percentage of hospitals that posted a standard fee schedule, had an indigent fee 
schedule, and posted an indigent fee schedule, by province
Allowing for payment after treatment for emergencies and for labor and delivery enables patients to receive 
care in a timely matter, rather than delaying until user fees can be paid. Nearly 93 percent of HCs treated
emergency cases before payment, and 90.9 percent accepted payment after labor and delivery (Figure 2.38). 
These rates were high in most provinces, with the exception of Sankuru, where no more than 75 percent of 
facilities accepted payment after emergencies or labor and delivery.
89.7
70.0
75.0
62.5
56.0
91.7
74.1
55.2
30.0 31.3 31.3
60.0
91.7
51.7 50.9
10.0
18.8 18.8
40.0
91.7
39.8
0
20
40
60
80
100
Sud Kivu (n=29) Tanganyika
(n=10)
Kasai Oriental
(n=16)
Sankuru (n=16) Haut Katanga
(n=25)
Lualaba (n=12)
Eastern Congo Kasai Katanga Overall (n=108)
Standard fee schedule is posted Facility has indigent fee schedule Indigent fee schedule is posted
92 The Impact of USAID’s Integrated Health Program in the DRC
Figure 2.38. Percentage of health centers that accepted payment after treatment of emergencies 
and labor and delivery, by province
The majority of hospitals also treated emergency (94.4%) and labor and delivery cases (97.2%) before
demanding payment (Figure 2.39). Again, rates were high in most provinces, with Sankuru a low outlier.
Figure 2.39. Percentage of hospitals that accepted payment after treatment of emergencies and 
labor and delivery, by province
Health facility directors were asked to state the ways in which they would respond to a case in which a patient 
could not pay the fees that he or she owed. Table 2.24 shows the responses from HC directors. The most 
common reaction was to treat the patient as indigent, offering them free or reduced-cost services (59.2%). HCs 
also commonly allowed patients to give a guarantee, such as a signed promise to pay or an item held as 
98.8 96.8
89.4
70.5
97.6 94.6 92.7 90.7
100.0
95.7
75.0
90.4
97.3
90.9
0
20
40
60
80
100
Sud Kivu (n=86) Tanganyika
(n=30)
Kasai Oriental
(n=47)
Sankuru (n=45) Haut Katanga
(n=83)
Lualaba (n=37)
Eastern Congo Kasai Katanga Overall (n=328)
Allow payment after treatment for emergencies Allow payment after labor and delivery
96.6
90.0 93.8
81.3
100 100
94.4
100 100 100
81.3
100 100 97.2
0
20
40
60
80
100
Sud Kivu
(n=29)
Tanganyika
(n=10)
Kasai Oriental
(n=16)
Sankuru (n=16) Haut Katanga
(n=25)
Lualaba (n=12)
Eastern Congo Kasai Katanga Overall (n=108)
Allow payment after treatment for emergencies Allow payment after labor and delivery
Baseline Report 93
collateral (46.7%), or allowed patients to pay in-kind or work off the debt at the facility (42.4%). In some 
instances, the case was referred to the CODESA for collection (13.7%) or the patient was detained at the 
facility until he or she could pay (11%). Only a small percentage of the HCs refused to give services (0.3%) or 
future services (2.4%) to patients who could not pay. Provinces varied considerably in the prevalence of 
strategies used.
Table 2.24. Health centers’ responses to patients who could not pay fees owed, by province
Eastern Congo Kasai Katanga
Overall
Sud Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Free/reduced cost, 
considered indigent 50.0 48.4 61.7 50.0 73.5 64.9 59.2
Patient can give a guarantee 55.8 64.5 40.4 20.5 43.4 56.8 46.7
Patient can pay in-kind or 
work off debt 34.9 64.5 21.3 86.4 28.9 46.0 42.4
Owes/pays later/referred to 
CODESA 19.8 0.0 19.2 25.0 3.6 13.5 13.7
Not discharged until can pay 8.1 0.0 6.4 34.1 10.8 5.4 11.0
No recourse 3.5 3.2 4.3 2.3 6.0 2.7 4.0
Refused services in future 1.2 12.9 0.0 6.8 0.0 0.0 2.4
No services are given 0.0 0.0 0.0 2.3 0.0 0.0 0.3
n 86 30 47 45 83 37 328
Table 2.25 summarizes the responses from hospital directors. Hospital directors’ most common responses to 
patients who could not pay were to consider them indigent (68.5%) and to allow them to give a guarantee 
(41.7%). Compared with HCs, hospitals were less likely to allow patients to pay in-kind or work off debts 
(25%), and were more likely to detain a patient until they paid (18.5%). Again, there was considerable 
variation among the provinces.
Table 2.25. Hospitals’ responses to patients who could not pay fees owed, by province
Eastern Congo Kasai Katanga
Sud Overall
Kivu Tanganyika Kasai 
Oriental Sankuru Haut 
Katanga Lualaba
Free/reduced cost, considered 
indigent 48.3 80.0 62.5 62.5 84.0 91.7 68.5
Patient can give a guarantee 51.7 60.0 31.3 12.5 40.0 58.3 41.7
Patient can pay in-kind or work
off debt 27.6 20.0 18.8 56.3 4.0 33.3 25.0
Owes/pays later/referred to 
CODESA 10.3 10.0 25.0 31.3 4.0 0.0 13.0
Not discharged until can pay 31.0 20.0 0.0 37.5 12.0 0.0 18.5
No recourse 0.0 0.0 6.3 0.0 8.0 0.0 2.8
94 The Impact of USAID’s Integrated Health Program in the DRC
Refused services in future 0.0 10.0 0.0 0.0 4.0 0.0 1.9
No services are given 0.0 0.0 0.0 0.0 0.0 0.0 0.0
n 29 10 16 16 25 12 108
Health Behaviors
Data elements identified as both outcomes and non-outcomes for the impact evaluation were included as 
covariates in the regression model used to generate propensity-score weights. These weights were used to 
identify health facilities that did not receive the HSS intervention but that were similar in nature to health 
facilities that did receive the intervention. These identified health facilities will serve as the comparator or 
control group. The best comparison group is the one with the same characteristics as the intervention group,
and the propensity-score weights help identify health facilities to include in this comparison group. 
The 12 outcome data elements used to establish propensity-score weights are presented in Table 3.1, which 
shows both the unweighted and weighted mean and standard deviation stratified by control/treatment site. An 
absolute standardized mean difference value, represented in Table 3.1 as Cohen’s d, which is less than 0.1,
indicates attainment of a distributional balance of the DHIS2 data elements between the control and treatment 
sites. Balance of the covariate distribution across groups is important because it allows for more robust causal 
conclusions (i.e., did the HSS intervention truly have an effect?). 
Under the weighted scenario below, standardized mean differences for all data elements included as covariates 
were under 0.1. This indicates that an appropriate group of control sites was identified that do not show an 
appreciable level of bias with respect to treatment sites, as measured through a common pool of DHIS2 data 
elements. 
Table 3.1. Pooled estimates from multiply imputed data
Unweighted Weighted
DHIS2 data elements (transformed to rates)
Control sites
mean (Standard 
deviation)
Treatment sites
mean (Standard 
deviation)
Std. diff.
(Cohen's d)
Control sites
mean 
(Standard 
deviation)
Treatment sites
mean (Standard 
deviation)
Std. diff.
(Cohen's d)
Rate of live births per 1,000 population of women of 
reproductive age 5.73 (5.9) 6.20 (5.85) 0.080 5.87 (5.65) 6.20 (5.85) 0.057
Rate of live births <2,500g per 1,000 population of women 
of reproductive age 0.27 (0.77) 0.25 (0.78) 0.026 0.23 (0.65) 0.25 (0.78) 0.028
Rate of moderate acute malnutrition per 1,000 population 
of children ages 6–59 months 1.87 (4.48) 3.97 (9.36) 0.286 3.30 (6.38) 3.97 (9.36) 0.084
Rate of exclusive breastfeeding per 1,000 population of 
children under 6 months 141.93 (228.36) 138.08 (212.16) 0.018 129.11 
(221.34) 138.08 (212.16) 0.041
Rate of attendance at the fourth ANC visit per 1,000 
population of women of reproductive age 3.68 (4.46) 4.43 (4.81) 0.162 4.06 (4.55) 4.43 (4.81) 0.079
Rate of measles vaccination per 1,000 population of 
children ages 6–59 months 6.70 (7.2) 7.31 (7.02) 0.086 6.92 (7.28) 7.31 (7.02) 0.055
Rate of pentavalent vaccination per 1,000 population of 
children ages 6–59 months 6.71 (7.14) 7.44 (7.18) 0.102 7.05 (7.31) 7.44 (7.18) 0.054
Rate of new acceptors of modern contraceptive methods 
per 1,000 population of women of reproductive age 3.48 (6.79) 4.61 (13.81) 0.104 4.18 (7.01) 4.61 (13.81) 0.039
Rate of insecticide-treated net distribution during ANC 
visits per 1,000 population of women of reproductive age 5.36 (5.67) 4.51 (5.09) 0.158 4.40 (4.95) 4.51 (5.09) 0.022
Rate of severe malaria treatment per 1,000 population of 
children ages 6–59 months 1.06 (2.75) 1.06 (2.61) 0.000 0.96 (2.33) 1.06 (2.61) 0.040
Rate of severe pneumonia treatment per 1,000 population 
of children ages 6–59 months 0.36 (1.76) 0.39 (1.24) 0.020 0.34 (1.82) 0.39 (1.24) 0.032
Rate of severe diarrhea/dehydration treatment per 1,000 
population of children ages 6–59 months 0.10 (0.39) 0.12 (0.49) 0.045 0.10 (0.38) 0.12 (0.49) 0.046
96 The Impact of USAID’s Integrated Health Program in the DRC
Abt Associates conducted a baseline household survey in 2019 in all provinces supported by the project. Data 
from women of reproductive age (15‒49 years) pertaining to the care-seeking experience and level of 
participation in health services were tabulated.
Table 3.2 shows the percentage of patients who reported experiencing long wait times at public facilities during 
their most recent visit. Overall, the largest percentage of patients reported long wait times for ANC, with 35.2 
percent of those who sought it reporting that they waited a long time. More than one in four patients who sought 
RECO services also reported long wait times. Long wait times tended to be reported most often in Sankuru. 
Table 3.2. Percentage of women who sought care in a public facility who reported long wait times, 
by service and province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba Overall
ANC 29.6 41.0 13.0 70.2 30.7 19.1 35.2
RECO
services 37.9 47.2 6.2 76.0 3.5 18.5 26.8
Delivery 22.9 24.8 10.3 29.8 7.8 18.6 15.4
Child 
vaccination 17.9 26.9 7.7 34.9 8.0 16.1 15.3
Treatment 
of child 
illness 16.0 23.6 11.1 39.1 6.0 11.8 14.8
FP 17.4 10.2 6.2 22.7 7.5 29.8 11.8
n 46 47 126 111 136 119 585
Nearly 65 percent of women who sought ANC reported that the service was unaffordable (Table 3.3). This 
percentage was highest in Sankuru, at 92.6 percent. More than 30 percent of patients reported that RECO 
services, treatment of child illness, and delivery were also unaffordable.
Table 3.3. Percentage of women who sought care in a public facility who reported that the services 
listed were unaffordable, by service and province
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba Overall
ANC 58.0 75.2 54.0 92.6 49.5 46.6 64.5
RECO 
services 47.7 72.6 38.4 70.6 22.5 17.5 38.3
Treatment of 
child illness 44.0 63.5 33.7 77.5 17.6 27.7 38.1
Delivery 44.7 45.4 37.7 70.0 20.5 35.2 37.4
Child 
vaccination 32.8 48.0 20.2 23.7 12.0 18.7 23.4
FP 37.9 22.5 23.9 37.9 12.5 22.4 22.1
n 46 47 126 111 136 119 585
Figure 3.1 shows the percentage of caregivers of children under five who reported that they sought care the last 
time the child had a fever. Most (82.2%) of the children with a fever received care. This percentage ranged from 
78.1 percent in Kasai Oriental to 95.3 percent in Lualaba.
Baseline Report 97
Figure 3.1. Percentage of caregivers who sought care the last time their child under five had a 
fever, by province
Among the caregivers who reported that they did not seek care for a child with a fever, the most cited reason was 
lack of money (Table 3.4). Lack of access to a HC was reported by 14.3 percent of caregivers, and the rest were 
treated at home, did not feel that care was necessary, or gave another reason.
Table 3.4. Percentage distribution of reasons why care was not sought for fever (n=number of 
cases of fever for whom care was not sought)
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba Overall
Lack of money 83.5 57.2 71.8 73.8 23.2 62.5 64.7
Treated at home 50.8 6.3 24.2 39.7 19.7 44.7 29.4
Not necessary 12.4 9.9 13.5 0.0 45.0 0.0 16.7
Lack of access to HC 13.9 53.1 16.3 19.1 0.0 25.9 14.3
Other reason 0.0 0.0 2.2 5.4 20.4 24.4 6.0
n 11 8 46 44 15 14 138
To assess the degree to which RECOs were operating in project areas, the percentage of HAs in which at least 
one women reported using a RECO to care for herself or her children in the past three months was calculated 
(Figure 3.2). Overall, more than one-half (56.7%) of HAs appeared to have functioning RECOs. RECOs had the 
highest coverage in Sud Kivu, at 80 percent of HAs, and the lowest in Kasai Oriental and Sankuru, with 35 
percent.
84.3% 83.3%
78.1% 81.1%
85.1%
95.3%
82.2%
0%
20%
40%
60%
80%
100%
Sud Kivu
(n=70)
Tanganyika
(n=64)
Kasai
Oriental
(n=225)
Sankuru
(n=224)
Haut
Katanga
(n=97)
Lualaba
(n=129)
Eastern Congo Kasai Katanga Overall
(n=809)
98 The Impact of USAID’s Integrated Health Program in the DRC
Figure 3.2. Percentage of HAs in which at least one woman reported that she used RECOs for care 
for herself or her children in the past three months
Similarly, the percentage of HAs in which at least one woman reported accessing various services at a 
community care site such as an iCCM site was calculated (Table 3.5). The most frequently reported services 
accessed were maternal health counseling, followed by WASH counseling, and child health and nutrition 
counseling. 
Table 3.5. Percentage of HAs in which at least one woman reported accessing the following 
services at a community care site
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Overall
Kasai 
Oriental Sankuru
Haut 
Katanga Lualaba
Maternal health counseling 60.0 60.0 20.0 35.0 10.0 70.0 42.5
WASH counseling 60.0 65.0 25.0 30.0 20.0 55.0 42.5
Child health and nutrition 
counseling 55.0 50.0 25.0 35.0 10.0 70.0 40.8
Deworming medication 60.0 40.0 25.0 35.0 35.0 50.0 40.8
Newborn care counseling 55.0 60.0 5.0 35.0 15.0 50.0 36.7
Mosquito net distribution 80.0 30.0 20.0 30.0 10.0 40.0 35.0
Malaria treatment (ACT) 35.0 45.0 20.0 35.0 15.0 45.0 32.5
FP counseling 60.0 25.0 15.0 25.0 25.0 40.0 31.7
Iron/folate distribution 45.0 35.0 15.0 30.0 10.0 50.0 30.8
Rapid diagnostic testing for 
malaria 25.0 35.0 25.0 35.0 20.0 40.0 30.0
ORS distribution 25.0 25.0 10.0 20.0 10.0 25.0 19.2
FP commodities distribution 30.0 20.0 10.0 15.0 10.0 25.0 18.3
TB directly observed therapy 20.0 5.0 5.0 20.0 10.0 20.0 13.3
n 20 20 20 20 20 20 120
80.0
75.0
35.0 35.0
40.0
75.0
56.7
0
20
40
60
80
100
Sud Kivu
(n=20)
Tanganyika
(n=20)
Kasai
Oriental
(n=20)
Sankuru
(n=20)
Haut
Katanga
(n=20)
Lualaba
(n=20)
Eastern Congo Kasai Katanga Overall
(n=120)
Baseline Report 99
Questions assessing women’s civic participation detected low rates (Table 3.6). In the past 12 months, 2.8 
percent of women reported participating in a public or consultative meeting at the village level, and participation 
was lower at all other levels. 
Table 3.6. Percentage of women who reported that they participated in a public or consultative 
meeting organized by the administrative/political authority or civil society at various levels in the 
past 12 months
Eastern Congo Kasai Katanga
Sud Kivu Tanganyika Kasai Oriental Sankuru Haut Katanga Lualaba Overall
Municipality 0.9 0.0 0.6 0.3 0.8 1.4 0.8
Ward 1.8 0.9 0.7 0.4 0.8 2.3 1.2
Chiefship 1.3 0.6 0.1 0.3 0.4 0.7 0.7
Group 0.9 0.8 0.1 0.5 0.6 0.6 0.6
Village 2.9 5.3 3.3 3.1 1.7 3.2 2.8
n 1084 941 1116 1097 1014 1019 6271
Women were asked whether they had participated in a community scorecard meeting in the past 12 months 
(Figure 3.3). Less than one percent of all women had participated. The highest reported level of participation 
was in Tanganyika, at 2.0 percent. 
Figure 3.3. Percentage of women who participated in a community scorecard meeting in the past 
12 months
Key Informants’ Perspectives
This section begins with background information on our key informants, followed by a summary of the health 
system in the DRC from the perspective of key informants. Following this background, we provide information 
on USAID IHP and select technical approaches of the project, such as SBC, monitoring and evaluation (M&E), 
and child health and nutrition activities, as described by key informants working in these technical areas. We 
0.8
2.0
0.5 0.5
0.7
1.5
0.8
0.0
0.5
1.0
1.5
2.0
2.5
Sud Kivu
(n=1,084)
Tanganyika
(n=941)
Kasai
Oriental
(n=1,116)
Sankuru
(n=1,097)
Haut
Katanga
(n=1,014)
Lualaba
(n=1,019)
Eastern Congo Kasai Katanga Overall
(n=6,271)
100 The Impact of USAID’s Integrated Health Program in the DRC
then present information on government and nongovernmental collaborating institutions and projects, such as 
the Direction Provincial de la Santé (DPS [provincial directorate of health]), Inspection Provincial de la Santé (IPS 
[provincial health inspector]), Food for Peace (FFP), USAID/DRC’s Integrated Governance Activity (IGA), 
and the World Bank, including a description of their work approaches and activities, strengths and weaknesses, 
and the ways in which these organizations plan to collaborate with USAID IHP, as conveyed by key informants 
working in these institutions.
Background of Informants
Key informant interviews were carried out between April 16 and June 12, 2019 in Kinshasa and Kolwezi, the 
capital of Lualaba province. In Kinshasa, key informant interviews were conducted with MOH representatives 
(3); USAID IHP senior staff involved in program development, implementation, and M&E (4); USAID IHP 
partners leading behavior change interventions (1); and USAID staff overseeing USAID IHP (3). Based on 
preliminary interviews with USAID and USAID IHP staff, we decided to interview representatives of other 
USAID programs, including FFP (2) and the IGA (1) collaborating on USAID IHP activities. We also 
interviewed one representative from the World Bank overseeing PBF activities. Although we had planned to 
interview a staff member from Bluesquare—a USAID IHP partner responsible for the development of the 
project’s data-sharing platform—we learned that this USAID IHP partner was mostly involved in the mechanics 
of setting up systems rather than data quality control and assurance. Therefore, we held only an informal session 
with the Bluesquare representative.
In the Lualaba province, we interviewed three government health officials, including a senior provincial health 
official, a representative from the inspector’s office, and a health information systems expert. We also
interviewed an USAID IHP representative overseeing interventions in Lualaba. An informal interview was 
conducted with a MCZ working in Kolwezi. 
A total of 21 interviews were conducted with 20 informants. Two informants were interviewed on two occasions 
and, in one instance, two informants working on the same program were interviewed simultaneously. Thirteen
informants were physicians; most also had a Master of Public Health degree. These informants had a wealth of 
experience in health service delivery and health program development and implementation. Informants from 
USAID IHP and USAID likewise had vast experience in HSS. Other informants included a statistician, a 
pharmacist, an agronomist, a nutritionist, an expert in rural development, an expert in M&E, and an expert in 
international public policy. Only one informant had less than 10 years of work experience; two informants had 
more than 30 years of experience in health programming, development, and implementation.
Description of the DRC Health System 
Informants consistently described the health system as a pyramid comprising three levels: the periphery or 
operational level, provincial or intermediary level, and the central level. At the periphery or operational level 
were the health zones, consisting of a technical team directed by a MCZ, and the health structures, including a 
reference hospital; HCs led by an infirmière titulaire (IT [head nurse]); and health posts for people living in more 
distant locations. At the provincial level was the DPS, which was responsible for planning and assisting in the 
execution of health activities in the province. The office of inspection (Inspection de la Santé) was in charge of 
audits and controlled health activities and services to ensure that government standards and regulations were 
followed. The Ministère Provincial de la Santé (provincial ministry of health) was under the leadership of the 
provincial governor. Its mandate was to support health activities. At the central or national level, 13 departments 
were under the leadership of the secretary general of health, who oversaw the technical aspects of health service 
provision and care. The inspector general of health serves was an internal auditor, who oversaw the observance 
of good governance and management, and adherence to government health standards and norms. The central 
level was described as the foundation of the health system, where directives, policies, standards, and laws 
designed to govern healthcare and ensure the implementation of the national health strategy were enforced. 
There were other structures, such as the Centre de Distribution Régional (CDR [regional distribution center]), which 
stored and distributed medicines to health structures that were essential to the overall healthcare system.
Baseline Report 101
A reform designed to diminish the highly bureaucratic DRC health system was launched in 2006, mandating 
that the IPS become a separate entity providing independent oversight to ensure that national health standards 
were followed. As part of the reform, decentralization of the health system was instituted, with an intermediary￾level institution (DPS), to be situated closer to the population, established to give more local autonomy in the 
management and administration of health services. As of the baseline data collection, the DPS and IPS were 
located in 26 provinces. Each entity had technical units—the DPS had six internal offices and the IPS had four 
internal offices—to execute their different mandates and objectives according to the national health strategy. Key 
informants reported that although the reform was endorsed in 2006, its execution did not occur until 2015.
Informants described decentralization of the national health system strategy as being well-conceived and 
organized, encompassing key elements. We were told that the roles and responsibilities of actors at the various 
levels, and the mechanisms used to strengthen health systems were clearly described in documents defining 
national standards; that tools needed to implement the system were available; and that laws related to the 
provision of healthcare were in place. There was a separate national community strategy, which was also lauded 
for its design and detail. There was also a recently-developed financial strategy. Several informants claimed that 
the strong health systems framework and supporting documents attracted international donors. Informants also 
noted that the country has been successful in instituting decentralization so that DPS and IPS offices were 
separate entities. There was general agreement that the country had a wealth of highly capable human resources,
with strong expertise in the provision of healthcare.
Although the national health strategy was lauded, there was universal agreement that the health system was not 
being implemented as planned. Primary obstacles reported related to underfinancing and mismanagement of 
resources, which prevented the system from functioning as described in the national health plan, known as the 
Plan National de Développement Sanitaire (PNDS [national health development plan]). We were told that the 
Congolese government made minimal financial contributions, with informants reporting that the government 
contributed from three percent to seven percent of the annual national budget, and that a smaller percentage 
reached the MOH, with a large proportion of the health budget remaining at the central level. This amount fell 
far short of the 15 percent of the national annual budget cited as needed for the health system to function as 
planned.
We were told that the national health budget was controlled by the Ministry of Finance and Budget, which 
maintained complex systems for dispersing money, thus hampering other ministries from accessing the funds 
due them. Under these complex systems, the MOH did not fully understand its annual budget or have the 
capacity to know when funds were dispersed, preventing it from accessing funds. Recent changes in the system 
should allow the MOH to set up its own financial and administrative units to ensure that money was allocated 
directly to MOH line items. Although this should increase the MOH’s access to funds, inadequate government 
investment forced the country to continue to rely on international donors, which provided more than 50 percent 
of the healthcare budget. Moreover, informants reported that fee-based payments for health services accounted
for more than 40 percent of healthcare financing. They indicated that the government invested between US$21 
to US$22 per person for healthcare services each year, whereas guidelines for low-income countries showed that 
this figure should be US$80 per year. Informants said that the failure of the government to invest in healthcare 
impacted national productivity and revenue. Various approaches had been used to strengthen financial support 
and to decrease individual health costs, including fee-based services, community-based health mutuelles, and 
PBF.
An underfinanced system influences the low use of health services, which informants reported was related to 
limited geographical access, the low quality of services, the fact that many services were not routinely offered, 
and the unaffordable costs. Although there was agreement that trained MOH personnel had solid technical 
skills, the working conditions did not allow them to use their capabilities. Informants stated that the failure of the 
government to inject adequate resources to provide healthcare personnel with essential equipment and supplies 
affected health worker motivation. We were also told that only a small percentage of the health workforce 
received a salary, leading to the creation of parallel health systems. Moreover, paid salaries often went to 
“phantom” health workers who were no longer working. Lack of pay incentivized health workers to raise health 
102 The Impact of USAID’s Integrated Health Program in the DRC
service fees, which affected access to healthcare in a context where poverty was rampant. It was not clear how 
USAID IHP would help address health worker motivation and user fees.
Poor governance was cited as another major challenge, with informants saying that the government failed to 
implement standards, directives, and oversight to allow the health system to function, as spelled out in the 
national health strategy. One informant said the following:
The skills are there. The real problem with the health system is what? It is that people are not paid, how will they work? People 
stop working in the health system to create other parallel systems where they will be remunerated. The government is the 
regulator, sets the standards, gives directives. The government must assure healthcare to the population, take charge of 
healthcare. In order to do that, the government must allocate the budget needed, provide finances so that the health system is 
solid, effective, and responds to population needs. So, in the government role as regulator they must give the budgetary means. 
In addition to poor management and limited resources, informants highlighted many other problems. Although 
the reforms were followed at the central level, informants claimed that many key actors at the provincial level 
still did not understand the rationale for key changes, such as separating the functions of the DPS and IPS. Some 
informants suggested that many provincial-level health personnel were reluctant to take charge of the 
management of the healthcare system, as needed. Others emphasized that corruption and lack of accountability 
continued to plague the system, undermining progress in decentralization.
Several informants mentioned that the role of the provincial MOH was not clear in relation to the DPS. 
International donors also did not provide support to the provincial MOH, creating conflict between the DPS and 
provincial MOH. Other problems related to ethnic and political affiliations, which informants said caused MOH 
personnel to refuse to work together. Informants consistently cited problems with the timeliness of reporting and 
the completeness of data entry. Generally, data quality was reported to be poor, with many highlighting manual 
data entry at the HC level and limited Internet access as major obstacles. The medical supply chain was 
hampered by delays getting supplies through customs, difficulties transporting medical supplies to the CDRs and 
subsequently to health zones, late and inaccurate estimates of medical supply needs by health personnel, and 
insufficient capital limiting health workers’ ability to order drugs as needed, all leading to regular stockouts. Poor 
identification and management of disease epidemics were another major challenge.
Integrated Health Program Approach
Technical Programs and Cross-Cutting Approaches
The USAID IHP uses an integrated approach focusing on six technical programs: malaria, MCH, FP, nutrition, 
TB, and WASH. Malaria programs will be implemented across all health zones, and MCH and FP activities will 
be executed in most target zones. The other programs will be implemented according to the availability of 
resources, ongoing activities being executed by IPs, and local needs for assistance. For example, TB 
interventions will be concentrated in geographical areas with high TB prevalence, such as Lualaba. WASH 
activities, which require different inputs and technical expertise, will be implemented in limited geographic areas 
(eight zones each year), with the goal of improving their cost-effectiveness. We were told that technical 
approaches will be aligned with the MOH policies and the national health strategy.
The fact that USAID technical programs have separate funding streams with specific objectives and budgets 
influences the degree to which USAID IHP technical programs will be implemented across the project health 
zones. MCH has the biggest percentage of financial support, followed by malaria and FP. USAID IHP will rely 
on other USAID projects, such as FFP, to assist with the implementation of other technical areas, such as 
nutrition and WASH, which receive limited funds through USAID IHP.
There are also crosscutting approaches, such as strengthening health systems, the provision of medications, 
improving information systems, finance, community development, youth, and gender, with separate funding 
allocated for each approach. Gender will be an important focus of USAID IHP, with informants highlighting 
that women are often marginalized in the Congolese context, thus affecting their decision-making power, access 
Baseline Report 103
to healthcare, and health status. Although a gender analysis had been conducted, Abt Associates staff were not 
completely satisfied with the final report, which was described as lacking detail and contextualized information. 
USAID IHP was trying to address other crosscutting aspects of healthcare service delivery, such as respect for
beneficiaries, transparency and reduction of fraud, and community participation.
Because the needs are huge, the project will focus on geographical areas where USAID believes a difference can 
be made, thus potentially creating discrepancies in quality and consistency of health service delivery. Informants 
stated that project activities will focus on two corridors located in Katanga and Kasai to increase synergy with 
other USAID programs and, thereby, improve overall project impact.
We were also told that USAID had some priority health zones where it would aim to ensure that a full package 
of services was available. In health zones, USAID IHP will first concentrate on strengthening higher-performing 
HCs, with these structures used as models and learning centers for other HCs and health posts in the same zone. 
Informants reported that community development will attempt to reinforce the national approach composed of 
CAC and relais communautaire (RECO [community relay]), volunteer health workers involved in community 
sensitization and outreach. First steps will include the selection and training of RECO, the establishment of 
iCCM sites, community sensitization on key health issues, and implementation of specific behavior change 
strategies, such as improved care-seeking at health facilities. Although community activities will engage local 
associations in mobilization efforts, informants stated that associations were not found everywhere.
USAID Involvement and Oversight
A contracting officer’s representative (COR) in the USAID health team is in charge of overseeing USAID IHP 
and ensuring that the contract agreement (objectives and deliverables) is followed. The COR is accountable to 
the USAID contracts office regarding ongoing project execution. The COR works closely with Abt Associates, 
providing general oversight and management, following daily project activities, and reviewing all technical and 
financial reports submitted. The COR leads a team of USAID technical experts who contribute to the project 
design and are responsible for providing ongoing technical advice and oversight related to their specialties. 
Although we were told that any decisions to modify the contract were made in consultation with the USAID 
technical team, only the COR can officially make changes, including those related to finances. The COR is also 
in charge of coordinating activities with other USAID programs and collaborating partners.
Perceptions of the Project
In general, informants described USAID IHP as a complex project comprising many interventions and actors, 
with several informants reporting that it was overly ambitious in relation to the challenges in the field. Given the 
geographical size and diversity of the project, USAID IHP will partner with other organizations to piece together 
a cohesive approach that covers all six technical programs in the nine target provinces. Informants reported that 
program modifications will be made based on the availability of other donors to fill needs. Informants 
emphasized that good coordination (to avoid duplication of activities and resources and to ensure 
complementarity) will be critical to project success. Informants recognized that maintaining high quality when 
working with numerous partners will be challenging, requiring supervision to verify that quality standards were
met, as defined in the USAID IHP protocol.
Although the project appeared to be well-financed, with funding at around US$314 million, informants 
expressed concern that resources would not adequately cover 178 zones and more than 3,000 HCs. Informants 
stressed that many project objectives—such as strengthening government leadership capabilities; technical 
knowledge; and organizational, planning, and decision-making skills—were far-reaching and ambitious. 
However, USAID staff emphasized that these were critical steps to ensure that the government took ownership 
of and implemented the national health strategy, as planned. At the provincial level, informants stressed that the 
DPS capacity must be strengthened to support health zones, as needed, and that health zones, in turn, must have 
the capabilities to provide adequate oversight and assistance to hospitals and HCs. One informant said:
104 The Impact of USAID’s Integrated Health Program in the DRC
It is not easy. We hope the conditions [in the health system] will end, that it will change one day. It does not have to 
continue like this, but as the saying goes, it's a long journey. But the journey is essential. It took time to build the national 
system, the national health system, now it's time to know how we can make it work. How to take ownership of the system. 
We had debts, that's true, but we must take ownership, and with that, we hope that things will go well. For example, the 
gentleman you met at the health government office [someone with whom the research team had been 
unimpressed], if there was any ownership, I do not think we would hire such people.
Work Completed at the Time of Interviews 
During a workshop in the fall 2018 attended by MOH officials, former and current USAID IHP staff shared 
thematic strategies that PROSANI Plus had executed—as the predecessor project to USAID IHP—and 
discussed approaches to be implemented under USAID IHP. In the last quarter of 2018, USAID IHP staff 
invited all DPS directors located in target provinces to meet in Kinshasa to develop annual workplans 
(operational action plan, plan d’action opérationnel [PAO]), which were approved in early December 2018. The 
workplans included objectives and activities based on the PNDS strategy, plus cross-cutting approaches, such as 
those related to gender and community development. Start-up action plans were also developed.
At the time of our study, PICAL assessments were underway to examine how the DPS system functioned in 
regard to human resources, financial resources, and specific outputs, with action plans developed to address 
functional problems. We were told that activities were gradually being implemented at the provincial and zonal 
levels, including planning and review meetings at the provincial level, training of health workers serving 
beneficiaries, supervision of health workers, and community sensitization efforts. The supply chain strategy was 
still being finalized, and there was acknowledgement that the project was experiencing problems getting 
medications to the CDRs, which was under the mandate of Chemonics. We were told that the distribution of 
other materials and supplies was slow. USAID IHP did not have a website, which we were told was being 
developed.
Social and Behavioral Change
Key Partners and Approaches
SBC efforts are led by an advisor from Pathfinder, who had been involved in the predecessor project. Activities 
focus on Objective 3 of the project, which promotes the adoption of healthy behaviors. The SBC team was
working with Matchboxology, a South African organization, and Breakthrough Action, based at Johns Hopkins 
University in the United States, to develop communication strategies. Matchboxology concentrates its efforts on 
healthcare workers and Breakthrough Action will focus on community-based activities.
We were told that the SBC approach will use a human-centered design (called HCD) approach to develop 
behavior change strategies. Respondents described the current health system as highly medicalized and 
dominated by health professionals, with little involvement by community members and minimal appreciation of 
health problems. Aligned with the national community strategy to empower communities to take greater charge 
of healthcare, a primary component of SBC activities involves communication efforts aimed to encourage 
community engagement and oversight of health services.
At the provincial level, the USAID IHP’s SBC team works with DPS personnel in the communication sector. 
Respondents reported that DPS communication staff have little authority, which impeded the timely 
implementation of communication activities. At the zonal level, the SBC team will work closely with the 
animateur communautaire (AC [community animator]), who will be involved in supervising community activities. 
We were told that during PROSANI Plus, supervision by the AC was inadequate and that another supervision 
strategy may need to be developed.
Baseline Report 105
Proposed Activities
Mini campaigns, which require little funding, will constitute a primary component of community activities. Mini 
campaigns involve identifying a health problem in conjunction with health zone staff; initiating a dialogue with 
community members to define recommendations and develop a feasible action plan to address the health 
problem; and implementing community mobilization and sensitization related to the health problem. HCD will 
be used to ensure that local contextual factors are considered when designing mini campaigns. Campaigns 
follow an action plan that spells out the timeline and the roles for participants, and will generally offer a small 
incentive for those involved. We were told that mini campaigns will typically involve the participation of 
community agents, such as RECOs, CODESA members, influential leaders, and community organizations, to 
sensitize the population on important health practices and promote the use of health services, with an overall 
goal of establishing a long-term approach that encourages the adoption of healthy behaviors.
Another activity, which was also implemented during PROSANI Plus, was the “Champion Community” 
model, which encourages communities to design interventions, mobilize resources, and control intervention 
activities and the use of funds. Led by influential leaders, communities identify a community activity that may or 
may not be related to health, and define an action plan that includes objectives and expected results. The AC at 
the zonal level is responsible for helping communities develop proposals and seek funds. Project cycles last six 
months and are evaluated by external groups, such as NGOs or government structures. Other planned SBC 
activities included a family campaign, which will use serial stories to convey information about health problems 
through the media, theater, or radio spots. Another intervention was the journée porte ouvertes, which is an open 
house event during which community members are invited to HCs to learn about health services. Community 
activities will also include the establishment of iCCMs sites, which are located in remote locations, where 
RECOs are trained to treat childhood illnesses with basic medications and refer patients to health facilities. Jeux 
concours—contests used to motivate behavior change—were also mentioned as an intervention.
The SBC approach also aims to train government community agents, such as RECO and CODESA members, 
who will be provided with small sums of money so that they can function as described in the national strategy. 
We were told that a training plan for community agents will be developed for each province. Key informants 
noted that the current selection of CODESA members was problematic. Specifically, they contended that better￾educated community members were selected, creating a social bias that influenced the CODESAs to liaise more 
closely with health personnel than with community members. In an effort to create a more balanced approach, 
USAID IHP will involve community organizations in the promotion of healthy behaviors. The USAID IHP 
gender specialist will assist in developing strategies that involve women in community activities.
Informants indicated that efforts will be made to share lessons learned, harmonize strategies, and improve 
approaches by collaborating and coordinating with other groups involved in SBC. They include the following: 
key government institutions working on communications; government officials, IPs and other stakeholders 
participating in coordination meetings at the central, provincial, and zonal levels; USAID staff and partners; and 
community-level actors, such as CODESA and CAC representatives. We were told that during the development 
of operational action plans, USAID IHP will provide assistance to health zones to ensure scalability of sound 
and effective messaging that aligns with agreed on health goals. The project also plans to share SBC activity 
results with international audiences during academic conferences and through peer-reviewed, scientific papers.
Work Completed at the Time of Interviews 
At the time of our interviews, the SBC advisor was working closely with Matchboxology on the development of 
an action plan involving HCD. Several activities were underway, including the design and implementation of 
mini campaigns focusing on TB and malaria, which coincided with national TB and malaria days. Other 
activities included an evaluation of CODESA members and preparations for a workshop on community 
scorecards (USAID IHP is supporting government efforts to pilot community scorecards in health zones); and 
“Ne Pas Nuire” or Don’t Do Harm, which aimed to develop strategies to avoid causing additional harm when 
106 The Impact of USAID’s Integrated Health Program in the DRC
implementing humanitarian aid. The team was also preparing for a week-long campaign on exclusive 
breastfeeding to be held in August 2019.
We were told that communication efforts at the provincial level had begun, with interviews carried out in the 
DPS and some Central Health Office Areas (BCZs), hospitals, HCs, and communities to develop 
communication strategies in the provinces of Kasai Oriental (March 2019), Haut Katanga and Lualaba (May
2019), and Tanganyika and South Kivu (June 2019). Respondents indicated that three to four health zones 
(including a mix of urban, peri-urban, and rural zones) will be identified in six target provinces in which
communication approaches will be implemented. As part of this process, workshops will be held in August 2019
during which communication strategies will be developed in conjunction with personnel from Matchboxology in 
each of the target provinces, with the goal of finalizing six communication plans by the end of the fiscal year. In 
addition, Breakthrough Action was carrying out research to inform its community-based activities in Kasai 
Oriental and Haut Katanga in preparation for family campaigns. We were informed that Matchboxology and 
Breakthrough Action were working together to ensure that strategies focusing on health personnel and 
community beneficiaries were complementary. A combination of mass media and interpersonal community 
approaches were likely to be used to convey messages.
Monitoring and Evaluation
Team Members and Partners
The project’s M&E unit is led by a director, with two support staff in Kinshasa and one USAID IHP staff 
member in charge of M&E in each USAID IHP province. At the time of the study, not all M&E provincial 
positions had been filled. The M&E team was supported by two M&E specialists from Abt Associates 
headquarters who had been providing ongoing assistance in Kinshasa.
As mentioned earlier, USAID IHP was working with Bluesquare, a Belgian company delivering innovative 
technology. Bluesquare was in charge of setting up and improving information systems, and ensuring that data 
system platforms were functioning and could be used by government staff at different levels. We were told that 
Bluesquare was not involved in ensuring data quality (which was the responsibility of government personnel 
working on data collection, entry, and validation), and that data were gathered in HAs and validated during 
monthly meetings in health zones. At the provincial and central level, data were supposed to be reviewed 
regularly for inconsistencies, and the DPS was responsible for contacting health zones when concerns arose 
about data.
One of the M&E team’s first tasks was to prepare the project M&E plan, which defined how each of the three 
program objectives would be monitored and evaluated. At the time of this study, there were 118 project 
indicators, including outcome, process, and output indicators. Respondents stated that additional indicators will 
be added to monitor other project components, such as environmental activities required by USAID. We were 
told that the team will fix annual targets at the provincial and regional levels for each indicator.
Problems with the Health Information Systems
Informants highlighted multiple problems at different levels of the health information system that affected data 
quality. The most frequent issue highlighted was that data were often incomplete and received late. They 
explained that the information technology (IT) unit was responsible for compiling monthly HA data, which were
entered on paper forms at HCs. Informants reported that the data submitted by facility- and community-based 
health staff responsible for monitoring monthly activities were often inaccurate. We were told that many staff 
had not been properly trained in data entry procedures, which was partly due to ongoing turnover of facility- and 
community-level staff. Moreover, HAs frequently did not have the appropriate forms and, therefore, data were
often entered and transmitted on pieces of paper, sometimes in an unintelligible format. Informants explained 
that monthly data entry required extensive time, and that the IT team could easily make mistakes while 
transcribing data, especially because zonal staff often failed to fulfill their responsibilities for providing training in 
Baseline Report 107
and monitoring data management. The IT team may also have reasons to manipulate the data, which we were 
told can occur at all levels of the system. Once the HA data were compiled, the IT units were required to deliver 
the information to the zonal offices, which can be as far as 250 km away. Another problem was that health 
facilities that no were longer functioning may not be removed from the health information system.
Another major obstacle related to the Internet infrastructure, which often did not work. (One informant reported 
that 60 of the 178 health zones did not have an adequate Internet connection.) In these cases, the person in 
charge of data entry must travel to another health zone that had an Internet connection. After the data were
entered, they were validated with the zonal team and other ITs. When errors were discovered, a return visit to 
the health zone with Internet connection was needed to make appropriate corrections in the DHIS2 systems. 
Our informants suggested that because of fatigue, errors identified during the validation session were often not 
corrected. In general, our informants suggested that the health staff were not motivated to complete all the 
necessary steps to overcome challenges confronted during data entry and validation. One informant said the 
following:
We have so many problems in the country, which cause difficulties operating the system. After entering the data, the data 
are incomplete. Sometimes it's 60 percent [complete], sometimes it's 70 percent, and that is what is reported. And when 
you get into what is reported, that's where the problem of quality now comes in. And these problems are due to what? We 
cannot call it lack of motivation, but it is because the working conditions do not allow for health staff to do things 
normally to guarantee the quality of the data.
We were told that the M&E team will work on strengthening the capacity of the information systems, with a first 
step of improving Internet connections, which in some cases will require reactivating the very small aperture 
terminal (VSAT) system. USAID IHP was exploring ways to ensure that data entry forms were available on a 
regular basis across all health zones.
Work Status at the Time of Interviews 
At the time of our study, the M&E team was focused on the development of the study design and tools for the 
mapping exercise, which involved facility-based and household surveys to be carried out in all 178 USAID IHP 
heath zones before the start of field activities. The main purpose of this exercise was to delineate the type of 
assistance being offered by other IPs and donors, the time period for the implementation of activities, and ways 
to work with other organizations so that target health zones will benefit from a package of integrated services 
involving the six USAID IHP technical approaches. The data will be used as baseline information, in addition to 
several other data sources, including the DHIS2, the Malaria Indicator Cluster Survey (2017), and ongoing 
monitoring carried out through other activities, such as SBC. After completion of the mapping exercise, 
responsible partners and the timeframe for activities were to be spelled out in the contrat unique (unique contract) 
developed for each province. Informants asserted that in the future, coordination with IPs will be critical to 
prevent duplication of data collection, and to ensure that data were available on a timely basis and used to 
strengthen project implementation.
Child Health and Nutrition
Key Partners and Activities
The advisor on child health and nutrition was in charge of overseeing the implementation of a package of child 
health activities linked to five government programs, including PRONANUT (Programme National de Nutrition), 
PEV (Programme Elargi de Vaccination [National Nutrition Program]), PCIME (Prise en Charge Intégrée de Maladies 
de l'Enfant) [Integrated Management of Childhood Illnesses], PNIRA (Programme National de Lutte contre les 
Maladies Respiratoires Aiguës) [National Acute Respiratory Disease Control Program], and PNECHOL-MD 
(Programme National d’Elimination du Choléra et de Lutte contre les autres Maladies Diarrhéiques) [National Program 
for the Elimination of Cholera and the Fight against Other Diarrheal Diseases] at the central, provincial, and 
zonal levels. Activities related to malaria will be covered separately by the USAID IHP malaria program 
108 The Impact of USAID’s Integrated Health Program in the DRC
advisor. We were told that a major focus of the child health approach was to ensure that the five child health 
programs were well integrated in the service packages so that sick children can reach health facilities in a timely 
manner and were provided care according to official treatment protocols. Although the malaria and nutrition 
programs were well established, the other three programs were reported to lack coordination and technical 
support.
Training, supervision, and monitoring of health workers (especially in relation to the treatment of malaria, ARI, 
and diarrhea disease) were expected to be major focuses of child health activities. Although health workers in all 
USAID IHP provinces should already be trained on the treatment and prevention of the target programs, high 
attrition of health personnel necessitated regular training. We were told that the mapping exercise would be used 
to identify training needs. Informants also emphasized the importance of supervision to ensure that health 
workers were treating children according to national and international standards. USAID IHP will provide 
support to the DPS technical team and the zonal leadership team, including the MCZ and nurse supervisor, for 
supervision of facility- and community-based activities. Informants expected that an ongoing challenge will be 
ensuring that medications and medical supplies were made available in a timely manner. We were told that 
USAID IHP will provide support to ensure ongoing production and distribution of reporting tools for the 
DHIS2.
Ongoing Collaboration and Potential Challenges
Our informants stressed that collaboration within USAID IHP was very good, and included formal weekly 
meetings with staff representing different technical sectors. Informants cited effective ongoing planning between 
the SBC and child health group as an example. Although informants stated that the MOH supported the focus 
on strengthening health systems, they noted that USAID IHP was encountering problems related to financial 
agreements, with some DPS offices suggesting that they will not sign a contract unless they can control project 
funds. One informant said the following:
In fact, the ministry is in favor of health systems strengthening for supporting planning activities, training, and all that,
but there is a problem; it is the funding problem. For them, they believe that when we say strengthening it means we 
will strengthen their ability to manage themselves, not for USAID to manage in their place. This remains a problem 
because when we explained the situation, they said ‘no, we won’t work as your substitutes. If you want us to work then 
give us the money to manage.’ You will see that we have also become competent in the management of financial 
resources. There are provinces that bluntly state that if we are not going to give the money, they are not going to sign 
the contract.
Informants maintained that the financial aspects of project support were always challenging, especially the
remuneration of health workers. It was reported that there was little ownership of the work, with 
implementation of many activities based on obtaining money. As a result, the longevity of interventions was
undermined. As soon as funding ended, people looked for work elsewhere.
At the time of the study, common problems confronted in the USAID IHP zones included declines in 
vaccination coverage of measles and bacillus Calmette-Guérin due to stockouts of syringes and needles, 
difficulties with the DHIS2 data (February and March 2019 were cited as months when data were not
available), and project activities from the predecessor project having slowed or stopped due to the lack of 
funding. Interestingly, some informants were unaware of the drug stockouts plaguing USAID IHP provinces or
problems involving Chemonics getting medications to the CDRs that were reported by other key informants. 
Not all informants had been informed that community health agents would be responsible for transporting 
medications from the zonal offices to the health facilities.
Work Status at the Time of Interviews 
A workplan for child health activities from October 2018 to September 2019 had been developed, with USAID 
IHP efforts concentrating on coordination with the five national-level child health programs. Another focus was 
to establish a collaboration plan with FFP staff in Kinshasa, with the USAID IHP staff having made two field 
Baseline Report 109
visits to FFP sites to assess how USAID IHP and FFP could work together. USAID IHP and FFP decided to 
collaborate in all 12 health zones where FFP was implementing activities, with USAID IHP taking the lead on 
facility-based activities and FFP overseeing community-based approaches, including those related to nutrition. 
Informants reported that funding and coverage of nutrition activities were limited, but explained that nutrition 
will be offered through the iCCMs sites, with training provided so that RECOs can better identify and refer 
malnourished children to HCs. It was noted that ready-to-use therapeutic foods were not provided by USAID, 
and UNICEF will not support treatment of malnourished children in all USAID IHP zones. Overall, the 
USAID IHP nutrition approach will focus on prevention, including counseling during Consultation Préscolaire
(CPS [preschool consultation]) and mother support groups (L'Alimentation du Nourrisson et du Jeune Enfant) [Infant 
and Young Child Feeding]; dietary demonstrations promoting local foods; and the sharing of information 
through text messaging. When we asked about the PEV, we were told that USAID IHP will support the 
maintenance of the cold chain and field-based approaches aimed at reaching all eligible children, including 
children living in isolated areas with limited access to health structures.
During our data collection, USAID IHP was developing an action plan for October 2019 through September 
2020. We were told that the aim was to use results from the mapping exercise to guide proposed activities for 
fiscal year 2020. However, the mapping exercise was taking longer to implement than planned and, as a result, 
the annual workplan mentioned above had to be developed before the mapping results were available. The slow 
start of USAID IHP activities was a commonly reported weakness.
Differences with the Predecessor Project 
The previous project, PROSANI Plus, targeted 78 health zones and focused on service delivery, whereas USAID 
IHP targets 178 health zones and is concentrating on HSS. The additional 100 health zones were added to 
USAID IHP to meet an agreement made with the MOH and other partners to provide support for malaria in all 
health zones located in the nine project provinces as part of the U.S. President’s Malaria Initiative. Although 
PROSANI Plus was composed of different programs working on such technical areas as FP and TB, USAID 
IHP integrates all technical approaches under one project. One informant made the following statement:
When USAID talks about integration, it means integrating all programs under one project. With the previous project, 
there were different projects working on different technical areas, like FP and TB; M&E was done by MEASURE 
Evaluation. Now it is one project with all the money under IHP.
Informants indicated that there should be general continuity in terms of other crosscutting approaches, such as 
the training of health personnel, supervision, and the provision and distribution of medications.
Another major difference is that USAID has a contract with Abt Associates, whereas the predecessor project 
functioned under a cooperative agreement. A contract gives USAID program directors much more decision￾making power and technical oversight for project development, implementation, and the use of funds. We were 
told that USAID designed the project, with Abt Associates responsible for the execution of activities and 
ensuring that indicators were closely followed and results achieved. Any program adaptations need approval 
from USAID. One informant said the following:
It is their [USAID’s] program. In the contract, we are an instrument in the hands of USAID to implement their 
program.
Our informants reported that contracts have strict requirements, involve extensive documentation, and permit 
limited direct government access to cash funds. From the USAID perspective, the nature of a contract ensures 
greater accountability, with USAID providing daily oversight to ensure that program activities are implemented 
as planned, all with the aim of improving overall project results. We were told that the switch to HSS and 
limiting direct cash access is part of the USAID Journey to Self-Reliance strategy, which focuses on 
strengthening systems, improving work environments, and shifting the approach such that governments are in a 
better position to fund and implement high-quality health systems.
110 The Impact of USAID’s Integrated Health Program in the DRC
As part of the contract, USAID is providing Abt Associates with funding for operational costs. The agreement 
also includes 19 fee-based indicators to be paid based on the completion of deliverables. The contract does not 
allow for budgetary modifications without consulting the USAID COR, who must go through the contracts
office to make changes. In addition, Abt Associates is required to get approval from USAID to carry out all
activities.
Another difference between USAID IHP and the predecessor project concerns the direct involvement of other 
USAID projects, such as FFP and the IGA, and of collaborating partners executing interventions designed to 
complement USAID HIP activities. Examples include the World Bank, which is implementing PBF in the 
Katanga region; FFP, which is working on community nutrition and WASH in South Kivu, Tanganyika, and 
Kasai Oriental; and Access aux Soins de Santé Primaire, which was implementing an integrated health program in 
Kasai Centrale at the time of the interviews.
The provision of medications has also changed. The former project purchased and distributed medications to 
health structures, although The Global Fund to Fight AIDS, Tuberculosis and Malaria was responsible for 
ordering HIV and TB drugs. Toward the end of PROSANI Plus, USAID established a global project in charge 
of ordering medications for all USAID projects around the world. The new project is composed of two 
branches, Procurement and Supply Management, which is responsible for procuring and transporting 
medications to countries, and Global Health Supply Chain Technical Assistance, which is based in countries 
and oversees the quantification, regulation, quality control, storage, and distribution of medications. Global 
Health Supply Chain Technical Assistance was also working with the CDRs to improve storage and 
management.
Under the predecessor project, Management Sciences for Health was granted a government waiver allowing it to 
bypass onerous customs regulations. However, with the new USAID approach, medications have to go through 
customs, which has caused severe delays (up to a year) in getting medications to CDRs. USAID was relying on a 
subpartner, Chemonics, to procure and distribute medications and to carry out quality control, which is causing 
challenges. During interviews, we learned that estimated drug costs initially provided by Chemonics were 
inflated because Chemonics had based estimates on specialized rather than generic medications, and made larger 
orders than requested by USAID. With Chemonics, which is also responsible for getting medication from CDRs 
to health zones (normally the mandate of the CDRs), there have been long delays in distributing medications, 
causing stockouts. At the time our interviews in April 2019, only 60 percent of essential generic medications 
ordered in July 2017 had arrived in the CDRs, with USAID having to make an agreement with the World Bank 
to help fill the gap in drug supplies. Rather than relying on the health zone, another change made was that the 
project had decided to provide resources to community personnel, such as CAC representatives, CODESA 
members, or RECOs, to transport medications from health zones to facilities. USAID believed that this 
approach would better ensure that medications were transported quickly and would reduce the possibility of 
drugs being stolen.
Problems with Chemonics were attributed to a lack of experience and the fact that Chemonics did not have an 
official office in the DRC but was relying on sub-partners. Our informants stressed that the project’s success 
depended on the availability of drugs and expressed concern that inadequate and late deliveries could undermine 
results. One informant said the following:
This issue of drugs. A difference between this project and the former project is that the former project had the 
opportunity to purchase drugs. You cannot implement a health project without drugs because health means treating 
people. You strengthen the health system but give the procurement of drugs to someone else? The results depend on 
medications. What a design, the project structure is quite complicated. This is the first time I have seen a health project 
where another group is responsible for the drugs. We will continue to support the [health] system, but for the system to 
work, it is necessary to have the drugs. My fear is what? If the drugs are not available, people will not understand. 
Even if the system is strengthened, in what way will this be effective if the drugs are not there....
Baseline Report 111
USAID Integrated Health Program Challenges
The project has faced many unforeseen delays. They include a period of more than four months when another 
organization bidding for the project contested the award given to Abt Associates; turmoil and uncertainty 
leading up to the Congolese presidential elections; mandatory evacuations of U.S. government staff around the 
time of the Congolese presidential elections; and the U.S. government shutdown in early 2019. At the time of 
the key informant interviews, Trafficking in Persons (TIP) sanctions posed a major threat to the project. We 
were told that if TIP sanctions were enforced, which informants expected would be decided in June 2019, 
USAID IHP would have to identify alternative sources of funds. USAID was consulting legal experts about
project revisions that would have to be made with the enforcement of TIP. There was much talk about 
“descoping,” which would involve revising the workplan designed through 2021 to remove activities that 
directly supported the government or government entities, thus changing the overall focus of the project. 
Uncertainty about TIP put USAID IHP in a difficult situation with government collaborators in terms of the 
start-up of activities.
Another factor slowing implementation related to cash transfers to government entities. Although health zones 
received and managed a monthly budget under the previous project, with the contractual agreement, USAID 
IHP was forced to closely monitor how all project money and resources were used. Specifically, the contract 
stipulated that USAID IHP controlled the purchase of all materials and supplies, and monitored the use of even 
small sums of money. At the time of the study, USAID IHP was developing a system for regular cash transfers 
to more than 3,000 health structures in 178 zones needed for ongoing activities, such as monthly supervision 
carried out by health zones (US$850), reporting meetings held in HAs (US$15), and zonal meetings (US$50). 
We were told that monitoring to prevent the misuse of funds would be laborious; for example, Abt Associates 
must verify that monthly supervision of activities by the DPS and health zone teams was occurring as described 
in the protocol. In addition, subcontracts established with government entities will require that each recipient 
receiving U.S. government funds followed rules related to the management of Federal funds. This approach 
will also require a great deal of time and work, requiring the monitoring of finances and deliverables of all 
subcontractors.
We were told that there had been some misunderstandings between Abt Associates and USAID regarding the 
project design and its execution. For example, the initial workplan developed by Abt Associates was apparently 
more closely aligned with the PNDS strategy than with the USAID approach. Over time, Abt Associates 
personnel were gaining a greater understanding of the USAID approach and vision for the project. In general, 
the Abt Associates team received favorable endorsements from other key informants, who noted the 
organization’s strong technical background and experience, commitment to HSS, and flexibility.
Another problem arose from the fact that most medications provided through the previous project had run out 
and were not being replenished quickly, due to challenges faced by Chemonics. During interviews, we learned 
that computer software was being introduced for tracking the status of drug stocks in all CDRs and HCs across 
the country. Once operational, the program will predict stockouts of drugs in health facilities based on their use 
and will notify health workers when they need to order drugs. As stated above, the mapping exercise was taking 
longer than planned, slowing the implementation of workplans. Last, because of security concerns, many 
USAID staff were not permitted to visit more remote, rural areas, preventing them from getting a first-hand 
understanding of field conditions and operations.
Collaborators
Direction Provincial de la Santé
The DPS in Lualaba was established in 2015 and is composed of 14 health zones. There were six offices in the 
DPS: technical support, resource management, information systems, hygiene, teaching in health sciences, and 
inspection control. Each office had a director who coordinated activities and technical analysts, with additional 
staff including secretaries, drivers, and security guards. Of the 75 staff officially needed to fulfill the work 
112 The Impact of USAID’s Integrated Health Program in the DRC
requirements of a DPS, the office included 32 personnel, of which only two were women, both in 
administrative positions. We were told that professional positions in Lualaba were mostly occupied by men and 
that representatives on health committees were also generally men. However, this was changing because more 
women than men were currently in medical programs, and women were more willing to serve in rural areas. 
The Lualaba DPS rented a building that had recently been sold, and at the time of the study, the director did 
not know where the office would relocate.
We were told that the DPS followed an annual workplan and that each trimester the DPS was evaluated based 
on activities implemented according to the annual plan. In addition, each health entity (BCZS), hospital, HC) 
was responsible for designing an annual plan that aligned with the DPS workplan. The DPS participated in a 
contrat unique, which was guided by the PAO, spelling out roles and activities of IPs and donors and informing 
trimester activity workplans. We were told that funds from partners often arrived late, causing activities to fall 
behind. For example, DPS staff reported that they did not have funds to implement planned activities in the 
first trimester of 2019, which affected their performance and forced them to revise their workplan.
Our informants indicated that the DPS attempted to follow the PNDS as a guideline for implementing health 
interventions. They stated that—although the national strategy was well designed with all essential 
components—the Lualaba DPS office did not have the capacity to follow national norms and implement the 
strategy as proposed. In addition, the provincial steering committee in charge of making decisions and ensuring 
that activities were executed according to national health norms was described as ineffective, in part because 
the governor had failed to take a leadership role to ensure the support of health zones. We were told that other 
working groups and committees set up to ensure coordination of activities at the provincial and zonal levels 
lacked leadership, finances, and adequate participation of government representatives. As a result, 
recommendations and resolutions established during meetings were not generally applied. It was reported that 
the DPS office was severely hampered by the lack of resources, with informants indicating that the government 
failed to provide even the most essential support, such as funding for the construction and rehabilitation of 
health structures, equipment and materials, equipment maintenance, supervision of health services, and health 
worker salaries and primes (i.e., salary supplements), needed for the health system to function.
Key informants said that only three percent of health workers in Lualaba received their salaries, many of whom 
were already at retirement age and no longer working. Even the director of the DPS did not receive a regular 
salary. In addition, 50 percent of health personnel had received the prime de risque. In 2018, the provincial
government provided three prime payments to all health workers in the province, with higher primes given to 
workers in more isolated areas. Apparently, this was a first-time occurrence that served as an important 
incentive. In general, lack of government support was reported to force the DPS to rely on support from IPs and 
health worker fees. IPs may provide primes to DPS, BCZS, hospitals, and some HC personnel as motivation, 
with informants indicating that the IP primes were more generous than the government premiums. During our 
interviews, the DPS director provided a detailed description of the challenges that health workers faced, 
emphasizing that the work was demanding and that workers should be paid appropriately for their efforts. As 
an illustration of the sacrifices made, he presented a case study involving a RECO who had traveled two days 
and 110 km each way to obtain vaccines for his HA.
Lack of government support forced health workers to rely on out-of-pocket payments by sick patients to generate 
revenue, which was managed internally by staff to pay health workers and invest in health structure needs. We 
were told that health workers developed approaches to increase payments, which generally involved increasing 
user fees, which, in turn, affected the use of health services. Another strategy used to get money was called 
pharmacie de tiroir et poche (pharmacy in the drawer and pocket), which was a common practice involving health 
workers selling facility drugs for their personal benefit. Lack of salaries also led to high attrition and, in turn, 
created vacancies in health structures. Our informants reported that the turnover of well-trained staff placed a 
burden on the system, leading to increased training needs and lowering health worker capacity. We were also 
told that when projects with primes or other incentives ended, trained workers often searched for other, more 
lucrative opportunities. When talking about motivation and USAID IHP, one informant said the following:
Baseline Report 113
Motivation is a serious problem in almost all health zones because the government does not pay everyone, and even 
when it pays, it is not enough. The USAID partner comes and does not give a prime. PROSANI does not give a prime 
to the staff, which causes terrible demotivation. This is the weakness of the USAID partner; the approach prevents 
sustainability of activities because when the partner leaves, everything closes and stops. There is no good appropriation 
of activities that PROSANI implements because when PROSANI is there, it is PROSANI that does everything. 
PROSANI brings all the funds. When there is training, it is PROSANI who has the money. PROSANI pays for 
trainers, food. We will take a house and PROSANI pays; the training facility, PROSANI also pays for that. This does 
not give a sense of responsibility to representatives of the Ministry of Health. We feel that this is their project, they are 
the ones who come with the money, it is their project.
This informant had numerous criticisms of USAID IHP assistance offered through the predecessor project, 
indicating that USAID IHP was strictly in charge, providing funds, making decisions, and executing activities, 
and because USAID IHP failed to delegate responsibility, it was catastrophic when it left. He cited joint 
supervision visits carried out with the DPS as an example, indicating that USAID IHP determined the terms of 
reference and provided feedback to health personnel without soliciting input from the DPS counterpart. The 
same informant reported that as a MCZ, he received money and fuel for supervision from USAID IHP, but the 
zone did not have working vehicles. Some informants described a general disinterest of government authorities 
in strengthening the health system due to the assumption that money and technical assistance would be 
provided through international sources.
Another major DPS challenge related to tracking the status of health personnel, with DPS personnel explaining 
that they did not have an updated list of staff currently working in health zones. Although the DPS was
developing ways of maintaining a list of active personnel, it was difficult to stay current on health worker 
deaths or new recruits. This was partly because health workers were commonly hired through unofficial 
mechanisms. Other weaknesses mentioned included limited technical capacity of DPS personnel; the inability 
of health workers to provide quality care; poor management of materials and equipment, especially vehicles;
and the inability of the inspection control office of the DPS to function properly. One informant said the 
following:
One of the big weaknesses that we regularly observe is related to the inspection. As you know, we are a provincial health 
division. Next to it they put inspection, but the provincial health division also has the role of inspection, internal 
inspection, which was established before the external inspection. That is to say that the provincial division has an office 
of inspection to control healthcare structures, such as hospitals, health zone offices, health centers, to ensure control in 
terms of human resources, material resources, financial resources, whether they are used well or not. It is an office that 
remains compartmentalized, which does not work so well, I think, due to overlap, or to the confusion between the 
inspection structure, which is a decentralized entity at the national level, and the inspection office, which is part of the 
office of the provincial health division, which must carry out its role of internal control.
We were told that the DPS went through a PICAL assessment supported by Abt Associates in 2016‒2017, 
which helped define roles and increased leadership capabilities to delegate responsibilities to staff members. The 
same project provided assistance to identify needs in terms of capacity building, training, and resource 
management, which some informants claimed enhanced the way the DPS office functioned. Informants 
reported that the USAID IHP predecessor project offered training to DPS and zonal staff on a range of topics 
(e.g., FP, revitalization of CPS, SNIS, DHIS2, TB, etc.) to strengthen capacity.
Monitoring and Evaluation 
DPS personnel stated that training on using the DHIS2 software was first carried out in 2012 and a refresher 
workshop was held in 2016. Health zones are responsible for submitting health service data at the end of each 
month, with data entry typically taking about five days. The DPS Office of Health Information was responsible 
for overseeing the monitoring and analysis of health zone data. Respondents reported that Internet access 
presented an ongoing challenge; although the VSAT was installed, the health system did not have money to 
pay for Internet subscriptions or credit for a modem. Even when there was a connection, it may not be strong 
enough to access the Internet or to use the DHIS2 system. These problems forced health workers to find 
114 The Impact of USAID’s Integrated Health Program in the DRC
alternative ways to access the Internet, such as using personal modems or traveling to areas with Internet 
connection, which may cause delays in submission of monthly reports. Other problems mentioned included 
lack of data entry forms, forcing health personnel to use pieces of paper for data entry; inadequate training for 
health workers on data entry; transcription mistakes; long distances between the HC and the zonal offices (up 
to 250 km), causing data to arrive late; and old and improperly maintained computers. An M&E staff member 
reported that the head nurses frequently did not understand the SNIS and, as a result, submitted monthly 
reports with errors or missing data. He said the following:
The big challenge relates to Internet connectivity. Although modems were given, units for an Internet connection are 
provided irregularly. It is a really big challenge. And the other challenge is that head nurses don't have electronic tools, 
they have to report on hard copies, and the distances between the central zonal offices and the health structures are 
really huge. Sometime, the health structures bring the reports late, and if it is not late, there is also the problem with the 
quality of the [work of] the head nurses. Because in most rural areas, the head nurses are sometimes uninformed. If a
head nurse has little understanding of the SNIS, you get reports with lots of data that has been crossed out with a lot of 
changes or gaps, and there are a lot of inconsistencies, which creates problems.
We were also told that HC and zonal staff lacked the capacity to analyze and interpret the data to inform their 
field activities. Informants indicated that the zonal reviews were rapid and often superficial, and that more time 
was needed (two days rather than one day was suggested) during monthly zonal meetings to validate data and 
identify errors generated by health structures.
The DPS held a meeting with all provincial health zones every three months to review data. During these 
meetings, the DPS Office of Health Information , along with zonal representatives, identified errors, identified 
data that did not make sense, and gaps (an especially big problem), and gave feedback to the health zone about
corrections, with each zone graded on data quality. Monthly data reported were also analyzed by the provincial 
M&E team and were used to plan routine activities, such as supervision visits. An analysis was also done of 
annual health zone data, which were used to inform annual workplans. DPS informants highlighted the need 
for more training and improved capacity on the use of the DHIS2.
Disease Surveillance 
Health zones generally employed a passive disease surveillance system, with HCs transmitting a weekly report 
to the zonal offices when disease was detected. More active reporting was done for certain illnesses, such as 
cholera. RECOs were encouraged to bring suspected cases of disease (measles or polio were mentioned) to the 
HC and, during epidemics, RECOs were requested to go house-to-house to identify cases. Weaknesses in the 
surveillance system were that HCs may not report on a weekly basis, reporting forms were not available, or 
health personnel were not available to deliver weekly reports to the zonal offices. Moreover, when a report was
delivered to the zonal offices, the person delivering the report may not be able to describe the suspected illness 
cases appropriately. Informants stated that health personnel at all levels required additional training to ensure 
more accurate diagnoses.
Provision of Medications 
Lualaba shared a CDR with Lubumbashi, which DPS informants said prevented them from having adequate 
control of the acquisition and management of drugs. DPS staff stated that USAID IHP was in charge of 
ensuring that CDRs were adequately stocked with essential medications and with delivering drugs from the 
CDRs to health zones. DPS staff indicated that since Chemonics started its contract (more than one year before
the interviews), there had been deficits in medicine stocks. In fact, at the time of data collection, there was a 
serious shortage of medications, with informants reporting that Chemonics had been unable to stock adequate 
supplies, causing shortages in the CDRs and stockouts of certain medications at health facilities. We were told 
that this was forcing HCs to purchase medications from Pakistani- and Indian-run depots, with informants 
questioning the quality of the supply chain and of the drugs themselves. We learned that inexpensive 
counterfeit medications had recently infiltrated the local market and that government workers frequently 
purchased them to stock their pharmacies. It was also noted that small, private pharmacies had recently sprung 
Baseline Report 115
up to fill the void in drug availability. Another problem was that health personnel lacked the capacity to 
manage medications, which served as health structure capital, often failing to maintain enough revenue to 
replenish stocks for subsequent months. Inadequate funds forced health structures to order insufficient 
quantities of drugs to meet ongoing needs or to resort to the purchase of low-quality drugs. Health personnel at 
the HC and zonal level were also lacked capacity to quantify ongoing needs; this, along with poor drug 
management, led to regular stockouts. Another issue was that health workers tended to over-prescribe 
medications.
Performance-Based Financing 
The PBF approach in Lualaba started in 2017 in six zones, with the other eight zones added in 2018. 
Informants explained that the DPS and zonal offices were given a score based on a list of deliverables that they 
had to meet every trimester. If they reached 20 to 50 percent of the total score, they received 50 percent of the 
potential monetary benefit, and if they reached more than 50 percent, they received the full amount, which was
US$30,000 for the DPS and health zone offices. For hospitals, indicators were based both on quality of care 
and number of patients treated, with hospitals potentially receiving more than $30,000 per trimester. Other 
incentives, such as building a maternity ward, were also offered. When health structures met trimester 
performance targets, 50 percent of the funds received were intended to be used for health worker primes and 50 
percent for health structure investments, with health personnel responsible for making investment decisions. 
Primes were supposed to be based on health personnel qualifications, seniority, and performance related to 
caseloads and accomplishments during the trimester, with both quantity and quality of care assessed. There was 
agreement that health workers may be incentivized to manipulate health structure performance data to meet 
targets and to increase scores and monetary benefits.
Community Health
According to the national plan, community members should participate in healthcare provision related to 
generating financial resources and the management of health facilities. CODESA members were supposed to 
represent the population, serving as a liaison between health structures and local populations. Another aim was
to establish community committees and structures to ensure community participation in healthcare.
In general, we were told that the engagement of community members in decision making and resource 
generation designed to strengthen the health system was limited. Moreover, little effort was made to understand 
the perspective of community members on local health needs and problems faced in accessing care. Informants 
also indicated that CODESA members generally established ties with health personnel, butfailed to advocate 
for the needs of the local population. Although CODESA redynamisation (revitalization), which included the 
promotion of female CODESA members, started in 2016 with funds from UNICEF, initiatives were only 
carried out in some HAs and, according to our respondents, the efforts were ineffective. RECOs were described 
as frequently inactive. When active, informants said that RECOs failed to fulfill their roles according to the 
national community strategy. Specifically, we were told that RECOs were not identified according to the 
official selection criteria, did not receive adequate training, and often committed without understanding that the 
position was voluntary. Respondents reported that in Lualaba, RECOs were frequently female, with some 
informants noting that women were more motivated to work and that men in Lualaba province were highly 
mobile.
Informants reported that the Management Sciences for Health-led IHP project provided assistance to establish 
iCCM sites in remote areas. Informants also mentioned the following community-based initiatives: champion 
communities, which involved activities related to community agriculture, gardening, and health; mini 
campaigns focusing on FP and TB; revitalizing CPS; CODESA meetings; training of RECOs on sensitization 
to HIV and TB; training of RECOs on screening and prevention of malnutrition; and engagement of 
community members in the prevention of malnutrition.
116 The Impact of USAID’s Integrated Health Program in the DRC
USAID Integrated Health Program Activities Initiated at the Time of the Interviews 
The Lualaba DPS participated in a workshop in Kinshasa in late 2018 to develop the PAO. Another workshop 
was held in Lualaba in February 2019 to officially adopt the PAO and its activity plan. In addition, USAID 
IHP had sponsored a meeting with other IPs to introduce the project and review workplans. Some training of 
DPS staff had been carried out, but the topical areas were not mentioned. The provincial USAID IHP office 
staff also visited all health zones in the province to meet with zonal staff and IPs. At the time of the interviews, 
USAID IHP had also started to support health zone supervision. USAID IHP had provided support for World 
Tuberculosis Day, with activities carried out in both communities and prisons. Although USAID IHP had 
promised to provide support for National Malaria Day, which occurred during our visit, money to implement 
activities did not arrive in time. It is important to note that DPS personnel were not aware of the funding 
changes made in USAID IHP compared with the predecessor project. Most DPS informants were anxious to 
sign a contract and to start activities.
Inspection Provincial de la Santé
The first IPS office was opened in June 2016, with only one inspector serving since then. The office had all 26 
staff officially required for the four IPS divisions to function: pharmacy; teaching science and health; resources, 
administration, and finances; and medical technique. However, we were told that the government did not 
provide adequate resources for work activities to be implemented as planned. The IPS Lualaba headquarters 
was situated in the inspector’s home compound, with one office space for all 26 staff. All office furniture and 
materials were donated by the former IHP project. The IPS had three motorcycles, with two provided by the 
predecessor project and one by the DPS, which were used to carry out inspection visits.
Informants reported that, initially, there was inadequate clarification about the roles of the DPS and the IPS 
and how they were supposed to interact, with the two offices often duplicating roles. Over time, and with the 
involvement of members of the Comité Provincial de Pilotage (CPP [Provincial Steering Committee]), which was
presided over by the governor and included IPs, the two offices formulated a working framework conducive for 
both groups to carry out their prescribed roles. Although some difficulties still existed, especially in relation to 
interactions between the IPS and the DPS office of inspection control, it was clear that the DPS office was in 
charge of internal audits, whereas the IPS did external audits. We were told that coordination bodies designated 
to provide oversight of the IPS at different levels, including the CPP, the Conseil d’Administration and Comité de 
Gestion (Board of Directors and Management Committee) at the zonal level, the Comité Directeur de l’Hôpital
(Hospital Management Committee) in reference hospitals, and CODESA at the community level, were
ineffective due to a lack of funds, poor participation in and management of meetings, and insufficient 
monitoring of IPS activities.
At the time of our interviews, the IPS was following an annual workplan and a trimester activity plan, which 
were designed in accordance with DPS activities. The IPS was assisted by the World Bank under the PBF 
project, with deliverables based on field visits and the identification of irregularities in healthcare services. Such 
irregularities can lead to administrative and penal sanctions. Examples of situations that merited penal 
sanctions included fictional workers on the government payroll, or workers receiving a prime for work in a 
health structure when they were officially working in another location.
We were told that the Lualaba IPS—because of the lack of funds—had mostly worked in the eight zones 
funded by the previous IHP project, most of which were accessible by road and closer to Kolwezi. Visits to 
health zones must be approved by the governor’s office, with the terms of reference also shared with the MOH. 
Health zones were not informed of the visits in advance. Staff used motorcycles or local buses for transport, and 
were supposed to carry out field visits 10 to 15 days per month. Visits generally entailed one day in the zonal 
offices, two days in the reference hospital, and two days in three to four HCs. Visits were guided by an 
inspection checklist and a list of questions. When IPS staff arrived in a zone, they were required to hold a 
meeting with the MCZ and chef de village (village chief), who must sign a form indicating that the team had
arrived to carry out an inspection. Five days after a field visit, a report was submitted to the MOH in Kinshasa 
Baseline Report 117
and the provincial governor, with recommended actions sent to the DPS and the concerned health structures. 
When irregularities in the use of finances were detected, the IPS requested that the health structure return the 
misappropriated funds. If this was not done, the IPS could impose sanctions.
We were told that the biggest challenge the IPS faced was a lack of funds to carry out visits as planned. As to 
irregularities that IPS staff identified, the biggest problem was the mismanagement of funds and medications. A 
specific challenge in Lualaba was that many health structures were privately run by mining companies and, 
therefore, did not follow official standards. Other problems were that health structures did not have the 
appropriate equipment, such as incinerators, to follow government standards or lacked qualified personnel. The 
IPS reported a recent surge in the circulation of “fake” drugs, indicating that health workers were tempted to 
buy these drugs because they were cheaper, and that health workers did not have enough capital to stock their 
pharmacies with high-quality medications. Another problem was the use of expired medicines in the health 
structures. The IPS said that corruption was rampant and serious, especially because it affected lives. The IPS
had a big role in curtailing corruption in the province. When asked whether a hotline would help, we were told 
that health workers must be motivated to denounce irregularities and that community members may be afraid 
to report corrupt practices.
At the time of the study, the IPS office was establishing a budget for control and audit visits. Respondents 
indicated that the second-trimester plan required US$45,000, although USAID IHP had only promised 
US$5,000. USAID IHP had also supported the inspector’s participation in an institutional capacity￾strengthening training in Lubumbashi in February 2019. We were told that the focus was on leadership and that 
gender was also discussed. USAID IHP had not provided any other support, and informants stated that USAID 
IHP was still setting up its offices. Respondents raised questions about the delay in contracts and the slow start 
of USAID IHP.
Medical Director of a Health Zone
The MCZ indicated that the previous IHP project had provided the zone with extensive support, highlighting 
funding for supervision, medications, and community activities, such as iCCM. We were told that after May 
2018, when USAID’s PROSANI Plus ended, activities in the health zone slowed significantly because funds 
were no longer available. Activities especially affected included the delivery of medications (although 
medications for malaria and HIV continued, as did the provision of certain FP methods); data entry and 
reporting of DHIS2 data (due to a lack of credit for modems); and community services, such as CODESA 
meetings and RECO activities. At the time of the interview, the MCZ reported that the DPS was requesting 
that health structures provide money to the zonal offices to support supervision visits and Internet connectivity.
Our informant reported that USAID IHP representatives had given a presentation on the USAID IHP 
approach to health zone personnel, but that USAID IHP was still defining key strategies. Since the beginning of 
2019, USAID IHP had started to provide some assistance to health zones, such as the development of health 
zone PAOs and financial support to hold meetings with the health zone board of directors. The MCZ also 
reported that USAID IHP, in conjunction with the DPS, had carried out a supervision visit to the health zone. 
The MCZ expressed concern that the slow start of USAID IHP was affecting the execution of ongoing zonal 
activities.
Food for Peace
FFP works with vulnerable populations to provide assistance for a range of activities, such as agricultural 
production, nutrition and health, WASH, and FP. This assistance was offered through two programs. The first 
supported people affected by emergencies and primarily involved food distribution, money transfers or 
vouchers, the promotion of agricultural production, and the treatment of malnutrition. The second program, 
Development Food Security Activities (DFSA), focused on community development to enhance food security 
activities (through improved food production and the management of natural resources), and the prevention of 
chronic and severe malnutrition through improved breastfeeding and complementary child feeding practices. 
118 The Impact of USAID’s Integrated Health Program in the DRC
Development interventions also involved WASH; economic activities, such as credit approaches; FP; literacy;
and interventions to address the structural causes of chronic malnutrition related to gender discrimination and 
poor governance. Community sensitization activities were conducted through Care Groups targeting mother 
leaders responsible for delivering messages to other mothers on health, nutrition, and FP. 
At the time of our key informant interviews, FFP had three staff members, including an interim director, an 
agricultural specialist, and a nutrition specialist. Respondents indicated that the annual budget for emergency 
activities was US$180 million and US$20‒US$30 million for DFSAs. Emergency activities typically lasted
anywhere from 12 to 18 months. FFP had three ongoing DFSA projects that started in 2016 in 12 health zones 
located in South Kivu (six health zones), Tanganyika (three health zones), and Kasai Occidental (three health 
zones). The projects will run through 2021. The USAID IHP will collaborate with FFP in the DFSA project 
areas, with joint activities structured around a results framework and a workplan designed to complement 
USAID IHP activities. The FFP team emphasized the value of working together, stating that FFP implements 
revenue-generating activities that will facilitate payment for health services. Moreover, informants stated that in 
the past, FFP had received criticism from beneficiaries who were referred to health facilities at which child 
nutrition services were unavailable. With the HSS approach, the hope was that HCs would be higher 
functioning and would offer comprehensive services. One informant provided the following explanation:
We have mothers of malnourished children who were referred to health structures as part of the program. It was a 
problem for FFP because sometimes people were referred to health centers where services were not being offered. The 
beneficiaries would accuse us of sending them to facilities where there were no services, nothing offered. This had a 
negative effect on the care-seeking messages we were disseminating. Working together will really help.
One foreseeable challenge mentioned by informants was that the timeframe of the two projects was different.
Integrated Governance Activity
The IGA was a cross-sectorial program primarily collaborating with the USAID health and education sectors 
and Congolese government institutions in efforts to strengthen policy frameworks. Our informant highlighted 
the benefits when USAID technical offices worked together to ensure a more holistic approach and to 
maximize outcomes. However, we were told that working with other sectors can be time-consuming, can 
increase workloads of the CORs, and typically required strong entrepreneurial skills and the desire to learn 
about other technical approaches and projects.
The IGA promoted transparent, credible, and inclusive elections; human rights; good governance; and anti￾corruption, with the aim of improving public service delivery at the local level. The IGA also helped
government entities pass legislation conducive to improving the delivery of public services. At the grassroots 
level, the IGA worked with local municipalities to identify funding priorities and to build skills in financial 
management and participatory budgeting of local projects, often building technical skills of local institutions,
such as CODESA. The IGA also had a civil society component that used community scorecards to equip 
people with skills to better advocate for priority health service needs and help provide local services related to 
health. As part of this effort, the IGA was conducting an impact evaluation to assess how improved skills in 
financial management and community scorecards strengthened transparency and health services, and affected
health outcomes.
The IGA office in Kinshasa had four national and two international staff. Their mandate, which focused on 
Objective 2 of the Country Development Strategy started in 2017 and will be implemented for five years in 
provinces where USAID IHP is being executed, including South Kivu, Haut Katanga, Lualaba, Kasai Centrale, 
and Kasai Oriental. At the time of the study, the IGA was under TIP sanctions, which stipulated that USAID￾funded programs could not work with the Congolese government. Although the IGA had been able to continue 
to use money obligated before the sanctions, the money was running out and the IGA was forced to stop 
supporting government structures. When talking about TIP, our IGA informant said the following:
Baseline Report 119
That was decided I think in early December [2018. And that has, you know, affected our health and education 
collaborations. The entire mission is kind of reeling from TIP. It has been catastrophic. Our judgment day is coming. 
In the next couple of months, we will know if DRC is removed from TIP Tier 3 ranking. If we get downgraded to Tier 
2, then we go back to normal.
We were told that the TIP ranking was based on an annual report drafted by the U.S. Department of State that 
assesses government commitment to counter trafficking. The assessment reflects Institute of Medicine reports 
on the incidence of sexual- and gender-based violence, sex trafficking, and child labor. Although the DRC had
been at Tier 3 for many years, the U.S. government had previously signed a waiver. Our informant explained 
that to be removed from Tier 3, the Congolese government must demonstrate concrete ways that it was
addressing the trafficking violations and making improvements. If the DRC was not removed from Tier 3 in 
July 2019, another year without assistance to government would be applied. The IGA had the mandate to work 
with governments and was examining modifications to its approach that would allow it to meet this mandate.
The IGA had held joint planning discussions and meetings with USAID IHP—the biggest partner it expected 
to work with—at the central and provincial levels to identify potential partners for collaboration. In USAID 
IHP provinces, the IGA planned to work on strengthening governance through improved legislation and policy 
in the health sector at local and provincial levels. Given the size and breadth of USAID IHP, the IGA would 
defer to USAID IHP to cultivate strong relationships and technical assistance in governance and capacity 
building with the DPS. At the local level, the IGA planned to work with CODESA on its role in strengthening 
community participation and advocacy, the accountability of health workers, and reinforcing health systems in 
HAs. Interestingly, a recent IGA-funded community political analysis stated that CODESA members had been 
co-opted by HC workers and local officials, who used their relations with CODESA to get free healthcare. The 
assessment also showed that, although regular elections of CODESA were mandated, elections had not been 
held for approximately five to ten years in most zones. Results also highlighted that community members were
uninformed about the role of CODESA, when CODESA elections should be held, and what they should expect 
from local health officials. Results showed that citizens were not using accountability mechanisms, such as laws 
designed to encourage the responsiveness of health personnel to local health needs.
At the time of the study, the IGA was working with a legal team to understand which entities it could work 
with (including CODESA) under the TIP sanctions. Our informant indicated that the IGA partner 
implementing field interventions would continue to participate in USAID multisectoral meetings to identify 
ways for the IGA to support activities that did not involve the Congolese government.
World Bank
The World Bank was involved in several projects in the DRC, including interventions focused on strengthening 
health systems through PBF, supporting the government to improve health reforms and administration, and 
addressing gender-based violence in South Kivu. It was also working on the development and implementation 
of a new health structure in the DRC, and was planning a large, multisectoral nutrition project to be executed 
in the Kasai region. At the central level, the World Bank was supporting the creation of a new office that would
oversee information systems. It was also leading several studies, including research examining the feasibility of 
universal health coverage, ways to ensure the retirement of health workers when they reached retirement age, 
and the mobilization of resources for the health sector.
The PBF project (PDSS) was being implemented in approximately 179 zones, providing care to at least thirty 
million people in 11 provinces (including the USAID IHP provinces of Lualaba, Haut Katanga, and Haut 
Lomami) with the aim of motivating health workers and reducing healthcare costs. Although the project 
supported all DPS offices in the 11 provinces, the degree of support was based on assistance provided by other 
partners and local needs. In the Katanga region, the project started in 2015 and was scheduled to continue until 
2022, with our informant indicating that there would likely be a five-year extension. We were told that the 
Congolese government had recently adopted a national PBF strategy guided by the World Bank approach, with 
the World Bank providing technical support to a pilot project replicating the approach in three to four health 
120 The Impact of USAID’s Integrated Health Program in the DRC
zones in Kinshasa. When asked about the sustainability of the PBF approach, our informant argued that all 
projects require regular funding and, therefore, PBF was similar to other health interventions. At the same time, 
our informant contended that PBF would only be sustainable when it could be funded and operated by the 
government.
In provinces where PBF was being implemented, the World Bank participated in a joint contract (contrat unique)
to capture financial commitments and activities of different partners at the central, DPS, and health structure 
levels, and to ensure that activities were well-coordinated and standardized. The World Bank had established 
performance frameworks with government collaborators that defined expected trimester results and associated 
costs. As part of the approach, the World Bank encouraged the government to establish agencies in charge of 
buying services (agence achat des services) in hospitals and HCs based on a defined package of services with set 
payment costs. These agencies were in charge of verifying whether reported services were provided (e.g., 
number of assisted births, vaccinations given, collaboration with local associations), and provincial 
administrators evaluated the service quality. Based on services provided, payments were supposed to be made 
every trimester according to trimester results. Our informant said that the validation of services provided 
presented many challenges. For example, external checks may not correspond with the results given by the 
health structure; many health structures were inaccessible, making a formal validation difficult; and in some 
areas, high seasonal migration altered expected service provision.
The World Bank worked with the USAID IHP predecessor project in Haut Lomani. Although our informant 
stated that PBF activities were being implemented in USAID IHP health zones in the Katanga region, he noted 
that USAID IHP had not yet started field activities. However, he was aware that USAID IHP had worked with 
DPS directors to develop PAOs. In addition, he recently attended a talk presented by the Chief of Party of 
USAID IHP during a groupe interpersonnels de santé, a group comprising donors and IPs that administer health 
services. The meeting provided information on the USAID IHP mandate and clarified his understanding of the 
USAID IHP approach.
Baseline Report 121
Qualitative Baseline Report, Health Zone of Bunkeya
Background Information
We collected data between November and December 2019 in the Bunkeya health zone situated in the Lualaba 
Province, a province established in 2015. The evaluation was conducted in the Kikobe and Kalwa HAs. Kikobe 
is a higher performing HA and Kalwa is a lower performing HA, according to child health indicators for service 
use for key childhood illnesses and vaccination coverage. In each HA, we conducted in-depth interviews with an 
IT (head nurse), a member of the CODESA (health development committee), a RECO (community health 
worker), and a village chief or a village chief representative. We also administered in-depth interviews with one 
physician and the hospital administrator at the reference hospital, and conducted a key informant interview with 
the Bunkeya health zone medical officer (MCZ). We also carried out observations of facility infrastructures (3) 
and health worker-patient interactions (27). 
The average age of in-depth interview informants was 45 years and the majority (8 of 10) were male (Table 4.1).
Both ITs had A2 level training. ITs, CODESA members, RECOs, and village chief informants had 10 years of 
schooling, on average, whereas the two physicians had completed 18 years of education. Informants had nine 
years of work experience in their roles, on average. All but two informants participated in other work, most 
frequently farming. In one HC, the health staff also worked as teachers at the local school. 
We administered focus group discussions with 12 caregivers of children under five years of age in Kikobe HA 
and eight caregivers in Kalwa HA. Discussions focused mainly on child health services and care seeking for sick 
children. 
Table 4.1. Background information collected from in-depth interviews and key informants in 
Bunkeya
Variable In-depth interviews
(10)
Key informant
(1)
Average age (years) 45 37
 Average years of education 11 18
Sex
- Male
- Female
8
2
1
N/A
Religion
- Catholic
- Protestant
4
6
1
N/A
Average years of experience in their roles 9 6
Participation in other work*
- Farming
- Teaching
- Nun
- Preacher
- Judge for the village chief
- None
6
1
1
1
1
2
1
N/A
N/A
N/A
N/A
N/A
Average number of household members 6 4
*One informant had more than one additional job.
122 The Impact of USAID’s Integrated Health Program in the DRC
Facility-Based Services
Infrastructure
The Kikobe HA is comprised of eight villages and includes one HC and one iCCM site. The HC is in the town of 
Kikobe, situated 12 km from Bunkeya, the capitol of the health zone. The Kikobe HC is a small building built in 
2008 and is owned by the Catholic Church. Staff include the IT (A2), the assistant infirmier titulaire (ITA) (A1), 
and a nurse (A3) who acts as the pharmacist. Solar panels provided by the ACCESS project around 2008 were 
not functioning and electricity was not available. The HC has a maternity made of local brick and a thatched 
roof. The HC recently used funds provided by the PDSS (the World Bank health systems development project)
to build a veranda, showers, and latrines. Informants reported that the small size of the HC forced providers to 
treat adults and children, and sick and well patients, in the same area. The Catholic Church recently requested 
that health officials vacate the building so that the Church could use it for their ongoing activities. At the time of 
the evaluation, zonal health officials, in conjunction with community members, were planning the construction 
of another HC. 
The Kalwa HA has 10 villages, with one HC, one health post. and two iCCM sites. Two of the 10 villages, 
including Kalwa, where the HC is located, are on the main road. The other villages are in the interior of the HA 
and are often inaccessible, especially during the rainy season. The HA is vast and sparsely populated. The Kalwa 
HC, which is located 55 km from Bunkeya, is a small brick building with a mud floor. Originally a house, health 
zone officials started renting the building in 2008. No renovations have been made since that date. Staff include 
the IT (A2), an ITA (A2), and two A3 staff recruited locally. Hospitalized patients receiving treatment are in the 
entrance; across from these hospital beds is a waiting area for sick patients. In 2019, the HC used PDSS funds to 
build a small annex for sick patients. That same year, community members constructed a second building, which 
is used as a storeroom and pharmacy. Community members also built a small maternity made of brick. 
The reference hospital was originally constructed in 1953 and is comprised of numerous units, including a 
separate ward for children. A generator is run in the evenings and to perform surgery, and solar panels are used 
at night to light the hospital corridors and grounds. Informants indicated that the building requires ongoing and 
significant renovations, which are financed through monthly hospital revenue and assistance from the European 
Union (EU) and PDSS. Although the hospital is meant to serve Bunkeya health zone residents, most patients 
come from outside the zone. This is due to the configuration of the health zone, which is surrounded by two 
health zones located in Haut Katanga Province, with villages in the neighboring province far from zonal 
reference hospitals. The hospital is also known for being less expensive and accepting all patients, with 
informants indicating that this reflects the approach of the Spanish nuns in charge of hospital administration.
Additional information on the facilities’ infrastructure is presented in Table 4.2.
Baseline Report 123
Table 4.2.Facility infrastructure, supplies, and medications for child health services based on 
observations in Bunkeya
Kikobe
Higher performing HA
Kalwa
Lower performing HA
Reference Hospital
Has the health center been 
renovated/construction 
added in the last five 
years?
A veranda and latrines 
were built, and a maternity 
made of brick and thatched 
roof.
Two small buildings adjacent 
to the HC were built; one 
building was constructed by 
local community members 
and one was built with PDSS 
funds.
Yes, ongoing renovations 
are made with funds from 
the EU and PDSS.
Is electricity available in the 
health center?
No, the solar panels were 
not working.
Yes, solar paneling was
working.
A generator was run in the 
evening from 18h to 23h. 
Solar panels were used to 
light corridors and 
walkways on the hospital 
grounds. 
Is there a separate area of 
the building where child 
health services are 
provided?
No, treatment for children 
and adults was provided in 
the same room.
No, all treatment was
provided in the same room.
There was a separate 
children’s ward.
Is an infant treatment table 
available?
No No Infant tables were located 
in the maternity.
Is an infant scale available?
The infant scale was not 
working.
The infant scale was not 
working.
Yes, an infant balance was
working and located in the 
maternity.
Is a salter weighing scale 
with trousers available?
Yes Yes Yes
Is a weighing scale (munie) 
available?
No There were two; one was
located in the maternity and 
the other was in the 
consultation area.
Yes
Is a height measure 
available?
Yes Yes Yes
Are growth monitoring kits 
available?
There were mid-upper arm 
circumference (MUAC), 
height measures, and 
growth monitoring forms.
There were MUAC, height 
measures, and growth 
monitoring forms.
Yes
124 The Impact of USAID’s Integrated Health Program in the DRC
Kikobe
Higher performing HA
Kalwa
Lower performing HA
Reference Hospital
Is sterilizing equipment 
available?
Yes, in the treatment 
consultation area.
Yes, one was in the maternity 
and one was in the 
consultation area.
Yes
Does the health provider 
have key instruments, such 
as a stethoscope, 
thermometer, and timer? 
A stethoscope and 
thermometer were
available, but not a timer. 
Gloves were not available. 
A stethoscope, thermometer, 
timer, and gloves were
available. 
A stethoscope, 
thermometer, timer, and 
gloves were available. 
Are essential medications 
available, such as zinc, oral 
rehydration solutions 
(ORS), amoxicillin, 
artemisinin-based 
combination therapies
(ACTs) and other malaria 
drugs?
ACT had been out of stock 
for several weeks. There were many stockouts, 
including stockouts of ACT, 
zinc, SRO. Supplies of 
amoxicillin, vitamin A, 
mebendazole, and 
metronidazole were
insufficient.
The hospital had these 
medications, but ACTs, 
mebendazole, and 
metronidazole were only 
available in small 
quantities even though the 
hospital had received a 
delivery from Chemonics
just before the 
observations.
Are treated mosquito nets 
available?
Mosquito nets have not 
been available for several 
years.
The center was out of bed
nets.
Yes, bed nets were 
available in the maternity 
for women who had 
recently delivered.
Are rapid diagnostic kits for 
malaria available?
No Yes, but they were using their 
last carton.
Six and one-half cartons 
were available. According 
to the health providers, 
they would go through this 
supply very quickly.
Are all essential 
vaccinations available?
No. Because the HC 
refrigerator was not 
working, vaccines were
stored in the Bunkeya 
BCZS.
All childhood vaccines were
available and there was a 
large stock.
All childhood vaccines 
were available in 
adequate quantities.
Is there a refrigerator which 
is functioning?
No. The refrigerator, which 
operates on solar energy,
was not working. A second 
kerosene- run refrigerator 
had not been used for 
more than five years 
because the HC cannot 
afford to buy fuel.
Yes. A solar-run refrigerator 
provided by ACCESS was
working well.
Yes, the refrigerator was 
provided by the 
Programme des 
équipement pour les 
structure sanitaire (PESS)
three to four years before
the evaluation.
Baseline Report 125
Kikobe
Higher performing HA
Kalwa
Lower performing HA
Reference Hospital
Are fee schedules posted? Yes, in both French and 
local language.
Yes, in local language. Yes, in both French and 
local language.
Are there educational 
materials, such as posters 
on the walls?
Yes, including messages 
about FP, vaccines, and 
TB. They were informative 
and esthetically pleasing. 
Yes, including messages 
about FP, vaccines, and TB. 
They were informative and 
esthetically pleasing. 
Yes, including messages 
about FP, vaccines (the 
vaccine calendar), and 
transmission of TB. 
Are there behavior change 
communication (BCC)
materials/aids for the health 
workers to use?
Yes, there were lots of flip 
charts (PCIME, FP, 
prevention of malnutrition, 
postnatal care [CPON]) 
which were in good 
condition, but covered in 
dust and clearly not being 
used. 
There were many flip charts 
(fewer than in Kikobe), but 
some appeared to be 
extremely old. Once again, 
they were covered in dust 
and clearly not used. 
No. They do not have aids 
to help convey messages. 
Health workers indicated 
that this would be useful. 
Is there evidence of 
activities to discourage 
fraud and increase 
transparency, such as a 
hotline or a complaint box?
No, we were told that a 
suggestion box had been 
hung in the past but was 
damaged by termites. 
No. It was reported that a 
carton box had been used as 
a suggestion box previously. 
The box did not last long. 
Yes, there was a 
suggestion box located in 
a more private location of 
the hospital. 
Services Offered
Health Centers
Health services consisted of treatment consultations for outpatients, 24-hour care for more severe cases, basic
surgery, and preventive care. ITs explained that patients were not officially hospitalized, but because they 
traveled long distances for care, they might be asked to be observed for several days during treatment. Neither 
HC met the minimum package of health services and personnel, with both lacking trained midwives, adequate 
numbers of trained A1 or A2 nurses, and a laboratory and lab technician. In general, diagnostic capabilities 
appeared to be basic. Both facilities had a maternity where traditional midwives assist normal deliveries, and 
both HCs provided treatment for HIV/AIDS and TB cases. Treatment consultations were available 24-hours a 
day, with consultation fees for children set at 2500 Congolese franc (FC) in Kikobe and 2000 FC in Kalwa. 
Nurses followed a 2008 treatment protocol for malaria, diarrhea, and ARI in children, which had recently been 
revised based on the introduction of new medications, such as ACT. When medications were stocked, health 
workers were supposed to give ACT for malaria, amoxicillin for ARI, and mebendazole or ORS and zinc for 
diarrhea treatment. At the time of our study, ongoing stockouts of drugs, such as ACT and zinc, prevented 
health workers from following treatment protocols. Treatment for malnutrition was not available and only 
involved counselling. Blood transfusions were provided, but a physician in the reference hospital stated that the 
blood was not tested for HIV/AIDS. This informant reported that pharmacies also gave blood transfusions 
without testing for HIV/AIDS, reporting that many children identified as HIV-positive had parents who were 
HIV-negative and attributing a rise in HIV/AIDS to blood transfusions. 
126 The Impact of USAID’s Integrated Health Program in the DRC
During treatment consultations with child caregivers, nurses claimed to provide information on preventive care, 
mentioning breastfeeding, complementary feeding, hygiene, handwashing, preparation of potable water, birth 
spacing, vaccinations, and the importance of using a mosquito net. Preventive services reported by ITs included 
prenatal care (CPN), well-baby visits (CPS), FP consultations, and vaccinations, and one IT claimed that the HC
provided CPON. Data triangulation showed that the lower performing health center did not offer CPS, although 
education sessions on child health were held with mothers on a weekly basis. Both HCs relied on water from a 
local river, which was filthy, with informants reporting that the lack of potable water presented a tremendous 
health problem in the zone. 
In the higher performing HC, a quality assessment had been carried out by the Infirmier Superviseur (IS [zonal 
nurse supervisor]) just before our study; the same assessment had not been conducted in the lower performing 
facility. In addition, the PDSS is mandated to evaluate quality of care each trimester, as part of the process of 
determining whether the HC achieved pre-specified targets.
Reference Hospital 
Sick patients were encouraged to first go to the HC (centre niche) [nested center]located next to and linked to the 
hospital. Providers in the centre niche referred serious cases to the reference hospital, which provided treatment 
for a wide range of illnesses and conditions, including emergency obstetric care. Nurses followed treatment 
protocols received more than 10 years ago for common childhood illnesses (diarrhea, ARI, malaria), which were
posted in consultation rooms. Physicians followed a therapeutic guide developed years ago by the World Health 
Organization (WHO), and more recent treatment guides specific to DRC and established by the Congolese 
government. Informants stressed that it was critical that they and other health workers follow the protocols when 
treating patients. Informants stated that the hospital lacked adequate diagnostic capabilities, forcing personnel to 
rely on government laboratories in Fungurame, a mining town 110 km from Bunkeya. Informants described the 
Fungurame laboratories as unreliable and slow. Informants also stated that the hospital was understaffed. 
Hospital clinicians said that malaria was by far the most common childhood illness, especially during the rainy 
season when families lived in makeshift huts located by their fields and did not use mosquito nets. Especially 
during the rains, informants reported that parents sought care only when the situation was urgent, such as when 
a child experienced convulsions, and suffered from anemia and required a blood transfusion. We were told that 
severe malaria cases arrived in waves and at night, often inundating hospital personnel. Hospital informants 
stated that children were frequently malnourished, and that treatment for malnutrition had not been available 
since 2018. We also learned that severe pediatric cases frequently suffered from diarrhea, vomiting, and other 
gastroenteric problems.
A full package of preventive care was offered through the centre niche linked to the hospital. The hospital also 
offered some preventive services for children, such as vaccinations, BCC, and household visits carried out by 
RECOs. Meetings with parents of hospitalized children were conducted to share information about child health. 
Hospital staff also worked with RECOs to monitor patients who had recently received hospital treatment and to 
track cases of HIV/AIDS and TB. 
Physician informants indicated that a quality assessment of hospital services had been conducted by the DPS 
several months before our study. Hospital needs included improvements in treatment capacity, diagnostic 
laboratories, and more capable personnel.
Equipment 
Equipment in the Kikobe HC was basic, with informants reporting that much of it was provided in 2010 by the 
ACCESS project. Equipment included beds for sick patients, cabinets, benches, a desk for the IT, plastic chairs, a 
cooler, and a microscope. The solar-operated refrigerator did not function, forcing providers to store vaccines in 
the BZCS; there was also a petrol-operated refrigerator, but informants reported that they could not afford to 
purchase fuel. The maternity had a delivery bed, and other beds for women pre- and post-delivery. The baby 
scale was broken, but a salter scale with trousers and a height measure were available. An adult scale was not 
Baseline Report 127
available. No bed nets were in stock. The center lacked reporting forms (including for SNIS) and official 
registers, including a maternity register. Informants said that the center needed beds, mattresses, and equipment 
for blood transfusions, and mosquito nets, maternity kits, scissors, scalpels, blouses, and a table for newborns. 
The Kalwa HC had one bed for sick patients, some cabinets, a desk for the IT, a bench for people waiting for 
treatment, a table where medications were placed during consultations, and a refrigerator run by solar panels. 
The maternity had a delivery bed, but due to the confined quarters, there was no space at the base of the bed for 
the birth attendant to stand. There were other beds in the maternity for women in labor or who had recently 
delivered. The newborn scale was broken, but a salter scale and height measure were available. Two adult scales 
were available and working. Bed nets were not available. When asked about materials needed, informants 
mostly mentioned medications. 
Both ITs reported that, since their arrival at the HCs, they had never received new equipment. When materials 
or equipment were needed, or equipment repairs were necessary, the ITs contacted the BCZS, which
subsequently informed the DPS. The BCZS administrateur gestionnaire (AG [health zone financial and 
administrative manager]), needed to give approval before repairs were made, even though costs were absorbed 
by the HC. One CODESA member from Kikobe explained,
If the refrigerator is not working, as is the case here, before calling a repairman, we must inform and get permission 
from the health zone. If the repair does not last, there is little we can do. We cannot make decisions about equipment 
in the health center because it is under the orders of the health zone. They are our superiors and we must inform 
them, and they will tell us what to do. 
Hospital informants stated that the hospital had essential materials for the treatment of childhood illnesses.
Equipment was obtained through a range of sources, including the PESS, donors, NGOs, and the Catholic 
Church, and was often provided randomly as charity and already used. For example, the hospital unexpectedly 
received a container of secondhand beds, cabinets, and hospital supplies from USAID, which were originally 
destined for the Kasai region but could not be delivered due to conflict and unrest. The hospital also purchased
secondhand equipment, such as a 1997 portable x-ray machine and microscope, from Europe. Informants were 
unable to confirm whether the hospital met basic equipment standards, reporting that basic was defined 
according to the context. Hospital needs included diagnostic equipment so that it did not need to rely on the 
laboratories in Fugarume, a computerized machine to perform bio-chemistry analyses, surgical equipment, a 
dialysis machine, and a respirator, which we were told would be lifesaving for children suffering from certain 
pathologies. Informants reported that, although the government had promised to provide a high-quality x-ray 
machine and a generator, the equipment disappeared after arriving in Kolwezi. Table 4.2 presents a list of 
equipment, supplies, and medications available in the hospital and HCs based on our observations.
Medications
The MCZ indicated that 68 medications were included in the official drug package, not including medications 
provided by the different national government programs. Informants stated that drugs provided by national 
programs, such as for HIV/AIDS and TB, were received regularly in sufficient quantities. However, ACT, 
which is known to be an effective, high quality, malaria drug, was never delivered in adequate quantities and
was not available in Congolese pharmacies. Therefore, when stockouts of ACTs occurred, which was the case at
all facilities evaluated during our study, health workers had to resort to less effective drugs or drugs that 
produced severe side effects, such as quinine or artemether. At the time of the evaluation, informants stated that 
ACTs for adults would be available soon; was not clear when the children’s dose would be delivered. 
During the data collection, informants reported stockouts of many drugs (e.g., zinc, ACT, fanzidar, paracetamol, 
malaria prophylaxis, mebendazole, ORS), which forced providers to use alternative, less quality therapeutics.
ITs indicated that the HAs had not received drugs since July 2019, four to five months before the evaluation. 
Health providers also mentioned regular shortages of testing kits for such illnesses as malaria, HIV, and syphilis, 
and for blood typing. The informants stated that if they relied solely on drugs delivered by Camelu (the company 
delivering medications from the CDR and sub-contracted by Chemonics), they would always have stockouts. 
128 The Impact of USAID’s Integrated Health Program in the DRC
Informants described Camelu drug deliveries as irregular and occurring every four months rather than the 
scheduled three months; they also said that orders were not respected, did not coincide with their needs, and 
were generally insufficient, forcing health providers to purchase medications. The MCZ added that ITs often 
made irrational decisions when ordering drugs.
There was consensus that insufficient medications and supplies, such as kits to test for malaria or to assess blood 
type, presented a tremendous obstacle to meeting population needs and providing safe and effective treatment. 
When describing a delivery received from Chemonics at the time of our evaluation, a medical doctor said,
If I show you the quantity of what we received, you will see it is disgraceful. A few products, a single grouping kit. 
One kit. During this period, when we will need to give several transfusions, the kits will last less than three days. 
That is going to help us with what? A few small cartons of products and bags for intravenous therapy. 
If we wait for products from the CDR (delivered by Camelu), we will always be out of stock. Before [during the 
predecessor IHP project] it was a bit regular, deliveries were quarterly. We could count on our orders being filled 
each quarter. We would place orders; we were sure we were going to have supplies even though our orders were 
never fully filled. Now we are supplied with products depending on the availability of Camelu. Sometimes I can't 
understand why they do certain things. I was there to collect the products yesterday, I asked myself how they can 
give such small quantities to the reference hospital. For the BCZS, we can understand, they receive everything, 
mosquito nets in large quantities, but there are, for example, liquids. They should provide according to policy. The 
health centers do not use intravenous therapy, you supply them with liquids to do what? There is a lot that we don’t 
understand. There was a large quantity of products for the BCZS. But for the hospital there was only a small 
amount. 
Health workers reported that when stockouts occurred, they contacted the BCZS to see whether the zone had the 
drug. If not, ITs traveled to Lubumbashi or Likassi where they could purchase drugs in private pharmacies 
recommended by the government to sell regulated products in bulk. Some drugs, such as paracetamol, 
mebendazole, and most antibiotics, were easy to replace, but special imported drugs, such as ACT, were not. 
Although hospital staff appeared to try to replace drugs before stockouts occurred, the ITs seemed less proactive. 
Physician-informants suggested that private pharmacies selling unregulated drugs were emerging in larger 
communities, and it was likely that health workers would resort to the purchase of these drugs. In the lower 
performing HA, where the HC was located three kms from a large community in Haut Katanga province, health 
workers provided prescriptions for medications from pharmacies in the adjacent province when stockouts 
occurred. In addition, the plethora of pharmacies selling unregulated drugs allowed community members living 
in more populated areas to self-treat before seeking care from trained providers. One hospital clinician said,
Bunkeya is full of pharmacies, health posts, all kinds of places. If it is 40, I don’t know how many, so people start 
there and when things are not going well, that’s when they come [to the hospital]. Up to 2012 or 2013, lots of 
patients we received were simple cases. A normal malaria case treated in five days, severe malaria and the person
gets better and leaves. Up to 2014, it was like this, and then pharmacies exploded. But now we see really serious 
cases. Because they [the patients] have already been everywhere. We receive serious cases and sometimes after an 
hour the patient dies. Or the patient is brought to the hospital already dead.
Focus group participants mentioned that insufficient medications and drug stockouts were a common problem 
with HC services, forcing women in Kalwa to buy drugs from local pharmacies. 
Service Utilization
Health worker informants said that the major obstacles to care seeking from formal healthcare, especially from
higher-level facilities, were economic constraints, distance, lack of or inappropriate transport for sick patients, 
and poor roads. During the rainy season, when people live in remote locations next to their agricultural fields, 
delays were especially prolonged due to the long distances to health facilities. Because residents practice
subsistence farming, they lack cash, making it difficult to pay for treatment until after the harvest. As discussed, 
the proliferation of pharmacies, especially in more populated areas, encourages community members to first seek 
care from unqualified providers, causing delays in care seeking. (It should be noted that before our evaluation, 
Baseline Report 129
which occurred before the main harvest, there was a maternal death that the MCZ attributed to a delay in 
reaching a facility. At the same time, informants reported that police request 100,000‒200,000 FC, an unofficial 
penalty, from women giving birth at home, thus coercing women to deliver in the facilities.)
During focus group discussions, female caregivers claimed to obtain treatment primarily at the HCs, explaining 
that the HCs were nearby, treatment was effective, and no other formal health services were available, with some 
adding that HC care increased the survival of their children. Some mother participants from Kikobe also stated 
that they traveled to the reference hospital, which was perceived to provide higher quality of care. However, 
several mothers expressed concern that the limited space at the facilities forced sick and well patients to mix. In 
Kikobe, several mothers highlighted the lack of laboratory facilities to diagnose illness. One participant stated,
There is no lab to find out what is bothering the child. They treat the child without examining him [diagnosing the 
problem], how will the child be cured?
Mothers stated that a primary obstacle to seeking facility care was the concern that medications were 
unavailable; other barriers mentioned included belief systems contradicting biomedical treatment, parental 
negligence, and lack of money, with mothers suggesting that health workers would not treat on credit. One 
mother stated,
People go to the local healer maybe believing that if I go to the hospital, they will not treat my child…It is money. If 
you have money you will go quickly to the center and if you don’t have money you will hesitate because you cannot 
go there with your hands empty, without money they are not going to provide treatment.
Another mother said,
It is the money. If you don't have money how can you go to go to health center? You will have to remain at home
with the disease. 
As regards traditional remedies, in the higher performing HA, facility- and community-based health workers 
reported that local healers did not exist, with informants insisting that people only sought care at the HC, a local 
pharmacy, or the iCCM site. In the lower performing HA, informants cited a preference for traditional care that 
coincided with belief systems related to witchcraft or herbal remedies as a major barrier to health service 
utilization, also noting that traditional practitioners treated on credit. These informants described the existence of 
strong beliefs in witchcraft, which often raised suspicions that somebody had cast a spell on a sick child and 
commonly guided parents to first or simultaneously seek care from traditional practitioners who were respected 
for their healing skills. A village leader said,
People are attracted to what the traditional healer says. Since we are in a village, people always think that maybe 
somebody cast bad spirits on my child and then lied by claiming others want to harm the child. It could even be your 
own brother [who wants to harm the child]. Here a traditional healer [in this case soothsayer] is someone we 
respect. Everything they say is followed to the T. When the soothsayer bans food, people obey. But the same 
prohibition given by the nurse will never be followed.
A CODESA member said,
Here witchcraft is at the forefront of people's minds, if someone gets sick, we first think that witchcraft is involved. 
When this is suspected, families take the sick child to the traditional healer first… With us the big problem is 
witchcraft, when the child gets sick, we first think that maybe it's the grandmother who wants to kill my child and 
directly, instead of going to the hospital, the parents first go to see the traditional healer, thinking maybe he can 
have a remedy for this. The hospital comes later.
Later, the same CHW shared some of his personal beliefs, stating,
They [the health facility workers] are good, they are good. But sick people who die in our health area, they are 
the ones who are possessed by bad spirits. In the hospital, they can treat the illness if it is from God. If someone is 
already bewitched in their home, someone like that cannot get better [through health center treatment].
130 The Impact of USAID’s Integrated Health Program in the DRC
Hospital informants also said that prevailing beliefs influenced care seeking from traditional healers, with people 
commonly consulting devins (healers and soothsayers who specialize in treatment related to the supernatural and 
sorcery) or using herbal therapeutics before seeking formal care, thus delaying care seeking and interfering with 
effective biomedical treatment. When talking about barriers to care seeking, one physician said,
I don’t think that it is just economics, because if someone has an economic problem, we always treat. But there are 
other factors related to culture, no, not culture, beliefs. This area is known for sorcery and things like that. There is 
even a proverb in Kisanga that says, ‘People cannot accept [put closure on] a death, unless someone is accused [of 
the death].’ Before coming here, there are people who come directly, but those who don’t come directly often go to 
the ‘banganga,’ traditional practitioner. When it doesn’t go well, they come here. Sometimes they come and get the 
diagnosis here, but the person says, no, I need to see a local practitioner because it is something spiritual, it is 
something else. Lots of patients at the hospital, a big percentage, take indigenous medicines, a lot. We talk to them; 
we even look in their bags to find the medications. The last case was terrible. We did a cesarean; they had given her 
indigenous medicine. When we opened her stomach, we found five liters of black liquid in the intestines. In another 
instance, where the woman had severe abdomen problems, we operated and found bandages that she had 
swallowed. I make a lot of noise because it is not okay. The person comes, you operate, the post evaluation is good. 
The fourth day you see the patient vomiting. These are the problems we have here. Both in children and adults. 
Another physician said that especially during the rainy season, people delay care, stating,
During this period, they only come when they are pushed by disease. For surgical pathologies, they know the 
diagnosis, but they leave the hospital, stating they cannot do it now. But after the harvest they will come back. 
There is a difference between the city and the village. Here it’s the bush, I can show you someone who came today 
with a very big tumor. He went through all the traditional healers, all the charlatans. Yesterday, a woman was 
brought to me, at the end of pregnancy, her breasts increased in volume, she just gave birth two weeks ago, or three 
weeks ago. They kept her with the traditional practitioner for a long time, she was anemic and the blood had not yet 
finished, but she died. So that is how it is in this period, it's the urgency that brings them [to the hospital].
Take all the women, take all the men, lift their shirts off and you will see scarifications everywhere. That is to say 
that they see traditional healers. It is due to pain that brings them to the hospital…But you will see people taking 
products. Last week a woman came to the hospital, she was 5 cm dilated, she was pregnant, she left and came back 
after 20 minutes to give birth. What happened, a serious tear that you cannot imagine. Why take these drugs? They 
cannot tell you that they are going to see the traditional healer. But that is what happens when they are sick, they 
go to the traditional healer first. Even if you try to discourage it. When we go to the sick rooms and search their 
bags, we find the bottles. In the maternity we hear these stories every day. Portions, concoctions.
After extensive probing, participants in both focus groups admitted that traditional therapies were widely used, 
with parents either opting to seek traditional care as a first option or after visiting a biomedical facility. Mothers 
stated that the perceived cause of the illness determined which approach was appropriate—biomedical or 
traditional. If the first treatment did not work, it was assumed that the cause was misdiagnosed, and an 
alternative treatment was needed. One mother from Kikobe said,
There is the diarrhea of God and then there is another diarrhea which is of Satan. If you take the child to the hospital 
and there is no change, you go to see the traditional healer who will give roots, which you prepare and give to the 
child and the diarrhea stops.
Caregivers indicated that traditional healers, who live near their agricultural fields during the rainy season, can 
refer to a biomedical facility if the treatment they provide was ineffective. Mothers also stipulated that local 
healers cannot provide certain biomedical care, such as blood transfusions or effective medicines for malaria.
Management and Governance
Coordination
The health zone held biannual board meetings that were presided over by the DPS director. ITs participated in 
monthly reporting comité de gestion (COGE [management committee]) meetings held in the BCZS during which 
annual operational plans and monthly activity schedules were monitored. During these meetings, each HA
Baseline Report 131
presented data based on a series of health indicators. The MCZ indicated that HA reports were complete and 
timely but contained many errors. He also mentioned that ITs lacked capacity to use the monthly results to 
inform HA activities. The BZCS also held weekly coordination meetings with office staff to monitor zonal 
activities and transfer information. 
In the higher performing HA, the CODESA members reported periodically attending the monthly zonal 
reporting sessions. In this HA, it was also mentioned that both CODESA members and RECOs participated in 
monthly HC data entry and reporting. RECOs stated that on Sundays, meetings were held with the HC nurses to 
determine weekly workplans and key health messages to deliver. CHWs also claimed to hold community 
meetings to discuss development strategies with community members. CODESA members and RECOs in the 
lower performing HA did not participate regularly in monthly reporting meetings and did not appear to attend 
HC meetings. Village chiefs claimed that they did not participate in coordination meetings, but they might be 
invited to the HC when a special guest arrived or to be briefed after the IT attended an important meeting. 
Hospital staff participated in weekly coordination meetings convened by the BCZS and involving senior 
personnel; they also attended monthly COGE meetings with ITs from each HA. In addition, they attended
meetings to review epidemiologic data and care provided to indigent populations. Other meetings may occur 
with NGO staff or the PDSS coach during periodic visits.
Informants said that coordination meetings allowed health providers to share recent information on health 
problems, treatment practices, cases studies, and lessons learned, and general work challenges. Informants 
consistently mentioned the importance of exchanging ideas and experiences, which they indicated can help 
improve work performance and serve as a motivation. Meetings also facilitated the dissemination of health￾related news beyond Bunkeya, such as health directives or problems shared by the provincial or national level.
Accountability Mechanisms
HC personnel claimed to have set up a suggestion box. In Kikobe, the IT said that the box became infested with 
termites, and in Kalwa, the box was made of cardboard and got damaged quickly. At the time of the study, both 
ITs stated that a new, more durable box made of wood was being made by a carpenter. Although the ITs 
reported that the suggestion box was designed for community members to provide feedbackabout health 
services, both nurses admitted that the box was generally empty and community members preferred to share 
feedback verbally. Kikobe informants said that when RECOs received verbal complaints, they informed the 
CODESA president and subsequently called a meeting with the IT to address the problem. Community 
members may also share complaints with the village chief; if the problem was minor, the chief tried to address it 
on his own. Otherwise, the chief informed the CHWs, who subsequently called a village meeting. Informants 
reported that CHWs were effective in resolving community issues quickly. Only if the problem was serious
would a written grievance be submitted to government officials in Bunkeya. In Kalwa, complaints were 
commonly transmitted verbally to the nurses. The health providers and CHWs used to hold bi-monthly meetings 
to discuss and address concerns raised by community members, with decisions shared with the population. 
However, these meetings were no longer held, and feedback mechanisms to address community grievances were 
not functioning. 
The reference hospital had a suggestion box that served as a mechanism to receive feedback on hospital care and 
ways to improve services. One hospital informant said,
There are always problems. The suggestion box allows us to talk to each other, to identify issues, and to revise our 
approaches.
The suggestion box was initiated by a project working with PROSANI Plus, but since the start of the PDSS, it
received less attention. The Catholic nuns working at the hospital kept the key and oversaw opening the box; the 
hospital compiled and analyzed suggestions, shared results with health personnel, and took action, as needed. 
Examples of suggestions included a recommendation to establish a cafeteria, complaints about health provider 
behaviors, or problems with the hospital environment. Although the hospital informants believed that the 
132 The Impact of USAID’s Integrated Health Program in the DRC
suggestion box served to identify and address problems, they stressed that people tended to exaggerate. Patients 
and family members also shared complaints verbally with trusted hospital staff.
Everybody agreed that a telephone line to report problems would be well received. We were told that community 
members liked to have contact with medical personnel, but did not have phones or the means to buy phone 
credit. Although both HCs were supposed to have official phones provided by the PDSS, one IT indicated that 
the phone had been stolen. 
There was agreement that accountability mechanisms were important to identify and address problems. 
However, informants stated that low literacy rates limited their use and the usefulness of a suggestion box.
Informants also expressed concern about encouraging community members to amplify problems or that 
mechanisms could be used to escalate personal conflicts. One hospital informant stated,
It's not a bad idea in principle, but you know, in our community at least since I've been here, I've come up against a 
lot of hype. Lots of hype. People accuse a lot; they can say anything. So, I don't know, maybe it’s a problem in rural 
areas, in the city I don't know…But the suggestion box is good, it helped us improve certain things, to consider 
what people think. 
A village chief said,
Some problems that occur are based on rumors. Sometimes people dramatize negative rumors, they may use a 
megaphone to diminish the reputation of another person. Where there are people, there is no shortage of conflict. 
Someone can take a conflict to another level to harm the work of the other person involved. 
Referral Systems
The health zone referral system involved different layers, starting at the community level where RECOs were 
charged with referring sick community members identified during household visits. If a sick person refused to 
follow a RECO’s recommendation to get facility treatment, health providers can visit the household. Other 
levels included iCCM sites (according to the MCZ, more than 12 existed in the health zone and were introduced 
with PROSANI Plus), health posts, and HCs, with reference hospitals providing the highest level of care. In 
instances when reference hospitals were unable to treat, patients were referred to more sophisticated hospital 
care, generally in Likasi or Lubumbashi, but often families refused due to economic constraints. Sick community 
members generally traveled by foot or bicycle to HCs and relied on motorcycles to get to the reference hospital. 
Although the zone had an ambulance, patients had to absorb the costs, which were not affordable for most. 
Moreover, during the rainy season, most HAs were inaccessible by car, making motorcycles the only option. 
Transport costs by motorcycle from the HCs to Bunkeya ranged from less than US$1 to US$20, depending on 
the distance. The MCZ considered transport for sick patients as a critical need.
Although it is preferable that patients first be assessed and, if possible, treated at HCs, the reference hospital 
accepted sick patients who went directly to the hospital, with informants indicating that these cases were often 
extremely serious. Referrals from the HA to the reference hospital were typically made by the IT and involved
patients who could not be managed in the HCs. Health workers claimed to be aware of treatment protocols and 
their treatment limitations. Patients or their family members can also request a referral. 
Referred patients should be provided with a referral slip; counter referral slips describing the patient’s condition 
and recommended treatment were provided by the hospital when patients were referred back to the HC. 
Although one IT insisted that referred patients were accompanied by a health provider, our data suggested that 
this rarely occurred. Hospital informants claimed that only one of the eight HC head nurses typically contacted
the hospital to learn about the status of referred patients. Although reference hospital doctors had received 
training on referrals, other health workers had never participated in such training, except for RECOs in Kikobe,
who reported receiving training sponsored by PROSANI. 
Hospital informants suggested that economic incentives encouraged nurses to retain sick patients at HCs and,
especially for distant and inaccessible HAs, we were told that nurses attempted to treat patients for dangerously 
Baseline Report 133
long periods, frequently only referring patients when the condition was dire. One reference hospital physician 
said, 
References are made, but the peripheral health centers refer fewer cases. They often detain the sick, who frequently 
arrive in a really bad state, and sometimes they bring them already dead.
Because community emergency funds did not exist, it was up to family members to pool resources. Some Kikobe 
informants said that the IT sometimes assisted with transport costs. Due to poverty, many people did not accept 
care from a higher level because of fear of the costs. 
Health Care Financing
HCs relied extensively on monthly revenue, with 50 percent allocated to ongoing operational costs and 50 
percent going to health personnel. The health zone was supported by the PBF program (PDSS), which is funded 
by USAID and aims to improve access to affordable healthcare. The PDSS was launched in late 2018, several 
months later than the planned July 2018 start up, when money for facility rehabilitation and construction was 
made available and initial performance validations started. Before implementation, an evaluation was carried 
out to assess patient fees and establish payment schemes. According to informants, the project categorized HAs 
according to their location and target population, and payment schemes were adjusted accordingly, but with 
input from community members. The PDSS has a long list of indicators, with corresponding payment schedules 
varying according to the HA categorization. Each trimester, third-party evaluators were supposed to validate 
performance indicators in target facilities. Informants indicated that half of the trimester payments were 
allocated for the operation of health services and the remaining funds were used to supplement health personnel 
payments. 
We were told that participation involved endless paperwork, but that the financial rewards motivated health 
workers to complete forms in a timely and quality fashion. Informants reported that some PDSS evaluators were 
unreasonably demanding, refusing to pay for certain indicators. However, informants in facilities where 
payments had been received lauded the approach, stating that it served as a tremendous motivation for health 
professionals and ensured affordable healthcare. The MCZ was also positive, mentioning that the salary 
supplement made a huge difference in work performance. Just before our study, a workshop was held in 
Kolwezi to review and adjust treatment schedules and address ongoing challenges. Subsequently, the PDSS sent 
coaches to resolve problems identified and claimed that performance validators would be more flexible in the 
future. 
With the start of the PDSS, HCs reduced consultation fees to 3500 FC for adults and 2000 FC for children in 
Kikobe, whereas in Kalwa, treatment for adults and children was decreased to 2000 FC. The majority of 
informants agreed that the fees were affordable for most residents, encouraging people from even remote areas to 
frequent the HC, with ITs reporting an increase in service utilization. In Kikobe, the HC had received two or 
three PDSS payments of around US$1,800 per trimester, whereas Kalwa had received only one payment of 
US$800. The MCZ speculated that Kalwa was not receiving regular payment due to its low performance score, 
which he attributed to the use of unqualified staff (non-nurses) and poor community outreach. Another factor 
was that patients included residents from the neighboring health zone located outside Lualaba province. 
ITs stated that the PDSS had failed to adhere to the planned schedule of performance validations and payments 
and was chronically behind schedule. Ongoing medicine stockouts forced HCs to purchase medicines at higher 
costs and, compounded with the reduced patient fees, impacted the benefits obtained through the PDSS 
approach. Nevertheless, those receiving PDSS payments were positive about the financial benefits of the 
approach. The MCZ confirmed that the start has been fraught with challenges, noting that two Bunkeya HAs 
had not yet received their trimester assistance, that Kalwa had been evaluated and received assistance only one 
time, and that the BCZS had not received two PDSS payments.
In December 2018, the reference hospital received the first PDSS payment for infrastructure rehabilitation, and 
in the spring 2019, the hospital started receiving financial support based on PDSS indicators. Since then, PDSS 
134 The Impact of USAID’s Integrated Health Program in the DRC
validation of indicators and subsequent payments were made on a trimester basis, with payments to the hospital 
between US$16,000 and US$18,000. Under the PDSS, fees for five days of hospital care were 11,000 FC for 
children and 16,000 FC for adults, which represented a significant reduction in patient costs. Fees included costs 
for the bed, health services, and consultations, and all medications, except for intravenous therapy, injections,
and transfusions, and antibiotics for certain illnesses requiring high doses, such as meningitis. Our informants 
reported that some payment schemes were poorly calibrated, such as US$.50 coverage for CPN, which was 
meant to cover various tests (e.g., for HIV, syphilis, malaria), certain medications, personnel and treatment costs, 
and enrollment forms. Hospital informants also mentioned that for the approach to work, deliveries of 
medications and tests provided by other IPs must be timely and adequate, with stockouts avoided. A benefit 
mentioned was that the PDSS targets encouraged facilities to monitor certain previously neglected diseases, with 
hospital workers referring to active surveillance and follow up of TB patients. 
The PDSS had a set criterion for indigent community members (e.g., people who are blind, handicapped, 
homeless, widowed, and old). Neighborhood chiefs and RECOs were responsible for establishing lists of 
indigent community members, who received free treatment at HCs and paid a reduced percentage (20%‒40%) 
for hospital care. In Kikobe, the list included nine people. 
Both ITs reported treating on credit as part of the strategy to encourage sick patients to seek rapid care. However, 
other informants suggested that ITs were reluctant to accept credit from people who were traveling from distant 
areas and were unfamiliar. In Kikobe, we were told that family members of patients who cannot afford
treatment can sign a contract and pay later or work for the HC in exchange for treatment costs. Although no 
community emergency funds existed, family members generally pooled resources to pay for the treatment of sick 
relatives; however, informants added that many poor people did not seek care due to concerns about the costs.
Hospital informants emphasized that patients seeking care in the reference hospital were never refused due to 
lack of money, and that only transfusions must be paid up front and in full, with allowances for other payments 
made incrementally and after treatment. We were told that some patients fled the hospital in the night without 
paying for mandatory costs at the time of discharge or before an agreement was made about the payment 
schedule. 
Health mutuelles (community-based insurance schemes) were not available, with some informants noting that 
the underlying concept—paying for something before it happens—was in opposition to cultural norms and might 
even be viewed as an invitation to bad luck and poor health, and that they would not work in the Bunkeya 
context. Mining companies used a voucher system to cover healthcare costs for employees and their families, 
with payments made at the end of each month. No other financing initiatives were in place.
Although the MCZ praised the notion of decentralization and the national health strategy, he complained that 
the zone lacked adequate financial support to operationalize workplans and activities. He said,
The needs are enormous, really huge, and all we get is partial support. The needs in terms of infrastructure, we have 
seen that the government is reviewing how to support infrastructures, but there are so many infrastructures. You have 
seen health centers made of local bricks. There are needs in terms of equipment. It’s appalling. If you go to the field, 
you will see that equipment needs are urgent. There is a desperate need for essential and generic drugs. 
Facility-Based Human Resources
The MCZ was transferred to Bunkeya in 2019, eight months before the evaluation; there were also an AG; a
zonal nurse supervisor (Infirmier Superviseur [IS]); nurse supervisors for nutrition, HIV/AIDS, and TB; a 
pharmacist, and an AC (health zone officer in charge of community activities), although this person worked in 
the hospital fulltime. Both the MCZ and IS lived in Kolwezi, which was more than three and one-half hours 
away by vehicle, and informants reported that they only visited Bunkeya to participate in special meetings or 
activities. During our 12-day stay in Bunkeya, the MCZ appeared only on the last day of our evaluation, due to a 
measles vaccination campaign. The IS was absent the entire period. 
Baseline Report 135
In each HA, there was an IT (both A2 level) and an ITA (one A1 and one A2 level). Both HCs had A3 staff 
providing treatment, but they were locally recruited and had received only informal training. The MCZ indicated 
that government regulations now stipulated that A3 were not qualified to provide treatment. He also said that 
recruitment of new staff was extremely difficult, with the DPS unable to identify nursing staff to work in rural 
HAs. After initiating work, nurses typically worked in one health zone, rotating from one HA to another. 
The MCZ mentioned that individual performance evaluations were rare, and that action was not taken if health 
personnel performed poorly. The governor was the only one who could fire government workers, which was
never done. The MCZ also discussed the rampant practice of hiring family members, which was carried out by 
people in powerful positions, indicating that this practice also undermined performance in the health sector and 
in other sectors.
Training
Informants reported a recent and significant decrease in training, which appeared to coincide with the departure 
of the predecessor PROSANI project. Topics covered during training sessions formerly offered by PROSANI 
included HIV/AIDS treatment, reproductive health, protection of mothers and children, health worker 
participation in community healthcare, FP, infant and child feeding (for CHWs), and gender. Training in 2019 
included a regional workshop on the PDSS attended by hospital clinicians, and a provincial-level training on 
HIV/AIDS offered to ITs. CODESA members and RECOs had not participated in any training for more than 
three years. The MCZ called for the urgent need to strengthen the capacity of health personnel providing 
primary healthcare.
Supervision
ITs stated that supervision of the HCs was frequent (two to three times a month in Kalwa)—although no set 
schedule was mentioned—and was conducted by the MCZ, the provincial health inspector and the AG. The 
MCZ mentioned that the lack of transport funds prevented supervision, indicating that the health zone carried
out 15 percent to 16 percent of the scheduled supervision visits. The DPS also conducted periodic visits to 
Kikobe, located on the main road to Bunkeya. Other supervision visits took place, but HA informants could not 
identify the people involved. 
Informants indicated that BCZS staff followed specific objectives and that supervision entailed a review of HC
registers, forms, and records. At the end of the supervision visit, which typically took several hours, supervisors 
entered results and made recommendations in a notebook. Supervision was generally limited to a review of 
services offered at the HCs, with little focus on community activities and CHWs. Informants reported that 
supervisors never visited communities or households or talked to community members, although PDSS 
evaluations involved interviews with community members. The MCZ mentioned that supervisors were not 
adequately trained, mentioning limited knowledge in certain topics, such as pharmaceutical management and 
primary healthcare. The MCZ said,
Primary healthcare has been lacking since 2007 or 2008. There are people who have not been trained for more than
ten years. When we send a supervisor to support the facilities and to improve primary healthcare, he too does not 
know what to do ... [laugh]. Even routine vaccination, the last training in Lualaba dates to 2013. So, you can
understand that in terms of quality, what the supervisors do, leaves something to be desired. This is why I am trying
to organize training, a briefing for my agents on supervision… We have a lot of people in the health zone who are not 
capable. 
Supervision of the reference hospital was frequent and carried out by the different technical programs 
(HIV/AIDS, TB, malaria) of the DPS and the inspection office. Representatives of the Catholic Church’s Bureau 
Diocésain d'Œuvres Médicales (Diocesan Office for Medical Affairs or Activities) conducted supervision less 
frequently. Hospital workers said that coordination was poor, with technical program staff often descending on 
the hospital at one time, and that this can be followed by long periods devoid of supervision. 
136 The Impact of USAID’s Integrated Health Program in the DRC
The MCZ was positive about the role the office of inspection played ensuring that health regulations were
followed. However, he emphasized that its work was hampered by underfunding, preventing inspection workers 
from carrying out regulatory supervision as scheduled. 
Information Available
The findings showed that ongoing access to health and medical information was extremely limited. At the HA 
level, reference books and other written material were not available. ITs reported receiving health-related 
information through the radio or telephone, and from feedback provided by supervisors. RECOs and CODESA 
members stated that training was their primary source of information, with virtually no mention of coaching by 
the IT. They may also get information during HC meetings; however, in the lower performing HC, their 
participation was limited. CODESA members and RECOs appeared uninformed about the purpose of meetings 
in the BCZS or the training that ITs had received, suggesting that the ITs shared little or no information. One 
village chief complained that the head nurse failed to report to him and the general population about special 
activities, such as training.
The reference hospital did not have Internet access, and although the BCZS had a modem and was supposed to 
receive monthly Internet credit, hospital staff did not use the BCZS system. An association of doctors had
recently been established to share case studies and other medical information through the Internet, but the lack 
of Internet at the hospital made it virtually impossible to participate. The hospital had a small library with 
dictionaries and electronic manuals. 
Hospital informants reported that research on numerous tropical diseases had been conducted in conjunction 
with universities, mentioning studies on trypanosomiasis, filariasis, and schistosomiases, but no studies were 
done at the HA level. In general, informants viewed research, evaluation, and supervision as valuable methods 
to increase knowledge and improve their work capabilities. Informants uniformly expressed a need and desire for 
regular access to updated information.
Health Provider Attitudes
We administered a series of questions about health worker attitudes and whether provider behaviors changed 
according to the socioeconomic background, ethnic background, age, sex, or health condition of the patient, 
especially if the patient had a condition that could evoke stigma, such as HIV/AIDS, TB, adolescent pregnancy, 
or fistula. Informants working in HAs categorically stated that facility-based health providers were welcoming, 
sensitive to patient needs, and treated all patients with respect, never showing discrimination toward patients, 
with some adding that free care was provided to indigent community members. Some informants referred to 
specific cases when health workers demonstrated compassion by paying for healthcare, providing food, or caring 
for community members with special needs. Several informants admitted that negative interactions occasionally 
arose, but attributed these instances to patients who lacked respect or who disregarded HC protocols. Both ITs 
stressed that it was in the best interests of HC staff to maintain good relations with community members, 
emphasizing that the aim was to increase the use of the HC and revenue. The Kikobe IT said,
Here in the village, if you display inappropriate behavior towards parents [of sick children], you risk that these 
parents will no longer use the health center. You must know how to collaborate with the community. If not, the 
community will run away from us. The payment that we receive here in the center, 50 percent is for operations and 
the other half goes to the health agents. If community members don't use the facility, we won't receive that anymore.
The RECO in Kalwa said,
Bad behavior is not good. It decreases the number of people. But good behavior attracts people and encourages 
patients to follow care. 
Informants said that community members often first communicated complaints of inappropriate behavior to 
CHWs. Subsequently, a meeting was held with the CHWs and health staff to discuss the complaint and identify 
needed corrections. Although these meetings were held on an as needed basis in Kikobe, we learned that they 
Baseline Report 137
had been discontinued in Kalwa. Examples of inappropriate behavior in Kikobe included prioritizing family 
members to receive treatment quickly or refusing to treat on credit, especially people coming from far away. In 
Kalwa, CHWs reported that staff sometimes charged patients additional fees beyond the official schedule. In 
Kalwa, birth attendants had previously been accused of using harsh treatment while attending mothers during 
childbirth, which the IT claimed had been addressed. None of our informants had ever participated in training 
related to health worker behavior. 
Hospital informants stated that staff were respectful and highly sensitive to the needs of the population, 
emphasizing that the influence of the Spanish nuns bred compassion to ensure that health services were
accessible to all and that patients were treated with respect, notwithstanding their background. We were told that 
the nuns took special measures, such as waiving or covering payments community members could not afford. 
Although informants admitted that there were occasional negative interactions, they stated that transgressions 
were quickly addressed. The hospital routinely conducted individual performance evaluations, which entailed an 
examination of interpersonal interactions. Staff also held regular meetings at which negative interactions and 
appropriate corrections were discussed and addressed directly.
Our observations of health worker-caregiver interactions confirmed that facility-based providers were generally 
respectful and empathetic. An exception included an interaction between a doctor and a 14-year-old mother 
seeking care for her infant, during which the provider conveyed distain toward the young mother. Focus group 
participants agreed that the health workers were welcoming and followed appropriate behavior, unless the 
patient was unable to pay, as several Kikobe mothers mentioned.
Health Worker Motivation
HA informants routinely indicated that health workers were primarily motivated by monetary compensation. 
None of the HC workers received a government salary, with all relying almost exclusively on monthly revenue, 
and more recently, PDSS supplements. The Kikobe IT said that monthly revenue was about US$480, with half 
allocated to salaries. In Kalwa, monthly revenue was from US$300 to US$425, with the IT claiming to use only 
20 percent for healthcare worker salaries and five percent for CHW payments. One informant stressed the 
importance of regular drug supplies, highlighting that healthcare workers can only provide treatment and 
generate revenue when medications were available. As indicated, the Kikobe HC staff received additional funds 
through the PDSS, and health workers also received US$15 to US$20 during periodic vaccination campaigns,
and per diem when they participated in training. The MCZ reported that only eight percent of the zonal health 
workers received a government bonus, referred to as a prime.
Most hospital staff were not on the government payroll, nor did they receive a government bonus. Only two of 
the four hospital physicians obtained a government salary and a prime. Bonuses were paid in FC, which was 
experiencing rapid inflation. At the time of the study, physicians getting a bonus received about US$700, 
whereas nursing staff were getting less than US$100. Hospital staff were also provided support from monthly 
hospital revenue, which was US$700 for physicians and US$400 for nurses. In addition, the PDSS was 
supplementing health worker payments, adding from US$300 to US$500 to the nurse’s pay each trimester. Other 
benefits included free hospital care provided to hospital staff, their spouses, and their children up to age 12, with 
healthcare benefits limited to the first wife and her children. The hospital also supported education for one child 
in primary or secondary school. 
It should be noted that in 2018 and 2019, the Governor of Lualaba instituted a special bonus for government 
health workers each trimester, with an extra amount given to personnel working in rural areas. The Governor 
provided the bonus three or four times; our informants said that it was around US$50 to US$150 for physicians 
and US$20 to US$45 for nursing staff. At the time of the evaluation, this bonus had not been provided for more 
than four to five months. 
Clinician informants uniformly expressed discontent about the poor compensation but stated that helping the 
population provided satisfaction. Knowledge gained through training increased performance and motivation. 
When asked about other forms of motivation, such as scholarships or transfers to urban centers, HA informants 
138 The Impact of USAID’s Integrated Health Program in the DRC
indicated that these did not exist, suggesting that there were no opportunities to advance. Although hospital 
workers were aware of scholarships for advanced education, such as a Master’s in Public Health, they 
complained that a fair selection criterion was not followed. Informants recommended that the best way to 
improve health worker motivation was for the government to pay salaries. One physician informant stated,
It’s really good to be in our profession, which is noble, but we also need to satisfy our needs. There are certain needs 
that we cannot do without. Some of my friends from medical school went to other countries, they are recognized for 
their work, they have bought vehicles and some built houses. Transport is a need, it is not a luxury, communication 
is a need, and it is not a luxury. These are among the needs of doctors. If we must steal to get a vehicle, then that is a 
shame. I don't know what the government is thinking! Imagine, a doctor at my age, I have spent how many years in 
medicine? Twelve years and I haven’t yet built a house, I do not have a vehicle. After how many years? A doctor! It 
does not make sense. There are those who went to Zambia. The first month they already had a vehicle loan. After 
two years they started building a house. I will be satisfied when my needs are satisfied. It's very complicated, very, 
very complicated! I can’t be dissatisfied, I know it’s good, I am very happy when I see someone who was sick in the 
morning and gets better, I am very happy. But when I see that from year to year, I cannot make investments, you 
speak only in terms of public health, in terms of hospital treatment. Work without savings, without investment is 
zero! It is not just the doctors, I’m speaking on behalf of all the staff. Everybody is worn out.
This informant pointed out that doctors in urban centers had opportunities to work in several hospitals 
simultaneously and could increase their earnings, whereas in rural settings, clinicians did not have such
opportunities. 
Health Workers’ Perceptions of Health Service Quality
HA informants generally praised the quality of health services and the work of personnel, reporting that many 
people, even those from outside the zone, frequented the centers and that most patients recovered from illness. 
Obstacles to providing care included insufficient medications and the fact that the HCs were small, did not meet 
HC norms, and could not appropriately accommodate patients, with some deploring the mixing of males and 
females and adults and children. Lack of basic supplies and materials (beds, registers, mattresses, mosquito nets, 
etc.) was also cited as a limitation, as was the fact that health facilities did not offer transport for referrals. Both 
ITs stated that staff needed more training, but were unable to specify on what. The Kalwa IT mentioned that he 
worked with two A3 workers who had limited capacity and that the HC needed more qualified staff. 
Hospital respondents reported that deficits in laboratory and operating room equipment prevented them from 
offering critical services and forced personnel to continually seek outside funds. One hospital clinician 
emphasized that many hospitalized children were acutely malnourished, making it difficult for children to 
respond well to medical care, and that the hospital lacked supplies to treat malnourishment. Another obstacle 
related to the distances people had to travel over difficult terrain, especially during the rainy season, often 
delaying care seeking and causing patients to arrive when they were in a critical state. The widespread use of 
traditional remedies was also mentioned and that it interfered with effective biomedical treatment.
Direct Observations (of Treatment)
Direct observations of parents of sick children seeking healthcare showed that the waiting time to see a health 
provider was minimal. In the Kikobe and Kalwa HCs, parents and sick children waited in an area with other 
sick patients and where patients were being treated. In Kikobe, patients also waited on the veranda, with many 
forced to stand due to the lack of seating. In the hospital, patients sat in the corridor outside the consultation 
area, where benches and chairs were available. We did not observe triage at any of the facilities. Fee schedules 
were posted in the local language, and in Kikobe and at the reference hospital, also in French. Other information 
about the waiting area is available in Table 4.3.
Baseline Report 139
Table 4.3. Results from observations of health provider-client interactions
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
Average age of 
providers observed
37 26 36
Title A1, A2, A3 A2, A3 A1, A2 (2), physician
Average number of 
years working at the 
facility
2 5 5
Training received on 
childhood illnesses 
post formal 
education
2014, malaria (1)
2018, diarrhea (1)
None (1)
2014, malaria (1)
None (1)
2016, measles, polio, yellow 
fever, tetanus (1)
2017, IRA, diarrhea, malaria (1)
None (2)
Waiting area and triage
At the hour that 
treatment services 
opened, were 
caregivers waiting to 
see the health 
worker?
The HC was open 24 hours a 
day and accepts patients at 
any time.
The HC was open 24 hours a 
day and accepts patients at 
any time.
The hospital received patients 
24 hours a day.
Is there a designated 
waiting area for 
caregivers and sick 
children?
No. Patients waited in a room 
where sick patients were
hospitalized or on the veranda. 
Both had benches for seating. 
No. Patients waited in a small 
room where sick patients were
hospitalized or in the IT’s 
office.
Yes, patients waited in the 
corridor outside the consultation 
area, where benches and 
chairs were available. 
Was this area 
separate from the 
area where well 
baby services are 
carried out?
CPS was held in a hangar near 
the health center, which was
small and could not
accommodate all CPS 
participants. 
CPS was carried out in a 
hangar in the HC compound. 
At the time of the evaluation, 
CPS had not been carried out 
for several months. 
CPS was held in the HC next to 
the hospital. 
Were there seats 
available and were 
there enough seats 
for all caregivers and 
patients?
No, there were only three 
benches, which could not
accommodate everybody, with 
many caregivers having to 
stand. 
No, there was only one bench 
that seated four people. Others 
had to stand.
Yes, there were adequate 
plastic chairs and benches 
outside the consultation area. 
Was triage carried 
out to ensure that 
more serious cases 
were examined first?
Not generally, but in one 
instance, we observed that a 
baby with a high fever was 
examined before others who 
had arrived earlier. Otherwise, 
No, health workers saw
patients according to the order 
in which they arrived.
Our observers did not see any 
triage taking place, with 
patients seen in the order in 
which they arrived. However, 
triage may have been done 
140 The Impact of USAID’s Integrated Health Program in the DRC
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
patients were seen in the order 
that they arrived. 
when patients first entered the 
hospital. 
Did caregivers have 
to wait more than 15 
minutes before the 
child was seen for 
treatment?
No, health workers were
available to see patients 
quickly. 
No, health workers were
always present and if many 
people were waiting, another 
worker would assist with 
consultations.
No, patients were seen quickly 
after they arrived. 
Was the waiting area 
clean and orderly?
The veranda at the entrance 
was extremely active. It was 
generally dirt, with food and 
paper on the ground. 
Yes, the waiting area was 
clean.
Yes, the waiting area was clean 
and orderly. 
Were there 
educational 
materials, such as 
posters on the walls 
of the waiting area?
Posters on handwashing and a 
calendar for vaccinations were 
posted, as were the 
consultation fees.
Some education materials 
were posted in the treatment 
area, which also served as the 
waiting area. 
Yes, there was a poster on 
vaccinations in the waiting area. 
Were sick children 
(other than those 
who were seen 
earlier due to the 
seriousness of their 
condition) seen in 
the order that they 
arrived at the health 
center?
They generally used a number 
system to follow the order of 
arrival, although one day 
during our observations,
numbers were not used. Some 
parents complained that the 
order was not always followed. 
No system was in place to 
ensure that patients were seen 
according to the order in which 
they arrived. One father of a 
child that others referred to as 
“commandant” insisted to be 
seen before other children who 
had arrived earlier. 
Caregivers were supposed to 
follow an order based on when 
patients arrived. However, there 
was no way that this system 
was being formally 
implemented. 
Were any 
caregivers/children 
sent away without 
being treated?
No, all children were seen. No, all children were seen. 
All children were seen, even 
children of patients who did not 
have money. 
Health Provider Interactions with the Caregiver and Child
Did the health worker 
greet the caregiver?
Yes, all providers greeted the 
caregivers.
The ITA greeted the 
caregivers, but the A3 provider 
did not. 
The three nurses all greeted the 
caregivers, but the doctor did 
not. 
Did the health worker 
ask for the name of 
the child?
Yes, the health workers asked 
for the child’s name when 
completing the patient form.
Yes, the health workers asked 
for the child’s name when 
completing the patient form.
Yes, the health workers asked 
for the child’s name when
completing the patient form.
Did the health worker 
ask questions about
the history of the 
illness, including 
when it started and 
In six of seven cases In two of three cases
In two of four cases, the health 
provider only asked when the 
illness started, but did not ask 
Baseline Report 141
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
the signs and 
symptoms?
other questions about initial 
signs and symptoms. 
Did the health 
workers ask 
questions about the 
child’s eating 
behaviors?
In four of seven cases; 
however, in cases where 
questions were asked, 
responses were minimal, with 
little additional probing.
In two of three cases
No questions were asked about 
the child’s eating behaviors.
Did the health worker 
ask questions about
the presence of fever 
and the duration?
Yes, in all seven cases Yes, in all three cases Yes, in all four cases 
Did the health worker 
ask questions about
the presence of 
cough and the 
duration?
Yes, in all seven cases In two of three cases Yes, in all four cases 
Did the health worker 
ask questions about
the presence of 
diarrhea, its 
frequency and 
duration, and
whether there was
mucus or blood in 
the stool?
In six of seven cases Yes, in all three cases
In three of four cases
Did the health worker 
ask questions about 
the treatment given 
before bringing the 
child to the health 
facility?
In five of seven cases Only in one of three cases In two of four cases
Did the health worker 
determine the age of 
the child?
Yes, in all seven cases Yes, in all three cases In three of four cases
Did the health worker 
determine the weight 
of the child?
Yes, all seven children were 
weighed.
Yes, all three children were 
weighed.
Yes, all four children were 
weighed.
Did the health worker 
physically examine 
the child?
Yes, in all seven cases, the 
children was examined.
In two of three cases, the 
children were examined.
Yes, in all four cases, the 
children were examined.
142 The Impact of USAID’s Integrated Health Program in the DRC
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
Did the health worker 
follow a treatment 
protocol when 
diagnosing the 
illness and providing 
treatment 
recommendations?
In, four of seven cases a 
protocol was followed.
A treatment protocol was never 
followed.
In two of four cases a protocol 
was followed.
Did the health worker 
explain the 
diagnosis?
In three of seven cases the 
diagnosis was explained.
Yes in all three cases Yes, in all four cases 
Did the health worker 
explain the treatment 
regimen?
In two of seven cases the 
treatment regimen was 
explained.
In one of three cases the 
treatment regimen was 
explained.
Yes, in all four cases
Did the health worker 
provide medication?
In four of seven cases 
medication was provided. In 
the other cases, a syringe was 
provided and the mother was 
asked to return later in the day.
None of the children received 
medication; in one case, it was 
a follow-up visit and the mother 
already had medication.
In only one of four cases did the 
health provider give medication.
In the case of 
diarrhea, did the 
health worker 
provide ORS 
sachets and zinc 
tablets? 
Only in one of three diarrhea 
cases; the other children did 
not have diarrhea.
N/A N/A
Did the health worker 
provide counseling 
on feeding the young 
child?
Yes, in all seven cases 
counseling was provided.
In one of three cases
counseling was provided; in 
this case the child suffered 
from severe malnutrition.
In one of four cases counseling 
was provided.
Did the health worker 
request that the 
caregiver return to 
the health facility 
immediately if illness 
signs worsened?
In three of seven cases In one of three cases All children were under 
observation in the hospital. 
Did the health worker 
ask questions to 
confirm that the 
caregiver understood 
the diagnosis?
In two of seven cases In one of three cases In three of four cases 
Baseline Report 143
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
Did the health worker 
ask questions to 
confirm that the 
caregiver understood 
home treatment?
In two of seven cases No, in none of the cases did 
the health worker confirm that 
the caregiver understood home 
treatment.
In one case; the other children 
were being treated and 
observed in the hospital.
Did the health worker 
ask the caregiver 
whether s/he had 
any additional 
questions?
In one of seven cases No, in none of the cases
No, in none of the cases 
Did the caregiver ask 
the health provider 
any questions?
Three of seven caregivers 
asked questions about the 
treatment.
One of three caregivers asked 
questions about the treatment.
One of four caregivers asked 
questions about the treatment.
Did the caregiver 
appear to 
understand the 
information provided 
by the health 
worker?
Yes, in all cases. In two cases,
the health worker asked 
whether the caregiver 
understood.
Yes, in all three cases
All caregivers were asked 
whether they understood and 
responded affirmatively.
Did the health 
provider request that 
the caregiver bring 
the child back for a 
follow-up visit?
In six of seven cases, the 
health worker requested that 
the caregiver return for a 
follow-up visit.
No, in none of the cases Only in one case, where the 
child was not hospitalized and 
was residing at home.
Was the session 
interactive?
In three of seven cases the 
session was described as 
interactive. In the other cases, 
the health worker spoke to the 
caregiver and the caregiver 
listened.
In all cases the caregiver 
mostly listened.
In three of four cases the 
session was described as 
interactive.
Was the health 
worker respectful 
toward the caregiver 
and the child?
Yes, in all seven cases the 
health worker was described 
as respectful.
Yes, in all three cases the 
health provider was polite and 
respectful.
In three of four cases the health 
worker was described as 
respectful. In the final case, the 
doctor was judgmental, asking 
144 The Impact of USAID’s Integrated Health Program in the DRC
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
the 14-year-old mother why she 
had a child so young.
Was the health 
worker nice when 
interacting with the 
caregiver?*
In five of six cases the health 
worker was described as kind; 
in one case the health worker 
expressed disapproval that the 
child was not wearing 
underwear.
Yes, in all cases the health 
worker exhibited kindness.
Again, in one instance the 
health worker (doctor) 
expressed disapproval toward a 
teenage mother.
Did the caregiver 
appear to be happy 
with the 
consultation?
In five of six cases the 
caregivers appeared to be 
happy with the consultation. In 
one case the mother was 
anxious about her child’s 
health and apparently was not 
satisfied with the consultation.
Two mothers appeared to be 
happy with the consultation; 
one mother appeared to be 
unhappy and extremely 
worried about her child.
In two cases the caregivers 
appeared to be happy, 
including one family who did 
not have money but the child 
was treated anyway. The 
teenage mother was not happy. 
In addition, parents who were 
told that their child needed a 
transfusiontransfusion were not 
happy. 
Was the consultation 
carried out in a 
setting where privacy 
was maintained?
During the consultation, people 
were talking to the health 
provider through an open 
window. The consultation area 
is curtained off and other 
people were entering the area 
during the consultation.
In two cases the consultation 
took place in the area where 
patients were hospitalized and 
in the presence of other 
parents and sick children. In 
addition, people in the health 
center courtyard peered 
through an open window 
during the consultation. In the 
third case, the consultation 
was carried out in the ITs office 
and in privacy. 
Yes, only the health provider, 
caregiver, and child were 
present in all cases.
Was the consultation 
carried out in a clean 
environment?
In three of six cases the 
consultation room was 
described as unclean and 
disorderly. The space where 
consultations were conducted 
was small and difficult to keep 
orderly.
In two cases the environment 
was described as dirty and 
disorderly. For the consultation 
carried out in the IT’s office, 
the environment was described 
as clean. 
The consultation room was 
described as clean and orderly. 
Was the consultation 
carried out in a quiet 
environment?
No, noise from outside the HC 
was coming through the open 
window (people were even 
asking the nurse questions 
during the consultations). 
There was also noise coming 
No, there was lots of noise and 
it was often difficult for the 
caregiver to hear the nurse.
In three cases the consultation 
was carried out in a quiet 
environment. In the final 
instance, there was a lot of 
Baseline Report 145
Kikobe: Higher performing 
HA
3 providers; 7 interactions 
observed
Kalwa: Lower performing HA
2 providers; 3 interactions 
observed
Reference Hospital
4 providers; 4 interactions 
observed
from inside the HC. In three of 
six cases, the nurse was 
playing the radio during 
consultations.
noise coming from outside the 
consultation room. 
How much was paid 
for the consultation?
Each caregiver paid 2000 FC Each caregiver paid 2000 FC In two instances, the family paid 
2000 FC. In one case, the 
family did not have any money 
but agreed to pay later. No data 
were collected on the final 
case.
Providers greeted all caregivers and always asked for the child’s name. Most providers collected background 
information about the inception of the illness and signs and symptoms, although information on feeding 
practices was generally not collected, or when collected, was limited. All providers asked about fever, and most 
inquired about cough and diarrhea. All providers determined the age and weight of the child; only one 
healthcare worker failed to carry out a physical examination. The observations also identified numerous 
deficiencies, notably that many health providers failed to: ask questions about prior treatment; follow a treatment 
protocol; explain the recommended treatment regimen; request that the caregiver return to the facility if signs of 
illness worsened; provide counseling on child feeding; and ask the caregiver whether she understood the 
diagnosis and home treatment or if she had any questions. In Kalwa, health workers did not recommend a 
follow-up visit. Consultations in the HCs were generally not interactive, with most caregivers only participating 
when asked a question. All caregivers seemed to understand the information provided and most appeared to be 
satisfied with the consultation. The few exceptions included caregivers who were anxious about their child’s 
health or the prescribed treatment, and in one instance, a teenage mother who was chastised by the health 
provider. 
Privacy was not maintained during consultations in the HCs. Research assistants commonly described the 
consultation room as unclean, disorderly, and noisy, with health workers in Kikobe listening to the radio during 
consultations. By contrast, consultations in the reference hospital were done in a private, clean, and generally 
quiet setting. More information on health worker-caregiver interactions and the consultation environment is 
presented in Table 4.3.
Community Health Services
Infrastructure 
Health Areas
According to informants, routine services involved sensitization on health problems and associated prevention 
and treatment, which were carried out during household visits and community discussions. Household visits 
were made to assess the health of community members, and to identify and refer sick patients to facilities
especially children. Other community activities included stratégies avancées—outreach involving well baby 
consultations and vaccinations, which were supposed to be carried out one to two times a month in HA villages. 
Informants also mentioned vaccination campaigns and mosquito net distribution. Radio programs conveying 
health-related messages by reference hospital health workers were transmitted regularly and designed to 
146 The Impact of USAID’s Integrated Health Program in the DRC
supplement the community approaches. Religious leaders and CHWs shared health messages during church 
services.
Community health workers included CODESA members and RECOs, who respondents generally described as 
having similar, interchangeable functions. Critical roles included providing oversight of the management of 
essential medications, interpersonal relations with patients, and the functioning of the HC. CHWs were 
responsible for sharing complaints submitted by community members about health treatment or personnel, and 
to work with facility-based health workers to resolve allegations raised by community members. Although 
CHWs were supposed to engage in regular community-based interventions, our data showed that there was no 
set schedule of activities at the HA level.
Informants reported that facility nurses also engaged in community activities, such as stratégies avancées, 
community discussions, and vaccination campaigns. Both ITs claimed to conduct household visits (especially 
when a sick patient refused to go to the HC and needed additional persuasion), but other informants denied that 
these visits occurred. In both study HAs, ITs reported holding weekly sessions to share health-related messages 
with community members and HC patients and caregivers. The HCs, especially in the higher performing HA, 
had stacks of flip charts covering a variety of topics (e.g., prevention and treatment of childhood illnesses, FP, 
sexual behavior, and HIV), which they claimed to use when administering health education sessions. However, 
the flip charts were covered in dust and were clearly not being used. Although CHWs in the higher performing 
HA reported receiving flip charts to convey messages, they stated that these materials were torn and no longer 
useable. CHWs in the lower performing HA did not have official educational aids; rather, they used pieces of 
paper, which had photos of children, to convey messages on such topics as bed net use and hygiene. There was 
consensus that messages and visual aids, all developed in Kinshasa, had not been changed for many years. 
Informants expressed concern that messaging lacked innovation and failed to stimulate the adoption of 
improved behaviors. Informants had never received information through text messaging. 
CHWs and health workers disseminated health messages during discussion sessions attached to CPN and CPS 
sessions, although at the time of the evaluation, CPS had not been offered in the lower performing HA for 
several months. In the higher performing HA, CHWs reported holding informal meetings with groups of 
mothers or community members in villages during which they shared information on such topics as prevention 
of childhood illnesses, portable drinking water, handwashing and good hygiene, the importance of using a 
mosquito net, vaccinations, and critical nutrition practices. They indicated that the IT also periodically 
participated in community discussions. Although CHWs in the lower performing HA reported previously 
holding community discussions, they suggested that it was difficult to sustain this type of work on a voluntary 
basis, and that community meetings were held only during disease outbreaks. Our data suggested that routine 
activities, especially in Kalwa, were relatively dormant, except when special events, such as disease outbreaks or 
vaccination campaigns occurred, which often involved monetary incentives for the CHWs. During such events, 
we were told that information was shared rapidly and extensively, with RECOs using megaphones to 
disseminate messages. Messages were also shared during church services, either by religious leaders or CHWs, 
where it was possible to reach large and captive audiences. During epidemics, CHWs also went house to house 
to identify sick household members and bring them to the HC. Teachers also conveyed health-related messages 
to school children, who were encouraged to share the information with their parents. The radio was also an 
important way to share information, especially in the evening when families listened to the radio. 
Focus group participants said that they obtained health-related information during treatment consultations and 
CPS, mentioning information about common childhood diseases, hygiene, handwashing, potable drinking 
water, vaccinations, and child feeding. They confirmed that household visits occurred periodically, often during 
specific months (probably in preparation for vaccination campaigns) and at times of an outbreak or for a census,
but were more frequent in the past. In Kalwa, mothers stated that “foreigners” had recently come to their homes 
to ask about treatment provided by facility health workers, which we suspect was related to ongoing PDSS 
validations. Mothers also mentioned that health workers shared messages by megaphone, especially during 
epidemics. They stated that community discussions occurred on rare occasions, especially when doctors from 
outside the zone visited during special events, such as during a recent cholera outbreak. Information was also 
Baseline Report 147
disseminated in churches and schools, and by radio, but they confirmed that radio reception from Bunkeya can 
only be received in Kikobe and most participants did not have a radio. No participants had a telephone. 
Both health workers and caregivers reported that there were no community-based organizations involved in 
healthcare in either HA. Respondents were unaware of the CAC— the village-level community structures 
designed to organize and provide oversight of community activities as part of the national community health 
strategy. Champion communities had never been implemented in the Bunkeya zone. Mechanisms to allow 
community members to participate in the oversight of health services, such as the bulletin communautaire, also did 
not exist. Health workers said that community members had never been invited to facilities to learn about the 
availability of services, which was confirmed by focus group participants. Although informants in the lower 
performing HA mentioned inviting members to visit the newly constructed buildings, the invitation proved 
problematic because of the expectation that community members would receive some form of compensation. 
Informants described iCCM posts as sites created for populations living in remote areas with inadequate access 
to healthcare, at which childhood illnesses, such as malaria, diarrhea, and ARI, were treated for free. However, 
not all CHWs were aware of the iCCM sites. The higher performing HA had one operational iCCM site located 
25 km from the HC. In the lower performing HA, there were two iCCM sites, with one 45 km from Kalwa and 
relatively close to Bunkeya. Informants reported that iCCM sites were operated by RECOs, who received 
instructional and practical training at the HCs. RECOs in charge of iCCM were mandated to treat childhood 
illnesses and make rapid referral of sick children to the health facilities. However, informants suggested that due 
to the distance, RECOs often saw and treated sick children multiple times, and only if the illness persisted, 
referred them to the HC. To carry out the work, RECOs were given basic materials, such as a basin for 
handwashing, a chair, a scale flip charts to convey messages, and essential medications, including paracetamol, 
SRO, mebendazol, zinc, and ACT for the treatment of childhood illnesses. One IT said that the iCCM sites had 
antibiotics, such as amoxicillin, but the second IT denied that RECOs were permitted to treat with antibiotics. 
RECOs overseeing iCCM were supervised by ITs and relied on HCs for supplies, with informants reporting that 
they received small quantities of medications and frequently confronted stockouts. Drugs were difficult to 
restock due to the long distances and the fact that HCs may experience stockouts of the same medications. 
Lack of transport for both CHWs and community members presented a major obstacle to the provision of 
community health services, especially during the agricultural season when people lived in isolated areas. Kalwa 
informants admitted that during the rainy season, CHWs did not carry out or reduced household visits, also 
pointing to the fact that RECOs resided near their fields during the rainy season. The Kalwa village chief said, 
The problem is where they go, that is what causes the work to stop, especially during the rainy season, the work stops. 
The IT says the norm is for RECOs to carry out 50 household visits, but during the rainy season it is reduced to 10‒
15 households. It is difficult to go to the fields to make household visits, somebody who is not paid, you cannot 
prevent him from going to his fields. He also must work his fields. 
Reference Hospital
Clinicians reported having a formal relationship with CHWs, who in conjunction with the niche HC, worked
directly with the reference hospital to carry out active screening for TB and HIV/AIDS, monitor treatment of 
HIV/AIDS cases, monitor a peer education approach, share information about illnesses identified as 
problematic and on preventive measures, and target cases identified in the hospital that could benefit from 
follow-up visits. Identifying TB cases and tracking people with HIV/AIDs falls under the PDSS, with assistance 
from PROSANI (for TB), and RECOs received compensation for active screening (10,000 FC for identifying a 
positive TB case, 3000 FC for screening and referring a suspected case that tests negative). We were told that 
drug resistant cases of TB had been identified in neighboring zones, raising serious concerns about TB in the 
health zone. 
Hospital staff analyzed epidemiologic data weekly to identify immediate health problems and to determine key 
messages to share with parents and family members during bi-weekly meetings in the hospital compound. The 
information also guided messages conveyed by RECOs during visites à domicile VAD [household visits]. 
148 The Impact of USAID’s Integrated Health Program in the DRC
Hospital sessions often focused on the prevention of prevalent childhood illnesses, such as diarrhea, malaria, 
ARI, and typhoid, and the importance of rapid care seeking. In conjunction with the HC, the hospital also held
monthly meetings to assess treatment provided to indigent community patients. The hospital was involved in 
broadcasts of health-related information by radio, which was accompanied by an interactive question-answer 
session. However, the radio transmission could not be received in the study HAs. As a result, activities 
implemented less regularly, such as community outreach, were missed because the health workers failed to 
receive the information shared on the radio. Hospital informants claimed that the most effective way to 
introduce information quickly was through the RECOs and radio. 
The hospital’s approach to involving the community was to engage family members of patients in the upkeep of 
the hospital compound, such as cleaning the pediatric ward or ensuring that water was available in the latrines. 
Hospital staff held meetings with family members to explain how they expected them to assist. One physician 
noted a public health saying, which stated, “If you do something without the community, you have 
accomplished nothing.” We were told that community members had been invited to the hospital on two 
occasions to learn about the services that were available.
System Design
Role of CODESA Members
ITs and CODESA members reported that the CODESA committee was responsible for supporting the 
development of the HC; providing community oversight of HC services and the use of materials and 
medications; and creating a bridge between the population and the health workers. In reality, CODESA 
members appeared to carry out activities officially delegated to the RECOs, such as sensitizing community 
members about health issues and carrying out household visits to identify and refer sick community members, 
especially children and during times of outbreaks. Other activities included participating in the construction of 
health facilities, weeding around the HC compound, and cleaning the HC. CODESA members in the higher 
performing HA participated in monthly CODESA meetings and zonal meetings. CODESA members in the 
lower performing zone, where the CODESA president was also the village chief, appeared less organized and 
active. One informant suggested that the village chief’s involvement complicated the relationship with the HC 
and general activities. The MCZ contended that most CODESAs were not functional.
In the higher performing HA, there were nine active CODESA members, including one woman who served as 
treasurer, with one informant mentioning that women were more reliable managing money. In the second HA, 
the CODESA committee consisted of four members, with no females. One informant explained that few female 
residents were literate, and women were therefore not eligible. CODESA members had not been formally 
evaluated and had not participated in any training for several years. Only the HC linked to the reference hospital 
recently held CODESA elections. We were told that CODESA members received occasional coaching by the 
IT, especially if an event, such as an outbreak or a new activity, was introduced.
Role of RECOs 
Broadly, the RECO’s mandate was to support health services at the community level and to help manage the 
HC. Informants described their main role involving household visits to monitor the health of community 
members and identifying and referring (in more serious cases, accompanying) sick members and pregnant 
women to the HC, with some describing RECOs as the “entrance” to the health system. One clinician said,
You know, community members will not listen to us, but they listen to the RECOs. They are the link between us and 
the community. They are the ones who can explain things well so that the community listens. 
In the HAs, RECOs shared health-related messages about hygiene and handwashing, water treatment and 
storage, the importance of using a mosquito net (especially for children), FP, exclusive breastfeeding, 
complementary feeding, and malnutrition, at the community level, during CPN and CPS, and in churches. They 
were also expected to identify children who had missed vaccinations. RECOs were especially active during times 
Baseline Report 149
of outbreak, when they carried out household surveillance to identify and refer cases, although no follow-up was
done post treatment. Materials given to RECOs were minimal; the MCZ noted that RECOs even lacked bags 
and an umbrella.
As indicated, RECOs assisted with periodic vaccination campaigns and, in the high performing HA, they 
participated in outreach. RECOs were also involved in the distribution of FP methods. Another role was to
maintain lists of indigent community members. They also participated in projects designed to upgrade the health 
facilities, such as making bricks, constructing hangars where educational sessions were held, and building 
latrines. RECOs were responsible for maintaining notebooks of their ongoing activities and submitting activity 
reports to the IT at the end of the month. Reports included the number of household visits and sick children 
identified and collection of surveillance data during epidemics. 
Information about the number of households that RECOs followed varied from 30 to 50 in the high performing 
HA, to 10 to 50 in the low performing HA, with each household supposed to be visited at least twice a month. 
There was general confusion about how many households RECOs should follow and how often household visits 
should take place. In the higher performing HA, there appeared to be a push to increase household visits, which 
is a PDSS indicator. Our data suggested that CHWs in the lower performing area were generally inactive, except 
during special events when money can be made, or during outbreaks when they carried out household visits to 
identify sick children. The MCZ described all RECOs in Bunkeya as inactive, claiming that they did not even 
participate in monthly reporting.
Informants reported inconsistent numbers of active RECOs, with ITs suggesting higher numbers than other 
informants. In the higher performing HA, informants indicated that there were anywhere from five to nine active 
RECOs, of which three were women, whereas in the lower performing HA, there were three to twelve RECOs, 
with two to five women. Neither HA had RECOs in each HA village, as stipulated by government policy. In 
Kalwa, our RECO-informant said that when she joined, there were 20 female RECOs, but of the 20, she was the 
sole remaining female. The IT explained that when they learned that there was no remuneration, they quit. The 
MCZ claimed that there were more women RECOs than men in the zone.
In both HAs, RECOs had not been elected, but had volunteered to participate. Informants stated that RECOs 
had not received training for several years, with some mentioning since 2016, but had previously participated in 
training on breastfeeding and alimentation du nourrisson et du jeune enfant [infant and young child feeding], FP, 
diarrhea treatment, and good hygiene. Although regular briefings on activities and coaching were conducted in 
Kikobe, in the lower performing HA, the IT appeared to have little interaction with the RECOs. 
Informants applauded the relations that RECOs had with communities, generally describing RECOs as sensitive 
to the needs of community members and well respected. The characteristics of a successful RECO included 
being sociable, non-confrontational, understanding, and a community role model, with one stating “like a 
pastor,” suggesting that their messages would not be accepted otherwise. In the higher performing HA, we were 
told that health workers held sessions to talk about the appropriate behaviors that RECOs should have with 
community members, and if anybody displayed inappropriate behavior, they were counseled. RECOs said that 
they occasionally interacted with unreasonable community members. When needed, the IT intervened during 
CPN and CPS sessions by sensitizing community members on the role of the RECOs and the respect they 
deserved.
Informants agreed that RECOs required additional training, with one IT indicating that some did not understand 
their roles. When asked why the ITs did not train the RECOs, one IT explained that if formal training was held, 
the RECOs would expect per diem. Coaching had become an alternative, but the MCZ claimed that nobody had 
received training on how to coach. He stated,
In my monthly report for October, we realized that we had deficits in what is called coaching. Well, personally I have 
never been taught how to coach. I have been taught how to support, how to supervise, but how to coach, I have never 
been trained. It seems to be a special theme. As we are expected to coach the structures on this or that theme, we 
thought that maybe what we are doing is not good. We asked the DPS, who are the only ones who have been 
150 The Impact of USAID’s Integrated Health Program in the DRC
formally trained on coaching, for help. But for three, four, five months we have not been visited by the DPS, we feel 
abandoned.
RECOs claimed that community members believed that the RECOs received payment for routine work and 
large sums of money when they participated in special activities. CHWs said that they needed uniforms, flip 
charts, bags, and umbrellas to better carry out their work. 
Specific Services Offered
Mosquito Nets
HA informants reported that insecticide-treated bed nets were supposed to be distributed during the first CPN 
visit and after children attending CPS received the measles vaccination, which was given at nine months of age. 
Although the ITs claimed that they had been out of mosquito nets for about one month, we learned through 
other sources that bed nets had not been available for much longer periods (since 2016 in the higher performing 
HA). In the lower performing HA, health workers distributed bed nets to pregnant women only because CPS 
was not held. Campaigns involving bed net distribution to households had not been conducted since 2016, and 
when campaigns had been held, informants said that the number of nets was always insufficient. Informants 
reported that the bed nets that community members used were old and had holes, and that poverty prevented
people from purchasing them. The fact that households in Bunkeya, which are often made of canvas material, 
were extremely small, made it challenging to set up and use the nets, especially during the rainy season when 
people live in temporary housing. The RECO in Kalwa said that she did not feel comfortable entering
households to check whether bed nets were used. Informants stated that people understood that mosquitos posed
a major health threat and recognized the importance of using a net for protection.
Focus group participants in both HAs claimed that bed nets had not been distributed for about three years, with 
most stating that they no longer used a bed net because they were torn. Mothers reported that bed nets had 
previously been distributed during CPN, CPS, and after delivery, and there was also mention of campaigns. 
Although most participants claimed that residents who had received bed nets used them, there were some reports 
of bed nets being sold to fishermen. 
Hospital informants indicated that 75 percent of all patients tested positive for malaria, and that malaria was 
especially lethal during the rainy season, when parents brought their children for care when they were 
dangerously sick and required a blood transfusion. Hospital informants stated that the niche HC regularly 
distributed nets during CPN and CPS, and that RECOs working in the town of Bunkeya conducted household 
visits to assess whether and how bed nets were used, especially when epidemiologic data showed surges of 
malaria. 
Vaccinations
Vaccinations were provided routinely and during campaigns. In the high performing HA, routine vaccinations 
were given in the HC once or twice a month during CPS for residents living near the HC and in three 
surrounding villages. Twice monthly, health workers provided vaccinations during outreach activities in four 
HA villages. Because CPS was not being held in the lower performing HC, vaccinations appeared to be offered 
only sporadically during special sessions when health workers requested community members to bring their 
children to the HC, with CHWs reporting that it was difficult to mobilize residents who resided next to their 
fields. The Kalwa IT claimed to carry out outreach to HA villages occasionally, depending on the availability of 
transport money, stressing that some villages were extremely far away and only accessible by motorcycle, which 
had to be rented for 25,000 FC per day. 
Informants from both HAs reported that vaccination campaigns were held at least twice a year when children 
were vaccinated for vaccin antipoliomyélitique oral [oral polio vaccine]and vaccin contre la varicelle [chicken pox 
vaccine], with the aim of covering the entire HA. RECOs and CHWs played a critical role, dividing into teams 
to cover different parts of the HAs. Given the limited number of active CHWs in Kalwa and the large geographic 
Baseline Report 151
area, vaccination teams could not reach all community members, explaining the low vaccination coverage in 
Kalwa. During campaigns, the administration of the oral VPO was primarily done by CHWs, whereas facility￾based health providers, including hospital nurses, administered the measles vaccine, which was injected. The 
CHWs oversaw the mobilization of community members with the help of village criers. CHWs reported 
traveling long distances (more than 20 kms) by foot to villages. In Kalwa, they also used bicycles for transport. 
Vaccinations were always free and stockouts were not reported. The MCZ said that IPs had decreased funding 
for campaigns, impacting on the motivation of health workers and coverage.
The informants emphasized that there was extensive community resistance to vaccinations, especially among 
people living in more isolated areas who were less educated and less exposed to information. We were told that 
villagers, more commonly men, contended that vaccines caused illness, with some reporting that campaigns 
were part of a strategy to increase the use of the HC and HC revenue. The fact that vaccines were free appeared
to raise skepticism. One village chief said,
They refuse, stating that the vaccines given for free cause illness in children and push people to come to the hospital. 
They describe it as a business, claiming that the vaccines manifest fever in children, forcing them to come to the 
hospital to pay for health services.
Several informants said that village residents often fled when campaign teams appeared. A Kalwa RECO said,
When we arrive in villages, as soon as they see that it is the vaccine team, they flee to the fields or tell the children to 
hide by the river. We can remain standing for a long time, and if we ask questions, parents or their children will 
answer that we and our children will not be vaccinated because vaccines are where there are diseases, and what 
causes diseases are vaccines. Most of them eventually come out, but the others who say it is the vaccines that give 
disease, flee. When we return to the health center, we inform the nurse that so and so fled, and refused vaccination.
Informants gave accounts of men physically assaulting CHWs or chasing them away. They reported that certain 
churches, including the Protestant denomination called Black Church (église de noir) and Jehovah’s Witnesses 
systematically opposed vaccines. In Kikobe, a RECO talked about trying to educate church goers, stating, 
We go to church. Everyone is there, all RECOs, to talk about vaccination. Most people refuse to have their children 
vaccinated, they say that our children are not sick, and we come with our things [vaccines] to make our children 
sick. We really have difficulties; they call us the soldiers of the nurses who give us drugs to give to our children. I 
personally have been hit, it was in a field and by a father who did not want his child vaccinated.
A CODESA member from Kalwa said,
Sometimes during vaccination campaigns, some parents chase us, saying that vaccines cause disease. Despite this, 
we educate them about these things. And, if the community supervisor intervenes and the parent continues to resist, 
he will take the child by force. This is how vaccination takes place. 
Mothers participating in focus groups said that vaccination campaigns were held, with women in Kikobe better 
informed about eligibility, frequency, and the type of vaccines administered. Participants indicated that vaccines 
were given to protect against illness and to decrease the virulence of disease. Caregivers confirmed that some 
people refused vaccines by hiding their children, and sometimes they insulted the health workers, claiming that 
vaccines caused fever and sickness. Other reasons for refusal were that churches opposed vaccines or parents did 
not understand the importance or held opposing belief systems. A woman from Kalwa said,
Some people hide their children due to the belief that if a child gets vaccinated, he will experience blood loss and the 
parents will not have money to pay for hospital treatment.
Another respondent said,
There are times that community members insult the health providers and even grab them by their clothes, stating ‘I 
refuse that [the vaccination] for my children and the others refuse also.’
A Kikobe mother said,
152 The Impact of USAID’s Integrated Health Program in the DRC
There are some parents who refuse that their child be vaccinated, saying that if they are vaccinated their temperature 
will increase and the child will get sick.
During campaigns, vaccines were administered in households, which was considered more convenient and safer 
because children were not forced to interact with other children and possibly be exposed to disease. Caregivers 
from the higher performing HA mentioned that routine vaccinations were also provided during CPS, but women 
living in the lower performing HA claimed that the frequency of CPS was irregular, and even when held, many 
women did not attend, especially after the child received the measles vaccination. Women from the higher 
performing HA reported that CPS was offered once a month and attendance appeared regular up to the time the 
child was two years of age. 
Community Worker Motivation 
Most CODESA members and RECOs stated that they were motivated by the small sums of money they received
from participating in periodic vaccination campaigns, typically US$5 to US$15. Training also presented
opportunities for remuneration, but because PROSANI was no longer active, no training had been held for 
years. Even when training was conducted, our data showed that the CHWs did not receive official per diem 
rates. Under the PDSS, CHWs were supposed to be paid US$1 per household visit, but the RECOs stated that 
they were not appropriately compensated, with one IT giving a few dollars to RECOs for VADs at the end of 
each month. The IT in the second HA claimed to give a small monthly payment, but the CHW informants 
maintained that they were not remunerated. In Kikobe, when RECOs participated in outreach, they were not 
given the official transport money. Informants emphasized the injustice of not being paid. One RECO said,
Honestly, we are treated badly, you cannot imagine! During vaccination campaigns, we are on foot, walking 
distances up to 20 km.
At the same time, CHWs mentioned a desire to assist community members, as one RECO explained,
I am not motivated in terms of money, but what pushed me to become a RECO is compassion for the community 
and the desire for their well-being. Living around death all the time is not good.
Another RECO said,
We are there to serve our people. It is not for money. What drives us is to see the community in good health. We are 
there for the people. We do not work for money and we are not formally engaged. 
Another maintained that holding a recognized job brought pride and esteem compared with manual labor, such 
as farming or pounding grain. This RECO expressed the “love” she had for her job: 
There is not so much (financial) motivation, but I am used to that and I like this work. We work like this, if there is 
a benefit, I will receive it, and if not, it is the work that I love. We know that it is voluntary, if we will gain 
something or if we gain nothing, we work only out of love.
One RECO highlighted increased knowledge about disease as another benefit and source of motivation. Another 
CHW believed that she would be compensated sometime in the future for her years of hard work.
USAID Projects in the Area
Informants reported a disruption in the provision of medications between the present USAID IHP project and 
the predecessor project, locally referred to as PROSANI. At the time of the study, most informants indicated that 
the current project was only supporting the provision of medications, especially for malaria, HIV/AIDS, and 
TB, and for supplies, such as testing kits for malaria or to assess blood type. At the HA level, there was confusion 
about USAID IHP’s role and its relationship with Camelu. 
From the BCZS standpoint, PROSANI had not started. The MCZ stated that support had been far less than 
given in the 2019 operational plan, which involved extensive input from USAID IHP staff. We learned that 
many promised activities were not being executed (e.g., support for monthly transport of medications from the 
Baseline Report 153
zone to the HA, iCCM, evaluation and revitalization of CODESA members, reestablishment of community 
participation, training) or that support was much less than planned (e.g., payment for one supervision visit rather 
than regular supervision, fewer special campaigns and activities for FP, CPN, and TB). Along with government 
failure to fulfill promises, this made it difficult to implement the operational plan. The MCZ also expressed 
frustration that USAID IHP did not provide money and that each expenditure had to be justified. He indicated 
that during DPS meetings, the MCZ interacted with partners, but once they were in their zones, there was no 
direct communication, making it difficult to understand what assistance to expect and to plan for activities. The 
MCZ added that it would be helpful if partners, including USAID IHP, had more of a presence in the field. 
Informants reported that the previous provision of medications and medical supplies had been more regular and 
that larger quantities were given. Many noted that PROSANI activities had dramatically decreased compared 
with prior years when diverse training for facility-based workers and CHWs was offered. Other key activities,
such as supervision, M&E, provision of medical equipment, forms and registers, WASH, and financial support, 
had been discontinued in 2018. One hospital informant stated,
This year PROSANI is not active as in the past. It’s as if PROSANI experienced a metamorphosis. If I’ve heard 
about PROSANI, it’s regarding drug supplies, that’s all for this year. When we had PROSANI, PROSANI was 
here every day. There were PROSANI supervisions to monitor HIV cases, they monitored assessments. We went to 
trainings, this year not at all. Now it is as if PROSANI is not there, PROSANI seems to have disappeared, we 
haven't heard about PROSANI for a while.
Some referred longingly to former USAID projects, especially ACCESS, which assisted with the construction of 
HCs and distributed equipment, such as refrigerators and solar panels. Most informants appeared to be unaware 
of the USAID IHP mapping exercise, which had been administered by health zone staff and was likely assumed 
to be part of routine supervision. 
154 The Impact of USAID’s Integrated Health Program in the DRC
Qualitative Baseline Report, Health Zone of Kasaji
Background Information
This research was conducted between November and December 2019 in Kasaji health zone, which is comprised 
of 312 villages and 26 HAs, of which 24 HAs were functional, having medications and trained staff available to
provide basic treatment. The health zone is isolated and difficult to access, especially during the rainy season 
when holes several feet deep form on the main road between Kolwezi (the capital of Lualaba) and Kasaji, 
making sections of the road impassable. The zone is vast, with the most distant HA 133 km from the central 
zonal offices. 
Data were collected in two HAs—Methodist and Lueu. In each HA, we conducted in-depth interviews with an 
IT (head nurse), a member of the CODESA (health development committee), RECOs (CHWs), and a village 
chief or a village chief representative. We also carried out in-depth interviews with a physician working in the 
reference hospital and the AG (health zone financial and administrative manager), and the acting health zone 
medical officer (MCZ) in the central zonal office (BCZS). At the time of the evaluation, the MCZ was in 
Kinshasa working on a master’s degree at the Kinshasa School of Public Health. We therefore administered the 
key informant interview to the MCZ in Kinshasa. We also conducted observations of the health facility 
infrastructure and interactions between health workers (4) and caregivers of sick children (13).
The average age of in-depth interview informants was 46 years and the majority (10 of 11) were men. Both ITs 
had A2 level training. CODESA members, RECOs, and village chiefs had 17 years of schooling, on average,
whereas the two doctors had 18 years of training. Informants had eight years of work experience in the same 
position, on average. All informants participated in other work, most often agriculture. Some worked as 
instructors at a primary school or a university or as religious leaders. The informants were Protestant (8) and 
Catholic (3). Informants had seven people living in their households, on average. 
We carried out focus group discussions in each site, with 12 caregivers of children under five years of age 
participating in each session. A summary of the characteristics of in-depth interviews and key informants is 
shown in Table 4.4.
Table 4.4. Background information collected from in-depth interviews and key informants in Kasaji
Variable In-depth interview
informant
(11)
Key informant
(1)
Average age (years) 46 45
 Average years of education 17 18
Sex
- Male
- Female
10
1
1
-
Religion
- Catholic
- Protestant
3
8
1
-
Average years of experience in their roles 8 7
Participation in other work*
- Farming
- Teaching
- Nun
- Preacher
5
3
-
1
-
1
-
-
Baseline Report 155
Variable In-depth interview
informant
(11)
Key informant
(1)
- Judge for the village chief
- None
-
2
-
-
Average number of household members 7 7
Description of Facility-Based Services
Infrastructure
The Methodist HA HC was in the city of Kasaji and was less than one km from the BCZS. Although originally 
affiliated with the Methodist Church, the HC was government operated. The HC was built between 1984 and 
1985. It was a small, narrow building that included a maternity and a laboratory. Due to limited space, treatment 
for adults and children was given in the same consultation area. Informants reported that the HC required
extensive renovation. The Methodist IT said, 
Our health center needs more than a simple renovation. Everything is old. You can see it for yourself. We don’t 
have a waiting room, we don’t have a pediatric room, and we have many kids here, we have many sick patients. 
The maternity ward is not big enough. We don’t have any beds, no mattresses, we should have bed sheets, and we 
don’t have a clean room for the lab. The pharmacy itself does not meet required standards, and there is also the 
roof–there are many problems. Our needs go beyond renovation. 
A month before our assessment, the HC electrical cables were stolen, and at the time of our evaluation, 
electricity was not available. Before this, electricity was limited and based on a government schedule. The HC
had a well that provided water for sick patients and women delivering in the maternity. HC staff included an IT 
(A2), an ITA (A2), and a nurse (A3) who managed the pharmacy, and a laboratory technician and five 
traditional birth attendants. 
Lueu HA had a reference HC located seven kms from the Kasaji BCZS and two health posts, 11 and 8 kms from 
the HC. Only one village in the HA was outside the city limits of Kasaji. The health facility was originally 
constructed in the 1940s when it served as a hospital for Belgian missionaries. When the missionaries left, the 
Catholic Church took over hospital management. The HC was comprised of four buildings, including a 
maternity and two operating theaters. It had the capacity to hospitalize 100 patients. Child consultations were 
carried out in a separate treatment room. Solar panels functioned and provided a regular source of electricity;
Lueu also had access to electricity from Kasaji. Although the center was government run, the Catholic Church 
provided emergency funds during times of crisis. Many informants suggested that the building was in disrepair, 
indicating that the only renovations carried out in the past five years involved repairs to the roof of the main 
building. A CHW said,
There was some renovation, but it wasn’t enough. You can see how dilapidated the building is. Although we 
changed the roof tiles to metal sheets, there are cracks everywhere. We put some metal sheets here and there, but 
there is no ceiling. There are gaping holes that allow dust and hot air in. It would be good to have a ceiling. Also, 
we no longer have windows and there are no functioning latrines. 
However, the MCZ described the Lueu center as well equipped and organized and that it could be used as a 
referral hospital. Staff included physicians (2), one of whom was the managing director, an IT (A2), an ITA 
(A2), a laboratory technician, a nun in charge of the pharmacy and the cash register, an AG, and several nurses. 
The reference hospital was a large hospital built between 1943 and 1945 and comprised of 10 to 11 buildings, 
including pavilions for internal medicine, surgery, gynecology, obstetrics, pediatrics, and childbirth. The hospital 
also included a HC (centre niche), a private clinic, a laboratory, and a chapel. Electricity was available 24 hours a 
156 The Impact of USAID’s Integrated Health Program in the DRC
day. Originally a denominational hospital of the Ngarengaze church, it became recognized over time as a 
government referral hospital, although the facility was still linked to the church. The MCZ mentioned that the 
hospital had received extensive support from the provincial government, which had recently provided two new 
vehicles, funds to build a mortuary, and support for vulnerable patients. Hospital buildings had been renovated 
in the last five years and the MCZ said that the facility’s structures were in good condition. The reference 
hospital employed 102 workers, of which 80 percent had administrative or support roles. Clinical staff included
20 nurses and two physicians. The MCZ indicated that the hospital needed more physicians, but that the 
recruitment process was difficult due to the involvement of the Ngarengaze church, which must approve the 
hiring of medical doctors. Additional information on the infrastructure at the facilities is presented in Table 4.5.
Table 4.5. Facility infrastructure, supplies, and medications related to childcare based on 
observations in Kasaji
Methodist Health Center Lueu Reference Health Center Reference Hospital 
Has the structure 
been renovated in 
the past 5 years? 
The health center was generally in 
good condition, but needed some 
renovation. The building was very 
narrow and did not accommodate 
patients. 
The health center was 
renovated in the past five years. 
Renovations involved painting 
the facility, replacing the main 
door, and roof repairs.
Some buildings were 
renovated in the past five 
years and walls were 
painted. 
Is electricity 
available in the 
health center? 
The health center power cables 
were stolen about one month 
before the evaluation; the HC did 
not have any electricity. 
The refrigerator was run on solar 
power. The center had
electricity, but there were
frequent power cuts. 
Electricity was available 
24 hours a day.
Is there a 
separate area of 
the facility where 
child health 
services are 
provided? 
There was no specific area 
dedicated to services for children. 
The health center was small and 
narrow, and did not have adequate 
space to have a specific space for 
child services. 
There was a whole room 
dedicated to child health. 
There was a pediatric 
ward. 
Is an infant 
treatment table 
available?
No, there were no funds and 
insufficient space for an 
examination table for babies.
Yes, in the room where child 
services were provided.
Yes, in the pediatric 
ward.
Is there a baby 
scale available? 
No, there was not a functional baby 
scale.
Yes, there was a newborn scale 
in good condition. 
Yes 
Is there a Salter 
scale with 
trousers 
available? 
Yes Yes Yes 
Is there a munie
scale available? No
There was one in one of the 
operating theaters. 
Yes, and there were a 
few in stock in the 
pharmacy. 
Baseline Report 157
Methodist Health Center Lueu Reference Health Center Reference Hospital 
Is there a height 
measure 
available?
No Yes, in the consultation room for 
children
Yes, in the outpatient 
consultation area and 
maternity ward.
Are growth 
monitoring kits 
available? 
There were no growth charts 
available; the provider was 
unaware of how to use growth 
charts. 
Yes, growth charts were in the 
examination room.
There were growth 
monitoring charts, height 
measures, and weighing 
scales.
Is sterilizing 
equipment 
available?
Yes Yes There was an autoclave 
sterilization system.
Are there key 
instruments, such 
as a stethoscope, 
thermometer, and 
timer available for 
the health 
providers to use? 
Yes, and all were functional. Yes, and all were functional All these instruments 
were available in each 
ward.
Are essential 
medications 
available, such as 
zinc, ORS, 
amoxicillin, ACT, 
and other 
antimalaria 
medicines?
Yes, but not in insufficient 
quantities. 
All medicines were available in 
the HC pharmacy.
Available in sufficient 
quantities in the 
pharmacy.
Are insecticide￾treated mosquito 
nets available?
Yes, but in small quantities Yes, but mosquito nets were
insufficient. Bed nets were used 
on all patient beds. 
There was a stock of 
nets. Each hospital bed 
was covered with a net.
Are there rapid 
diagnosis kits for 
malaria available? 
Yes, but in insufficient quantities. Yes Yes, and in sufficient 
quantity.
Are all essential 
vaccines 
available?
Yes, but they were stored in the 
BCZS. 
There were none at the HC
when we conducted the survey. 
They were stored in the BCZS 
and needed to be collected two 
days before the next CPN/CPS 
consultation.
All vaccines were
available, except for the 
vaccine for rotavirus 
because it had not yet 
been introduced.
Is there a 
refrigerator which 
is functioning?
No. They used the BCZS 
refrigerator to store vaccines.
Yes There was a solar￾powered refrigerator, but 
it had not been working 
for a month. 
158 The Impact of USAID’s Integrated Health Program in the DRC
Methodist Health Center Lueu Reference Health Center Reference Hospital 
Are fee schedules 
posted? 
Yes, they were displayed in the 
waiting room and the examination 
room. 
Yes, they were displayed on the 
veranda where patients wait for 
care. 
Yes, they were displayed 
in the waiting room. 
Are there any 
educational 
materials, such as 
posters, displayed 
on walls? 
No No Yes, there was a poster 
on TB transmission. 
Are there BCC 
materials/aides 
for the health 
workers to use? 
Yes Yes No, because it was a 
reference hospital 
focusing more on 
curative care. 
Is there evidence 
of activities to 
discourage fraud 
and increase 
transparency, 
such as a hotline 
or a complaint 
box? 
No No There is a suggestion 
box.
Services Offered
Health Centers
Health services in the Methodist HC included outpatient treatment, 24-hour observation of patients with more 
serious conditions, basic surgery, and preventative care. As a reference HC, Lueu offered a broader package of 
complementary activities, including treatment for severe acute malnutrition and surgery, which was carried out 
in two operating theaters. Each HC had a laboratory and the facilities were open 24 hours a day. 
Providers followed treatment protocols introduced by a former World Bank initiative called Projet d'Appui au 
Renforcement du Système de Santé (PARSS [Health System Support and Strengthening Project]). The 
evaluation team found treatment protocols available in both HCs, with abbreviated versions displayed on walls 
where child consultations were conducted. However, both ITs said that health workers frequently failed to 
consult the protocols when administering care. One IT stated,
You understand that humans make mistakes, at times some providers do not follow the protocol. Instead of following 
the norm, a provider may do something else. Let me give you an example; a sick child comes in, he does not meet 
criteria for acute malaria, but the provider sees that the child is fatigued, and he decides to give a blood transfusion or 
he gives quinine, which should only be given if the child exhibits specific danger signs. At times, the treatment 
protocols are ignored.
Baseline Report 159
Although the health zone officials emphasized the importance of following treatment protocols during 
supervision visits, the MCZ indicated that many health workers lacked basic training, which he linked to 
deficiencies in treatment practices. 
Nurses reported that treatment for simple cases of malaria involved the drug Coartem. For severe malaria, 
quinine was administered and sometimes blood transfusions were necessary, which was an old treatment 
protocol. As for diarrhea, zinc was provided, and if the child was dehydrated, oral rehydration solution was 
given. In addition, children with diarrhea were tested for worms, and if worms were detected, mebendazole was 
provided. In cases of pneumonia, injectable antibiotics were typically administered. Challenges in treating 
children mentioned included drug shortages; poverty, which prevents families from paying for certain treatment 
and drugs; low quality treatment regimens provided by the national malaria program; and resistance to malaria 
drugs. When talking about treatment provided by the national malaria program, one IT said,
We can’t cure malaria with Coartem only. A good treatment must be given with other products. Right now, the 
treatment against malaria does not include all the medicines that should be administered [only Coartem]. A child 
who has malaria is given Coartem with amoxicillin. But other medicines must be paid for. Because the population is 
poor, they cannot afford to pay for the other medications. Which means that the next time the child has malaria, they 
will think that the treatment was not effective and the parents won’t come back.
Preventive services mentioned included CPN, CPS, CPON, distribution of mosquito nets, and vaccinations. 
Informants reported sharing preventive messages with caregivers during treatment consultations for children 
related to diarrhea prevention, healthy diets, the importance of maintaining a clean compound and latrine, 
handwashing with soap, and the use of insecticide-treated bed nets. 
Focus group participants said that HCs provided treatment for common childhood diseases, such as malaria, 
diarrhea, cough, and typhoid fever, blood transfusions and intravenous therapy, labor and delivery services, and 
laboratory examinations. They also mentioned that CPN, CPS, and vaccinations were offered and that centers 
distributed mosquito nets impregnated with insecticide. 
Reference Hospital 
The reference hospitaloffered a wide range of basic curative care for children, including care for HIV-positive 
patients. The reference hospital had a treatment unit for severely malnourished children requiring emergency 
care and hospitalization. The physician interviewed indicated that the Kasaji population was extremely poor and 
had limited access to healthcare, stating that sick patients often delayed care-seeking until the situation became 
complicated and dire. He said that patients often arrived at the hospital without money, and that they often 
could not procure everything needed for effective treatment, stating, 
First and foremost, is the lack of resources. Antibiotics are expensive. A small bottle of Amoxi (amoxicillin) costs 
1,000 FC, and maybe you need 7 or 8 bottles; you ask the mother to go pay, and she doesn’t have the means. In the 
case of pneumonia, you must do an x-ray to see how the lungs are affected, and the x-ray costs 15,000 FC. She’ll tell 
you, ‘I don’t have that.’ Sometimes, we must make do with what we can do in the clinic. If you carry out an exam 
and the results suggest that it is pneumonia, then you conclude that is what it is. Why? Because they can’t afford to 
get an x-ray to confirm the diagnosis. 
Preventive care was offered in the niche HC, which was under the same administrative and medical structure, 
and was located in the hospital compound. The niche HC offered a minimum package of curative care and a 
range of preventive services, including CPS, CPN vaccinations, FP, and treatment for children with moderately 
severe malnutrition. When sick patients went beyond the HC capabilities, they were referred to the hospital. 
Equipment
Methodist HC had equipment to provide basic child services, including benches for sick patients waiting for 
treatment and a table used to assess patients during treatment consultations. The center had salter scales with 
160 The Impact of USAID’s Integrated Health Program in the DRC
trousers but did not have a newborn scale; the height measure was broken. At the time of the evaluation, the 
center did not have growth charts. There was sterilizing equipment, a stethoscope, thermometers, a timer, 
registers, kits for the rapid diagnosis of malaria, and bed nets, but in small quantities. In the maternity ward was 
a delivery bed and three beds for women in labor and after delivery. The HC did not have a refrigerator and, as a 
result, vaccines were stored in the BCZS, which was only 800 meters away. A water well was next to the HC. 
Informants reported that the HC lacked a lot of materials, emphasizing the need for a patient observation bed 
and a refrigerator.
The Lueu reference HC had benches for patients waiting to be consulted, beds for sick patients under 
observation, a cabinet to store drugs, and registers to monitor treatment and preventive services. There was a 
treatment table for babies, an infant scale and salter scales with trousers, a height measure, and growth 
monitoring kits. Other basic equipment included sterilization equipment, a stethoscope, a thermometer, a timer, 
kits for the rapid diagnosis of malaria, and bed nets, which informants stated were in insufficient quantities. In 
the maternity, there was a delivery bed, and several beds for women in labor or postpartum. A solar operated 
refrigerator provided by the Global Vaccine Alliance in 2017 was used to store vaccines. Informants in Lueu 
could not recall the last time they had received medical equipment, underlining the need for an operating room 
table, sciatic lamps, surgical kits, and another refrigerator. 
The reference hospital had the same basic materials needed for child consultation as found in the HCs, but in 
larger quantities. Unfortunately, the evaluation team did not collect detailed information on more sophisticated 
equipment. The MCZ indicated that the hospital had benefited from support from the provincial government, 
which provided an ambulance (although it had been out of order for several months), a new Land Cruiser, and a 
mortuary with a functioning cold room, and extensive funds for ongoing hospital operations. Regarding hospital 
needs, the MCZ mentioned that the hospital lacked an intensive care unit. Our hospital informant reported a 
need for beds, mattresses, wheelchairs, stretchers, an x-ray machine, an ultrasound machine, an 
electrocardiogram machine, and an aspirator.
When asked how the facilities procured equipment, most informants reported that requests were made to the 
health authorities, including the BCZS, provincial DPS, or the national MOH, or the provincial governor. 
Facilities with religious affiliations can requested religious authorities to procure equipment. Administrators can 
also reach out to national and international development partners to assist. A reference hospital doctor noted, 
When we need equipment, the first thing we do is write a memo to the Ministry of Health, or the provincial governor, 
since it is a public facility. If we work with partners, people who support us, we don’t hesitate to ask them for help.
Another informant from Lueu said, 
We buy equipment here and there. When we arrived here, we found that a lot was lacking. But with the help of 
PDSS [the World Bank-supported PBF project], we are currently buying equipment here and there, but it’s 
not enough. We need a lot more. If another partner can help, it will be welcome.
Informants said that equipment repairs did not present a challenge if the facility had the financial means or 
human resources available. Otherwise, the facility had to wait until it received support from a partner. 
Respondents agreed that maintenance of equipment was challenging. A hospital clinician stated, 
Repairs depend on the resources we have; if the cost of a repair is not very high, we use our petty cash, we repair it, 
and we move on. But if it goes beyond the scope of our skills, for instance the ambulance over there, which has four 
flat tires, a broken engine, and a broken injection pump‒-this is out of our control. We wait to see if we can 
miraculously find a donor. 
Medications
Up to 2014, the health zone received medications from PARSS, an implementing partner supported by the 
European Union. Between 2014 and 2017, the MCZ reported that the health zone did not have a partner to 
assist with the provision of medicines. Around 2017, the national malaria program began to supply health zones 
Baseline Report 161
with free antimalarial medications and supplies, and some antipyretic drugs from the CDR. At the time of the 
evaluation, the MCZ mentioned that the health zone was still receiving bed nets; antimalarials, such as fansidar;
and antipyretic drugs, which the BCZS distributed to the HAs. 
The MCZ stated that during the 2019 PAO review, USAID IHP agreed to provide the health zone with other 
essential drugs. According to the MCZ, this had not happened, and the health facilities continued to purchase 
essential medications using their own resources and revenue. The MCZ added that Lualaba health zones located 
closer to Kolwezi were receiving medicines from USAID IHP; before decentralization, these zones were in a 
health district receiving assistance from the US government, and according to the MCZ, these health zones 
continued to be favored by USAID. 
In 2019, the DRC government started to provide the BCZS US$10,000 monthly to obtain materials and for 
salary support. The BCZS was asked to use a portion of the money (US$2,000) to purchase drugs, which HCs 
located in the zone could subsequently buy from the BCZS. The MCZ indicated that the approach aimed to 
guarantee an ongoing supply of medicines, ensure standard drug prices, and reduce trips that ITs had to take to 
Kolwezi to restock drugs. Another advantage was that the HC could buy the drugs on credit. The MCZ reported 
that the BCZS obtained the medications from retailers in Kolwezi, but there was no way to confirm the quality 
of the drugs. 
Despite these efforts, the MCZ stated that drug stockouts continued to be a problem, indicating that HCs did not 
have adequate means to purchase large quantities of medications. The MCZ stated that during stockouts, most 
health workers gave prescriptions; however, he added that many facilities were in remote areas where people had 
no access to pharmacies. He also mentioned a decline in the quality of malaria treatment, reporting that Coartem 
had replaced ACT. 
Health facility informants confirmed the frequent stockouts of essential children’s drugs, mentioning zinc, ORS, 
ACT, mebendazole, artesunate, rapid diagnostic tests, paracetamol in syrup, amoxicillin in syrup, and F75 and 
F100 milk formulas for treatment of malnutrition. Informants from Lueu said that stockouts lasted a long time, 
with one health provider stating, 
Stockouts are frequent. Sometimes they can last six, seven, or even eight months.
Many Methodist HC informants reported that during stockouts, they purchased medicines from Kasaji or 
Kolwezi, insisting that they did not rely on government supplies and that it was critical to replenish medications 
quickly. One CODESA member declared, 
When there is a stockout, we try to obtain medicines because otherwise the population will not use the facility. They 
will start going elsewhere. From the money we receive from treating patients, we first try to motivate the nurses a 
little, and then we take some to buy medications to keep our clients.
A RECO said, 
When there is a stockout, we make a lot of effort to obtain the medicines, even in private pharmacies, with our own 
resources, because when there are no medicines, people leave. They will start going elsewhere, and this will decrease 
utilization of the health center. Around here, it’s not easy to get people to come back to something they’ve rejected. 
This is why facilities do whatever possible to keep their clients.
Fewer Methodist informants stated that they gave prescriptions, indicating that patients opposed this practice. By 
contrast, Lueu informants indicated that prescriptions were frequently provided, as a CODESA member 
declared, 
Nurses provide prescriptions; sick patients buy the medicines in private pharmacies and bring them back to the health 
facility to be treated. During a stockout, the population suffers a lot.
Some informants mentioned that stockouts were especially frequent during the rainy season when poor 
roadways created a major obstacle to the delivery of medications and other essential supplies to the health zone.
162 The Impact of USAID’s Integrated Health Program in the DRC
During the rainy season, some HAs can only be reached by motorcycle, and others cannot be reached at all. One 
village leader said, 
Right now, it is the rainy season. There may be stockouts because reaching Kolwezi is a big challenge, and coming 
here from Kolwezi, because of road conditions, is really difficult. Supplies get blocked between Kolwezi and here.
Service Utilization
Most informants mentioned that poverty was the main obstacle to seeking care at facilities for sick children, with 
some focus group participants reporting that they faced major challenges when they were required to pay before 
receiving treatment. Other barriers mentioned included distance to the health facility, parental negligence, 
resistance by parents to use biomedical care, and self-medication and/or the use of traditional medicine. One 
Methodist nurse stated,
The first thing is poverty–people do not have enough money to bring a sick child to the hospital. Second, around here, 
people prefer using traditional treatment first. When it fails, they come here. This is why the rate of transfusions is 
very high, because people bring their children only after receiving other care and when they are in serious condition. 
Third, people make their own decisions about treatment. Pharmacies have been transformed into health centers and 
everyone is a doctor or a nurse! When they come here [to the health facility], they say, ‘Give me quinine, give me 
paracetamol.’ So, 99% of patients coming for care have already started a home treatment. When it fails, they come to 
see us.
All types of informants reported that traditional beliefs constituted a major obstacle to care-seeking from health 
structures. One informant explained that when a simple condition, such as fever, rapidly became serious, or 
when patients showed inexplicable signs and symptoms, family members often assumed that the condition was 
human-inflicted. In these cases, care was sought from traditional healers, such as a soothsayer or witch doctor.
Management and Governance
Coordination 
Informants said that there were biannual meetings with the board of directors, which was chaired by the director 
of the provincial health division (DPS) or a DPS representative, with the MCZ acting as secretary. Other 
participants involved local politico-administrative authorities, such as the mayor of Kasaji, members of civil 
society, representatives of large local churches, HCs, CODESAs, and the central zonal management team. The 
MCZ explained that, although CODESA members were from the community, they were linked to HCs and 
were part of the health framework. He stated that it was critical to include civil society leaders, who represented
multifaceted sectors of social life and did not necessarily understand how the health system worked. 
The first annual board meeting was designed to share the annual operational action plan (PAO) developed by the 
health zone. Meeting participants were requested to critique and adopt the plan. During the meeting, major 
health zone decisions were discussed, such as dividing a large HA into two areas. If the board accepted, the DPS 
would present the proposal to the MOH at the central level. Board meetings offered a forum to discuss other 
important issues, such as community resistance to vaccination. Meeting participants were expected to report 
meeting decisions to work affiliates, with the overall goal of informing all sectors working in the health zone 
about ongoing operations of the health sector.
Monthly meetings were also held with the management committee or COGE. These meetings involved members 
of the board of directors, except for a DPS representative, with the MCZ acting as president. The purpose of 
these meetings was to ensure the accountability of health zone operations, with health zone representatives 
reporting to the politico-administrative authorities, representatives of religious denominations, and members of 
civil society about achievements, HA performance, challenges faced, and proposals for future activities. During 
monthly meetings, members examined the execution of the PAO, which was broken down into quarters, 
Baseline Report 163
months, and weeks, and prepared for subsequent activities according to the PAO. They also reviewed ongoing 
activities, such as preparations for meetings, the development of reports that must be transmitted to health 
authorities, epidemiologic data submitted by HCs, and disciplinary actions to be taken against health workers. 
Health zone finances were likewise presented, including money raised, expenditures made in HAs, and staff 
changes. 
There were monthly monitoring meetings during which head nurses from all HAs submitted their monthly SNIS 
and other reports. These meetings were also attended by key BCZS supervisors, who were required to stay 
informed about data from each HA. During these meetings, monthly reports of HA service data were presented 
in relation to monthly targets, with specific services assessed and recommendations made based on the evidence. 
When the HA failed to meet targets, discussions ensued to analyze the situation, to identify the reasons for the 
gaps and strategies to prevent this from happening in the future. Health provider informants reported that these 
meetings provided a platform for ITs with more experience to share field experiences and practices, and to coach 
less capable head nurses. 
The central office held separate weekly meetings with the core management team, the entire central office staff, 
and the team monitoring epidemiologic data. The executive or core team was made up of the MCZ, the AG, the 
director of the reference hospital, the director of nursing, and the IS (zonal nurse supervisor). The BCZS 
pharmacist and a medical director of another hospital also participated. These core team members represented
the steering committee responsible for making decisions to ensure the smooth functioning of the health zone. 
The central office staff included all workers in the health zone offices, the medical director of the reference 
hospital, and the director of nursing. During the epidemiological meeting, core team members, along with zonal 
supervisors, reviewed the data collected weekly by HC head nurses. The data provided information on the 
number of illness cases treated during the week and allowed for the identification of potential outbreaks. HAs far 
from the BCZS either submitted the epidemiologic data by phone or delivered a paper form with the weekly 
epidemiologic data to another IT working in a HC where a phone connection was available. The MCZ reported 
that, generally, no fewer than 18 of the 24 HAs provided the weekly epidemiologic data, although promptness 
was a problem.
CHW coordination meetings, called CODESA meetings, were supposed to be held monthly in the HAs. The 
MCZ indicated that in each HA village, there should be a CAC comprised of RECOs associated with the HC. 
At the end of each month, a CAC representative traveled to the HC to present health information from their 
village, and ongoing activities, such as vaccinations administered or bed net distribution, to the head nurse who 
was in charge of the HA. CODESA members also participated. These sessions provided critical village-level 
information, which allowed the IT to understand the HA performance, including strengths and weaknesses, and 
to identify possible solutions to problems. Problems that the IT was unable to resolve were supposed to be 
reported to the community animator in the BCZS. CODESA members and RECOs said that they were 
occasionally included in BCZS meetings to discuss community health activities. 
Other BCZS meetings were convened when a problem needed to be addressed or a special event or intervention 
was to be implemented. All health providers stressed the importance of the meetings, indicating that they 
allowed health providers to share information and helped improve the provision of health services. Specifically, 
we were told that meetings with other health professionals served to strengthen and reorient community 
outreach; identify capacity building needs; and identify ways to strengthen the functioning of health facilities.
Accountability Mechanisms
The MZC reported that suggestion boxes were included as an indicator in the PDSS approach, and that during 
PDSS validations, PDSS evaluators checked whether a box was posted. Despite this, the evaluation team found 
that a suggestion box was only posted in the reference hospital, and not in the HCs. The clinician working in the 
hospital was the only informant familiar with a mechanism used to signal negative practices. The MCZ 
attributed the failure of HCs to post a suggestion box to negligence, and concerns about being accused of 
wrongdoing. The MCZ also noted that illiteracy was high and community members were unaccustomed to 
164 The Impact of USAID’s Integrated Health Program in the DRC
putting grievances in writing. Rather, the MCZ stated that community members typically shared complaints 
among themselves, intentionally avoiding direct confrontation. If CODESA members or RECOs heard about 
complaints, they were supposed to share community concerns with the head nurse during monthly meetings. 
Despite these obstacles, the MCZ viewed the suggestion box as a potentially effective tool to identify difficulties 
from the perspective of community members and to resolve service delivery problems.
The PDSS also provided funds for HCs to purchase a telephone, which was to be kept by the head nurse. The 
telephone number was supposed to be posted, with the goal of encouraging community members to report 
complaints or problems with health services. The MCZ reported that 24 of the 26 HAs in the Kasaji health zone 
had already purchased a phone, indicating that the final two HAs were lower performing and had not yet 
received PDSS funds. The two HCs we evaluated had purchased phones with PDSS funds, but the evaluation 
team did not observe a phone number posted. The MCZ was not aware of the hot line or green line approach, 
which involves the installation of free phone lines for community members to use to submit complaints. 
The MCZ emphasized the importance of instituting mechanisms designed to ensure health worker 
accountability, stating that the only way to improve services and to increase service use was to involve 
community members. 
Referral Systems
Informants indicated that the decision to seek health services was guided by a patient’s family members. RECOs 
may intervene when a community member was seriously ill and their family resisted or did not know how to 
seek formal healthcare. Families were responsible for transporting sick family members to the HC, which was 
typically done by motorcycle or bicycle, or if the distance was not far, by foot. In serious cases, or when the sick 
person was considered vulnerable, such as in the case of pregnant women, young children, or the elderly, 
RECOs and community members may assist by providing transport or resources for transport. According to our 
informants, when a sick person was brought to a HC, the families did not expect referral to another facility. 
Referrals were made between institutions, with lower level facilities making the decision to refer to institutions 
capable of providing more advanced care. One provider from Lueu described referrals as follows: 
Referrals are done either between health posts and health centers, or between health centers and reference health 
centers or hospitals. 
The health facility manager, such as the head nurse in charge of a health post or HC, or a doctor in charge of a 
reference HC, decided which cases to refer. Health provider informants followed two guidelines, including 
making referrals as early as possible and using referral forms called “transfer forms” (fiches de transfert). The 
transfer form was completed by the person initiating the referral and included clinical observations and the 
reason for making the referral. The form was carried by the patient’s family and submitted to the higher-level 
facility on arrival. Once again, transportation was the family’s responsibility, and if the distance was not long 
and the patient was able, the patient might walk to the facility. Some informants mentioned that RECOs 
sometimes accompanied the family. 
All participants stated that referrals were conducted when the facility did not have the capacity to provide 
appropriate care to a patient. Common reasons for referrals included pregnancy complications, acute malaria, 
conditions requiring surgery, prolonged coma, medication stockouts, and the need for blood transfusion or 
intravenous treatment. Health provider informants reported that the facility receiving the referred patient was 
supposed to send a patient health status report back to the referring facility. However, some admitted that the 
follow-up report was not always sent. 
Informants mentioned two major obstacles to referrals. First, if health personnel needed money, they might 
avoid referring patients. The second obstacle was that family members might refuse that patients be transferred 
due to cost concerns. One physician explained,
Baseline Report 165
Since we work in a system where everyone is trying to increase revenue, this means that even when it is time to refer a 
patient, the facility does not let them go because they will lose money. They prefer to keep them in the facility to 
generate more money. This is the biggest obstacle. The other obstacle comes from families themselves. If you indicate 
you want to transfer a patient, the family says ‘no, if you send us there, they will ask us for a lot of money. Seeing a 
doctor is too expensive. At the hospital, the bills are huge. We cannot go there. We do not have enough funds.’
Informants reported that a facility with the capacity to provide care for a given condition cannot refuse a referral, 
even if the patient arrived late. 
Regarding training, both nurses and community health workers had received training on referrals. Health 
professionals suggested that they learned about referrals during formal studies and did not need additional 
training. 
Healthcare Financing
PDSS activities began in October 2017. It was the major funding partner of this health zone. The project
involved PBF, with the aim of lowering service fees and increasing healthcare access. Evaluations were carried 
out every three months and health facilities were rewarded according to a performance template, which 
combined service provision and health facility improvements over time. The MCZ indicated that DPS staff 
evaluated the BCZS, reference hospital, and referral HCs, whereas PDSS staff evaluated the HCs. 
At the start of the PDSS, each HC was asked to develop a management plan, which included facility needs. The 
PDSS signed contracts with 24 HCs, which were given start-up funds of US$2,500. Health workers, CODESA 
members, and PDSS staff worked together to determine affordable service fees that would cover treatment costs. 
Treatment of simple illnesses was set at 1,500 FC, with the costs for minor and major surgery established at 
US$5 to US$10, and US$20, respectively. The MCZ felt that providing a standard amount for start-up was 
inappropriate, claiming that HC management plans were not followed. The MCZ also noted that service fees 
had not previously been standardized, and it was important to establish fixed fees. 
Initially, the reduced flat rate pricing fees decreased HC revenue, making it difficult to obtain essential supplies 
and to pay workers. In response, nurses reverted to fees used before the PDSS, causing what the MCZ described 
as a chaotic situation. The MCZ stated,
In the first month, all the structures, and I mean all the structures, whether it was the BCZS, the referral hospital, 
referral health centers or other health centers, everything was paralyzed. How was it to continue? We government 
representatives were supposed to make sure that the approach was followed and successful in improving accessibility 
to healthcare. We received a lot of criticism. At the same time, PDSS could not meet their own commitments. After 
this debacle, nurses reinstated original service fees to recoup losses. It was total chaos. The population deserted the 
facilities, and the health indicators, which had seemed to be going up, fell much lower [than before the project]. 
These are the difficulties that we experienced with PDSS.
After this initial experience, some facilities refused to implement reduced fees. The PDSS also regularly provided 
late payments, sometimes by more than six months, diminishing the ability of HCs to function. Another 
challenge mentioned was the failure of USAID IHP to provide support, especially for the provision of medicines, 
which the MCZ maintained would have reduced the negative effects of late PDSS payments. 
The MCZ reported that health facilities that performed well received large payments that could be used to 
improve infrastructure and services, and to motivate health workers, indicating that 50 percent of payments were 
intended for operational costs and 50 percent were reserved for health provider bonuses. For example, the MCZ 
said that the BCZS could receive US$8,000 per quarter. The money was used to purchase motorcycles for 
supervision, construct a large depot to store medications, rehabilitate offices, and obtain critical office 
equipment. The reference hospital received US$15,000 to US$20,000 per quarter, which was used to buy 
essential medical equipment; and HCs received up to US$6,000 each quarter. However, the MCZ stressed that 
the initiative continued to be hampered by late payments, making it difficult to convince head nurses about its 
166 The Impact of USAID’s Integrated Health Program in the DRC
merits. The MCZ also mentioned that the PDSS prohibited the BCZS from receiving a small percentage of the 
health facility revenues, an approach previously used to purchase critical supplies, such as fuel to carry out 
supervision visits, money to repair motorcycles, or small bonuses for staff. 
As to the payment of health service fees, the MCZ stated that the zone promoted the provision of treatment, even 
if patients lacked money. When treated on credit, patients may be asked to leave material goods, such as clothes,
as a guarantee of payment. The MCZ maintained that treating on credit, combined with late PDSS payments, 
prevented health workers from purchasing medications and supplies needed to provide care. He stated,
Our philosophy is to first treat and save lives and the money comes after. We hoped that the PDSS would quickly 
compensate in situations when people cannot pay. We expected them to tell us to treat first and that we would 
regularly get reimbursed. But this is not the case. Head nurses are forced to pay for drugs, and when the PDSS makes 
payments, it is too late. There are periods when nurses are unable to purchase the drugs and supplies needed to treat 
other patients. The health providers become blocked [cannot purchase medicines or supplies] because the 
payment is too late.
The MCZ claimed that the PDSS was impeding the proper functioning of the health zone and influencing the 
decline of key indicators. 
Health worker informants provided somewhat different information, with Methodist HC and referral hospital 
informants indicating that before the PDSS, higher service fees deterred care-seeking from facilities and that fee 
reductions had increased the use of healthcare. When talking about the PDSS, one hospital provider said,
It’s effective because the project compensates health workers. Health facilities, in turn, lower the cost of care. As a 
result, patients are coming to facilities. Now they easily accept to see a doctor for 1,500 FC. It’s not too much of a 
burden, compared with paying 20,000 FC to see a doctor in larger cities.
Lueu reference HC appeared to follow different standards, reverting to higher fees, and forcing patients to pay 
before consultations. Health provider informants from the different health facilities mentioned that the PDSS 
provided funds for the care of vulnerable population members. 
Regarding PDSS service acquisition, several providers raised objections, maintaining that some services were not 
included, and in some cases, compensation was inadequate. Other weaknesses commonly identified by our 
health worker informants included late payments, lack of flexibility, and the fact that the approach favored better 
skilled workers. Informants reported the PDSS had developed deterrents for corruption, indicating that a facility 
accused of fraud was penalized with a 50 percent reduction in PDSS funds. Additional transgressions were 
considered a breach of the contract, and the person in charge of the facility was replaced. 
Aside from the PDSS, there were no other health financing initiatives. The MCZ mentioned efforts to implement 
health mutuelles for health clinicians, but participants were unwilling to contribute regularly and the approach 
was unsustainable.
Facility-Based Human Resources
The MCZ started working in the health zone in 2013. The BCZS also had an AG, an IS, a pharmacist who is not 
formally trained, and supervisors for several technical areas, including vaccinations, nutrition, leprosy, TB, and 
malaria. Including support staff, such as drivers and security guards, the office had 16 staff, exceeding the 
government standard of 10 staff per zonal office. The MCZ explained that it was impossible for the IS to cover 
all technical areas in a timely and quality manner, forcing the BCZS to hire ITs working in the zone as technical 
supervisors. The MCZ added that the DPS sometimes assigned people to the zone, duplicating positions already 
filled and making it difficult to adhere to the government norm of 10 staff per zonal office. 
In each HA, there was an IT (A2), an ITA (A2), a laboratory assistant, and five traditional birth attendants. In 
Lueu, there were two physicians. At the Methodist HC, there was a nurse (A3) who took care of the pharmacy,
and in Lueu, there was a nun in charge of the pharmacy and the cash register. Neither HC met government 
Baseline Report 167
standards for an urban HC. As mentioned earlier, the reference hospital had 104 staff, with about 20 nurses and 
only two physicians. 
Training
Health professionals and CHWs recalled receiving training in recent years on revitalizing CPN, immunization, 
FP, TB, leprosy, and HIV/AIDS. Village leaders were unaware of the training that health providers had 
received. Informants noted that training on CPN revitalization and HIV/AIDS treatment were particularly 
useful, strengthening their capacity to provide comprehensive CPN activities and up-to-date HIV/AIDS 
treatment. Informants also mentioned that in 2018, the CODESA received training as part of efforts to revitalize 
community-based activities. Informants reported receiving recent training on treatment of severely malnourished 
children, nutrition surveillance, and awareness raising. All informants mentioned the urgent need for capacity 
building of health personnel, with several noting that many health workers were not adequately qualified. One 
health provider from Methodist stated, 
We need a lab worker who is competent. Building capacity for our lab worker is the first thing we need. Moreover, the 
midwives in the maternity ward need training; if possible, we would like qualified personnel instead of matrons 
without any qualifications. The maternity offers a critical service. 
The MCZ reported that in 2019, health workers received training sponsored by the Neglected Tropical Disease 
program on treatment of filariasis. He also mentioned that in 2018, PROSANI Plus trained head nurses, 
members of the BCZS, and the DPS on the iCCM sites.
Supervision 
The MCZ said that HAs were supposed to be supervised by BCZS core team members once a month. 
Emergency visits can also be made during outbreaks. Supervisors followed general objectives, with more specific 
terms of reference established monthly according to information presented during monitoring meetings. During 
HA supervision visits, supervisors may visit iCCM sites or health posts, or make unannounced visits to other 
facilities en route to HCs. Although the BCZS team was responsible for supervising nurses and their teams, the 
head nurses supervised the CHWs. However, if community activities were facing problems, the BCZS team 
might talk to RECOs.
Before the PDSS, BCZS staff supervised the reference hospital. However, because hospital administrators were 
also part of the BCZS executive core team, supervision responsibilities were transferred to the DPS. We were 
told that DPS supervision visits were irregular, sometimes occurring after six months, which prevented the 
BCZS from staying informed about hospital activities and delaying the submission of PDSS evaluation reports 
and performance-based payments. The MCZ indicated that central-level MOH representatives and technical 
program officials also conducted supervision. IPs might accompany them, but IP staff cannot supervise. 
All facility-based informants reported being supervised by BCZS staff once or twice monthly, stating that 
supervision entailed a review of registers and documents related to curative care, laboratory services, CPN, CPS, 
immunization, and finances, followed by a series of questions posed to health providers. Health providers 
explained that supervision visits informed recommendations given at the end of the supervision visit. Our health 
worker informants confirmed that supervision carried out by the BCZS did not involve community health 
activities. Rather, they said that RECOs were supervised by the IT, who carried out home visits to validate 
whether RECOs visited households and conveyed messages effectively. We were told that the ITs used this 
information to strengthen community activities. 
Information Available
All informants reported that they were able to obtain information that strengthened their ability to work. 
Information sources mentioned included television, radio, newspapers, health-related documents, and data 
168 The Impact of USAID’s Integrated Health Program in the DRC
collected during outreach activities carried out by RECOs. Informants also mentioned receiving results of 
research examining the provision of health services in Lualaba province. All informants stated that research on 
health service delivery was helpful because it identified care-seeking challenges and problems that health facilities 
confronted in the provision of healthcare. They emphasized that the healthcare system was dynamic, and that 
updated information was essential to improving the quality of care. 
Health Provider Attitudes 
All informants reported that health providers were generally respectful toward patients and provider-client 
relations were good. However, several informants mentioned that some health providers occasionally exhibited
anger or annoyance with patients, which was shown by refusing to answer questions, responding curtly,
interrupting before a patient had finished asking a question, or providing routine responses that failed to address 
the specifics of the situation. Some informants suggested that providers frequently made assumptions about 
caregiver or patient knowledge and behavior. Informants mentioned fatigue, insufficient medical training, lack of 
training on health provider-patient interactions, poor remuneration, and difficult work conditions as the main 
reasons for negative interactions with patients. 
Most informants indicated that all patients were treated the same, irrespective of their health conditions and 
socioeconomic backgrounds. The majority said that gender had no influence on the provider-client relationship. 
Although most informants reported no differences between male and female providers, some stated that men 
complained less and that women were less adaptive to difficult work conditions. Age was believed to affect 
provider-client interactions, with young health providers viewed as inexperienced and, therefore, less capable of 
providing quality care. 
Informants emphasized that health providers should be humble and compassionate when interacting with 
caregivers and patients, indicating that negative behaviors led to a decrease in the use of health services. Some 
noted that the causes of bad behavior or attitudes, such as those associated with health worker education or 
motivation, were difficult to change. Most informants had never participated in a training or formal discussions 
about the importance of health provider attitudes and behavior when administering care.
Focus group participants, who were caregivers of children under five years of age, maintained that HC personnel 
were welcoming, friendly, and respectful, and provided rapid and effective treatment. 
Health Worker Motivation
The sources of motivation mentioned were income generated through monthly revenue, bonuses (primes), an 
understanding of the population and their health needs, and passion for their work. One hospital clinician said, 
If I tell you what we get, it’s nothing, really nothing. What motivates us primarily is our passion. When one is 
passionate about the work they chose, even when they get little money, they stay (with the work). Some of our 
colleagues who are doctors flee shortly after they have arrived. Here, the consultation fee is 1,500 FC. How many sick 
patients do you have to see to make a living? You need to be passionate about your work to stay here. 
The MCZ stated that only four of the 400 health workers in the health zone received a government salary, 
explaining that these health providers were older and were enrolled decades earlier in the national payroll. The 
MCZ indicated that all other health workers, including himself, received only a government bonus. Due to 
inflation, government bonuses had been significantly reduced, with most workers receiving small sums (the 
MCZ mentioned US$5 or less). Because health workers did not receive regular payments, they were forced to 
rely on facility resources and monthly revenue made through user fees, which the MCZ reported was about 
500,000 to 600,000 FC in the Lueu reference health center, and 200,000 to 300,000 FC in most HCs. Facility￾based informants said that ITs and ITAs received about 45,000 FC and 30,000 FC, respectively, with other 
nurses receiving 15,000 to 25,000 FC monthly. Health personnel argued that it was not possible to replace 
salaries with health facility funds, which they described as insignificant. A hospital informant said, 
Baseline Report 169
What we make for a visit is low. Only if we carry out many surgeries, which gives us a little breather and increases 
the resources. If you are 28 personnel and at the end of the month you have 500,000 FC, you divide that by 28. You 
give 20,000 FC, 18,000 FC, 15,000 FC, what is somebody going to do with that? These workers have children. They 
need to pay their bills, their rents, they need food and clothes. When there are real deficits, we take from the medicine 
account to compensate workers’ pay a bit, to motivate them. Otherwise the system would not function.
All informants reported being underpaid, stating that their work performance would only improve with an 
increase in renumeration. The MCZ emphasized that physicians working in rural areas suffered because they 
were unable to generate supplementary income by providing advanced care, indicating that they frequently left 
their posts to seek more profitable work in cities. He stated,
Particularly us, the chief doctors, the doctors working in the bush, we suffer a lot. When you are in a city you can do 
a cesarean, and you get money, you can get three hundred dollars. You do another procedure like an appendectomy, I 
don't know, you can get two hundred or I don't know how many dollars, but here in the village, if somebody has 
appendicitis, you many receive twenty thousand [FC] or you are given God’s blessing as compensation. How can 
you make ends meet at the end of the month? Why must we suffer when we studied to lead good lives.
Virtually all informants said that they lacked opportunities for career advancement and that there was an urgent 
need to strengthen health worker capacity. 
Health Workers’ Perceptions of Health Service Quality
Informants from both HCs reported multiple factors that negatively influenced health service quality. The most 
common obstacle was ongoing drug stockouts, especially during the rainy season when nurses must travel by 
motorcycle to Kolwezi to obtain medications. Lueu informants said that some nurses had been injured making 
the journey. Methodist health workers indicated that the lack of electricity affected their ability to provide quality 
care. They also mentioned having inadequate personnel to deal with recent increases in the use of healthcare. 
Lueu providers reported insufficient skilled workers and a decrease in the use of healthcare and facility revenue, 
which affected the quality of care. Our data showed that Lueu charged high service fees; the HC also required
patients to pay before treatment and to purchase medications. According to informants, these factors were 
pushing patients to go to Methodist, where services were cheaper and the quality of care was perceived to be 
better. 
To improve the quality of care, some Lueu informants recommended the renegotiation of the PDSS health 
service fees and not requiring payment before treatment, which would increase health service use, increase 
revenue, and impact monthly wages. Informants from Methodist HC recommended that the Congolese 
government provide support to purchase a refrigerator and reinstall electricity. 
Direct Observations (of Treatment)
The Methodist HC and the reference hospital had waiting rooms for sick patients, whereas in Lueu, a veranda 
served as a waiting area. Only the waiting room in the hospital was described as clean and tidy. The hospital had 
educational materials, such as posters displayed on the waiting room walls, whereas the other facilities did not 
display such materials. Most child guardians arrived at the facility before the health provider. In the HCs, sick 
children were consulted on a first-come, first-serve basis, whereas in the hospital, children were prioritized 
according to the severity of their conditions. No sick child was sent home without receiving treatment, but one 
caregiver in the Methodist HC was required to leave a piece of cloth (pagne) as a guarantee that she would pay 
for treatment later. 
Providers greeted all parents, asked for the children’s names, and collected background information on the illness 
inception and signs and symptoms. Although all providers asked about fever, questioning about cough and 
diarrhea was inconsistent, especially by the medical doctor in the reference hospital. HC nurses did not always 
inquire about treatment that had been given before the child came to the health facility. All providers determined 
the age and weight of each child, did a physical examination, and followed a treatment protocol to diagnose the 
170 The Impact of USAID’s Integrated Health Program in the DRC
disease and prescribe treatment. Health providers did not consistently explain the diagnosis, and in two 
instances, the nurse did not explain the treatment. Half of the caregivers observed in Methodist HC and most 
parents observed in the hospital were given a prescription after the consultation to purchase medicine. Most 
health workers provided counseling on appropriate child feeding and instructed parents to return immediately to 
the health facility if symptoms worsened. In several instances, the health providers failed to confirm whether the 
parent understood the diagnosis and the home treatment. Only the doctor asked whether the parent had any 
further questions. Although only one of the 13 caregivers asked questions of the provider, all parents appeared to 
understand the information provided. 
Providers were observed to be respectful, engaged, and friendly. All consultations at Methodist and at the 
reference hospital and half of the consultations at Lueu were carried out in privacy. The consultation rooms in 
Methodist and Lueu were described as unclean, whereas at the hospital, the environment was observed to be 
clean. Fee schedules for health services were displayed at the facilities. Other information about the waiting 
areas is provided in Table 4.6.
Table 4.6. Results from observations of health provider-client interactions
Methodist HA
1 provider; 
OBSERVATIONS
Lueu HA
1 provider; 
OBSERVATIONS
Reference Hospital
1 provider; 
OBSERVATIONS
Average age of 
providers observed 
45 56 35
Title A2 A2 Medical Doctor
Years of experience 
in this position
15 28 06
Training received 
on childhood 
illnesses beyond 
formal training
2017 and 2018 on acute 
respiratory infections, 
diarrhea, and malaria
2018, without specification 
of what childhood illnesses
None 
Waiting room and triage
At the hour that 
treatment services 
were open, were 
caregivers waiting 
to see the health 
worker? 
In 3 of 4 instances, parents 
had to wait for the provider.
In all cases, parents had to 
wait for the provider.
In 4 of 5 cases, parents 
had to wait for the 
provider.
Is there a 
designated waiting 
room for caregivers 
and sick children?
Yes, there was a waiting 
room for sick children.
No, there was no 
designated waiting room for 
sick children.
Yes, there was a 
designated waiting room 
for sick children.
Was this area 
separate from the 
area where well￾baby services are 
carried out?
Yes, the waiting room was 
separate from the well-baby 
visit area. 
No, the waiting room was 
not separate from the well￾baby visit area. 
Yes, the waiting room was 
separate from the well￾baby visit area. 
Were there seats 
available and were 
there enough seats 
for all of the 
caregivers and 
patients? 
Yes, there were seats 
available and enough seats 
for all caregivers and 
patients. 
Yes, there were seats 
available and enough seats 
for all caregivers and 
patients.
Yes, there were seats 
available and enough 
seats for all caregivers 
and patients.
Baseline Report 171
Was triage 
performed to ensure 
that most serious 
cases were 
examined first? 
No triage was performed. 
No triage was performed
Yes, triage was 
performed.
Did caregivers have 
to wait more than 
15 minutes before 
the child was seen 
for treatment? 
No, the parents did not have 
to wait. No, the parents did not 
have to wait. 
No, the parents did not 
have to wait. 
Was the waiting 
area clean and 
orderly? 
No, the waiting room was 
not clean. The veranda where people 
wait is clean.
Yes, the waiting room was 
clean and tidy.
Were there 
educational 
materials such as 
posters on walls of 
the waiting area? 
No, there were no 
educational materials 
displayed on the walls in the 
waiting room.
No, there were no 
educational materials 
displayed on the walls in 
the waiting room.
Yes, there were 
educational materials 
such as posters displayed 
on the walls in the waiting 
room.
Were sick children 
(other than those 
who were seen 
earlier due to the 
seriousness of their 
case) seen in the 
order that they 
arrived in the health 
center?
Yes, the four children 
observed were seen on a 
first come, first serve basis.
Yes, the four children 
observed were seen on a 
first come, first serve basis.
Yes, the five children 
observed were seen on a 
first come, first serve 
basis.
Were any 
caregivers/children 
sent away without 
being treated? 
No, all children were 
consulted. 
No, all children were 
consulted. 
No, all children were 
consulted. 
Community Health Services
Infrastructure 
Informants stated that CODESA members and RECOs were the CHWs who provided critical links to 
community members. We were told that RECOs carried out home visits to identify sick children and to sensitize 
parents about preventive care for immunization, use of bed nets, hygiene and sanitation, handwashing, and 
appropriate dietary intake. Some informants suggested that CHWs were mostly involved in campaign activities, 
such as vaccinations, and failed to perform routine community outreach activities. The MCZ said that in the 
past three years, UNICEF had done training as part of efforts to restart community activities, with the goal of 
ensuring that one trained RECO was posted in each village. Despite this, many villages lacked RECOs, with the 
MCZ explaining that poor motivation led to high attrition. In general, informants maintained that CHW skills 
were lacking and that extensive capacity building was needed to improve their performance. Some informants 
mentioned that CHWs were not fully aware of their roles and responsibilities. Informants also mentioned that 
poor motivation discouraged CHWs from fulfilling their roles. 
Informants reported that IT involvement in community activities included supervision of RECOs, awareness 
raising on specific health issues, especially during times of epidemics, and monitoring activities during 
172 The Impact of USAID’s Integrated Health Program in the DRC
vaccination campaigns. Informants mentioned that nurses trained and oriented the RECOs, but they were not 
aware of ongoing monitoring of community-based activities. 
CHWs reported sharing health-related information during CPN and CPS visits; most indicated that the messages 
did not change. Although aids, such as flip charts, were available in the HCs, CHWs said that some materials 
were in poor condition. One hospital informant highlighted the need to translate messages, which are in 
Kiswahili, into the local language, stating, 
To improve messages, we should translate them into local languages. Many people do not speak Swahili. They speak 
Kikatchokwe and Runde. For them to understand, one needs an interpreter. So, in remote places like here, these 
messages should be translated in the local language, so they can read them on their own. That’s what I hear a lot, 
especially from women. 
Half the informants, including the RECOs, reported never participating in community discussions. The MCZ 
maintained that community discussions were not held. Those who had been involved mentioned that 
discussions focused on the treatment of diarrhea, vaccination of young children, and placing children under a 
mosquito net at night. The data collection team did not gather information on community-based discussions 
from participants. Focus group participants stated that they received health information from nurses and CHWs 
during CPN and CPS visits and treatment consultations, and from RECOs during household visits. Some 
mentioned receiving health messages from the radio or television or in church. 
Informants stated that community-based organizations did not exist; no informant had heard of champion 
communities. The MCZ indicated that in February 2018, and under the auspices of the PROSANI predecessor 
project, the health zone installed iCCM sites in 15 HAs, with all sites located at least five kilometers from health 
facilities. The MCZ explained that the approach was designed to facilitate the administration of first aid 
treatment to sick children before they could reach a health facility. The MCZ stated that two RECOs were 
trained to manage each site, with RECOs responsible for monitoring the health of children between two months 
and 59 months of age living in proximity to the iCCM site. The project provided medicines, such as 
antimalarials, antipyretics, ORS, and zinc, and basic supplies, such as a thermometer, a scale, height measure, 
jerry cans, a basin for handwashing, and small cupboards for storage of medications. The MCZ also mentioned 
that RECOs were responsible for producing ongoing progress reports, which they submitted to the DPS. With 
the end of PROSANI Plus, the distribution of drugs and supplies, including reporting forms, to the iCCM sites 
decreased. The pressure to perform well and submit reports also declined, leading to the discontinuation of many 
iCCM sites. During our evaluation, many HA informants were unaware of the iCCM approach and its sites. 
Those informants who knew about iCCM activities mentioned frequent stockouts of medicines, lack of transport 
to get sick children to HCs, insufficient training of RECOs to carry out the work, and high turnover and absence 
of RECOs to oversee the iCCM sites. 
System Design
Role of CODESA Members
Informants reported that CODESAs were a bridge between the community and the health facility, and that it 
provided oversight of health facility activities. One CHW informant from Methodist explained, 
In my opinion, CODESAs have an essential role in knowing whether the center receives a lot of sick patients, how they 
[the patients] are treated, and for how much. Is the official price applied? The CODESA President is like the president 
of a parents’ committee. Between parents and the school, there is a president, since parents cannot go to school, they 
must go through the committee. This is how it works with CODESA. 
Fewer informants stated that CODESA members supervised RECOs. Surprisingly, one RECO did not know the 
role of CODESA members in his HA. 
Regarding training of CODESA members, most informants could not recall any recent training, indicating that 
CODESA members received minimal technical support. Informants from the Methodist HA mentioned regular 
Baseline Report 173
monitoring meetings involving CODESA members and RECOs to assess community activities. In Lueu, 
meetings designed to monitor community activities appeared to be infrequent. 
In the HAs evaluated, we identified one female CODESA member who was the CODESA president in the 
Methodist HA.
Role of RECOs
Informants indicated that RECOs were responsible for carrying out household visits to identify sick children, 
pregnant women, and people with disabilities, and to refer community members to the HCs for treatment and 
CPN. Their work also involved awareness raising around key health topics, such as maintaining good hygiene 
and disease prevention, assisting with routine vaccination and mass immunization campaigns, and informing 
facility workers about health behaviors and care-seeking practices of community members. 
Informants’ estimates of active RECOs were inconsistent; informants from the Methodist HA reported 22 to 40 
RECOs, whereas in Lueu HA, they mentioned anywhere from 12 to 33 active RECOs. Of the active RECOs, 
Methodist informants said that more than one-quarter were female, whereas most Lueu informants suggested 
that there were no female RECOs. One Lueu informant explained that the low number of female RECOs was 
influenced by spousal opposition, which he described as follows: 
It’s due to their husbands. You see, villages are different from cities. In villages, men are so complicated. A man 
cannot let his wife move around freely or go to other villages to conduct outreach. This can end a marriage. This is 
why we are not very interested in enrolling more women. 
As for recent training, capacity building workshops in Methodist HA and a training on nutrition for Lueu 
RECOs were mentioned. 
All informants reported that RECOs maintained positive relations with community members, with some noting 
that, as community representatives, RECOs must be respectful and supportive. Several mentioned that the 
RECO work activities, which involved identifying sick patients in their homes, accompanying them to HCs, and 
mobilizing community members who were reluctant to seek care in facilities, demonstrated their compassion for 
the community. Some emphasized that maintaining trust and respect were central to the RECO role, pointing 
out that, otherwise, community members would disregard awareness activities and efforts to improve health 
behaviors. Informants said that community members followed the advice provided by RECOs, which they 
considered a testament to the trust established. One village leader from Methodists HA said, 
I think the RECOs have a good relationship with communities. I have seen, on multiple occasions, that people give 
the RECOs gifts [out of appreciation for their work]. One thing I see a lot is that certain church goers don’t like 
them very much, particularly the Apostolo and Kitawala groups, who refuse mass vaccination. Apart from them, 
RECOs are well appreciated.
Specific Services Offered
Mosquito Nets
Most informants reported involvement in the distribution of bed nets, which were distributed monthly during 
CPN and CPS visits and in the maternity. The last mass distribution of bed nets was conducted in 2016, and 
although the MCZ said that a bed net campaign was carried out in other provinces in “grand” Katanga in 2018, 
Lualaba was excluded. The MCZ noted that mass distribution was important to ensure widespread bed net 
coverage. Regarding eligibility, study informants reported that they were pregnant women attending CPN, 
women who delivered in the maternity, and children under five years of age attending CPS. The major challenge 
mentioned to achieving high coverage was that mosquito nets were insufficient to meet the population’s needs. 
One Methodist village leader informant said, 
174 The Impact of USAID’s Integrated Health Program in the DRC
This is the problem–even if the State provides mosquito nets, they don’t get to everyone. The population is very large. 
There will always be a challenge. Some will get it, others will not. You will see that in one household, there may be 
10 people. The nets are insufficient, which triggers a lot of negative rumors in the community.
All informants said that mosquito nets were set up in households and used correctly, as confirmed by RECOs 
during home visits. Some maintained that recently distributed bed nets were made of a lighter material, 
preventing people from using them as fishing nets. Unfortunately, the evaluation team did not ask focus group 
participants when they last received mosquito nets. All focus group participants from the Methodist HA claimed 
to have a mosquito net, which they used to protect their children from malaria. 
Vaccinations
Informants reported that vaccinations were administered during routine services offered to pregnant women and 
young children at health facilities or during outreach services in remote villages. HAs were supposed to carry out 
at least two routine vaccine sessions each month, one in the facility and one in an HA community. The MCZ 
said that only some HAs had a refrigerator to maintain the cold chain, which they shared with neighboring HAs. 
He also indicated that high vaccination coverage required four monthly sessions, noting that vaccine coverage in 
the zone was low due to limited outreach activities, adding that outreach was easier in urban HAs, such as 
Methodist. Vaccines were also administered through campaigns that were held twice a year, generally in April 
and September, for specific diseases affecting children, such as measles or polio. Mass campaigns were 
dependent on donor support and involved all levels of the health system, with RECOs playing a key role in 
vaccine administration. 
Challenges to vaccinations mentioned included stockouts, the fact that many community members lived in hard 
to reach areas, and resistance by parents. The village leader from Lueu said, 
The challenges we face are with parents. Some do not like to send their kids [for vaccines]. They may say that 
vaccines trigger disease, or that the child’s blood will be drained out. Others ask us if we ourselves vaccinate our 
children. Some say vaccines are a white man’s strategy to exterminate our children, as Herod did in the Bible. Many 
of those who resist are practicing Kitawala and Apostolo parishioners. 
Other informants reported that resistance was declining, as this health worker from Lueu said,
Because vaccinations are free, the community had a bad perception. Thankfully, [this perception] is slowly 
disappearing due to epidemics such as measles. Before people thought that the vaccine would cause disease in 
children. When we had a measles outbreak recently, everyone understood its [the vaccine’s] importance. Children 
without the vaccine developed complications from measles and some even died. Only a few reluctant religious groups 
such as the Apostolo and Kitawala are still resisting vaccination.
The village leader from Methodist said,
There were many challenges before, but now people are starting to adapt and bring their children to get their shots. 
Before, there was resistance. People would say that the vaccine causes disease. But thanks to outreach efforts, some 
people have started to vaccinate their children and they can see for themselves that, even if their vaccinated child gets 
sick, it is not as serious as it is in children who aren’t vaccinated. So, people understand that vaccines are a good 
protection. 
Focus group participants mentioned that they were required to pay a fee for the CPN and CPS form before 
receiving vaccinations. Unfortunately, the data collection team did not collect other information from focus 
group participants on vaccinations.
Baseline Report 175
Community Worker Motivation 
CHWs unanimously reported that love for their work and dedication to serving their communities motivated
them, with some noting that from the outset, they knew the work was voluntary. Several maintained that 
continued involvement in the work signified that they were satisfied, whereas those who did not enjoy the work 
quit. CHW informants mentioned that training and educational materials would enhance their effectiveness as 
community agents. 
The MCZ stated that stipends provided during vaccination campaigns motivated the CHWs. He also indicated 
that some ITs gave free healthcare to RECOs. The MCZ said that some projects provided benefits, such as 
bicycles (a project funded by the U.S. President’s Emergency Plan for AIDS Relief) and small stipends, which 
the PDSS gave to CODESA presidents for their involvement in the management of HC funds. 
USAID Projects in the Area
In 2016, the health zone received some assistance from the PROSANI predecessor project for the treatment of 
HIV-positive cases. According to the MCZ, antiretrovirals were going to expire and PROSANI leadership 
needed to distribute the medications quickly. In 2018, PROSANI Plus provided training for the installation of 
iCCM sites and materials, including kits and drugs that RECOs needed to manage the sites. 
Starting in 2019, USAID IHP began funding meetings, such as monthly monitoring reviews and one biannual 
board of directors meeting. USAID IHP also supported work on HIV treatment and the organization of data 
evaluation and validation meetings on malaria. USAID IHP was also providing funding for the PBF activities. 
However, the MCZ claimed that USAID IHP had not fulfilled many promises, especially for the provision of 
medications, which they had promised to deliver from the CDR to the health zone. Other promised activities, 
such as TB treatment work, likewise never came to fruition. The MCZ believed that USAID IHP was mostly 
supporting health zones in proximity to Kolwezi and neglecting more remote zones. The MCZ said, 
PROSANI amazes me. If we had met in Kasaji, I could have shown you the commitments that USAID IHP made, 
which included provision and transport of drugs. There were a lot of other things, but I'm most interested in the 
medicine. Before I left, they had only supported the board meeting and the data validation meeting as part of PNLP
[National Malaria Control Program]. This is good, but it does not solve the biggest problem, which is drug supply.
Other informants were not aware of previous USAID-supported activities in the health zone. In Methodist HA, 
health providers and community agents had heard of the USAID IHP project, with some indicating that the IT 
participated in a briefing about the project in the BCZS. However, they were generally unaware of the nature of 
future activities or whether interventions had begun. A nurse said, 
Indeed, I have heard of the PROSANI Project, but I don’t know the reality. I have never participated in any meetings. 
In our health area, it is the very first time we’ve spoken with the project’s delegates [meaning the evaluation team]… 
I’ve heard that a project arrived, they conducted a briefing in the central offices with the head nurses, but I did not 
attend. 
One RECO suggested that the project supported nutrition activities and provided malaria supplies, stating, 
We received a delegation that came to train the head nurses in nutrition. After the training, we received some products 
for nutrition activities. After that, we received rapid malaria tests, and the injectable artesunate. We were told it was 
PROSANI that was supporting us with these medicines. 
In Lueu, informants had heard of a USAID-funded project that would provide support to their facility, but they 
had not attended any meetings about the project and were not even aware of the project name.
Hospital informants affirmed that they knew about a USAID-funded project called "PROSANI,” which had 
supported training in nutrition and provided supplies for the treatment of malnourished children. 
176 The Impact of USAID’s Integrated Health Program in the DRC
Summary and Implications
Summary
The purpose of the study was to assess baseline levels of health governance and leadership, service readiness,
and service quality as part of an evaluation of USAID IHP. The empirical results were based on surveys of 
provincial health offices (n=6), health zone offices (n=113), HCs (n=328), hospitals (n=110), and health 
workers (n=1,213). We also used data from Abt Associate’s baseline household survey to characterize the 
care seeking experience and level of participation in health services among women of reproductive age.
The empirical findings were supplemented by interviews with 20 key informants at central and provincial 
levels, including MOH representatives (n=7), USAID IHP senior staff (n=6), USAID staff overseeing USAID 
IHP (n=3), and collaborating partners (n=4), to understand their perspectives about the project and the various 
health systems challenges that need to be addressed in the DRC. We also carried out an in-depth, qualitative 
investigation in two health zones in the Lualaba province, one that had received extensive support from the 
USAID IHP predecessor project and another that had received sup In each health zone, we administered a 
mix of qualitative research methods including key informant and in-depth interviews, observations, and focus 
group discussions. Data collection involved in-depth interviews with health center nurses (4), members of the
health development committee (4), community health workers (4), village chiefs or village chief representatives 
(4), reference hospital physicians (2), hospital or BZCS managers (2), and an acting health zone medical 
officer; key informant interviews with the MCZ (2); observations of health infrastructures (6) and health 
worker-client interactions (40); and focus group discussions with caregivers of children under five years of age 
(4). port for specific activities such as iCCM.
Both the empirical and qualitative analyses suggest that the government-run health system faces myriad 
challenges at both the health zone and facility levels to effectively plan, implement, and monitor services. At 
the health zone level, respondents mentioned several problems with communication and supervision that 
constrain the ability of health zone offices to effectively coordinate and manage health activities.
Communication problems include the limited and interrupted availability of electricity, lack of office cell 
phones, and limited Internet availability and credit. Health zone office respondents reported the lack of 
telephones and Internet to be the two most important barriers to the timely reporting of disease surveillance 
(MAPEPI) data and to receiving timely reports from HCs. In terms of supervision, MOH guidelines stipulate 
that health zone offices should receive external supervision from the provincial level at least once every three 
months, but only half of the offices mentioned being visited by a representative of a provincial health office in 
the three months before the survey. Health zone offices are also supposed to provide external supervision to 
hospitals through visits at least once every three months, but fewer than half of the hospital respondents 
reported being visited by a representative of a health zone office in the three months before the survey. 
At the facility level, most HCs do not offer the full minimum package of services because a relatively low 
percentage of facilities offered FP services, CPS, and minor surgery at HCs. For those services that are offered, 
we uncovered several issues with service quality and financial accessibility. Service quality problems include 
stockouts of medicines and supplies, the frequent use of unregulated medicines, lack of basic equipment, very 
low availability of electricity (especially at HCs), and many providers having inadequate knowledge about how 
to properly offer the standard of care for treatment of diarrhea and the provision of ANC and FP services 
(demonstrated through the data collected using provider vignettes). Qualitative data also show that HCs are 
hiring local community residents who have not received formal training to provide services. In terms of 
financial access to services, indigent fee schedules were found to be lacking, and facilities reported using other 
strategies when patients cannot pay, including having family members work at the health facility and allowing 
families to pay at a later date. Health workers rely on user fees as a source of income; therefore, staff may not 
be incentivized to reduce or waive fees. Problems with reporting SNIS data were also common, with 
Baseline Report 177
qualitative data suggesting that the lack of phone credit and access to the phone network force facilities to 
deliver hard copies of surveillance reports, which causes delays. Lack of paper forms and transportation were 
also mentioned as barriers to reporting on time. 
Problems with the availability and motivation of health workers at hospitals and HCs were also identified. 
Most health facilities have staffing levels that are well below MOH guidelines, and most health workers 
interviewed reported not being satisfied with their jobs due to low remuneration and poor working conditions.
The findings from the key informant interviews at the central level and in Lualaba province provide rich 
insights on several leadership and governance issues in the health system. Based on their wealth of experience 
developing and implementing health service delivery programs, and in HSS, informants consistently described 
the national health system strategy as well-conceived and organized, and encompassing key elements. 
However, there is universal agreement that many facets of the health system are not being implemented as 
planned. Underfinancing, mismanagement of resources, and poor governance are seen as the primary 
obstacles contributing to low use and quality of health services.
When asked to describe the USAID IHP approach, key informants from USAID and USAID IHP mentioned 
that malaria programs will be executed across all health zones (178) in USAID IHP-supported provinces, but 
that the implementation of the other programs will vary according to the availability of resources, local needs, 
and ongoing activities of IPs. The project will concentrate efforts on geographic areas to increase synergy with 
other USAID programs and improve overall project impact, increasing its potential to improve the quality and 
content of health service delivery across health zones. 
The funding of USAID IHP through a contractual agreement between USAID and Abt Associates is intended 
to provide USAID with ultimate decision-making power and technical oversight of project development and 
implementation, and the use of funds, whereas Abt Associates is responsible for the execution of activities and 
ensuring that indicators are followed and results are achieved. However, some informants raised concerns that 
the restrictive nature of the contract and USAID IHP’s approach will limit the ability of government personnel 
to lead project development and implementation, and to take ownership of HSS. Abt Associates 
representatives and USAID IHP collaborating partners also expressed frustration that they are simply playing 
the role of implementer but have little decision-making power. 
Informants described USAID IHP as a complex project comprising many interventions and actors, with 
several informants commenting that the project is overly ambitious in relation to the multiple challenges 
plaguing the DRC health system. Commonly cited problems include many of those mentioned above: poor 
health information systems affecting data quality and reporting, irregular provision of quality medications, low 
motivation of health workers linked to poor remuneration and work conditions, and rampant corruption and 
mismanagement of funds that infiltrate all levels of the health sector. Some respondents also mentioned 
problems with the DRC’s community strategy, notably that CODESAs and RECOs are not performing their 
roles and that cultural practices and beliefs among community members are major obstacles to seeking care at 
formal healthcare facilities. 
Findings show that MCZs are frequently physically absent from their posts. Staffing of health personnel does 
not meet government standards, with health centers often using untrained workers to provide medical care. 
Health centers are often small, and facilities are frequently poorly constructed, in disrepair, and lacking key 
equipment and supplies. Stock-outs of essential medications are common, forcing health workers to restock 
often with unregulated drugs or to give patients prescriptions to purchase drugs in local pharmacies. A growing 
number of private pharmacies selling unregulated drugs allows people to self-treat before seeking professional 
care. Community members often seek treatment with traditional healers who provide remedies that can 
interfere with medical care and cause harmful health effects. 
Health workers rely primarily on monthly facility revenue for compensation, although performance- based 
financing activities are providing important bonuses to facilities that meet standards. Despite low and irregular 
178 The Impact of USAID’s Integrated Health Program in the DRC
remuneration, health providers expressed gratitude for being employed. Informants described health workers as 
respectful of and courteous towards clients, which was confirmed during health worker-client observations. 
Observations illuminated that health workers fail to follow components of treatment protocols during patient 
consultations, which often take place in unclean, noisy environments, where privacy is not maintained. 
According to the individuals interviewed, no community-based organizations involved in health existed in the 
zones studied. Community outreach activities are not functioning according to the national strategy. 
Community health workers require training, supervision, and supplies to fulfill roles. Lack of oversight and 
supplies does not allow iCCM posts to operate as planned. Poor motivation causes high attrition of community 
health workers. Community health workers are predominantly male, with men controlling positions of 
leadership. 
Programmatic Implications
Although many of the health system challenges identified through the study—such as limited access to 
electricity and phone connectivity among health workers and problems with health worker remuneration—are 
outside the control of the project and lie instead with the government, they are nevertheless critical constraints 
that must be considered when designing and implementing USAID IHP-supported interventions. Obvious 
examples are the lack of electrical power and limited phone and Internet connectivity and Internet credit, 
which can affect efforts to improve service readiness, data collection, and SNIS reporting. 
However, other challenges identified can be partially addressed through project-supported strategies and 
interventions. Below are recommendations based on the study results:
• The design of both facility- and community-based service delivery interventions should be informed by
formative research on community perceptions and needs. This recommendation is based on the
qualitative research findings that highlight the importance of geographical and cultural differences in
the DRC, and the need to design program approaches to better coincide with contextual conditions.
More experimental interventions should also be tested to assess the role of cultural context on their
effectiveness.
• The program should explore alternative approaches to improve the remuneration of health workers,
possibly through coordination with the MOH’s PDSS program, to improve health worker motivation
and, in turn, service quality and availability. This recommendation is based on both quantitative and
qualitative research findings that suggest that a large percentage of health workers do not receive a
salary. We found that this affects health workers’ motivation and leads to a heavy reliance on income
received from household out-of-pocket payments.
• The program should place more emphasis on the supervision of local health officers and health
workers to improve service quality, and the collection, availability, and use of routine data beyond the
data available in the DHIS2. This recommendation is based on survey findings indicating that external
supervision is not carried out as frequently as MOH guidelines stipulate, and that providers need
support for adhering to provider practice guidelines.
• More emphasis should be placed on continuous education programs to improve adherence to provider
practice guidelines that can improve adherence to standards of care. Again, this is based on the findings
from the clinical vignettes, showing that providers often did not have the knowledge to correctly
diagnose and treat certain health problems.
• Stockouts of essential medications plague the health facilities, undermining health services and their
use, and jeopardizing the revenue needed for health facilities to function. Stockouts force health
workers to use unregulated drugs and provide prescriptions to sick patients. To ensure the provision of
Baseline Report 179
regular and quality care, efforts are needed to guarantee that medications meet drug orders and are 
delivered in a timely and routine fashion.
• Community health activities are not functioning as described in the national community health
strategy. CHWs require ongoing training, supervision, and materials to successfully carry out activities,
including their roles in the execution of iCCM activities. Community activities would benefit from the
oversight and support of community-based organizations and development committees. Mechanisms
to motivate and retain CHWs need to be explored.
Limitations
There were several limitations to the evaluation. Although the full set of limitations is presented in the 
methods section above, the limitation that relates to the interpretation of the baseline results is presented 
below. 
The results are based on the surveys conducted in USAID IHP-supported provinces only and, as a result, 
comparisons between project provinces and non-project areas were not feasible. Moreover, the D4I and 
USAID IHP surveys that are used as the source of baseline data were administered several months after 
USAID IHP started operations (in July 2018). This timing would be problematic if USAID IHP’s 
implementation activities had already begun because it would bias the performance evaluation component of 
the study. However, USAID IHP was engaged in its initial planning phase when the baseline survey was 
conducted and had not yet started implementing its approach in the provinces. In fact, based on previous 
meetings with USAID and the USAID IHP management teams, one of the key purposes of the USAID IHP 
surveys is to provide evidence that can be used to comprehensively assess the health system needs in the nine 
provinces.
References
Adam, T., Hsu, J., de Savigny, D., Lavis, J., Rottingen, J., & Bennett, S. (2012). Evaluating health systems 
strengthening interventions in low-income and middle-income countries: Are we asking the right 
questions?. Health Policy and Planning, 27(suppl 4), iv9-iv19. Retrieved from 
https://www.ncbi.nlm.nih.gov/pubmed/23014156
Baseline Report 180
Appendixes
Appendix 1: Evaluation Protocol
Research Protocol
Evaluation of USAID’s Integrated Health Program for the Democratic 
Republic of Congo
13 June 2019
Data for Impact
University of North Carolina at Chapel Hill
400 Meadowmont Village Circle, 3rd Floor
Chapel Hill, NC 27517 USA
TEL: 919-445-9350 FAX: 919-445-9353
http://www.cpc.unc.edu/measure
Baseline Report 181
Contents
Abbreviations............................................................................................................................................182
1. Purpose and Audience .....................................................................................................................183
2. Background.......................................................................................................................................185
3. USAID IHP Description......................................................................................................................188
4. Theory of Change .............................................................................................................................192
5. Research Questions..........................................................................................................................194
6. Evaluation Design.............................................................................................................................195
7. Limitations and Threats....................................................................................................................205
8. Quantitative Data Requirements, Collection, Management, and Use ............................................207
9. Qualitative Data Requirements, Collection, Management, and Use ...............................................210
10. Ethics and Informed Consent...........................................................................................................217
11. Data Management ...........................................................................................................................218
12. Evaluation Team and Stakeholder Roles..........................................................................................219
13. Timeline and Deliverables................................................................................................................220
References ................................................................................................................................................223
182 The Impact of USAID’s Integrated Health Program in the DRC 
Abbreviations 
ANC Antenatal care
ARI Acute respiratory infection
CBO Community-based organization
CHW Community health worker
CODESA Comités de Développement de l’Aire de Santé (Health area development committee)
CSO Community-supported organization
D4I Data for Impact
DHIS2 District health information system 2
DHS Demographic and Health Survey
DID-PSM
DRC
Difference-in-differences with propensity score matching
Democratic Republic of Congo
HZ Health zone
IHP Integrated Health Program
KSPH Kinshasa School of Public Health
LiST
MNCH
Lives Saved Tool
Maternal, neonatal, and child health
MOH Ministry of Health
MOU
PICAL
Memo of Understanding
Participatory Institutional Capacity Assessment and Learning
SBC Social and behavior change
TB Tuberculosis
USAID
USAID IHP
United States Agency for International Development
United States Agency for International Development’s Integrated Health Project in the 
Democratic Republic of Congo
USD United States Dollar
WASH Water, sanitation, and hygiene
Baseline Report 183
1. Purpose and Audience
As part of its strategy to improve health outcomes in the Democratic Republic of Congo (DRC), the 
United States Agency for International Development (USAID) funded the Integrated Health Program 
for the DRC (USAID IHP) in 2018. The program began operations in July 2018 and is being 
implemented by Abt Associates and several partner organizations. The purpose of USAID IHP is to 
strengthen the capacity of Congolese institutions and communities to deliver quality, integrated health 
services to sustainably improve the health status of the Congolese population. The specific health, 
population, and nutrition areas that will be the focus of the project include maternal health; neonatal, 
infant, and child health; tuberculosis (TB); malaria; child nutrition; water, sanitation and hygiene 
(WASH), and family planning. 
USAID IHP’s overall performance objectives to reach this goal include:
● Strengthen health systems, governance, and leadership at the provincial, health zone (HZ), 
and facility levels in target provinces (Objective 1)
● Increase access to quality, integrated health services in target provinces (Objective 2)
Increase adoption of healthy behaviors, including use of health services, in target provinces 
(Objective 3)
USAID IHP will work in nine contextually diverse provinces in the regions of Eastern Congo, Katanga, 
and Kasai and will include a wide array of interventions. 
Given the breadth and depth of the planned interventions, the USAID/DRC mission has requested Data 
for Impact (D4I) to conduct an independent third-party evaluation of the performance and impact of 
USAID IHP on key health systems-related outcomes, including the uptake of family planning and 
health care services; health systems functioning (i.e. improved disease surveillance, the availability of 
essential commodities, and health worker motivation); and the practice of key healthy behaviors.
The purposes of the evaluation are to investigate the following:
• The progress of USAID IHP over time in achieving Objectives 1, 2, and 3, as listed above: 
strengthened health systems, governance, and leadership at the provincial, health zone, and 
facility levels; increased access to quality, integrated services; and increased adoption of health 
behaviors.
• The impact of USAID IHP on several proxy indicators of healthy behaviors, including 
treatment for childhood illnesses, maternal health care use, and contraceptive method use.
• The factors that enabled or limited the success of USAID IHP, including the design and scope 
of the project, implementation factors, and external and contextual factors. 
To achieve these evaluation objectives, both a performance evaluation and an impact evaluation will be 
carried out. The performance evaluation will incorporate several study components based on data from
USAID IHP provinces only, including District Health Information System (DHIS2) data, population￾based household survey data; health facility, health zone office, and provincial health office survey data;
and qualitative data. This component of the evaluation will investigate whether the USAID IHP targets 
were achieved for all three USAID IHP performance objectives – strengthened health systems, 
184 The Impact of USAID’s Integrated Health Program in the DRC 
governance, and leadership; increased access to quality, integrated services, and increased adoption of 
health behaviors. To the extent possible, the empirical data will be triangulated with qualitative data to 
explore whether changes over time in the adoption of healthy behaviors were associated with changes in 
strengthened health systems and increased access to quality, integrated services, and to determine why 
expected changes were or were not observed. Finally, to explore the health impacts of the changes in 
intervention coverage, the Lives Saved Tool (LiST) will be used to estimate how changes in the 
adoption of healthy behaviors translated to changes in the number of lives saved. 
The impact evaluation will be carried out by comparing DHIS2 data of several proxy indicators of 
health behaviors in project areas and non-project areas using a difference-in-differences with propensity 
score matching approach. Because it will not be possible to administer the population-based household 
surveys and the health facility, health zone office, and provincial health office surveys outside of the 
nine USAID IHP provinces areas, it will not be feasible to assess the impact of USAID IHP on 
population-based service coverage rates, or on indicators of strengthened health systems, leadership and 
governance and increased access to quality, integrated services. 
Key audiences for the evaluation include USAID, the Ministry of Health (MOH), and other 
international health organizations and agencies. It is expected the results of the evaluation will be used 
to improve the design and implementation of future health systems strengthening activities in the DRC.
It is important to note that D4I has only been contracted to carry out baseline evaluation activities thus 
far. 
The protocol is structured as follows. Following this introduction, Section 2 provides background 
information on the country and health system context. Sections 3 and 4 describe the USAID IHP and 
the USAID IHP Theory of Change. Section 5 presents the research questions that will be investigated, 
and Section 6 describes the evaluation design and methods. Section 7 describes the limitations of the 
study. Sections 8 and 9 present the quantitative and qualitative data requirements and details on how 
the data will be collected, managed and used. Section 10 describes the ethics and informed consent 
considerations and procedures. Section 11 describes data storage and security issues, as well as data 
sharing and knowledge management considerations. Section 12 provides a description of the evaluation 
team. Finally, Section 13 describes the study timeline and the deliverables. 
Baseline Report 185
2. Background
a. Country setting
The DRC has experienced decades of sporadic conflict and widespread and extreme poverty. The 
conflict along with substantial weaknesses in governance have had devastating effects on the economy, 
institutions, and households in the DRC (World Bank, 2017). In the period from 1998 to 2007, an 
estimated 5.4 million people died as a result of the conflict and protracted humanitarian crisis 
(Moszynski, 2008). Millions more were pushed into poverty due to displacement and the loss of their 
economic livelihoods. By 2012, most of the country had returned to relative peace, although in eastern 
DRC, a crisis involving the M23 armed group as well as other armed factions persisted. Militia 
activities and ethnic tensions continue to erupt periodically in regions of the country. In addition to 
armed conflict, the DRC has experienced longstanding political tensions. Both the 2011 and 2018 
presidential and legislative elections were marred by violence and disputes about the results, which 
reflected deep political divisions and the fragility of DRC’s electoral institutions. 
While the DRC is endowed with extraordinary natural resources, it is also one of the least developed 
countries in the world. It ranks at the bottom of the International Food Policy Research Institute’s 
World Hunger Index, making it the hungriest country in the world, with only 10 percent of its 
agricultural potential exploited (USAID, 2014). The country is also tied for last on the United Nations 
Human Development Index. Gender inequalities are also prevalent, as the DRC ranks 148 out of 157 
countries on the Gender Development Index. Poverty is also widespread. In 2011, gross national 
income per capita was 190 USD and 71 percent of Congolese lived below the poverty line of $1.25 per 
day. Individuals living in rural areas were more likely to be impoverished than individuals in urban 
areas (75 percent vs. 61 percent) (World Bank, 2017).
The DRC is one of the world’s top five contributors to maternal mortality (846 deaths per 100,000 live 
births) and child mortality (104 deaths per 1,000 live births). The Total Fertility Rate has remained at
around 6.6 since 2007. Malaria, diarrhea, and pneumonia are significant causes of death for children 
under five years of age. The prevalence of malaria among children under five years of age was 30.8 
percent at the time of the most recent Demographic and Health Survey (DHS), and national health 
statistics indicate that 40 percent of outpatient visits are for suspected malaria (Ministère du Plan et 
Suivi de la Mise en œuvre de la Révolution de la Modernité (MPSMRM), Ministère de la Santé
Publique (MSP) et ICF International, 2014).
Malnutrition continues to be a serious issue among children under five years of age. Over 40 percent of 
children are malnourished as indicated by high rates of stunting (low height-for-age), with more than 
half of these children falling into the severe range. Malnutrition and child survival rates are closely 
linked to breastfeeding, and water, sanitation, and hygiene (WASH) practices. WASH indicators have 
improved little, with the majority of the population still lacking access to improved water and sanitation 
facilities. TB also is a serious problem and the DRC is ranked ninth among the 22 highest burden 
countries for the disease (Ministère du Plan et Suivi de la Mise en œuvre de la Révolution de la 
Modernité (MPSMRM), Ministère de la Santé Publique (MSP) et ICF International, 2014).
b. Health systems context
186 The Impact of USAID’s Integrated Health Program in the DRC 
The DRC’s government-run health system is organized on three levels: central, provincial, and peripheral 
(zone de santé or HZ, the equivalent of a district in most countries). The MOH at the central level is 
responsible for overall policy direction and stewardship, and the management of national programs. At 
the provincial level, the provinces are responsible for providing technical support and supervising HZs. At 
the peripheral level, each HZ covers an average population of 110,000 and includes a central HZ office 
and at least one general reference hospital. The HZ is divided into health areas (aires de santé), each of 
which contains, in theory, at least one health center or health post that is responsible for providing a 
minimum package of services as defined by the government. The government has received significant 
technical and financial support from major bilateral and multilateral partners, including USAID, the 
United Kingdom’s Department for International Development, the European Union, the World Bank, and 
the United Nations, including the World Health Organization, UNICEF, and the United Nations 
Population Fund.
The poor health outcomes described above are linked to low levels of effective coverage of reproductive, 
maternal, child, and adolescent services. In 2015, per capita health spending in the DRC was only 22 
USD, one-sixth of the average in sub-Saharan Africa and one fourth the amount necessary to provide 
basic health services to the population (Meheus & McIntyre, 2017). Private household health spending is 
substantial, with households bearing 40 percent of total health expenditures, 93 percent of which is made 
up of out-of-pocket expenditures, which contributes to inadequate financial access to services. Donor 
spending is also a key driver of total health expenditures, making up 40 percent (World Bank, 2017).
Inadequate health spending levels also contribute to inconsistent and often poor service quality (World 
Bank, 2017). While there has been extensive decentralization of financing and management 
responsibilities in the health system, inadequate provider payment contribute to poor health worker 
motivation (World Bank, 2017). In addition, the creation of 15 new provinces has led to challenges that 
result from low managerial capacity in the health sector. While community-based interventions are 
critical to providing support to health facility services, poor organization and lack of motivation of 
community health workers (CHWs) undermine community activities (Bertone et al, 2016). 
c. Project description 
In response to these health systems challenges gaps, USAID funded the USAID IHP, which is 
being implemented by Abt Associates and several partner organizations. The purpose of USAID’s
IHP is to achieve sustainable improvements in the health of the Congolese people through: (1) 
strengthened health systems, governance, and leadership at the provincial, HZ, and facility levels, 
(2) increased access to quality, integrated health services, and (3) increased adoption of healthy 
behaviors, including use of health services.
The project will be implemented in nine provinces in the regions of Eastern Congo, Kasai, and 
Katanga, and the USAID IHP management team plans to use a province-specific tailored approach
to achieve the three above-mentioned objectives of the project.
d. Motivation for the evaluation
Despite the need for a more responsive health system, the evidence base for improved policy decision￾making in the DRC is weak, due to limited research capacity, lack of transportation and 
communications infrastructure, security challenges, and limited funding for health systems research. 
Baseline Report 187
Beyond the DRC, there is also a paucity of information in low-income countries, particularly fragile 
states, regarding the efficacy of interventions to address system-level gaps and capacity shortcomings. 
In a 2012 systematic literature review of evaluations of health systems strengthening programs, few 
evaluations were found to be comprehensive across multiple health system building blocks and few 
included evaluation designs that considered the complex nature of the programs (Adam et al., 2012).
This evaluation represents an effort to help fill the present knowledge gaps by supplying critical 
information about the impact of USAID’s IHP, a large, complex health systems strengthening project. 
By contributing to the country’s evidence base of successful health systems strengthening activities, 
and those that are not successful, the proposed evaluation can be used to help design future projects 
intended deliver high quality family planning and health services that meet the needs of the Congolese 
people. 
188 The Impact of USAID’s Integrated Health Program in the DRC 
3. USAID IHP Description 
a. Project name, goals and objectives, key indicators and outcomes
The overall purpose of the USAID IHP is to improve the health status of the Congolese population. The 
program aims to achieve this goal through strengthening the capabilities of health systems, government 
institutions and communities to support the delivery of high-quality, integrated and sustainable health 
services, which will, in turn, increase access to improved health services. Another important component 
relates to promoting the adoption of healthy behaviors including increased utilization of health services, 
as well as health-related behaviors at the individual, household and community level.
The program includes three objectives to reach the main goal of improving the health status of the 
Congolese population, as follows:
● Objective 1: Strengthen health systems, governance, and leadership at provincial, HZ and facility 
levels in target HZs.
● Objective 2: Increase access to quality, integrated health services in target HZs.
● Objective 3: Increase adoption of health behaviors, including health services use in target HZs. 
The program components and interventions are designed to influence measurable improvements in 
several health outcomes. By the end of the project, USAID IHP is intended to achieve positive changes in 
the following:
● Proportion of children under five years of age for whom treatment/advice was sought for acute 
respiratory infection (ARI), diarrhea, and fever;
● Proportion of children under five years of age who slept under an Insecticide-Treated Net;
● Proportion of married women using any modern method of contraception;
● Proportion of children who received all eight basic vaccinations; and
● Proportion of pregnant women who attend four ANC visits.
The program is based on the assumption that improvements in these and other health-related outcomes 
will contribute to positive changes in impact-level indicators, including maternal mortality ratio; neonatal, 
infant, and under-five mortality rates; TB case notification rate; malaria prevalence rate; contraceptive 
prevalence rate; and acute and chronic malnutrition rates. 
b. Project components, specific interventions, and delivery mechanism
Project components and interventions are broken down to address the three program objectives as 
described below. 
Objective 1: Strengthen health systems, governance, and leadership at provincial, HZ and facility levels 
in target HZs.
Programmatic approaches related to Objective 1 aim to support provinces, HZs, and communities to be 
empowered stewards and effective managers of health system functions, via tailored needs-based 
interventions guided by results of Participatory Institutional Capacity Assessment and Learning (PICAL) 
Baseline Report 189
evaluations and human-centered design techniques. At the province and HZ levels, the PICAL tool will 
be applied to foster a culture of self-assessment, enhance institutional capacity building, and guide the 
development and implementation of performance improvement action plans to support improved 
governance, leadership, and accountability. To inform activities geared towards health systems 
strengthening, capacity-building needs identified during PICAL assessments will also be used to facilitate 
targeted technical assistance, coaching, and leadership training in (1) public financial management; (2) 
analysis and use of data for improved disease surveillance and facility-level data reporting; (3) 
management of Human Resources for Health, taking gender into consideration in the recruitment and 
deployment of staff; and (4) use of the performance dashboard tool to equip provincial and HZ managers 
with real-time, data-driven, decision-making capabilities. Further, USAID IHP will optimize use of 
existing methods such as results-based financing; employ mobile phone-based surveillance technologies; 
and strengthen supply chain activities to support quantification, forecasting, and timely inventory 
replenishment.
At the community level, USAID IHP will use the recently-developed MOH Community Dynamics 
strategy to improve stakeholder coordination and oversight functions. By facilitating collaboration of 
provincial, HZ and community stakeholders, this strategy aims to strengthen the capacity of Comités de 
Développement de l’Aire de Santé (CODESAs), civil society organizations (CSOs) and community-based 
organizations (CBOs) to be true partners in addressing social and behavior change (SBC) and mobilizing 
the demand for and uptake of improved health services. Activities to support community-level monitoring 
of health system performance will include streamlining community scorecard approaches; launching a 
toll-free fraud and complaints hotline number for reporting corruption, abuse or similar allegations; and 
providing rights-based education to communities. Capacity-building of CODESAs, select CSOs or CBOs 
will also take place through a Grants under Contract program. Together, this enhanced coordination 
capacity and multi-level collaboration will support more effective community stewardship of the health 
system, while demanding accountability of both local and provincial authorities.
Objective 2: Increase access to quality, integrated health services in target HZs.
Programmatic approaches related to Objective 2 focus on increasing health service demand, access, and 
quality in the program regions. A primary component entails scaling up health facilities that can provide 
essential, integrated and high-quality health services. Facility-based activities include renovating health 
infrastructures, equipping health facilities with drugs and medical supplies, and building knowledge and 
capacity among health workers so that health personnel can provide a package of integrated services 
related to Maternal, Neonatal, and Child Health (MNCH), nutrition, family planning, and reproductive 
health, WASH, malaria and TB. Interventions will also focus on improving health provider attitudes and 
interpersonal communications. As part of this approach, the project will implement a fraud and 
complaints hotline and reporting system to enhance health worker accountability. Using a cluster model 
strategy, the project will first prioritize building capacity in a high performing facility in a HZ, and once 
strengthened, use that health structure to provide support and outreach to facilities in the same HZ. The 
project aims to strengthen other facilities located in more remote locations over the course of the project. 
Community-based health activities are considered critical to increasing utilization of facility services and 
improving provision of essential health services, particularly in remote localities. Interventions designed 
to strengthen community-based health services will include recruitment of new CHWs, particularly 
women, training of CHWs on health promotion (with a focus on WASH) and integrated community case 
management, and training of facility-based health workers on community outreach and provision of 
190 The Impact of USAID’s Integrated Health Program in the DRC 
health services at the community level. Community activities will be scaled up over time, with an initial 
focus on remote communities with access to supported health facilities. Interventions will also involve 
strengthening of referrals from community platforms and health centers to referral hospitals. A general 
emphasis will involve building collaboration with government health structures, United States 
Government and other donors by supporting and actively participating in central level meetings during 
which learning experiences, needs, and priorities can be jointly identified and discussed, and policy 
influenced.
Objective 3: Increase adoption of health behaviors, including health services use in target HZs. 
Interventions related to Objective 3 are geared to increase the adoption of healthy behaviors and 
utilization of health services in the targeted provinces. The strategy aims to raise community awareness 
and knowledge of health care services and address barriers to optimal health care seeking, as well as to 
strengthen community engagement and social support which will enable healthy behaviors. Specific 
interventions will include a healthy family campaign comprised of a multipronged, educational program 
involving a family drama series focusing on common health problems and issues related to accessing 
facility and community-based health services, the care received, and satisfaction derived. Storylines 
disseminated through radio and text messaging will highlight sociocultural barriers that inhibit access to 
services and the practice of healthy behaviors and ways they can be overcome. Radio listening sessions 
will be organized to facilitate community discussions and reactions to scenarios presented during the 
drama series at the local level. Messages conveyed through the drama series will be complemented by 
interpersonal communication carried out by CHWs and CODESAs and supported by women’s 
organizations and other community-based groups through mobilization events. Open houses will be held 
to showcase improvements in health facilities and encourage utilization. 
The Champion Community model will be implemented to prioritize health areas and target audiences and 
develop work plans and monitor activities in the targeted areas. Mini-campaigns focused on addressing 
health problems will also be carried out according to specific and immediate needs. Efforts will be made 
to share lessons learned, harmonize strategies and improve approaches by collaborating and coordinating 
with other groups involved in SBC, including the following: key government institutions working on 
communications; government officials, implementing agencies and other stakeholders participating in 
coordination meetings (clusters, MCZ, head nurse) at the central, provincial and zonal level; and USAID 
staff and partners. 
The project aims to share SBC activity results to international audiences during academic conferences and 
through peer-reviewed, scientific manuscripts. At the more local level, coordination of SBC approaches 
will be carried out in conjunction with the HZ office, CODESAs and Cellules d’Animation 
Communitaire, with assistance provided to HZs during the development of their Operational Action Plans 
to ensure the overall goal of scalability of sound and effective messaging and activities that align with and 
contribute to the achievement of agreed-upon health goals. 
c. Targeting
The project will be implemented in nine provinces located in three contextually different regions of the 
DRC including South Kivu and Tanganyika in Eastern Congo; Haut-Katanga, Haut-Lomami, Lualaba in 
Katanga; and Kasai-Central, Kasai-Oriental, Sankuru, and Lomami in Kasai. The war-torn region of 
Eastern Congo is relatively densely populated with a high population of internally displaced persons. 
Baseline Report 191
Despite strong humanitarian donor support over an extended period, Eastern Congo lacks adequate and 
sustainable health services. Katanga, the home of commercial mining, has extreme wealth that has had 
limited benefits to local populations. The northern part of the Katanga region has poor infrastructure. It 
should also be noted that Haut-Katanga, located in the southern Katanga region, recently experienced
ethnic tensions and rebel attacks causing internal displacement. Transactional sex and internal mobility 
have caused increases in HIV and TB infection rates in the Katanga Region. Kasai is a vast, sparsely 
populated area with poor infrastructure. Recent militia activities have caused unrest and internal 
displacement within the region, contributing to an already fragile situation and causing additional strain 
on a weak health care system. 
The project will target all HZs located in the USAID IHP provinces offering services to residents living in 
the 178 targeted zones. Youth and gender equity will be an integral consideration in program 
implementation. The program is designed to be agile and results-focused, with project activities adapted 
according to ongoing measurement of the effectiveness of interventions and the particular context and 
health needs in each province. 
d. Project implementation plan
The project started in July 2018 and will be implemented over a four-year period, with the possibility of a 
three-year extension. The project is led by Abt Associates with core partners International Rescue 
Committee and Pathfinder International. Seven niche partners with expertise in health programming, 
designing innovative approaches and research in fragile states, including DRC, will participate. The 
project team will work closely with government health officials at the central, provincial, zonal and health 
facility level in efforts to build capacity, leadership and ownership of the interventions, and sustainability. 
The project team will maintain ongoing coordination with USAID personnel, sharing progress updates of 
project activities and results during regularly scheduled meetings and reporting. 
192 The Impact of USAID’s Integrated Health Program in the DRC 
4. Theory of Change
The USAID IHP theory of change addresses key areas of concern to influence and improve systems, 
services, and behaviors. The theory of change, which is presented in Figure 1, is being used by Abt 
Associates and its partners throughout the life of the program to validate assumptions, test the theory of 
change, and ensure that all activities and interventions effectively contribute to intended results. The 
theory of change extends the results framework to a more granular level, describing the relationships
between proposed activities and interventions and these results. 
USAID IHP is intended to build the capacity of Congolese institutions and communities to ensure that the 
DRC health system effectively provides improved availability, access, and use of high-quality health 
services leading to better health of Congolese citizens. 
The program’s overall theory of change maintains that sustained capacity requires:
● An enabling environment supported by enhanced leadership and stewardship to ensure an 
accountable health system, and organizational systems and processes that assist managers and 
providers to carry out critical health functions at every level, coordinate activities between 
levels, and manage the delivery of high-quality health care; 
● Skilled individuals at the facility and community level who have technical, managerial, and 
advocacy skills, and knowledge to ensure quality service delivery, people-centered approaches, 
and informed communities; 
● Communities that have confidence and trust in the health system and are engaged partners; and
● Communities that are empowered to improve their own health through healthy behaviors and 
appropriate and timely use of high impact health services. 
According to the theory of change, the successful enhancement of systems and human capacity within 
DRC’s health sector will result in more effective stewardship of the financial, human, and programmatic 
resources in the health sector; enhanced capacity at provincial, health zone, facility, and community levels 
for management and delivery of quality services; and increased engagement of communities in 
mobilization, planning, and advocacy for health. By improving the MOH’s capacity (institutional and 
human) at all levels, the health sector will be able to more effectively and efficiently plan, monitor, and 
deliver programs and services. The improved availability of high-quality services – along with increased 
demand for care and improved confidence in the health system – will lead to greater service utilization 
and consequently better health outcomes and improved livelihoods for Congolese people.
Baseline Report 193
Figure 1. USAID IHP Theory of Change.
The theory of change emphasizes the complex nature of USAID IHP. Among the characteristics1 of the 
project are the following:
• Multi-component and multi-level interventions (enabling environment interventions, service 
delivery interventions, health behavioral interventions) that will vary across provinces and time.
• Multiple, changing processes (behavior of households and health workers, organizational 
structures and processes).
• Multiple goals (strengthened health systems, improved quality of care, increased adoption of 
healthy behaviors).
• Dynamic, heterogeneous contextual settings across the nine USAID-supported provinces.
As will be described in Section 6 of this protocol, this complexity was considered in developing the 
research questions and evaluation methodology. 
1 This approach for characterizing the complex nature of the project is based on guidelines for evaluation 
of complex interventions that were developed by the Patient-Centered Outcomes Research Institute 
(PCORI) Methodology Committee (2019).
194 The Impact of USAID’s Integrated Health Program in the DRC 
5. Research Questions 
The specific research questions that will be addressed in the evaluation are the following:
1. Did the expected changes in outcomes and impacts occur?
a. Strengthen health systems, governance, and leadership at provincial, HZ, and facility 
levels in target HZs.
i. Outcome: Enhanced capacity (institutional and individual) of provincial health 
offices, HZs, and facilities to plan, implement, monitor, oversee and supervise 
services
ii. Outcome: Strengthened capacity of CSO’s and community structures to provide 
health systems oversight
b. Increase access to quality, integrated health services in target HZs.
i. Outcome: Increased availability of quality, integrated facility-based health 
services and commodities
ii. Outcome: Increased availability of quality, integrated community-based health 
services
iii. Outcome: Improved affordability of integrated health services
c. Increase adoption of healthy behaviors, including health service use, in target HZs.
i. Impact: Proportion of children under 5 for whom treatment/advice was sought for 
ARI, diarrhea, and fever
ii. Impact: Proportion of children under 5 who slept under an Insecticide-Treated 
Net
iii. Impact: Proportion of married women using any modern method of contraception
iv. Impact: Proportion of children who received all eight basic vaccinations
v. Impact: Proportion of pregnant women who attend four ANC visits
vi. Impact: Proportion of newborns cared for with the Kangaroo method
vii. Impact: Proportion of newborns placed on the breast within one hour of birth
viii. Impact: Proportion of children under 6 months breastfed exclusively
2. If there were changes in healthy behaviors over the course of the study period, to what extent 
were these attributable to USAID IHP?
3. Did the project contribute to gender equity in health services and within the health system?
4. What factors enabled or limited the success of USAID IHP? 
a. Design/scope
b. Implementation/management
c. External environment/contextual factors 
d. Government decentralization
Baseline Report 195
6. Evaluation Design 
Several issues were considered in developing the evaluation research questions and methodology. First, 
as is evident from the description of the project and the theory of change, USAID IHP is a large, 
complex health systems strengthening project that involves multiple components, interventions, and 
objectives. Second, the decisions regarding which types of interventions will be supported and where 
and when they will be introduced and scaled up will be made by USAID IHP management team in 
consultation with USAID, without any input from the D4I evaluation team. This effectively means that 
it will not be possible to randomize interventions supported by USAID IHP, which prevents the ability 
to estimate the impact evaluation of one or more specific health system strengthening interventions of 
interest. Third, while population-based household surveys will be conducted as part of USAID IHP, the
surveys will be administered by Abt Associates as part of the project’s Activity Monitoring and 
Evaluation Plan, and not independently by D4I. In consultation with USAID, the USAID IHP 
management team has decided only to carry out the surveys in the nine USAID IHP provinces and not 
in outside provinces, which effectively removes the possibility that the household surveys can be used 
as a source of data for the D4I impact evaluation. 
Given these considerations, a decision was made in consultation with USAID to carry out two types of 
evaluation components for this study: a performance evaluation and an impact evaluation. As defined by 
USAID Evaluation Policy, performance evaluations incorporate before and after comparisons, but 
generally lack a rigorously defined counterfactual to control for factors other than the project or 
intervention that might account for the observed change, whereas impact evaluations assess the extent to 
which changes in health outcomes or service utilization over time are attributable to an intervention 
(USAID 2016). Table 1 below describes the study component (performance evaluation or impact 
evaluation) and sources of data that will be used to address each of the research questions. As described 
in Table 1, the performance evaluation aspect of the study will address: Research Question 1, which 
investigates changes over time in USAID IHP areas; Research Question 3, which examines the extent to 
which the project addressed issues of gender equity; and Research Question 4, which investigates factors 
that enabled or limited the success of the project. Data for this component of the study will come from 
multiple sources, including: the DRC’s routine health information system (DHIS2); household surveys; 
surveys of health care facilities, HZ offices, and provincial health offices; and key informant and in-depth 
interviews and focus group discussions. The impact evaluation aspect of the study will address Research 
Question 2 which investigates the extent to which changes in healthy behaviors are attributable to USAID 
IHP. The impact of USAID IHP will be based on a difference-in-difference with propensity score 
matching model, a non-experimental design, based on data from the DHIS2. 
196 The Impact of USAID’s Integrated Health Program in the DRC 
Table 1. Overview of the D4I evaluation of USAID IHP
Research Question Study Component Sources of Data
1: Did the expected changes in 
outcomes and impacts occur?
Performance Evaluation DHIS2
USAID IHP Household Survey
USAID IHP Health Facility Survey 
D4I Health Facility, Health Zone 
Office, and Provincial Health Office 
Surveys
D4I Qualitative Key Informant 
Interviews, In-Depth Interviews, and 
Focus Group Discussions
2: If there were changes in 
healthy behaviors over the 
course of the study period, to 
what extent were these 
attributable to USAID IHP?
Impact Evaluation DHIS2
3: Did the project contribute to 
gender equity in health services 
and within the health system?
Performance Evaluation DHIS2
USAID IHP Household Survey
USAID IHP Health Facility Survey 
D4I Health Facility, Health Zone 
Office, and Provincial Health Office 
Surveys
D4I Qualitative Key Informant 
Interviews, In-Depth Interviews, and 
Focus Group Discussions
4: What factors enabled or 
limited the success of USAID 
IHP?
Performance Evaluation D4I Qualitative Key Informant 
Interviews, In-Depth Interviews, and 
Focus Group Discussions
a. Analysis of impact using a difference-in-differences model
Model description: A doubly robust model that combines difference-in-differences with propensity 
score matching (DID-PSM) will be used to estimate the impact2 of USAID IHP on the provision of 
2 It should be noted that, in the health evaluation research literature, the term ‘impact’ typically refers 
to the effects on health outcomes, such as lives saved, or disability-adjusted life years averted. 
However, in the health systems strengthening evaluation literature, “impact” often refers to the effects 
Baseline Report 197
maternal and child health care services and family planning services (as identified in Research 
Question 2). 
The unit of analysis will be the health zone. The treatment arm includes health zones in USAID IHP
provinces (based on data from both hospitals and health centers/posts) in the pre-intervention (2017-
18) and post-intervention (2019-23) periods and the control arm includes comparable health zones 
without USAID IHP support. The DID-PSM estimates of project impact will include health zone￾level fixed effects to adjust for time-invariant factors including baseline differences between USAID 
IHP-supported health zones and control health zones as well as location and socio-economic 
characteristics. To the extent allowed by our data, which come from the health management 
information system, the DID-PSM model will also include time-variant controls for volume of cases 
across health care facilities, and socio-economic characteristics, and account for the staggered 
implementation of USAID IHP. To account for serial correlation in monthly health zone outcomes, 
standard errors will be clustered by health zone. By including health zone and month fixed effects, the 
DID-PSM model uses trends in outcomes in the control health zones as the counter-factual for what 
would have happened in the treatment group without USAID IHP.
Sample: The health zones included in this component of the study will be: 1) health zones (n=178) in 
the nine provinces receiving technical assistance from USAID IHP (treatment arm); and 2) health 
zones (n to be determined) that are outside the nine USAID IHP provinces and NOT receiving 
assistance from a donor-supported health systems strengthening project comparable in scope to 
USAID IHP (control arm). 
Control health zones will be weighted to resemble treatment health zones using the propensity score 
matching technique. First, all health zones receiving donor-supported health systems strengthening 
interventions that are comparable in scope to USAID IHP between 2019 and 2023 and those that 
experienced an Ebola outbreak in 2018 or later will be excluded from the group of potential control 
health zones; all other non-USAID IHP health zones in the country will be retained as potential 
contributors to the weighted control group. The exclusion of health zones that received health systems 
strengthening interventions will be based on a list of donor-supported health projects compiled and 
periodically updated by the Ministry of Health for the purposes of the National Health Accounts. As 
of June 2019, examples of health systems strengthening projects that will be considered for exclusion 
from the study include the World Bank’s PDSS, the United Kingdom’s ASSP Project, and Belgium’s 
Memisa Project, which include that aim to strengthen the health system via improvements in health 
financing, management, and quality of primary health services. 
Next, the propensity score (i.e. probability of getting the treatment) will be calculated for each health 
zone based on a set of predictors that includes the mean values across the pre-intervention period 
(Table 2). These propensity scores will be used to generate weights for each health zone. We will 
weight each zone to recover the average treatment effect across the DRC by weighting by the inverse 
probability of treatment (1/propensity for the treated observations and 1/(1-propensity) for the control 
on service delivery or other aspects of health systems functioning (Adams et al., 2012). For the 
purposes of this evaluation, we use “impact” in the latter way, unless otherwise noted. 
198 The Impact of USAID’s Integrated Health Program in the DRC 
observations). Sample balance will be tested on the array of available predictor variables averaged 
across the pre-period using these weights. The two samples will be considered balanced when the 
weighted means of control variables are within 10% of each other as measured by standardized 
differences. Propensity scores will be recalculated using higher order polynomials of predictor 
variables or interaction terms until this balancing condition is satisfied. 
Baseline Report 199
Table 2. Predictor variables for Propensity Score Matching.
Category Predictor variable
Basic characteristics • Health zone population*
• Urban/rural setting
• Old/new province
• Performance-based financing program participant
• Number of health centers/posts*
• Number of hospitals*
• Mean expenditures and receipts per health facility*
Service delivery • Average length of stay of hospitalization*
• Number of reported, facility-delivered newborns who received five components 
of Newborn Essential Care and three exams in the first six days of life*
• Number of births assisted by qualified personnel at health facilities*
Health status • Number of reported, facility-delivered newborns with low birth weight (<2,500 
grams)*
• Number of child clients 6 to 59 months of age with moderate acute 
malnutrition*
• Number of child clients 6 to 23 months of age still breastfeeding*
• Number of child clients under 6 months seen exclusively breastfeeding*
*Indicates a DHIS2 indicator. The DHIS2 includes estimates of the total population for the catchment 
area of each health facility, but age- and gender-specific estimates are unavailable. DHIS2 indicators 
that measure service statistics are reported at the facility-level and will be aggregated to the health 
zone level for the purposes of the PSM modeling.
200 The Impact of USAID’s Integrated Health Program in the DRC 
Source of data: Data on services provided (treatment of ARI, diarrhea, fever, new family planning 
users, child vaccination, antenatal care, and skilled delivery assistance) will come from the DHIS2, an 
electronic database that compiles data reported from public and government-supported hospitals and 
health centers/posts. The DHIS2 was scaled up to all provinces in the DRC in 2016 and this study will 
use pre-intervention data over the period January 2017 to December 2018 and post-intervention data 
over the period 2019 to 2022 (and to 2025 if the project is extended for an additional three years). The 
DHIS2 data are available monthly for each participating health care facility and will be aggregated to 
the health zone level for three-month periods.
For the purposes of the impact evaluation, the dependent variables will consist of the numbers of 
individuals who received services, as opposed to coverage rates. Ideally, coverage rates based on the 
number of individuals in need of services would be used as the dependent variables. Unfortunately, 
this is not possible, due unavailability of age- and gender-specific health zone populations in the 
DHIS2. 
b. Analysis of changes over time in project areas
Facility-, health zone office-, and provincial health office-level changes. To evaluate the progress of 
IHP-supported areas on service readiness, service quality, and service utilization, a separate analysis 
component will use data from provincial health offices, HZ offices, health facilities and (health centers 
and hospitals), which we will collect, and data from baseline, midline, and endline facility and household 
surveys that USAID IHP is collecting independently. This is the performance evaluation component of 
the overall study. As USAID IHP is operating in all HZs within its nine provinces, it is not feasible to 
identify and survey a comparable control group of HZs within these same provinces. Comparisons will be 
made in selected indicators between baseline (Year 1), midline (Year 4), and endline (Year 7). To conduct 
the comparisons, the absolute changes for each indicator value will be compared between survey waves 
using t-tests or Chi2 tests, both overall and for the three regional sub-groups. We will also stratify results 
by sex and age when applicable. Table 3 lists the indicators that will be assessed. Reference sheets for 
each indicator can be found in Appendix A. 
Baseline Report 201
Table 3. Key outcome indicators by topic area and outcome measured
Service quality
1 Increased availability of quality, integrated facility-based health services and commodities
a Percent of health centers that offer select MOH Minimum Package of Preventive and Curative Activities
b Percent of hospitals that offer select MOH Complementary Package of Activities
c Percent of facilities offering a permanent method of family planning
d Percent of facilities meeting minimum standards with regard to essential supplies and equipment to support 
provision of long-acting or permanent methods of contraception
e Average provider attitudes and interpersonal skills
f Percentage of health facilities that incorporate patient feedback by intensity of incorporation
g Percent of health centers that do not require payment before treatment of emergency cases
h Percent of health facilities with a private delivery suite
i Percent of facilities with improved sanitation facilities
j Percent of eligible women who were referred to a higher-level of care (i.e. hospital) for prevention of 
mother-to-child transmission (PMTCT) of HIV
k Percent of facilities with adequate infection control equipment
l Percent of facilities with electricity
m Percent of patients who report passing the nearest IHP-supported health center or foregoing care due to 
quality of services.
n Percent of patients who report long wait times for care
o Percentage of women who are discharged at least 24 hours after a normal delivery
p Percent of facilities that have selected tracer drugs in stock on the day of the survey
q Percent of women giving birth who received uterotonics in the third stage of labor
r Percent of facilities with adequate staffing numbers/mix according to government guidelines and patient 
volume
s Percent of providers who respond correctly to clinical vignettes
t Percent of health facilities with all basic equipment
u Number of supported facilities offering a package of youth-friendly family planning services
v Number of supported facilities offering a package of comprehensive sexual- and gender-based violence 
(SGBV) services
2 Improved affordability of integrated health services
a Percent of health centers with a posted fee exemption policy for indigent patients
b Percent of health centers that accept payment after treatment
c Percent of facilities that detain patients until their fees are paid
d Percent of patients who report having to borrow money or sell possessions to pay for services
3 Increased availability of quality, integrated community-based health services
a Percent of health areas in which community health workers provide family planning information, referrals, 
and/or services
b Percent of health areas with an Integrated Community Case Management (iCCM) site
Leadership and Governance
4 Enhanced capacity to plan, implement and monitor services
a Participatory Institutional Capacity Assessment and Learning (PICAL) participation and score
b Leadership style (i.e. collaborative, autocratic or laissez-faire)
c Autonomy of the health facility/office
d Percentage of health workers receiving performance-based incentives
5 Improved transparency and oversight in health service financing and administration
a Percent of USG-supported health facilities that were audited by health zone or provincial-level authorities in 
the past 3 months
202 The Impact of USAID’s Integrated Health Program in the DRC 
b Percent of USG-supported health zones that were audited by provincial or national-level authorities in the 
past 3 months
c Percent of USG-supported DPS that were audited by central or national-level authorities in the past 3 
months
d Health worker supervision
6 Strengthened capacity of CSOs and Community Structures to provide health system oversight
a Community monitoring and oversight
b Percent of supported CODESAs that are woman-led
7 Improved effectiveness of stakeholder coordination at the provincial and health zone levels
a Percent of health zones and provincial offices that have increased communication with key stakeholders
8 Improved disease surveillance & strategic information gathering & use
a Percent of USG-supported provinces and health zones reporting Maladie à Potentiel Epidémique (MAPEPI) 
District Health Information System 2 (DHIS2) cases within 24 hours
9 Improved management and motivation of Human Resources for Health
a Percent of health workers and managers receiving training in Human Resources Management using the 
iHuman Resources Information System (iHRIS)
b Percent of health workers and managers who received training in Human Resources Management using the 
iHuman Resources Information System (iHRIS), and say they are using new skills/knowledge on the job
c Health worker satisfaction
d Health worker motivation
10 Strengthened collaboration between central and decentralized levels through sharing of best practices 
and contributions to policy dialogue
a Percent of health zones and provincial offices that have increased communication with key stakeholders
Data from facilities will include information on staffing, service delivery, infrastructure and equipment, 
information systems, and governance. Surveys at hospitals and health centers will also include medical 
record reviews to assess quality of care. Clinical vignettes on topics such as antenatal care, treatment of 
childhood diarrhea, and treatment of fever will be administered to clinicians (physicians, nurses, 
midwives as appropriate to the case) during the health worker survey. Responses to vignettes will be 
analyzed to assess health workers’ knowledge and practices relative to the standard of care. Vignettes will 
be re-administered during each survey wave, with changes in responses over time analyzed.
One component of the hospital and health center surveys will be quality assessments of the data reported 
in the DHIS2 (i.e. comparing DHIS2 data to data recorded in facility records). If data is of high quality, 
this will support its use in the impact evaluation component of study. If data quality is poor, we will 
assess whether it is randomly or systematically poor and adjust the analysis accordingly.
Household-level changes. The population-based household surveys that USAID IHP is administering 
will include data on the health care services and behaviors that the project is supporting, including family 
planning, antenatal care, skilled-delivery assistance, immunization, and treatment of childhood illnesses. 
In addition, questions on the exposure to the various interventions that will be supported by USAID IHP
will also be included in the household surveys. As with the facility- and health-worker data, changes will 
be analyzed for the entire sample and by the three regional sub-groups. 
The Lives Saved Tool (LiST) (Walker et al., 2013) will be used to evaluate the health impacts of USAID 
IHP at midline and endline. The LiST estimates of lives saved will be calculated at program baseline 
based on the 2019 population-based household and service provision assessment surveys that will be 
Baseline Report 203
conducted by Abt Associates, and then again at midline and endline based on similar surveys to be carried 
out in 2022 and 2025. Actual changes in coverage between baseline and midline and between baseline 
and endline will be compared to the changes targeted.
The LiST requires a number of data fields to calculate lives saved. Mortality rates and causes of death 
will be derived from the UN inter-agency group for child mortality estimation and the WHO maternal and 
child epidemiology estimation. Demographic projection data are derived from the most recent 
Demographic and Health Survey or its equivalent. However, in order to obtain estimates of lives saved for 
the USAID IHP targeted intervention areas, sub-national estimates for causes of death, health services 
coverage, population by age/sex, stunting and wasting, breastfeeding, and total fertility rate will need to 
be compiled. This will likely require drawing from the Abt-run surveys mentioned above as well as the 
2017-18 DRC Multiple Indicator Cluster Survey, published literature, and any other relevant survey data 
generated from the USAID IHP consortium.
The LiST will allow for estimates of lives saved by target population (mothers, newborns, and children 
<5) and target region based on the USAID IHP objective of increasing access to quality, integrated health 
services. Lives saved estimates will be independently calculated as a result of changes to coverage rates 
of curative care services for children, contraceptive use among females, childhood vaccinations, and 
attendance of antenatal care visits. This segmented approach will effectively yield intervention-specific 
impacts of the number of lives saved. Taking into consideration estimates of lives saved based on 
multiple scenarios of health services coverage rates, comparisons can be made for population-specific 
mortality rates. Line graphs will show mortality rates under scenarios where baseline coverage estimates 
are maintained and where IHP-DRC coverage targets are achieved. Additional plots will be made 
utilizing the interpolation function of the LiST given actual mid and endline health services coverage 
estimates as reported by the IHP-DRC and/or D4I teams. The D4I team will also explore the feasibility of 
conducting interrupted time series analyses on DHIS2-derived domain-specific monthly case counts for 
each of the targeted populations as a result of scaling up intervention coverage/use.
c. Analysis of enabling or limiting factors
To assess the perceptions of various stakeholders on the implementation of USAID IHP-supported 
interventions, qualitative research involving a mix of methods will be carried out during the baseline, 
midline and endline evaluations with the aim to complement the quantitative data analysis. During the 
baseline evaluation, we will carry out research at the central level (Kinshasa) and in one province in the 
Katanga Region to assess the status of health systems and to understand details of the USAID IHP
interventions and plans for implementation. 
At the central level, key informant interviews will be carried out with government officials, donors, and 
health care implementers to learn about facilitators and barriers to health systems strengthening. We have 
selected the province of Lualaba to conduct an initial in-depth analysis of institutional capacities and 
health delivery systems from the provincial down to the facility and community levels. The selection of 
Lualaba was based on the fact that the province was newly formed in 2015 and some of the Lualaba 
health zones had received assistance from the USAID IHP predecessor project, implemented by 
Management Sciences for Health. During the evaluation, we plan to compare data collected in zones that 
had and had not received previous IHP support. In addition, Lualaba will be one of three provinces where 
the healthy family campaigns (HFC), a central component to the USAID IHP behavioral change strategy, 
204 The Impact of USAID’s Integrated Health Program in the DRC 
will be launched from the outset of the project. In Lualaba, government officials and USAID IHP
program implementers will act as key informants at the provincial level. Two HZs with comparable health 
indicators, including one where the USAID IHP predecessor project led by Management Sciences for 
Health was implemented and one where the predecessor project was not implemented, will be identified 
for additional data collection. In these HZs, the chief medical doctor (MCZ) or an assistant will serve as 
key informants. In-depth interviews with reference hospital clinicians and administrators, health center 
nurses, CODESA and CHWs and facility-based observations will be employed to assess health service 
delivery, particularly in regard to child health services related to treatment of malaria, ARI and diarrhea, 
distribution of insecticidal nets, and vaccination coverage. Finally, focus group discussions will be 
administered with caregivers of children under five years of age to learn about care seeking behaviors and 
treatment practices associated with the leading causes of child morbidity and mortality, availability and 
utilization of Insecticide-Treated Nets, and access to essential children’s vaccinations, as well as 
perceptions of the delivery of facility and community level health services. A more detailed description of 
the qualitative methods is presented below. 
During the midline and endline data collection, we anticipate using a similar mixed methods approach but 
will conduct research in all three regions (Eastern Congo, Katanga, and Kasai) targeted by IHP. Data 
collected at midline and endline will concentrate on the activities the project has carried out, perceptions 
related to strengths and weaknesses of the interventions, and the extent to which the project was 
implemented according to plan. We will also explore the positive and negative consequences of the 
USAID IHP project, as well as assess the USAID IHP project’s impact on the functioning of activities, 
particularly related to child health. During all phases, data will be collected from a wide range of 
respondents including stakeholders involved in the design and implementation of interventions, service 
providers, and beneficiaries, with the goal to use environmental, methodological, and data triangulation to 
validate and interpret the research findings. 
d. Use of evidence-based population estimates. 
The DRC has not conducted a national census since 1984. The official government population estimates 
are projections from that census. We will incorporate more evidence-based population estimates in the 
event study and difference-in-difference analysis; these estimates are based on micro-census data 
extrapolated to the population level using satellite imagery and will be available from Oak Ridge National 
Laboratory and FlowMinder in early 2019.
Baseline Report 205
7. Limitations and Threats
There are a number of limitations of the evaluation, as well as threats to carrying out the evaluation as 
planned. 
First, due to the data limitations described in the previous section, the impact evaluation component of 
the study will only investigate the impact of USAID IHP on proxy indicators related to service 
provisions, including treatment of childhood illnesses, contraceptive use, vaccinations, and antenatal
care. Because data on health outcomes, service quality, and health systems governance and 
leadership will not be available from non-project areas, impacts on these aspects cannot be rigorously
assessed. However, to descriptively explore these aspects, a performance evaluation will be carried 
out using both quantitative and qualitative data that will be collected in the nine USAID IHP 
provinces to explore changes in proxy indicators of all three USAID IHP objectives – health systems 
strengthening, quality, integrated health services, and healthy behaviors – as well the factors that 
enabled or limited the success of the project. 
Second, the impact evaluation of the study will be based on routine data from the DHIS2. While it is 
expected that the advantages of using a research design based on DHIS2 data (i.e. numerous, repeated 
health zone observations over extended periods and the real-time indicators of service coverage) 
allow for power and cost advantages over a research design based on intermittent population-based 
surveys, poor data quality nevertheless remains a threat to the evaluation, due to inaccurate data on 
counts of services provided (numerators) and the populations that are served (denominators). This 
could lead to two consequences. First, poor data quality could add spurious variability to the 
dependent variable. If it is random measurement error, it will add to the variation of the random error 
in the model with the consequence of larger standard errors in the estimated coefficients and 
increasing the chances of not finding significant effects when there is impact. This is a common 
problem in research studies based on data from management information system, and there is little 
that the evaluator can do to address this issue. Second, the measurement error could potentially evolve 
over time as data quality improves with the improvements in the data reporting systems. Since 
USAID IHP aims to improve DHIS2 data quality, these improvements could be different in treatment 
and comparison areas, which will create a type of endogeneity in the program variable of the model 
that varies over time, so it is not controlled by the fixed effects. This heteroskadasticity should be 
accounted for through the estimation of robust standard errors. 
In order to address routinely assess data quality, the D4I evaluation team plans to partner with 
BlueSquare, a USAID IHP partner that is responsible for compiling and assessing DHIS2 data in all 
nine USAID IHP provinces, to carry out the same assessment and adjustment procedures to DHIS2 
data from non-project provinces. Moreover, data quality will be assessed as part of the D4I health 
facility surveys that will be carried out at baseline, midline, and endline, as will be described later in 
this protocol. 
Third, while it will not be possible to rigorously assess the impact of USAID IHP on health outcomes, 
the performance evaluation component of the study will include a LiST analysis to estimate the 
number of lives saved in IHP provinces as a result of changes in service coverage, based on 
demographic projections and health services coverage estimates from the USAID IHP population-
206 The Impact of USAID’s Integrated Health Program in the DRC 
based household surveys and service provision assessment surveys to be conducted by the project at 
baseline, midline, and endline. The LiST only provides estimates for lives saved and will not allow 
for estimates of other health impacts such as morbidity. Additionally, the LiST treats interventions as 
if they are delivered at full quality thereby assuming a degree of effectiveness that may not represent 
reality. However, the effect sizes for specific interventions are represented by global values from 
systematic reviews and meta-analyses, large-scale randomized controlled trials, and, in the absence of 
published data, from Delphi estimations (expert opinions). Further, there are over 60 indicators that 
can be calculated in the LiST software, but only about 20 are directly measured by large-scale, 
population-based household surveys (e.g. DHS/MICS). For example, antenatal care visits are directly 
measured, but relatively conservative coverage estimates for individual components of antenatal care 
are estimated from the parent indicator
Fourth, the D4I and USAID IHP surveys that will be used as the source of baseline data will be 
administered no earlier than June 2019, eleven months after USAID IHP started operations (in July 2018). 
This timing would be problematic if USAID IHP’s implementation activities had already begun, as it 
would bias the performance evaluation component of the study. However, based on previous meetings 
with USAID and the USAID IHP management teams, one of the key purposes of the USAID IHP surveys 
is to provide evidence that can be used to comprehensively assess the health systems needs within the 
nine provinces, and that USAID IHP will withhold most of its interventions until after the survey data has 
been analyzed, estimated to be no earlier than July 2019. 
Fifth, the DRC is an unstable environment, and there is a possibility that both the implementation of 
USAID IHP as well as USAID IHP and D4I survey activities could be affected by political and social 
unrest over the project period. This is not likely to affect the impact evaluation component of the study, 
which relies on routine health information system data, but it could affect future surveys if the data 
collection teams cannot safely travel to sampled provinces, health zones, and facilities affected by unrest, 
should that occur.
Baseline Report 207
8. Quantitative Data Requirements, Collection, 
Management, and Use
a. Data sources
Routine data: Routine data on service delivery will be obtained from the DRC’s DHIS2 system. The data 
are routinely updated onto a web-based platform, and D4I has been granted permission to access the data 
by the Government of the DRC. 
Primary quantitative data: D4I will partner with the Kinshasa School of Public Health (KSPH) to collect 
primary quantitative data (the scope of work and fieldwork plan can be found in Appendix B). 
Quantitative data will be collected through surveys of provincial health offices, HZ offices, hospitals, and 
health centers. Surveys of hospitals and health centers will include a medical record review and a module 
for health workers.
Table 4. Sampling strategy
Survey Module Sampling Frame Sampling Methodology e Size
Provincial health 
office
 f Provinces All in selected provinces 6
HZ office f HZs All in selected provinces 121
Health 
center/post
USAID IHP records Simple random sampling 
(3 per HZ)
363
General reference 
hospital
Census Purposive sampling/census
(1 per HZ)
121
Health worker: 
health center
Duty roster of all physicians, nurses,
and midwives responsible for 
providing health care services on duty 
in the selected facility the day of the 
survey*
Select all who meet criteria
(average of 3 per facility)
 1,089
Health worker: 
hospital
Duty roster of all physicians, nurses, 
and midwives responsible for 
providing maternal or child health 
services on duty in the selected 
facility the day of the survey*
Simple random sample
(1 doctor, 1 nurse, 1 midwife per facility)
363
Medical record 
review: health 
center/post and 
hospital
List of women who attended an ANC 
visit during the last calendar month at 
facilities selected for the health 
facility survey
Simple random sample of medical charts 
(10 per health facility or all that meet 
criteria if less than 10 meet criteria)
4,840
List of women who were discharged 
or died after delivery during the last 
calendar month
Simple random sample of medical charts 
(10 per health facility or all that meet 
criteria)
4,840
List of infants who were born alive 
during the last calendar month at 
facilities selected for the health 
facility survey
Simple random sample of medical charts 
(10 per health facility or all that meet 
criteria if less than 10)
4,840
208 The Impact of USAID’s Integrated Health Program in the DRC 
*Excludes pharmacy staff, laboratory staff, and those with clinical credentials who primarily work in an 
administrative capacity.
Surveys will be conducted at baseline (Year 1), midline (Year 4), and endline (Year 7). If possible, data 
collection will occur during the same months in each wave. Surveys will contain questions designed to 
assess the level at which governance and management are being carried out, the degree to which the 
health system is providing quality services, whether and why the population is using these services, 
gender and age dynamics within the health system, and the contributions of IHP. For each survey 
administered, a GPS point will be recorded. The survey instruments can be found in Appendix C. All 
instruments will be professionally translated into French. Data collectors will administer the survey 
verbally and record responses on tablets using OpenDataKit, with the exception of medical chart review, 
which the data collectors will conduct independently using pre-developed templates. Surveys will be 
pilot-tested in Kinshasa prior to deployment. Pilot testing will assess the formulation of questions and 
responses, skip patterns, and the tablet-based collection method. 
USAID IHP facility and household survey data: At baseline, USAID IHP will conduct a census of 
health facilities (from hospitals to health posts) in all nine provinces. This survey is designed to be a rapid 
assessment that Abt will use to tailor its approach throughout the project areas. Facility-based data 
collection for this evaluation will be conducted in a sample of facilities and will involve more in-depth 
questions. Therefore, the two surveys will be conducted independently. However, both will utilize the 
same sampling frame and facility identification system so that the two data sets can be linked. USAID 
IHP plans to conduct similar surveys on a subset of facilities at midline and endline. 
USAID IHP will also conduct a baseline survey in households across all nine provinces (n=9,000 
households). This survey will include separate modules for men and women. Data for Impact (D4I) is 
providing input on the sampling approach and questionnaires. USAID IHP plans to repeat the survey in 
the same villages at midline and endline.
D4I will incorporate data from both USAID IHP’s facility and household surveys in the process 
evaluation. Table 5 indicates which data are to be collected by IHP and D4I.
Table 5. Sources of primary data used in the evaluation, by organization
Implementer 
Data collection method
Baseline Midline Endline
IHP Health facility census Health facility survey 
or census
Health facility survey 
or census
Household survey (9 
provinces)
Household survey (9 
provinces)
Household survey (9 
provinces)
D4I Health facility survey (more 
in-depth than IHP, but fewer 
sites in 6 provinces)
Health facility survey 
(more in-depth than 
IHP, but fewer sites in 
6 provinces)
Health facility survey 
(more in-depth than 
IHP, but fewer sites in 
6 provinces)
Health zone and provincial 
health offices (census in 6 
provinces)
Health zone and 
provincial health 
offices (census in 6 
provinces)
Health zone and 
provincial health 
offices (census in 6 
provinces)
Baseline Report 209
In-depth and key informant 
interviews
In-depth and key 
informant interviews
In-depth and key 
informant interviews
USAID IHP quarterly report and annual work plans: As mentioned earlier, the specific interventions 
that will be supported by USAID IHP will vary across the health zones in the nine USAID provinces. In 
order to describe USAID IHP implementation activities, the D4I team will review USAID IHP quarterly 
reports, as well as the Annual Work Plans of the IHP USAID-supported health zones. Both sets of 
documents will be provided by the USAID IHP monitoring and evaluation team. 
b. Data collectors and training
Data collectors will be recruited from the surveyed regions and efforts will be made to recruit comparable 
numbers of male and female data collectors. All data collectors will be fluent in French and the local 
regional language. Many will have prior experience in survey administration, and all will receive 
comprehensive, multi-day training from D4I and KSPH. We will recruit data collectors with clinical 
backgrounds (physicians, nurses) to conduct the medical record review and administer clinical vignettes. 
Training will cover research methods, data collection procedures, research ethics and informed consent, 
and the use of tablets for data collection. 
c. Sampling and recruitment
The sample of provinces contains the province containing the capital city of each of the three regions. We 
then sampled provinces in a way that created a mix of conditions within the sample. We ensured 4 out of 
6 of the selected provinces were newly-created by the 2015 decoupage. At the start of USAID IHP, four 
provinces (Lualaba, Haut Katanga, Sud Kivu and Kasai Oriental) had already begun capacity-building 
activities, while the remaining five had not. Again, 4 out of 6 of the selected provinces had ongoing 
activities, while two did not. Table 6 illustrates the selection strategy for provinces, with selected 
provinces identified with an *.
Table 6. Selection methodology for provinces.
Region Province Capital Age Activities Selected
Eastern 
Congo
Sud Kivu* Yes Old Ongoing Yes
Tanganyika* No New New Yes
Kasai Kasai Oriental* Yes Old Ongoing Yes
Sankuru* No New New Yes
Kasai Central No Old New No
Lomami No New New No
Katanga Haut Katanga* Yes New Ongoing Yes
Lualaba* No New Ongoing Yes
Haut Lomami No New New No
*Province selected for primary quantitative data collection
210 The Impact of USAID’s Integrated Health Program in the DRC 
Within each selected province, we will attempt to survey all selected HZ central offices. If a HZ office 
refuses to participate, it will not be replaced. However, the rest of the planned surveys will be conducted 
within that HZ as long as permission can be obtained.
Within each HZ, we will randomly select three health centers/posts. Once sampled facilities have been 
selected, data collectors will call via phone or approach the facility and speak with the facility head. If the 
facility head agrees to participate, we will conduct surveys with that facility and its associated health 
workers. If the facility does not agree to participate, the next closest health facility in the HZ will be 
invited to participate. If a health worker refuses, they will be replaced if there is another eligible health 
worker present. All refusals will be recorded in OpenDataKit.
We will attempt to survey the same provinces, health zones, and facilities during all three waves of data 
collection. If a health center/post refuses to participate in a later wave, it will be replaced by the closest 
health center/post. 
d. Data collection
Survey data will be collected on mobile devices. Data will be cleaned by thoroughly checking whether 
indicator values fall within plausible ranges, confirming whether skip patterns have been respected and 
assessing whether survey responses are consistent with previous responses. In addition, for many 
indicators that are in common with those in the DRC DHS planned for 2020, the validity of the results 
will be assessed by comparing data from the baseline survey with the DHS data.
9. Qualitative Data Requirements, Collection, Management, 
and Use
a. Data sources
Key informant interviews: Key informant interviews will be conducted with a range of experts from the 
central to the zonal level working on health systems strengthening, with key informants either working 
directly on USAID IHP activities or involved in other health service delivery strategies in the DRC. 
Key informants will be selected purposively based on their expertise and/or role in USAID IHP. In the 
capital Kinshasa, we aim to carry out key informant interviews with MOH collaborators on USAID IHP
(3), Abt senior staff involved in program development, implementation, and monitoring and evaluation 
(3), and USAID IHP staff and partners leading behavioral change interventions (2-3) and data platform 
development and technologies designed to enhance data-driven decision making (1) (see Table 7). 
USAID staff including the head of health and national representative overseeing USAID IHP will also be 
interviewed. We also aim to interview the Project Director of the USAID IHP predecessor project, as well 
as a representative of the World Bank overseeing performance-based financing activities. In the province 
of Lualaba, key informants will include a provincial health office official, a representative from the 
inspector’s office, a representative from the MNCH program, an USAID IHP representative overseeing 
interventions in the Katanga region, and the chief medical officer or the chief medical officer assistant in 
Baseline Report 211
the two HZs selected for data collection. We also anticipate interviewing Abt and USAID headquarters 
staff involved in the project development and oversight. 
Key informants will provide initial information on the strengths and weaknesses of health systems in the 
DRC, perceptions of the functioning and shortcomings of governance in the provision of health care, and 
perceived needs related to institutional strengthening and support to DRC health systems and service 
delivery. Topics to be examined will focus on institutional and individual capacities to plan, lead, execute, 
and monitor health action plans; understandings and implementation of evidence-based decision making; 
roles in budget development and financial management; personnel recruitment and performance 
management, supervision structures and other accountability mechanisms; capabilities related to 
leadership and personnel, administrative, and financial management; utilization of existing support 
systems such as the integrated human resources information system, results-based financing and 
community scorecards; disease surveillance, information gathering strategies and data utilization; 
perceptions of community-based services and capacity strengthening needs; and collaboration, 
coordination and information sharing with other stakeholders. Additional information will be collected on 
staff satisfaction, compensation, the potential for advancement, and motivation for job performance 
improvement, as well as perceptions of transparency, accountability, issues related to gender and gender￾based discrimination, and capacity building needs. At the provincial and zonal level, we will assess 
inspection roles and capabilities and the evolution of decentralized services. At these levels, we will also 
collect information on contextual factors potentially affecting health care provision and demand and 
services offered prior to the USAID IHP intervention. Topics covered with individual key informants will 
depend on their expertise and involvement in the project. 
In-depth interviews: In-depth interviews will be administered to health providers at the facility level and 
CHW’s at the community level in the two HZs to examine essential child health care packages. In each 
zone, we will conduct interviews with the hospital administrator and one clinician working in the 
pediatric ward in the reference hospital. In addition, based on DHIS2 data related to utilization of curative 
care for children under five years of age seeking treatment for malaria, ARI, or diarrhea, we will identify 
one health center with relatively high volumes of maternal and child cases, and one with relatively low 
volumes of maternal and child cases where in-depth interviews will be carried out with a head nurse or an 
assistant head nurse.
Interviews with facility-based workers will focus on the availability of essential child health services, 
quality of care and factors affecting demand. Topics we aim to investigate relate to health facility staffing, 
training, roles and organization; availability and integration of essential child health services and 
utilization of treatment algorithms; the condition of facility infrastructures and equipment and availability 
of commodities and medical supplies needed to carry out key child health services at the facility and 
community level; referral systems from the community level to health centers and reference hospitals; 
health provider attitudes towards respectful care, particularly in relation to gender, age and ethnicity; 
perceptions of innovative financing approaches to reduce barriers to health care access by poor members 
of the population; monitoring of health service performance and data utilization; medical supply chain 
inventory management, reporting, requisition and transport; and participation in coordination meetings 
led by the MOH or donors to ensure sharing of field level learning experiences. We will also assess 
current outreach strategies and ways to strengthen community engagement and efforts to elicit 
information from local populations regarding health problems and needs. Topics covered with in-depth 
212 The Impact of USAID’s Integrated Health Program in the DRC 
interview informants will be guided by their role in the provision of health care and involvement in the 
IHP project. 
In-depth interviews will also be conducted with CHWs, including the CODESA president or vice￾president and a CHW selected by the CODESA informant, with the selection criteria targeting long￾tenured and high performing CHWs. During interviews, we will assess the existence of community-based 
activities aimed to encourage SBC-related to healthy behaviors and to mobilize the demand for and 
uptake of improved health services. Questioning will focus on health promotion, outreach, community 
mobilization, referrals and reporting; training and roles related to treatment (including the existence and 
functionality of integrated community case management sites), prevention and monitoring of services; 
promotional tools and adult learning approaches employed; and the involvement of CBO’s such as the 
Cellules d’Animation Communautaires, coordination of community activities, and linkages with facility￾based staff and services. Both facility-based providers and CHWs will be asked about local barriers to 
health care utilization, ways to improve affordability and quality of health care services, perceived biases 
in health care provision and utilization including those related to gender and youth, supervision of work 
activities, and previous and ongoing project activities in the area. Additional questions will focus on job 
satisfaction, compensation, and motivation and capacity building needs. We will also assess informant’s 
participation in technical and coordination meetings that present an opportunity to share lessons learned 
with other stakeholders.
Focus group discussions: Group discussion will be conducted with caregivers of children five years of 
age and under, with a target to carry out one focus group in each health center’s catchment area. 
Caregivers will be identified by CODESA members and CHWs, with the goal to include a mix of 
caregivers who regularly and do not regularly attend well baby visits in discussion groups. During group 
discussions, we will examine caregivers’ knowledge of facility and community-based child health 
services, including preventive and curative care, community mobilization and social support and 
educational activities, and efforts to improve health care access among vulnerable populations. We will 
also explore perceptions of treatment and preventive services for childhood illnesses at the facility and 
community level, health center infrastructures for child health services, health providers capacity to treat 
the leading causes of childhood mortality and morbidity, availability of essential drugs, vaccinations and 
other supplies, health provider attitudes and interpersonal communications, health care costs and 
affordability, and ways to improve services. Discussion topics will also revolve around household 
decision making and care-seeking behaviors related to treatment for malaria, diarrhea and ARI, 
distribution and utilization of insecticidal nets, and access to basic vaccinations for children, with a focus 
on identifying sociocultural barriers to the use of formal health services and practice of key healthy 
behaviors. We will explore exposure to radio, text and more local awareness-raising messaging (e.g. 
through CHWs, CODESA, schools, churches, community organization, etc.) related to child health. 
During group discussions, we will also assess whether efforts such as the use of community scorecards or 
group meetings have been made to elicit information from community members to assess their health 
needs.
Observations: Using a semi-structured observation guide, observations will be conducted in health 
centers and general reference hospitals to assess the condition of infrastructures where child health 
services are provided; availability of drugs, materials and supplies, and equipment to provide essential 
child health care; official fee schedules; and any evidence of activities to discourage fraud and increase 
transparency. In addition, we will observe provider-caregiver interactions during treatment of sick 
Baseline Report 213
children, with a focus on quality of care including whether the health provider greets the caregiver, asks 
questions related to the illness episode, physically examines the child, explains the diagnosis and 
treatment regimen, provides medication or a prescription, recommends a follow-up visit, and confirms 
whether the caregiver understands the diagnosis and recommended treatment or has additional questions. 
We will also carry out observations of the queuing process and the waiting area, whether triage is carried 
out, the waiting time, and if patients are turned away without being seen by a provider. We plan to take 
photographs of the exterior and interior of the health facilities, equipment and materials to record 
conditions in the health centers. Photographs will not be taken of clientele including caregivers and 
children observed during the health provider-caregiver interactions. 
Table 7. Targets for key informant and in-depth interviews, group discussions and observations according 
to research methods and respondent type.
Research methods and types of respondents
Total
n
Key informants
Central level/Kinshasa and Headquarters
MOH officials collaborating on IHP activities 2-3
USAID IHP senior staff involved in program development, implementation, and M&E 5
USAID IHP staff and partners leading behavioral change interventions 2-3
USAID IHP partners leading data platform development and technologies 1
USAID representatives in Kinshasa overseeing IHP activities 3
Chief of Party of USAID’s predecessor project 1
Representative of the World Bank overseeing performance-based financing 1
Lualaba
DPS representative 1
MNCH program representative 1
USAID IHP representative overseeing interventions in the Katanga region 1
Inspector’s office representative 1
Chief medical officer or the chief medical officer assistant in two health zones 1
In-depth interviews
Reference hospital administrator and clinician on the pediatric ward 4
Health center head nurse or head nurse assistant 4
CODESA president or vice president 4
Community health care provider 4
Village leader 4
Focus group discussions (4 groups of 8-12 participants)
Female caregivers of young children < 5 years old (age 18 or older) 48
Observations (12-19 pairs of providers and clients)
Health provider-client interactions during treatment of childhood illness 24-38
b. Data collectors and training
A 4-5-day training workshop will be carried out prior to the study. We anticipate training 4-6 potential 
male and female research assistant candidates with prior experience using qualitative methods. Trainees 
214 The Impact of USAID’s Integrated Health Program in the DRC 
will be introduced to the USAID IHP approach and activities, qualitative study objectives, research 
methodology, research ethics and informed consent, and study instruments. Initial sessions will focus on 
the USAID IHP objectives, structure and interventions. Subsequently, trainees will be introduced to the 
qualitative study design and data collection techniques to be employed during the study, with a focus on 
open-ended questioning and recommended approaches to be used when interacting with respondents. 
Extensive time will be devoted to each of the research methods, including the sampling procedures, data 
collection approaches, and instruments. Training will also include theoretical and practical sessions 
related to research ethics and obtaining informed consent. Field testing of the instruments will be 
conducted, with revisions made during the training period. The training will be led by the medical 
anthropologist and the supervisor overseeing the study. Two trainees who perform well will be selected to 
take part in the study. After selection of the data collectors, we will carry out additional training if deemed 
necessary. The study team will be comprised of the medical anthropologist, the study supervisor, and two 
research assistants. 
Initial data collection will involve key informant interviews at the central level. Subsequently, key 
informant interviews will be carried out in the provincial capital of Lualaba. Once completed, the research 
team will travel to one of the study HZs to interview the chief medical officer and identify a high and low 
performing health area in the HZ. Key informant interviews will be carried out by the medical 
anthropologist and the research supervisor. 
Key informant interviews will be open-ended and last approximately 1-1.5 hours. Interviews will be 
carried out in informant’s offices or in another location where privacy can be maintained. We will use an 
interview guide with questioning adjusted to informants’ backgrounds and expertise (see Appendix D). 
Data collection will be an iterative process, with the information gathered serving to inform subsequent 
key informant interviewing until data saturation is reached. Information collected from key informants 
will also be used to inform the content of in-depth interviews, focus group discussions and observations. 
We anticipate that during each evaluation (baseline, midline, and endline) some key informants will be 
interviewed on multiple occasions, with the goal to establish a relationship of trust, which will influence 
the willingness of informants to open up and enhance the data quality. Subsequent to the field visit to 
Lualaba, questioning of key informants located at the central level will allow us to clarify and interpret 
information gathered through the other data collection methods at the provincial and HZ level. 
In-depth interviews with health providers including nurses, CODESA members and CHWs will be carried 
out in the health area facility or a setting of their preference. Data collectors will follow a semi-structured 
guide (see Appendix D). Efforts will be made to conduct the in-depth interviews in a private setting, with 
each interview lasting no longer than 1hour and 15 minutes. If the research assistant is unable to address 
all of the topics listed in the interview guide, the assistant will schedule a follow-up session to complete 
the interview at a later time. 
Group discussions will be comprised of 8-12 child caregivers and held in a space where relative privacy 
can be maintained, such as a school or church. Discussions will be led by a moderator who will guide the 
questioning; a second research assistant will record notes to facilitate data transcription. Group 
discussions will last no longer than 1hour and 30 minutes. A guide based on the research objectives and 
primary themes and preliminary study results procured through the other data collection methods will be 
used (see Appendix D). 
Baseline Report 215
Observations of care provider-patient interactions will be carried out two mornings in each health center, 
starting early in the morning in the health center location where curative care is offered. Observations will 
continue until caregivers no longer seek treatment for child illnesses. We will also make direct 
observations of the condition of the health infrastructure, supplies and equipment available, the general 
cleanliness and organization of the facility, fee schedules, and any efforts to encourage rights-based 
education. Research assistants will employ a form to record observational data. 
Key informant interviews and in-depth interviews with facility-based health providers and CODESA 
members will be carried out in French or Kiswahili. In-depth interviews with CHWs and group discussion 
participants will be administered in Kiswahili. Some of the interviews done in Kiswahili may require the 
assistance of an interpreter, who will be trained by the research assistants. Key informant and in-depth 
interviews and group discussions will be audio recorded; interviewers will also take handwritten notes of 
information that will give additional insights into the data. Interviews and group discussions conducted in 
Kiswahili will first be transcribed in Kiswahili and subsequently translated into French after the data 
collection is completed, while interviews conducted in French will be transcribed directly. Transcripts 
will be reviewed by the research assistants and team supervisor, and electronic copies of the transcripts 
will be kept by D4I.
Data will only be collected after the informed consent process has been carried out and if potential study 
candidates agree to participate in the study. 
c. Sampling and recruitment
Key informants will be selected purposively based on their role in health systems management, expertise 
in health systems strengthening, and involvement in the USAID IHP project activities. Respondents will 
include representatives of the MOH at the national (3), provincial (2), and zonal (1 in each of two HZs) 
level, USAID IHP staff and technical and implementing partners involved in intervention development, 
implementation, and monitoring and evaluation at headquarters (1-2), central (6-7) and provincial (1) 
levels, and representatives of donor organizations (3-4). We also plan on interviewing a government 
official in the inspector’s office at the provincial level. No more than 25 key informants will be 
interviewed. An appointment to meet with the potential respondents will be made by phone or email, but 
respondents will be approached to participate in the study in their offices. 
In-depth interviews will be conducted with facility-based service providers and CHWs including the 
administrator and a clinician working on the pediatric ward in the reference hospital, the Infirmier 
Titulaire de l’Aire de Santé or their assistant in the health center, the CODESA president or vice 
president, a CHW selected by the CODESA respondent with the aim to identify a long-tenured and high 
performing community worker, and an influential community leader knowledgeable of health services 
and recommended by the CODESA and CHW respondents. In-depth interviews will be carried out in the 
two zonal reference hospitals and in each of the four health center areas to assess facility- and 
community-based health care services and especially child health activities. Health care respondents will 
be approached in the health facility for recruitment, while the community leader will be contacted in his 
or her home or place of work. No more than eight facility-based health workers, four CODESA members, 
for CHWs and four community leaders will be interviewed. 
216 The Impact of USAID’s Integrated Health Program in the DRC 
In each of the four health center areas, we will carry out focus group discussions with child caregivers 
including mothers and grandmothers. Each group will be comprised of 8-12 participants. Caregivers must 
have a child under five years of age living in their household and be a permanent resident of the health 
area. Caregivers will be purposively selected by the relais communautaires working in their village; we 
will search for experienced caregivers who are willing to share their opinions and experiences related to 
child health and care seeking in a group setting.
Observations will be carried out in each of the two reference hospitals and in the four health centers 
where the research will be conducted. During observations, a range of information will be collected 
including the general condition of the facilities, availability of drugs, materials and supplies, and 
equipment to provide essential child health care, and official fee schedules. We will also carry out 
observations of the way caregivers and patients are managed upon arrival in the facility and before 
receiving health care. Direct observations will be made of provider-caregiver interactions during 
treatment of sick children, with the aim to observe a minimum of four observations in each reference 
hospital and four interactions in each health center and no more than 38 observations in total. 
d. Data collection
Data from key informant and in-depth interviews and focus group discussions will be audio recorded, 
translated from local language into French when needed, and transcribed in French. Observational data 
handwritten on a structured form will be transcribed. Based on reviews of data transcripts, research 
assistants and the lead researcher will work together to develop a coding system. Coding categories will 
be derived from the initial research themes and questions, as well as from key concepts that emerged 
during data collection. Coding of the interview transcripts will be done on ATLAS.ti, a text-organizing 
software. Content analysis will be used to identify trends of concepts in and across individual codes. 
Photographs of the health facility environment will be used to complement information concerning 
facility infrastructures and equipment. The combination of data, environmental and methodological 
triangulation will allow us to analyze data across different research methods (e.g. key informant and in￾depth interviews) and sites and across and between respondents.
Baseline Report 217
10. Ethics and Informed Consent
Data collectors will carry out the informed consent process with each potential respondent. The informed 
consent process includes an explanation of the purpose of the study, the risks and benefits of participating, 
and the time required by each interview. Also, it explains that the individual has the choice to participate 
or not participate in the study. The consent process will include assurances that participation is voluntary, 
that those with power over the participant (work supervisors, physicians, etc.) will not be notified of 
whether or not the person participated, and that their individual responses will not be shared or linked to
them in the research products. All survey respondents will give informed consent before participating.
Patients whose medical records are reviewed will not be notified and will not give informed consent. 
Their identifiers (names, dates of birth) will not be collected.
Due to the fact that some participants (for example, the Provincial Health Officers) could be identified by 
their location alone, all results will be presented in aggregate. Data will be stored on secure servers under 
password protection, with access only available to research staff. Ethical approval of the evaluation will 
be obtained from the Institutional Review Board of the Tulane School of Public Health and the Kinshasa 
School of Public Health prior to data collection (see Appendix E).
We are not collecting any biomarkers or performing any medical interventions and we do not anticipate 
that any questions will trigger negative psychological responses. However, should this happen, the 
respondent will be referred to the nearest health facility.
Respondents will not receive incentives to participate. 
218 The Impact of USAID’s Integrated Health Program in the DRC 
11. Data Management
a. Data storage and security
D4I will be responsible for overseeing data management. All data forms and records collected during this 
research will be held in a secure location at KSPH and/or Tulane University for the duration of the 
proposed research by Principal Investigator, Dr. David Hotchkiss and co-investigators, Dr. Janna 
Wisniewski and Dr. Paul-Samson Lusamba-Dikassa. Confidentiality of all respondents will be ensured 
through the replacement of any personal information with unrelated unique identifiers. Where relevant, 
names and location information will be separated from the electronic data processed for analysis. The 
only identifiers used during the analysis will be a unique identification number. All data will be kept 
under lock and key or password-protected computer, with only key personnel having access.
b. Data-sharing procedures
Data sharing memorandums of understanding will be developed between D4I and KSPH to facilitate 
access to data files. De-identified data will be transferred to KSPH via a secure File Transfer Process 
server and then stored on a secure server managed. In accordance with the USAID Open Data Policy, de￾identified data will be transferred to a data archive such as the Dataverse Network, to facility third-party 
requests to access the data. Data will only be shared with third parties following written permission from 
Tulane University, represented by the PI, Dr. Hotchkiss. A copy of the data-sharing agreement between 
D4I and USAID can be found in Appendix F.
c. Knowledge management plan
Upon completion of the baseline, midline and endline survey reports, D4I and KSPH will be responsible 
for hosting a results dissemination workshop to inform all stakeholders of the survey results. Reports will 
be written in English and in French, summarizing the study results. The workshop will present the 
findings in a clear and concise manner and invitees will include representatives from USAID, Abt 
Associates, Implementing Partners, D4I, the MOH and where possible community leaders from the 
communities selected for the study. In addition, datasets will be publicly released after the conclusion of 
the study, following data sharing policies of the MOH and USAID. A copy of the Memorandum of 
Understanding on authorship can found in Appendix G.
Baseline Report 219
12. Evaluation Team and Stakeholder Roles
This evaluation is being conducted by the D4I project. D4I partner, Tulane University’s School of Public 
Health and Tropical Medicine, has extensive experience supporting health research and capacity building 
in the DRC over the past five decades and has established a research office in Kinshasa with a full-time 
Senior Research Director. The evaluation is led by Dr. David Hotchkiss (the Technical Lead based in 
New Orleans), Dr. Janna Wisniewski (a co-investigator based in New Orleans), and Dr. Paul-Samson 
Lusamba-Dikassa (a co-investigator and a faculty member of the Kinshasa School of Public Health based 
in Kinshasa). They are assisted by a grant management specialist who is responsible for the financial 
management of the study. 
Drs. Hotchkiss and Wisniewski will be responsible for overseeing all activities and analysis related to the 
quantitative component of the study, including submission of the protocol to the Institutional Review 
Boards of the Tulane and KSPH, the training of supervisors and data collectors responsible for the 
facility, health zone office, and provincial health office surveys, the compilation and analysis of DHIS2 
data, and writing reports based on the study findings. Through sub-contracts with Tulane, KSPH will be 
responsible for carrying out the D4I facility, health zone office, and provincial health office surveys at 
baseline, midline, and endline, and participating in the data analysis and report writing. The KSPH team 
will be led by Drs. Patrick Kayembe and Eric Mufata, faculty members at KSPH. It is also anticipated 
that a sub-contract will be established with BlueSquare to create a DHIS2 database, assist in carrying out 
data quality assessment of the DHIS2 data, and automate the indicators needed for the DID-PSM analysis. 
It should be noted that BlueSquare is a partner on USAID IHP with the responsibility of developing and 
managing USAID IHP’s Monitoring and Evaluation Platform, which synthesizes all monitoring data, 
including DHIS2 data, in one place. BlueSquare’s work and deliverables for the D4I evaluation will be in 
addition to those they are contracted to carry out for USAID IHP. 
Dr. Lauren Blum, a medical anthropologist and consultant to Tulane, will be responsible for overseeing 
all activities and analysis related to the qualitative study. Dr. Blum has over 18 years of experience 
leading qualitative studies. She lived and worked in the DRC for over seven years and speaks French. She 
will be responsible for the following activities: 1) develop the study protocol including data collection 
tools and consent forms; 2) submit the protocol to the Institutional Review Boards of Tulane and KSPH; 
3) train local qualitative researchers on data collection and management techniques; 4) oversee the pre￾test of the study instruments and revise the instruments based on the pre-test results; 5) ensure the 
fieldwork and data transcription and translation is carried out according to the protocol; 6) code and 
analyze the data in conjunction with the study supervisor; 7) write-up the study findings; and 8) 
participate in the data triangulation and the elaboration of reports based on the study findings. Dr. Paul￾Samson Lusamba-Dikassa will provide technical and managerial support to the study. Drs. Blum and 
Lusamba-Dikassa will be assisted by Dr. Eric Mafuta, who has extensive experience in qualitative 
research. As a co-investigator, Dr. Mafuta will supervise data collection and participate in data coding and 
analysis. 
The New Orleans-based members of the evaluation team regularly visit Kinshasa to provide oversight of 
the evaluation activities in coordination with USAID, USAID IHP, the local D4I partner team, and study 
contractors/subcontractors. D4I reports on the progress of the study to USAID and the Chapel Hill, NC 
D4I management team.
220 The Impact of USAID’s Integrated Health Program in the DRC 
13. Timeline and Deliverables
The timeline for the evaluation activities is presented below. Wave three activities are conditional on 
USAID approving a three-year extension for USAID IHP. 
Table 8. Timeline of quantitative data collection.
Start date End date Activity
Wave 1
6/01/19 Study documents finalized and translated
6/14/19 IRB approval (D4I and KSPH)
5/20/19 6/28/19 ODK programming and testing
6/10/19 6/14/19 Supervisor training and pilot testing (Kinshasa)
6/15/19 6/22/19 Supervisor travel from Kinshasa to provinces
6/30/19 7/01/19 Data collector recruitment and preparation (provinces)
7/02/19 7/11/19 Data collector training
7/11/19 8/11/19 Data collection
8/12/19 9/30/19 Data cleaning, analysis, and report writing
Wave 2
6/10/22 6/14/22 Supervisor training and pilot testing (Kinshasa)
6/15/22 6/22/22 Supervisor travel from Kinshasa to provinces
6/30/22 7/01/22 Data collector recruitment and preparation (provinces)
7/02/22 7/11/22 Data collector training
7/11/22 8/11/22 Data collection
8/12/22 9/30/22 Data cleaning, analysis, and report writing
Wave 3
6/10/25 6/14/25 Supervisor training and pilot testing (Kinshasa)
6/15/25 6/22/25 Supervisor travel from Kinshasa to provinces
6/30/25 7/01/25 Data collector recruitment and preparation (provinces)
7/02/25 7/11/25 Data collector training
7/11/25 8/11/25 Data collection
8/12/25 9/30/25 Data cleaning, analysis, and report writing
Baseline Report 221
Table 9. Timeline of qualitative data collection
Start date End date Activity
Wave 1
3/25/19 Study documents finalized and translated
3/26/19 4/09/19 IRB approval (D4I and KSPH)
4/15/19 5/1/19 Data collection by Lauren Blum (D4I and Lualaba)
5/2/19 5/17/19 Transcription
5/20/19 5/31/19 Data coding, analysis, and report writing
10/07/19 10/11/19 Data collector training
10/14/19 11/01/19 Data collection in provinces (facility and community-level)
11/2/19 12/17/19 Transcription
12/18/19 12/31/19 Data coding, analysis, and report writing
Wave 2
10/07/21 10/11/21 Data collector refresher training
10/14/21 11/01/21 Data collection
11/02/21 12/17/21 Transcription
12/18/21 12/31/21 Data coding, analysis, and report writing
Wave 3
10/07/24 10/11/24 Data collector refresher training
10/14/24 11/01/24 Data collection
11/02/24 12/17/24 Transcription
12/18/24 12/31/24 Data coding, analysis, and report writing
222 The Impact of USAID’s Integrated Health Program in the DRC 
Table 10. Schedule of deliverables
Date Deliverable Description
8/30/19 Wave 1 topline report Descriptive results of key indicators from facility 
surveys
9/30/19 Wave 1 preliminary 
report
Descriptive results from facility surveys and 
qualitative data collection done to date
1/01/20 Wave 1 report Includes qualitative data from October 2019
8/30/22 Wave 2 topline report Changes over time and difference-in-difference 
for key variables between Waves 1 and 2.
9/30/22 Wave 2 report Changes over time and difference-in-difference 
between Waves 1 and 2, and qualitative results.
8/30/25 Wave 3 topline report Changes over time and difference-in-difference 
for key variables between Waves 1, 2 and 3.
9/30/25 Final report Changes over time and difference-in-difference 
between Waves 1, 2, and 3, and qualitative results.
Baseline Report 223
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République Démocratique du Congo 2013-2014. Rockville, Maryland: MPSMRM, MSP et ICF 
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Patient-Centered Outcomes Research Institute (PCORI) Methodology Committee. (2019). The PCORI 
Methodology Report. 
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International Development.
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Suppl 3:S1.
World Bank. (2017). Congo, Democratic Republic of - Health System Strengthening for Better Maternal 
and Child Health Results Project: additional financing. Washington, DC: World Bank Group. Retrieved 
from http://documents.worldbank.org/curated/en/334761491184862554/Congo-Democratic-Republic-of￾Health-System-Strengthening-for-Better-Maternal-and-Child-Health-Results-Project-additional-financing

 Baseline Report 225
Appendix 2: Data Collection Instruments
IHP Evaluation
HEALTH FACILITY SURVEY
Part A. Management
SECTION 1. ORIENTATION
Upon arrival at the facility, do the following:
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province
2. Record the health zone
3. Record the name of the health facility
4. Enter your data collector ID number
5. Enter the facility ID number
Identify the highest-ranking person. Explain that some questions may have been asked in earlier interviews with USAID IHP 
representatives and that you appreciate their time and patience.
6. Have you read him/her the consent script? |_| No
|_| Yes
If no,  7
7. If no, why?
8. Did the respondent agree? |_| No
|_| Yes
If no,  9
9. If no, what was the reason? |_| No office members present 
at time of visit
|_| Office members absent for 
a long period of time
|_| Deferred
|_| Refused
|_| Office vacant or not an 
address
|_| Office destroyed
|_| Office not found
|_| Other (specify) _________
10. Take a photograph of the front of the facility
226 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 2. BASIC FACILITY INFORMATION
First, I would like to ask you some general questions about how this facility is organized, and what infrastructure and resources are 
available. 
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
11. On what days of the week is this facility typically open and for how 
many hours on these days?
|_|Monday
 Hours |__|__|
|_|Tuesday
 Hours |__|__|
|_|Wednesday
 Hours |__|__|
|_|Thursday
 Hours |__|__|
|_|Friday
 Hours |__|__|
|_|Saturday
 Hours |__|__|
|_|Sunday
 Hours |__|__|
12. In general, is there a trained health provider assigned to and present 
at the facility at all times (24 hours a day) for emergencies?
Yes, observed
Yes, not observed
No one on call 24/24
Don't know
If no,  13
13. In general, is there a trained health provider available away from 
the facility but officially on call, at all times, (24 hours a day) for 
emergencies?
Yes, observed
Yes, not observed
No one on call 24/24
Don't know
14. RECORD OBSERVATION OF THE MAIN MATERIAL OF THE FLOOR NATURAL FLOOR
EARTH/SAND
DUNG
RUDIMENTARY FLOOR
WOOD PLANKS
PALM/BAMBOO
FINISHED FLOOR
PARQUET OR POLISHED WOOD
VINYL OR ASPHALT STRIPS
CERAMIC TILES
CEMENT
CARPET
OTHER
_________________________
(SPECIFY)
 Baseline Report 227
15. RECORD OBSERVATION OF THE MAIN MATERIAL OF THE ROOF NATURAL ROOFLING
NO ROOF
THATCH/PALM LEAF
SOD
RUDIMENTARY ROOFING
MAT
PALM/BAMBOO
WOOD PLANKS
CARDBOARD
FINISHED ROOFING
METAL
WOOD
CALAMINE/CEMENT FIBRE
CERAMIC TILES
CEMENT
OTHER
_________________________
(SPECIFY)
16. RECORD OBSERVATION OF THE MAIN MATERIAL OF THE EXTERIOR 
WALLS
NATURAL WALLS
NO WALLS
BAMBOO/CANE/PALM/TRUNK
DIRT
RUDIMENTARY WALLS
BAMBOO WITH MUD
STONE WITH MUD
UNCOVERED ADOBE
PLYWOOD
CARDBOARD
REUSED WOOD
FINISHED WALLS
CEMENT
STONE WITH LIME/CEMENT
BRICKS
CEMENT BLOCKS
COVERED ADOBE
WOOD PLANKS
OTHER
_________________________
(SPECIFY)
228 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 2. GENERAL STAFFING
Now I have some questions about staffing for this facility. Please tell me how many staff members with 
each qualification are currently assigned to this facility and whether they are male or female staff, and how 
many positions are unfilled. This includes staff who work here full-time, part-time, or are volunteers. Enter 
-99 if unknown
USE THIS INFORMATION TO COMPLETE COLUMNS a, b and C. IF THE INFORMATION IN UNKNOWN, MARK 
COLUMN d AND LEAVE COLUMN a, b, and c BLANK.
ASK TO SEE THE STAFF ROSTER. FOR EACH QUALIFICATION, RECORD THE NUMBER OF PEOPLE WHO ARE 
ACTUALLY PRESENT THE DAY OF THE INTERVIEW. USE THIS INFORMATION TO COMPLETE COLUMN e.
Qualification Total Staff Number 
Female
Number 
Male
17. Medical doctor (specialist)
18. Medical doctor (General 
practitioner)
19. Nurse A0/L2
20. Nurse A1
21. Nurse A2
22. Nurse A3
23. Anesthetist
24. Midwife or trained birth attendant 
(A1 OR A0/L2)
25. Community health worker (L2 OR 
G3)
26. Pharmacist 
27. Pharmacy dispenser
28. Laboratory technician/technologist 
(A1)
29. Medical biologist L2
30. Radiology technician
31. Nutritionist
32. Hospital administrator
 Baseline Report 229
33. Maintenance technologist
34. Other staff (specify)
______________________
35. Other staff (specify)
______________________
36. Other staff (specify)
______________________
37. Other staff (specify)
______________________
38. What is the highest qualification of the facility head? Physician
Nurse
Other clinical
Other non-clinical
Don't know
39. Is the facility head male or female? MALE
FEMALE
DON'T KNOW
40. For how many years has the facility head held that position in this 
facility? |__|__| years
230 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 3. MANAGEMENT AND SUPERVISION
41. LEVEL FROM WHICH THE 
SUPERVISOR CAME
In 2018, how many times did 
a supervisor from [LEVEL]
visit this facility for the 
purpose of management or 
supervision?
In which month and 
year did a 
supervisor from 
[LEVEL] last visit?
What topics were 
discussed at the last 
visit? [SELECT ALL 
THAT APPLY]
After the last visit, 
did the supervisor 
send you a report 
based on his/her 
findings?
42. Another health center/post in 
your health zone
0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Not applicable (skip to 43)
Don't know
Month |_|_|
Year |_|_|_|_|
Enter 9999 if 
unknown
Quality of care
Management
Record keeping
Data reporting
Data use
Other ___________
No, no feedback
Yes, written in the 
supervision book
Yes, written report 
received
Don't know
43. Hospital in your health zone 0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Month |_|_|
Year |_|_|_|_|
Enter 9999 if 
unknown
Quality of care
Management
Record keeping
Data reporting
Data use
Other ___________
No, no feedback
Yes, written in the 
supervision book
Yes, written report 
received
Don't know
 Baseline Report 231
Not applicable (skip to 44)
Don't know
44. Health Zone Officer 0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Not applicable (skip to 45)
Don't know
Month |_|_|
Year |_|_|_|_|
Enter 9999 if 
unknown
Quality of care
Management
Record keeping
Data reporting
Data use
Other ___________
No, no feedback
Yes, written in the 
supervision book
Yes, written report 
received
Don't know
45. Agent/Officer of the DPS 0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Not applicable (skip to 46)
Don't know
Month |_|_|
Year |_|_|_|_|
Enter 9999 if 
unknown
Quality of care
Management
Record keeping
Data reporting
Data use
Other ___________
No, no feedback
Yes, written in the 
supervision book
Yes, written report 
received
Don't know
46. Provincial Health Inspector 0
1
Month |_|_| Quality of care
Management
No, no feedback
232 The Impact of USAID’s Integrated Health Program in the DRC
2
3
4
5
6
7
8
9
10
11
12 or more
Not applicable (skip to 47)
Don't know
Year |_|_|_|_|
Enter 9999 if 
unknown
Record keeping
Data reporting
Data use
Other ___________
Yes, written in the 
supervision book
Yes, written report 
received
Don't know
47. Other (specify) 0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Not applicable (skip to 48)
Don't know
Month |_|_|
Year |_|_|_|_|
Enter 9999 if 
unknown
Quality of care
Management
Record keeping
Data reporting
Data use
Other ___________
No, no feedback
Yes, written in the 
supervision book
Yes, written report 
received
Don't know
 Baseline Report 233
In this part of the questionnaire I would like to ask you some questions regarding how work is organized and how decisions are made 
in this health zone office. All answers are confidential.
I am now going to read you a series of statements about decision-making and authority in this facility. Please tell me how true each 
statement is for you: completely true, somewhat true, or not at all true.
RESPONSE CODE 
RECORD 
RESPONSE
COMPLETELY TRUE 1
SOMEWHAT TRUE 2
NOT AT ALL TRUE 3
NOT APPLICABLE 4
DON’T KNOW -98
48. I am able to allocate my facility budget according to how it is needed. There is enough flexibility in my 
budget.
49. I am able to assign tasks and activities to staff as needed to achieve the outcomes I want in this facility. 
There is enough flexibility to use staff to address needs.
50. The BCZ/ECZ supports my decisions and actions for doing a better job in my office.
51. I have choice over who I allocate for what tasks.
52. I have choice over what services are provided in this facility.
53. I have enough authority to obtain the resources I need (drugs, supplies, funding) to meet the needs of my 
facility.
54. The policies and procedures for doing things are clear to me.
55. The policies and procedures for doing things are useful tools for the challenges I face in providing services 
and reporting on activities.
56. The BCZ/ECZ provides adequate feedback to me about my job and the performance of my facility.
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
57. Who is responsible for the 
management of the health facility? 
Government
Private not-for-profit organization
Faith-based organization
Private for-profit organization
Other (specify) ___________________
Don't know
58. In 2018, how often did meetings to 
discuss the facility managerial and 
administrative matters take place?
Monthly or more often
Quarterly
Twice a year
Annually
Irregularly
Never
Don't know
234 The Impact of USAID’s Integrated Health Program in the DRC
59. In 2018, how often were routine 
meetings held with both facility staff 
and community members?
Monthly or more often
Quarterly
Twice a year
Annually
Irregularly
Never
Don't know
60. Is there a facility community advisory 
committee (CODESA) in this health 
area?
YES
NO
DON’T KNOW
If yes,  61; 
otherwise,  76
61. In 2018, how often did the head of this 
facility meet with the CODESA?
Monthly or more often
Quarterly
Twice a year
Annually
Irregularly
Never
Don't know
CODESAs have many different 
functions throughout the country. We 
are interested in what the CODESA 
does here. In the last 90 days, has a 
member of the CODESA, other than 
the IT, done the following at least one 
 
 
 
 
 
 
 
 
 
 
 
62. Been present when medications arrived 
at the facility
YES NO N/A DK
63. Ensured the cold chain of medicines 
was preserved
YES NO N/A DK
64. Assisted in taking inventory of 
medications
YES NO N/A DK
65. Completed the inventory analysis form 
and report
YES NO N/A DK
66. Completed the medication acceptance 
report
YES NO N/A DK
67. Discussed the fee schedule with the 
health facility staff
YES NO N/A DK
68. Examined the financial books at the 
health facility to see if they match the 
financial report
YES NO N/A DK
69. Assisted in developing the plan of 
monthly expenses
YES NO N/A DK
70. Examined the facility cash box YES NO N/A DK
71. Assisted in developing the monthly 
expenses report
YES NO N/A DK
72. Took an inventory of equipment and 
completed the inventory report
YES NO N/A DK
73. Assisted in developing health 
messaging for the community
YES NO N/A DK
74. Assisted in calculating health facility 
indicators
YES NO N/A DK
75. Presented/interpreted health facility 
indicators to the community
YES NO N/A DK
 Baseline Report 235
76. Does this facility have any system for 
soliciting patients’ opinions about the 
health facility or its services?
IF YES, CIRCLE ALL METHODS THAT ARE
USED FOR ELICITING PATIENTS’
OPINIONS.
PROBE FOR ALL METHODS USED.
YES
NO
DON’T KNOW
If yes,  77; 
otherwise,  78
77. If yes, what methods? Suggestion box
Interview/meetings with patients
Patient surveys
Information from CODESAs/Relais
Meetings with community leadres
Community scorecard
Community participation in budgeting
Community participation in management meetings
Other (specify) ________________________
78. Does this facility routinely carry out 
quality assurance activities? By this I 
mean some formal review system or 
comparison of work or systems to a 
standard?
YES
NO
DON’T KNOW
79. Are you aware of a program called the 
community scorecard?
YES
NO
If yes,  80; 
otherwise,  96
80. Has your facility participated in a 
community scorecard meeting within 
the past twelve months?
YES
NO
DON’T KNOW
If yes,  81; 
otherwise,  96
Has participation in the community 
scorecard program resulted in efforts to 
improve any of the following areas, 
even if actual improvements have not 
been made:
81. Availability of medicines and essential 
supplies to the health facility
YES NO NA DK
82. Materials/equipment available in 
health facility
YES NO NA DK
83. Physical state of buildings YES NO NA DK
84. Cleanliness of buildings and 
surroundings
YES NO NA DK
85. Accessibility of the health facility 
(roads, bridges, etc.)
YES NO NA DK
86. Patients’ opportunity to be treated out 
of sight of other people (privacy)
YES NO NA DK
87. Technical competence of health 
workers
YES NO NA DK
88. Presence and punctuality of health 
workers
YES NO NA DK
89. Staffing levels in health facilities YES NO NA DK
236 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 4. HEALTH INFORMATION SYSTEM
I would now like to ask you some questions regarding the SNIS and health information or data that the facility collects 
and reports.
No. QUESTION RESPONSE SKIP/ INSTRUCTIONS
96. Are you currently using the 
harmonized reporting tool 
[SHOW THE RESPONDENT 
A PHOTO OF THE 
CURRENT TOOL]
YES
NO
DON’T KNOW
97. In how many of the last six 
months has this facility 
submitted SNIS reports to 
the BCZS?
0
1
2
3
4
5
6
Don’t know
If 0 or don’t know, 
99
98. How does this facility 
submit the SNIS reports to 
the BCZS?
[CIRCLE ALL MENTIONED]
Hand-deliver to BCZ
BCZ picks up
Enter directly into the DHIS2
Phone call
Text message
Email
Other (specify) ______________________
Don't know
99. If this facility was unable 
to submit SNIS reports to 
the BCZ every month in 
the last six months, what 
were the reasons?
[CIRCLE ALL MENTIONED]
Did not have the correct form
No supervision visit
Lack of transportation
Lack of internet
Lack of phones
Lack of electricity
No time to complete reports
No staff to complete reports
Reference 97 and ask
if between 1 and 5; 
otherwise,  100.
90. Reception and attitudes of health 
workers toward patients
YES NO NA DK
91. Discretion and confidentiality of health 
workers
YES NO NA DK
92. Respect and confidence of the 
population in the health facility
YES NO NA DK
93. Affordability of user fees YES NO NA DK
94. Timeliness of payment of health facility 
employees
YES NO NA DK
95. Health facility employees’ salary 
amounts
YES NO NA DK
 Baseline Report 237
Not aware of submission deadlines
Other (specify) ________________________
Don't know
100. In how many of the last six 
months has this facility 
submitted SNIS reports to 
the BCZS on time?
0
1
2
3
4
5
6
Don’t know
If between 1 and 5, 
101; otherwise, 
102
101. If this facility was unable 
to submit SNIS reports to 
the BCZ on time every 
month in the last six 
months, what were the 
reasons?
[CIRCLE ALL MENTIONED]
Did not have the correct form
No supervision visit
Lack of transportation
Lack of internet
Lack of phones
Lack of electricity
No time to complete reports
No staff to complete reports
Not aware of submission deadlines
Other (specify) ________________________
Don't know
102. On the monthly SNIS 
report, are other facilities’
statistics included? For 
example, health posts, 
private facilities, etc.? 
YES
NO
DON’T KNOW
If no or don’t know, 
105.
103. How many other facilities’ 
statistics are included?
|___|___|
104. What other types of 
facilities are included on 
the monthly SNIS report?
[CIRCLE ALL MENTIONED]
Hospital (any type)
Health center
Health post
Other (specify) _______________________
Don't know
105. Who do you contact if you 
need more SNIS forms?
Hospital
BCZ
Other (specify) _______________________
Don't know
106. In the last month, how did 
this facility submit its 
weekly Maladie à Potentiel 
Epidémique (MAPEPI) to 
the BCZ? [SELECT ALL 
MENTIONED]
Hand-deliver to DPS
DPS picks up
Phone call
Text message
Email from office
Email-from cyber café or other off site location
Electronically via SNIS/DHIS2
Not applicable 
Other (specify)
238 The Impact of USAID’s Integrated Health Program in the DRC
Don't know
107. To the best of your 
knowledge, the last time 
you encountered a 
MAPEPI case, how much 
time passed between 
when you were made 
aware of the MAPEPI 
event and when you were 
able to report to the BCZ?
Immediately
Within 24 hours
Next day
More than 2 days
Not applicable
Don't know
If N/A,  109
108. What are some of the 
reasons why an immediate 
or weekly MAPEPI report 
may not be submitted on 
time? [SELECT ALL 
MENTIONED]
Did not have the correct form
No supervision visit
Lack of transportation
Lack of internet
Lack of phones
Lack of electricity
No time to complete reports
No staff to complete reports
Not aware of submission deadlines
Other (specify) ___________________________
Don't know
109. In addition to the SNIS and 
MAPEPI reports, which 
types of reports does this 
facility submit on a regular 
basis? [SELECT ALL 
MENTIONED]
Other programs (EPI, HIV)
IHP-specific reports
Other donor reports
Financial reports
Other (specify) ___________________________
Don't know
110. During the last 90 days, did 
the facility receive any 
feedback report from BCZ 
office on their 
performance?
Yes, verbal
Yes, written and viewed
Yes, not observed
None
Don't know
If no or don’t know, 
116.
Was any of the following feedback included in the report?
111. Verify or correct possibly 
inaccurate data
YES NO DK
112. Complete any data that 
was missing from the 
original submission
YES NO DK
113. Submit the report by the 
specified deadline
YES NO DK
114. Positive feedback YES NO DK
115. Other feedback YES NO DK
IF YES, SPECIFY
______________________________
116. Does this facility have 
access to a procedure 
YES
NO
DON’T KNOW
If no or don’t know, 
118.
 Baseline Report 239
manual for data 
collection?
117. Is the procedure manual 
for data collection easy or 
difficult to understand?
EASY
DIFFICULT
DON’T KNOW
Does the facility display 
the following data? Please 
indicate types of data 
displayed, whether the 
data is posted in a public 
area, and whether the 
data have been updated 
for the last reporting 
period. [RECORD 
OBSERVATION]
Indicator Yes/No
Type of 
Display Area posted Most recent month 
of data displayed
118. Demographic 
information 
Yes
No ( 120)
Don’t know ( 120)
Graph/chart
Map
Other
PUBLIC
STAFF ONLY
MONTH
YEAR
119.Facility 
utilization/ 
volume of 
service 
delivery
Yes
No ( 121)
Don’t know ( 121)
Graph/chart
Map
Other
PUBLIC
STAFF ONLY
MONTH
YEAR
120.Disease 
surveillance
Yes
No ( 122)
Don’t know ( 122)
Graph/chart
Map
Other
PUBLIC
STAFF ONLY
MONTH
YEAR
No. QUESTION RESPONSE SKIP/ INSTRUCTIONS
121. Does the facility have a 
map of the catchment area
and if so, what type of 
map is it?
TAKE A PHOTO OF THE 
MAP.
YES, COMPUTER-GENERATED
YES, HAND-DRAWN
NO MAP
DON’T KNOW
Now I would like to ask you some questions related to meetings and decisions based on the SNIS data.
122. How frequently does the 
facility have routine 
meetings in which the SNIS 
or facility data is 
discussed? This could be a 
separate meeting or in the 
routine managerial or 
administrative meetings.
Monthly or more often
Every 2-3 months
Every 4-6 months
Less than every 6 months or irregularly
Never
Don't know
If never,  126
123. Is an official record of 
management meetings 
maintained?
YES
NO
DON’T KNOW
124. Has the SNIS or facility 
data been used to make 
decisions?
YES
NO
DON’T KNOW
If no or don’t know, 
126
240 The Impact of USAID’s Integrated Health Program in the DRC
125. Has any follow-up action 
taken place regarding the 
decisions made during the 
previous meetings?
YES
NO
DON’T KNOW
126. Do you use a Performance 
Dashboard tool for 
management tasks? 
[SHOW A PHOTO OF THE 
TOOL]
YES
NO
DON’T KNOW
If no or don’t know, 
129.
127. What is the month of the 
last data entry on this 
dashboard? [ASK THE 
RESPONDENT TO ACCESS 
THE SYSTEM AND RECORD 
OBSERVATION]
January
February
March
April
May
June
July
August
September
October
November
December
Not accessible
Don't know
128. What is the year of the last 
data entry on this 
dashboard?
2019
2018
before 2018
Don't know
129. Record the GPS 
coordinates to six decimal 
places
Baseline Report 241
IHP Evaluation
HEALTH FACILITY SURVEY
Part B. Services
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province.
2. Record the health zone.
3. Record the name of the health facility or enter the facility ID 
number.
4. Enter your data collector ID number.
242 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 2. SERVICES
RESPONSE SKIP/ 
INSTRUCTIONS
Malnutrition
5. Does this facility provide growth monitoring (weighing and 
measurement) of children under five?
Yes
No
6. Does this facility provide nutritional rehabilitation for malnourished 
children? 
Yes
No
Antenatal care
7. Does this facility provide antenatal care? Yes
No
If no,  10.
8. What types of screenings are typically done for pregnant women? 
(Check all that apply.)
Anemia
Asymptomatic bacteriuria
Gestational diabetes
Syphilis
HIV
Proteinuria
High blood pressure
Malnutrition
Tuberculosis
Malaria
Intimate partner violence
Other (specify)
9. What services are typically administered to pregnant women? 
(Check all that apply.)
Tetanus vaccine
Iron supplements
Folate supplements
IpT for malaria
Anthelminthics/Deworming 
treatment
Counseling on family planning
Nutrition counseling
Other
10. Does this facility provide delivery services? Yes
No
If no,  12.
11. How long does a patient typically stay at the facility after an 
uncomplicated normal delivery?
Hours: ____________
Days: _____________
12. Does this facility provide postpartum care? Yes
No
If no,  14
Baseline Report 243
13. Which services are provided as part of postpartum care? (Check all 
that apply.)
Maternal examination
Breastfeeding counseling
Newborn examination
Growth monitoring and 
promotion
Vaccination counseling
Family planning counseling
PMTCT counseling
Dietary counseling for 
breastfeeding mother
Counseling on mother and child 
hygiene
Other
Tuberculosis
14. Does this facility offer tuberculosis screening? Yes
No
If no,  15
15. What types of tuberculosis screening are offered? (check all that 
apply)
Zielh Neelssen
Gene Xpert
Skin test
Chest X-ray
Culture Loweinstein
16. Does this facility offer tuberculosis treatment? Yes
No
If no,  18
17. What types of treatment are administered? Directly observed
Not directly observed
Malaria
18. Does this facility offer malaria screening? Yes
No
If no,  20
19. What types of malaria screening are offered? (check all that apply) Rapid test
Laboratory-confirmed
20. Does this facility offer malaria treatment? Yes
No
21. Does this facility distribute insecticide-treated nets to patients? Yes
No
If no,  24
22. Are nets provided free of charge, sold to patients, or both? Free to all patients
Free to some patients
All patients must pay
If “all patients must 
pay,”  24
23. Who is eligible for a free insecticide-treated net? All patients
Pregnant/postpartum women
Children under five
Patients with malaria
Other (specify) ____________
Family planning
24. Does this facility offer family planning counseling? Yes
No
25. Does this facility offer any family planning methods? Yes
No
If no,  42
244 The Impact of USAID’s Integrated Health Program in the DRC
26. Does this facility perform male sterilization? Yes
No
If no,  28
27. How may providers have been trained to perform male 
sterilization?
|__|__|__|
28. Does this facility perform female sterilization? Yes
No
If no,  30
29. How may providers have been trained to perform female 
sterilization?
|__|__|__|
30. Does this facility insert IUD’s? Yes
No
If no,  32
31. How may providers have been trained to insert IUD’s? |__|__|__|
32. Does this facility remove IUD’s? Yes
No
If no,  34
33. How many providers have been trained to remove IUD’s? |__|__|__|
34. Does this facility insert Norplant, Jadelle, or Sino-Implant II? Yes
No
If no,  36
35. How many providers have been trained to insert Norplant, Jadelle, 
or Sino-Implant II?
|__|__|__|
36. Does this facility remove Norplant, Jadelle, or Sino-Implant II? Yes
No
If no,  38
37. How many providers have been trained to remove Norplant, 
Jadelle, or Sino-Implant II?
|__|__|__|
38. Does this facility insert Implanon? Yes
No
If no,  40
39. How many providers have been trained to insert Implanon? |__|__|__|
40. Does this facility remove Implanon? Yes
No
If no,  42
41. How many providers have been trained to remove Implanon? |__|__|__|
42. How many providers have been trained in adolescent health / 
family planning for adolescents?
|__|__|__|
43. Does this facility have resources geared to address adolescent 
concerns and counsel them about sexual and reproductive health 
including family planning?
Yes
No
Don’t know
Vaccination
44. Does this facility offer immunization services? Yes
No
Don’t know
If no, or don’t 
know,  50
Does this facility provide any of the following immunization services in the facility only, as outreach at fixed post only, or 
both? 
Baseline Report 245
45. Birth doses (e.g. hepB0, BCG, OPV0, …) Both in the facility and as 
outreach
In the facility only
Outreach only
Service not offered
Don't know
46. Infant vaccines (under 1 year) Both in the facility and as 
outreach
In the facility only
Outreach only
Service not offered
Don't know
47. Adolescent/adult vaccines (e.g. HPV, tetanus, flu) Both in the facility and as 
outreach
In the facility only
Outreach only
Service not offered
Don't know
48. How often does this facility offer routine full child immunization 
services at the facility? 
Daily
2-4 times a week
Weekly
Monthly
Quarterly
Annually
Other (Specify) _____________
49. How often does this facility offer routine full child immunization 
services as outreach? 
Daily
2-4 times a week
Weekly
Monthly
Quarterly
Annually
Other (Specify) _____________
50. Does this facility provide counseling for victims of sexual and 
gender-based violence?
Yes
No
51. Does this facility provide care for physical injuries for victims of 
sexual and gender-based violence?
Yes
No
246 The Impact of USAID’s Integrated Health Program in the DRC
IHP Evaluation
HEALTH FACILITY SURVEY
Part C. Finance
Section 2. USER FEES
I would like to ask you a few questions about the payment of health care services by the patients.
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
5. Does this facility have a fee schedule? YES
NO
DON’T KNOW
If no or 
don’t know, 
 7
6. Is there a fee schedule posted where patients 
can see it? 
IF YES, ASK TO SEE THE GUIDELINES AND TAKE 
A PHOTO.
7. Have you received guidelines on the payment 
that the patients have to make for the health 
care services they need/receive?
YES
NO
DON’T KNOW
If no or 
don’t know, 
 9
8. To the best of your knowledge, where do the 
user fee guidelines come from?
NATIONAL MOH
DPS
HOSPITAL
BCZ
IHP
OTHER
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province
2. Record the health zone
3. Record the name of the health facility or enter the facility ID 
number
4. Enter your data collector ID number
Baseline Report 247
_____________________
(SPECIFY)
DON’T KNOW
9. Does this facility have different fees for patients 
who are considered indigent?
YES
NO
DON’T KNOW
10. Have you received guidelines on the EXEMPTION 
of payment for indigent patients?
YES
NO
DON’T KNOW
If no or 
don’t know, 
 12
11. To the best of your knowledge, where do the 
exemption guidelines come from?
NATIONAL MOH.
DPS
HOSPITAL
BCZ
IHP
OTHER (SPECIFY) _____________________
DON’T KNOW
12. Who are considered indigent? Meaning, what 
are the criteria for the user fee exemption?
CIRCLE ALL THAT ARE MENTIONED
ELDERLY
ORPHANED Reference 9 
and ask if 
yes.
WIDOW WITHOUT A SOURCE OF INCOME
PHYSICALLY HANDICAPED WITHOUT A SOURCE 
OF INCOME
REFUGEE/INTERNALLY DISPLACED PERSON
OTHER (SPECIFY) _____________________
DON’T KNOW
13. Do you have a list of households or individuals in 
your community who are considered indigent?
YES
NO
DON’T KNOW
Reference 9 
and ask if 
yes.
If no or 
don’t know, 
 17
14. Who participated in the process of identifying 
the individuals on this list?
CIRCLE ALL THAT ARE MENTIONED
THE RESPONDENT
OTHER HEALTH CENTRE STAFF
CODESA MEMBERS/RELAIS
OTHER COMMUNITY LEADERS
BCZ
OTHER (SPECIFY) _____________________
DON’T KNOW
15. Was this list approved by the CODESA? YES
NO
DON’T KNOW
248 The Impact of USAID’s Integrated Health Program in the DRC
16. How often is this list updated? EVERY 1-5 MONTHS
EVERY 6 MONTHS
EVERY 7-11 MONTHS
ONCE EVERY YEAR OR LESS
NEVER
DON’T KNOW
What is the standard fee at this facility for a non-indigent patient to receive?
ENTER 0 IF THE SERVICE IS FREE and -99 if the service is not offered.
ALL AMOUNTS ENTERED IN CF.
17. their first antenatal care visit? ___CF
18. normal (i.e. vaginal) delivery? ____CF
19. Does this facility offer tuberculosis screening or 
treatment?
YES
NO
If no,  22
20. tuberculosis screening? Sputum test :
____CF
Blood test:
____CF
Chest x-ray:
____CF
21. tuberculosis full course of treatment? Directly observed:
____CF
Not directly observed:
____CF
22. malaria screening? Rapid test:
____CF
Laboratory-confirmed:
____CF
23. Does this facility offer family planning services? YES
NO
If no,  32
24. male sterilization? ____CF
25. female sterilization? ____CF
26. IUD insertion (cost of the method and 
insertion)?
____CF
27. IUD removal? ____CF
28. Norplant, Jadelle, or Sino-Implant II insertion 
(cost of the method and insertion)?
____CF
29. Norplant, Jadelle, or Sino-Implant II removal? ____CF
30. Implanon insertion (cost of the method and 
insertion)?
____CF
Baseline Report 249
31. Implanon removal? ____CF
32. measles vaccination? ____CF
33. an insecticide-treated net? ____CF
34. Does this facility always require payment before
treatment in emergency cases?
YES
NO
DON’T KNOW
35. Does this facility always require payment before
labor and delivery?
YES
NO
DON’T KNOW
36. How does the facility handle cases in which a 
patient cannot pay for services? CHECK ALL 
THAT APPLY.
No services are given
The patient can pay in-kind
The patient can give a guarantee
The patient is treated for free/reduced cost
The patient is not discharged until they can pay
The patient is refused services in the future
Nothing; no recourse
Other (specify)
Don’t know
250 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 3. SOURCES AND USES OF FUNDING
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
What is the total amount of operational funds (i.e. funds not 
passed on to another organization) received from the following 
sources in the last calendar year (2018)?
37. Ministry of health/Provincial health office/Health zone office (not 
including performance-based financing payments)
|_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
38. Performance-based financing |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
39. USAID/IHP |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
40. Other NGO’s or FBO’s: Cordaid, Memisa, Foundation Damien,
Save the Children, Rescue, IRC, Caritas, Sanru, Chemonics, MCSP
|_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
41. User fees |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
42. Contributions from patients |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
43. Community financing (cooperatives/mutual) |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
44. Health insurance |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
45. Other (specify)________________ |_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
What percentage of operational funds was spent on the 
following during the last calendar year (2018)?
46. Savings |__|__|__| %
47. Building/grounds improvements |__|__|__| %
48. Equipment (vehicles, computers, etc.) |__|__|__| %
49. Utilities and communication (electricity, water, phone credit, 
internet, etc.)
|__|__|__| %
50. Medical supplies |__|__|__| %
51. Drugs |__|__|__| %
Baseline Report 251
52. Transport |__|__|__| %
53. Salaries and primes |__|__|__| %
54. Training |__|__|__| %
55. Other (specify)______________________ |__|__|__| %
SECTION 4. PERFORMANCE BASED FINANCING
No. QUESTION RESPONSE SKIP/ 
INSTRUCTIONS
56. Does this facility currently have a performance-based financing 
contract (i.e. is it eligible to receive financial incentives based on 
achieving pre-determined targets)? 
YES
NO
DON’T KNOW
If no or don’t 
know,  63
57. With what organization do you have a performance-based￾financing contract?
CHECK ALL THAT APPLY
GOVERNMENT/MOH
WORLD BANK
USAID/IHP
OTHER_______________
DON’T KNOW
58. According to your contract, what is the maximum number of 
payments that you could receive in a year?
59. In 2018, did you receive a performance-based financing payment 
for meeting specific targets?
60. How long ago did you receive your last performance-based 
incentive?
0-3 months ago
4-6 months ago 
7-12 months ago 
More than 1 year ago
Never
If never,  63
61. Which target(s) did you meet?
CHECK ALL THAT APPLY.
 
Maternal health
Newborn health
Sexual and reproductive 
health
Family planning
Adolescent health
Child health
Quality of care
Other (specify)___________
Don't know
252 The Impact of USAID’s Integrated Health Program in the DRC
62. In total, how much did you receive for the most recent payment?
 
|_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
SECTION 5. COMMUNITY FUNDING INITIATIVES
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
63. Are there any health mutuals operating in your health area? YES
NO
DON’T KNOW
If no or don’t 
know, skip to next 
module.
64. Does this facility have a list of members of this health mutual? YES
NO
DON’T KNOW
65. Do members of the health mutual make contributions of money 
or in-kind payments to this facility?
YES, MONEY ONLY
YES, IN-KIND ONLY
YES, MONEY & IN-KIND
NO
DON’T KNOW
If “Yes, money 
only” or “Yes, 
money & in-king”, 
 66; otherwise, 
 67
66. Are the contributions of the health mutual recorded in a registry? YES
NO
DON’T KNOW
If yes,  67; 
otherwise, 68
67. Can I see the health mutual contribution registry? YES, OBSERVED
NO, NOT OBSERVED
68. RECORD THE SUM OF ALL CONTRIBUTIONS FOR THE LAST 6 
COMPLETED MONTHS FROM THE REGISTERY. 
IF NO REGISTER EXISTS OR THE REGISTRY WAS NOT OBSERVED, 
ASK THE RESPONDANT TO ESTIMATE THE TOTAL SUM OF ALL 
CONTRIBUTIONS FOR THE LAST 6 COMPLETED MONTHS.
|_|_|_|_|_|_|_|_|_| CF
|_|_|_|_|_|_|_|_|_| USD
Reference 65 and 
ask if yes.
69. Do members of the health mutual receive any fee reduction for 
services performed at this facility?
YES
NO
DON’T KNOW
If no or don’t 
know, skip to next 
module.
Baseline Report 253
70. How is the amount of the fee reduction for health mutual
members determined?
FIXED AMOUNT
PERCENTAGE OF CHARGES
VARIES BY SERVICE
OTHER
DON’T KNOW
71. What services are covered by this fee reduction?
CIRCLE ALL THAT ARE MENTIONED
General outpatient
Immunization for children
Antenatal care
Normal delivery
Caesarean section delivery
Postnatal care
Family planning
Tuberculosis treatment
STI treatment
Community and outreach 
services
General inpatient medical 
services
General inpatient surgical 
services
All services
Other _________________
Don’t Know
254 The Impact of USAID’s Integrated Health Program in the DRC
IHP Evaluation
HEALTH FACILITY SURVEY
Part D. Basic Infrastructure and Laboratory
SECTION 2. BASIC INFRASTRUCTURE
Now I would like to ask you some questions related to the basic infrastructure of the facility. If the answer to the question is yes, 
please show me the room/equipment, and where applicable, verify the functionally. 
No. Questions and filters YES NO SKIP
5. Is there a reception/registration rooms or space? RECORD OBSERVATION 01 00
6. Is there a consultation/examination room for outpatients? RECORD 
OBSERVATION
01 00 If no,  11
7. Does the examination room have an examination bed? RECORD 
OBSERVATION
01 00
8. Does the examination room have an instrument trolley? RECORD 
OBSERVATION
01 00
9. Does the examination room have a hand-washing facility? RECORD 
OBSERVATION
01 00
10. Does the examination room have a spot light? RECORD OBSERVATION 01 00
11. Is there a separate treatment room? RECORD OBSERVATION 01 00
12. Is there a separate room for observation? RECORD OBSERVATION 01 00
13. Is there an emergency room? RECORD OBSERVATION 01 00
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province
2. Record the health zone
3. Record the name of the health facility or enter the facility ID 
number
4. Enter your data collector ID number
Baseline Report 255
14. Is there an operation theater? RECORD OBSERVATION 01 00
15. Is there a separate medicine dispensing room? RECORD OBSERVATION 01 00
16. Does this facility have an isolation ward?
17. Does this facility have a private delivery suite? 01 00
18. Does this facility have a maternity ward? RECORD OBSERVATION 01 00 If no,  20
19. How many beds are in the maternity ward? RECORD OBSERVATION
IF NONE, WRITE “000” IN THE BOXES.
|__|__|__|
20. Does the facility have a maternity-waiting house? RECORD 
OBSERVATION
01 00
21. Does the facility have cell phone reception? RECORD OBSERVATION 01 00
22. Does the facility have a satellite telephone? 01 00
23. Does the facility have a radio? RECORD OBSERVATION 01 00
24. Does the facility have internet? RECORD OBSERVATION 01 00
25. Does the facility have electricity? RECORD OBSERVATION 01 00 If no,  30
26. Is electricity functioning now? (CHECK TO SEE IF ELECTRICITY CAN BE 
TURNED ON.) RECORD OBSERVATION
01 00
27. Are there power cuts (excluding electricity supplied by a generator 
backup) during the hours when the facility is open?
01 00 If no,  30
28. What is the average duration of power cuts? TIME IN 
HOURS 
|__|__|
IF LESS 
THAN ONE 
HOUR, 
WRITE 00.
29. Has there been a break in power for more than two hours during the past 
seven days?
30. Does this facility have a generator for electricity?
This may be a back-up or stand-by generator. RECORD OBSERVATION
01 00 If no,  32
31. Is the generator functional? RECORD OBSERVATION 01 00
32. Is there a functional solar panel? RECORD OBSERVATION 01 00 If no,  34
33. Is there a functional battery for solar panel? RECORD OBSERVATION 01 00
256 The Impact of USAID’s Integrated Health Program in the DRC
34. What is the main source of water at this facility? Piped water from central supply
Protected spring
Supply truck
Rainwater collected and stored in 
cistern
Rainwater collected and not stored 
in cistern
Standpipe
Local river/lake
Other (specify)
Don't know
35. Is there potable water, that is to say safe drinking water, in the structure? YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
36. Do you have a water filtering system and is it functioning? YES FUNCTIONING……………
YES, NOT FUNCTIONING……
NO………………….………………….
DON’T KNOW………………..….
If no or 
don’t 
know, 
38
37. What type (brand) is the filter? RECORD OBSERVATION. LIFESTRAW…..……………………
OTHER………….………………….
DON’T KNOW………………..….
38. Is there a sanitary toilet or latrine that is available for clients to use, such 
as those with sewer connections, septic system connections, pour-flush 
latrines, ventilated improved pit latrines and pit latrines with a slab or 
covered pit? RECORD OBSERVATION
YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
If no or 
don’t 
know, 
41
39. Is there a separate sanitary toilet/latrine for the use of women patients? 
RECORD OBSERVATION
YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
40. Is there a separate sanitary toilet/latrine for the use of staff? RECORD 
OBSERVATION
YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
41. Is there a shower that is available for patients to use? RECORD 
OBSERVATION
YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
If no or 
don’t 
know, 
44
42. Is there a separate shower for use by women patients? RECORD 
OBSERVATION
YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
43. Is there a separate shower for use by staff? RECORD OBSERVATION YES………………..……………………
NO………………….………………….
DON’T KNOW………………..….
Baseline Report 257
SECTION 3. LABORATORY
44. Does this facility have a laboratory? YES…………………….
NO…………………….
01
00 If no,  61
45. Does the facility perform diagnostic tests? YES…………………….
NO……………………..
01
00 If no,  61
I am going to read you a list of laboratory tests. Please 
indicate whether the facility is able to do this test today, 
was able to do this test in the past 60 days but not today, 
or if the facility cannot do this test.
Able to do this test 
today
Able to do in 
past 60 days 
but not today
Cannot do this 
test
46. Hemoglobin testing 01 02 00
47. White blood cell count 01 02 00
48. Leukocyte formula 01 02 00
49. Sedimentation rate 01 02 00
50. Malaria microscopy 01 02 00
51. Blood glucose 01 02 00
52. HIV testing 01 02 00
53. Ziehl stains 01 02 00
54. Gram stains 01 02 00
55. Blood type and cross match 01 02 00
56. Syphilis testing 01 02 00
57. Urine analysis 01 02 00
58. Stool direct microscopic examination 01 02 00
59. Pregnancy testing 01 02 00
60. Hepatitis testing 01 02 00
61. Does the facility use external diagnostic services or an 
external laboratory?
YES…………………….
NO……………………..
DON’T KNOW…….
01
00
98
Now I would like to ask you some questions about the laboratory’s equipment. I will read you a list of equipment and for each piece 
please tell me how many the facility has and the number functional. For selected items I will ask to see the equipment to verify.
IF NONE, WRITE “00” IN THE BOXES.
SKIP THIS SECTION IF THERE IS NO LABORATORY AT THIS FACILITY 
How many?
a
Number functional?
B
62. Microscope |___|___| |___|___|
258 The Impact of USAID’s Integrated Health Program in the DRC
63. Centrifuge |___|___| |___|___|
64. Photometer |___|___| |___|___|
SECTION 4. MEDICAL WASTE TREATMENT
No. QUESTION RESPONSE
65. What is this facility’s disposal practice for sharps 
such as needles, glass, surgical instruments, etc.?
(CIRCLE THE CODES FOR ALL PRACTICES THAT ARE 
MENTIONED IN RESPONSE TO THE QUESTION 
AND INDICATE WHETHER THIS WAS OBSERVED 
OR NOT)
Incineration
Burn and bury
Bury but do not burn
Burn but do not bury
Safe box
Covered pit (could be latrine)
Placenta pit
Open pit
Store, collect, and move offsite
Throw out in open
Other (specify) __________________________
Don't know
66. What is this facility’s disposal practice for 
biomedical wastes such as placenta, human body 
parts, laboratory waste, etc.?
(CIRCLE THE CODES FOR ALL PRACTICES THAT ARE 
MENTIONED/OBSERVED IN RESPONSE TO 
THEQUESTION)
Incineration
Burn and bury
Bury but do not burn
Burn but do not bury
Safe box
Covered pit (could be latrine)
Placenta pit
Open pit
Store, collect, and move offsite
Throw out in open
Other (specify) __________________________
Don't know
67. Does the facility have a picture or written 
instructions on the wall for waste 
management/universal precautions?
YES………………………………………………………………………………………….
NO………………………………………………………………………………………….
DON’T KNOW………………………………………………………………………….
01
02
96
Baseline Report 259
IHP Evaluation
HEALTH FACILITY SURVEY
Part E. Drugs and Supplies
SECTION 2. EQUIPMENT
Now I would like to ask you some questions about the facilities equipment. I will read you a list of equipment and for each piece 
please tell me how many the facility has that are functional/usable today. 
IF NONE, WRITE “00” IN THE BOXES.
Large Medical Supplies Number functional
a
5. X-ray |___|___|
6. Ultrasound |___|___|
7. Autoclave |___|___|
8. Steam sterilizer / autoclave |___|___|
9. Anesthetic device |___|___|
Equipment for Newborns
10. Table to care for newborn |___|___|
11. Scale for baby weighing |___|___|
Other Materials 
12. Weighing scale for adults |___|___|
13. Height measure for children |___|___|
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province
2. Record the health zone
3. Record the name of the health facility or enter the facility ID 
number
4. Enter your data collector ID number
260 The Impact of USAID’s Integrated Health Program in the DRC
14. Height measure for adults |___|___|
15. Delivery kit |___|___|
16. Episiotomy Kit |___|___|
17. Simple Stretcher |___|___|
18. Instrument cart |___|___|
19. IV Stand |___|___|
20. Delivery table with stirrups |___|___|
21. Examination table |___|___|
22. Gynecological table |___|___|
23. Blood pressure monitor |___|___|
24. Stethoscope |___|___|
25. Thermometer |___|___|
26. Timer (clock with second hand) |___|___|
Family Planning Supplies
27. Non-scalpel vasectomy dissecting forceps
28. Non-scalpel vasectomy ringed forceps
29. Uterine elevator
30. Ramathibodi hook
31. Trocar
32. Scalpel |___|___|
33. Forceps |___|___|
34. Implanon applicator
Individual Protection Equipment and Infection control
35. Gown |___|___|
36. Mask |___|___|
37. Sterilized gloves |___|___|
38. Bucket with lid
39. Sharps container
40. Sink or basin
41. Eye protection
42. Sterilization test strip
43. Chlorine powder (500 grams or more)
Baseline Report 261
Transportation Equipment (in working condition)
44. Motorcycle |___|___|
45. Bicycles |___|___|
46. Canoe/boat |___|___|
47. Ambulance/car/truck |___|___|
SECTION 3. PHARMACY FACILITIES
Next, I would like to ask you a few questions about the pharmacy facilities. Can you please take me to the pharmacy or the room 
where you store drugs? 
No. QUESTION RESPONSE SKIP/
INSTRUC￾TIONS
48. Does this facility have a pharmacy or a separate room for 
drug storage? RECORD OBSERVATIONS
YES………………………………………………….
NO…………………………………………………..
01
00
If no,  51
49. Are there enough shelves for storing drugs/other supplies 
(nothing on the floor)? RECORD OBSERVATIONS
YES………………………………………………….
NO…………………………………………………..
01
00
50. Are the stored items protected from sun? RECORD 
OBSERVATIONS
YES………………………………………………….
NO…………………………………………………..
01
00
SECTION 4. BASIC DRUGS AND SUPPLIES
PLEASE ASK THE PERSON RESPONSIBLE FOR THE PHARMACY 
For this section, I need to speak with the pharmacist, or whoever 
is responsible for the pharmacy. I would like to ask some 
questions regarding the facility’s drug supply. I am going to read 
you a list of drugs. For each one, please tell me if the drug is 
currently in stock and if the drug has been out of stock at any 
point in the past 30 days. For selected drugs I will ask to see the 
drug and drug registry to verify.
Part A: Is this drug 
currently in stock?
YES…..01
NO….00
DON’T KNOW….99
Part B: If YES to part A,
has this drug been in 
stock continuously
during the past 30 days?
YES…..01
NO….00
DON’T KNOW….99
Basic drugs
51. Halothane or Ketamine 01 00 99 01 00 99
52. Atropine 01 00 99 01 00 99
Local anesthetics
53. Lidocaine or Bupvicaine 01 00 99 01 00 99
Analgesics, Antipyretics
54. Acetylsalicylic acid 01 00 99 01 00 99
262 The Impact of USAID’s Integrated Health Program in the DRC
55. Ibuprofene or paracetamol 
ASK TO SEE THE DRUG AND DRUG’S REGISTRY TO VERIFY.
01 00 99 01 00 99
Anti-Allergy
56. Hydrocortisone or Dexamethasone 01 00 99 01 00 99
Anticonvulsants
57. Diazepam 01 00 99 01 00 99
Intestinal anthelmintics
58. Mebendazole or albendazole
ASK TO SEE THE DRUG AND DRUG’S REGISTRY TO VERIFY.
01 00 99 01 00 99
Antibacterial
59. Amoxicilline 01 00 99 01 00 99
60. Ampicilline 01 00 99 01 00 99
61. Ciprofloxacine 01 00 99 01 00 99
62. Cotrimoxazole
ASK TO SEE THE DRUG AND DRUG’S REGISTRY TO VERIFY.
01 00 99 01 00 99
Antiviral
63. PEP kit 01 00 99 01 00 99
64. Tuberculosis
65. Isoniazide + rifampicine 01 00 99 01 00 99
66. Éthambutol + isoniazide 01 00 99 01 00 99
67. Streptomycine 01 00 99 01 00 99
68. Rifampicine + Isoniazide + éthambutol 01 00 99 01 00 99
69. Antiamoebic
70. Métronidazole 01 00 99 01 00 99
71. Antimalarial
72. Sulfadoxine-pyrimethamine (SP)
ASK TO SEE THE DRUG AND DRUG’S REGISTRY TO VERIFY.
01 00 99 01 00 99
73. Quinine 01 00 99 01 00 99
74. Artéméther + luméfantrine 01 00 99 01 00 99
75. Artésunate + Amodiaquine
ASK TO SEE THE DRUG AND DRUG’S REGISTRY TO VERIFY.
01 00 99 01 00 99
76. Insecticide-treated nets 01 00 99 01 00 99
77. Antianemic
78. Acide folique 01 00 99 01 00 99
79. Iron syrup or iron dextran or Iron sulfate + acide folique 01 00 99 01 00 99
Baseline Report 263
80. Antiangoreux
81. Nitroglycérine 01 00 99 01 00 99
82. Hypotensive
83. Aténolol/Nifedipine 01 00 99 01 00 99
84. Heart attack/failure
85. Digoxine 01 00 99 01 00 99
86. Épinéphrine 01 00 99 01 00 99
87. Furosémide ou Hydrochlorothiazide 01 00 99 01 00 99
88. Antidiabetic
89. Insuline 01 00 99 01 00 99
90. Metformine/Glibenclamide 01 00 99 01 00 99
91. Trouble Hydro-électrolutiques
92. ORS 01 00 99 01 00 99
93. Minerals
94. Zinc sulfate 01 00 99 01 00 99
95. Oxytocics
96. Oxytocine 01 00 99 01 00 99
97. Family Planning
98. Male condoms 01 00 99 01 00 99
99. Female condoms 01 00 99 01 00 99
100. Combined oral contraceptive pill (COC) 01 00 99 01 00 99
101. Progesterone only pills (POP) 01 00 99 01 00 99
102. Emergency contraception
103. Intrauterine device (IUD) 01 00 99 01 00 99
104. Norplant, Jadelle, and Sino-Implant II
105. Implanon or implanon nxt 01 00 99 01 00 99
106. Depot Medroxyprogesterine acetate (Depot Provera) 01 00 99 01 00 99
107. Saynana Press 01 00 99 01 00 99
108. Cycle beads 01 00 99 01 00 99
109. Antiseptics and disinfectants
110. Alcool dénaturé 70° 01 00 99 01 00 99
111. Alcool iodé 2 % ou polyvidone iodé 01 00 99 01 00 99
264 The Impact of USAID’s Integrated Health Program in the DRC
112. Other
113. Wound stitching material (Suture synthétique absorbable 
et Nylon)
01 00 99 01 00 99
114. Does this facility offer vaccination services? YES
NO
If no, skip to next 
module
Section 5. Cold Chain
115. How many refrigerators are used for 
vaccines?
ASK TO SEE THE REFRIGERATOR TO 
VERIFY.
If 0,  123
Respond to the following separately for 
each refrigerator.
116. How is the refrigerator powered? FUEL……………………………………………………….01
ELECTRIC………………………………………………..02
SOLAR…………………………………………………….03
GAS………………………………………………………..04
OTHER……………………………………………………05
__________________________________ 
(SPECIFY)
117. Does it have a working thermometer? YES
NO
If no,  119
118. What temperature is the thermometer 
currently displaying?
|__|__|__|
119. Does it have a temperature log?
TAKE A PHOTO OF THE LOG. IF THE LOG 
HAS MULTIPLE PAGES, TAKE A PHOTO OF 
THE MOST RECENT PAGE USED.
YES
NO
If no,  123
120. Was the temperature logged yesterday 
morning (AM)?
YES
NO
121. Was the temperature logged yesterday 
afternoon (PM)?
YES
NO
122. TAKE A PHOTO OF THE INSIDE OF THE REFRIGERATOR INCLUDING THE DOOR. 
123. Are vaccines stored in locations outside of 
a refrigerator?
ASK TO SEE THE LOCATIONS.
YES
NO
If no, skip to next 
section.
Baseline Report 265
TAKE A PHOTO OF THE VACCINE STORAGE 
AREA.
124. I am going to read you a list of vaccines. 
For each one, please tell me if the vaccine 
is currently in stock and if the vaccine has 
been out of stock at any point in the past 
30 days.
Part A: Is this drug 
currently in stock?
YES…..01
NO….00
DON’T KNOW….99
Part B: If YES to Part A, 
has this drug been in 
stock continuously
during the past 30 days?
YES…..01
NO….00
DON’T KNOW….99
125. BCG 01 00 99 01 00 99
126. Pentavalent (DTP, Hib, Hepatitis B) 01 00 99 01 00 99
127. IPV (polio) 01 00 99 01 00 99
128. OPV (polio) 01 00 99 01 00 99
129. Measles 01 00 99 01 00 99
130. Yellow fever 01 00 99 01 00 99
131. Pneumococcal vaccine (PCV) 01 00 99 01 00 99
132. Rotavirus 01 00 99 01 00 99
133. Td 01 00 99 01 00 99
134. TAKE A PHOTO OF THE VACCINE STORAGE AREA.
266 The Impact of USAID’s Integrated Health Program in the DRC
Select a random sample of three Pentavalent vaccines, or the largest number available up to 10 if less than three. 
Record the expiration date and whether the temperature monitor is in Phase 3 or 4.
Expiration date Phase 3 or Phase 4
Pentavalent
- Vial 1 [_] Phase 3 [_] Phase 4
- Vial 2 [_] Phase 3 [_] Phase 4
- Vial 3 [_] Phase 3 [_] Phase 4
- Vial 4 [_] Phase 3 [_] Phase 4
- Vial 5 [_] Phase 3 [_] Phase 4
- Vial 6 [_] Phase 3 [_] Phase 4
- Vial 7 [_] Phase 3 [_] Phase 4
- Vial 8 [_] Phase 3 [_] Phase 4
- Vial 9 [_] Phase 3 [_] Phase 4
- Vial 10 [_] Phase 3 [_] Phase 4
BCG
- Vial 1 [_] Phase 3 [_] Phase 4
- Vial 2 [_] Phase 3 [_] Phase 4
- Vial 3 [_] Phase 3 [_] Phase 4
- Vial 4 [_] Phase 3 [_] Phase 4
- Vial 5 [_] Phase 3 [_] Phase 4
- Vial 6 [_] Phase 3 [_] Phase 4
- Vial 7 [_] Phase 3 [_] Phase 4
- Vial 8 [_] Phase 3 [_] Phase 4
- Vial 9 [_] Phase 3 [_] Phase 4
- Vial 10 [_] Phase 3 [_] Phase 4
Measles
- Vial 1 [_] Phase 3 [_] Phase 4
- Vial 2 [_] Phase 3 [_] Phase 4
- Vial 3 [_] Phase 3 [_] Phase 4
- Vial 4 [_] Phase 3 [_] Phase 4
- Vial 5 [_] Phase 3 [_] Phase 4
- Vial 6 [_] Phase 3 [_] Phase 4
- Vial 7 [_] Phase 3 [_] Phase 4
- Vial 8 [_] Phase 3 [_] Phase 4
- Vial 9 [_] Phase 3 [_] Phase 4
- Vial 10 [_] Phase 3 [_] Phase 4
Baseline Report 267
IHP Evaluation
HEALTH FACILITY SURVEY
Part F. Medical Record Review
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province.
2. Record the health zone.
3. Record the name of the health facility or enter the facility ID 
number.
4. Enter your data collector ID number.
268 The Impact of USAID’s Integrated Health Program in the DRC 
ANTENATAL CARE: Randomly select 10 women who had their first ANC visit at the facility during the last calendar month(or highest number available if less 
than 10).
# Date of 
visit
Age of 
pregnancy 
(weeks/months)
First 
trimester?
Blood pressure Tested for 
Syphilis
Tested for 
HIV
Received SP 
dose 1
Received ITN ANC register version 
date
Measured Result (01/2020 if unknown)
1
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
2
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
3
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
4
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
5
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
6
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
7
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
8
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
9
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
10
|__|__|
weeks
months
yes 
no
yes 
no
S: 
D: 
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
 yes
 no
 don’t know
Baseline Report 269
MATERNAL AND NEONATAL CARE: Randomly select 10 women who delivered at the facility and who died or were discharged during the last calendar month 
(or highest number available if less than 10).
# Date of 
delivery
Ante￾partum 
hemrrhge
Post￾partum 
hemrrhge
Post￾partum 
infection
Active 
mgmt of 
the third 
period of 
labor
Cesarean Child death 
before 7 
days 
(includes 
stillbirth)
Essential 
neonatal 
services
Early 
initiation 
of breast￾feeding
Maternal 
death
Date of 
discharge
Delivery 
register 
version date
(01/2020 if 
unknown)
1
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
2
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
3
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
4
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
5
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
6
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
7
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
8
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
9
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
10
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
 yes
 no
 DK
270 The Impact of USAID’s Integrated Health Program in the DRC 
According to the registry, how many of the following occurred at this facility in April, May, and June 2019? Enter -99 if data is 
missing or unavailable.
April May June
Prenatal consultations (first 
visit)
Prenatal consultation (fourth 
visit)
Cases of simple diarrhea 
(children under five)
Cases of simple malaria, 
confirmed (children under 
five)
Cases of simple pneumonia 
(children under five)
LLINs quantity consumed 
during month
New acceptors of family 
planning (total)
BCG doses administered 
during month
Baseline Report 271
IHP Evaluation
HEALTH FACILITY SURVEY
Part G. Health Worker Interview
SECTION 2: PROVIDER INFORMATION, POSITION AND EXPERIENCE
First, I would like to ask you some general questions about you.
8. Are you the head of this facility? Yes
No
Not applicable (N/A)
9. Are you the head of a department or unit? Yes
No
If no, 
11
10. What department or unit do you head? General inpatient
Surgery
Pediatrics
Maternity
Other (specify) ______________________
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1. Record the province
2. Record the health zone
3. Record the name of the health facility or enter the facility ID 
number
4. Enter your data collector ID number
Select all of the physicians, nurses, and midwives responsible for service delivery who are at work on the day of the survey.
5. Have you read him/her the consent script? |_| No
|_| Yes
If yes,  7
6. If no, why?
7. Did the respondent(s) agree? |_| No
|_| Yes
If no, end interview
272 The Impact of USAID’s Integrated Health Program in the DRC
11. What is your clinical educational qualification 
(highest degree or certificate earned)?
General Physician……………………………...1
Medical Specialist (please specify)…………...2
Nurse A0/L2……………………………………..3
Nurse A1…............................................ ………4
Nurse A2 ….................................................…5
Nurse A3………………………………………..6
Midwife A0/L2 …………...………………….....7
Midwife A1…..............................................…8
Midwife A2 …………………………………. ...........…9
Midwife A3………………………………….….10
Trained birth attendant…………………..…...11
Community health worker L2………………...12
Community health worker G3 ……………….13
None……………………………………………14
Other……………………………………………96
_____________________________________
(Specify)
12. Do you have a Master’s degree? Yes
No
If no, 
15
13. In what subject is your Master’s degree(s)? (check 
all that apply)
Public health
Public administration
Business administration
Social science / Anthropology
Other (specify)
Baseline Report 273
14. In what province did you receive your highest 
clinical degree or certificate?
Kinshasa
Bas-Uele
Équateur
Haut-Katanga
Haut-Lomami
Haut-Uele
Ituri
Kasaï
Kasaï-Central
Kasaï-Oriental
Kongo Central
Kwango
Kwilu
Lomami
Lualaba
Mai-Ndombe
Maniema
Mongala
Nord Kivu
Nord-Ubangi
Sankuru
Sud Kivu
Sud-Ubangi
Tanganyika
Tshopo
Tshuapa
Other location (outside of DRC) (Specify 
country) ___________________________
No response
15. How many years have you worked at this facility? Less than 1 year
More than 1 year (specify number of years)
__________
Don't know
16. According to your contract, for how many hours are 
you supposed work in this health facility in a normal 
week?
Hours...............................................................
...................................................... |___|___| 
17. In the last month, how many days did you miss a full 
day of work due to any of the following reasons? 
[READ LIST and Enter 0 if no days missed for any 
reason] 
Days
Concern for safety |___|
Personal sickness |___|
Care for a sick child |___|
Care for a sick adult |___|
Lack of pay |___|
Bereavement/Funeral |___|
Other income generating activities |___|
Other reasons |___|
274 The Impact of USAID’s Integrated Health Program in the DRC
18. How do you usually get to work during the dry 
season?
SELECT ALL THAT APPLY
Walk
Bicycle
Motorbike
Boat
Private car
Public transportation
Other (specify)
19. How do you usually get to work during the rainy 
season?
SELECT ALL THAT APPLY
Walk
Bicycle
Motorbike
Boat
Private car
Public transportation
Other (specify)
20. How long does it usually take you to get to work 
during the dry season?
Minutes:
Hours:
21. How long does it usually take you to get to work 
during the rainy season?
Minutes:
Hours:
22. In general, how safe or unsafe is your trip to work 
during the dry season?
Very safe
Safe
Unsafe
Very unsafe
Don’t know
23. In general, how safe or unsafe is your trip to work 
during the rainy season?
Very safe
Safe
Unsafe
Very unsafe
Don’t know
24. How do you usually get home from work during the 
dry season?
SELECT ALL THAT APPLY
Walk
Bicycle
Motorbike
Boat
Private car
Public transportation
Other (specify)
25. How do you usually get home from work during the 
rainy season?
SELECT ALL THAT APPLY
Walk
Bicycle
Motorbike
Boat
Private car
Public transportation
Other (specify)
26. How long does it usually take you to get home from 
work during the dry season?
Minutes:
Hours:
27. How long does it usually take you to get home from 
work during the dry season?
Minutes:
Hours:
28. In general, how safe or unsafe is your trip home 
after work during the dry season?
Very safe
Safe
Unsafe
Very unsafe
Don’t know
Baseline Report 275
29. In general, how safe or unsafe is your trip home 
after work during the rainy season?
Very safe
Safe
Unsafe
Very unsafe
Don’t know
30. Now, we are going to ask you some personal questions. Remember that you can skip any questions that you do 
not want to answer.
31. In what province were you born? Kinshasa
Bas-Uele
Équateur
Haut-Katanga
Haut-Lomami
Haut-Uele
Ituri
Kasaï
Kasaï-Central
Kasaï-Oriental
Kongo Central
Kwango
Kwilu
Lomami
Lualaba
Mai-Ndombe
Maniema
Mongala
Nord Kivu
Nord-Ubangi
Sankuru
South Kivu
Sud-Ubangi
Tanganyika
Tshopo
Tshuapa
Other location (outside of DRC) (Specify 
country) ______________________________
No response
32. What is your age? (record age in years) |___|___| Years
33. Sex of the healthcare provider Male …..........................................................1
Female …......................................................2
34. What is your marital status? Married/in union……………………………………….1
Single…………………………………………….2
Widowed…………………………………………3
Separated………………………………………..4
Other……………………………………………96
35. How many living children, of any age, do you have? If < 0, 
37
36. How many of your living children are younger than 
five?
37. Do you live away from your family due to work 
reasons? 
No………………………………………………..0
Yes……………………………………………….1
276 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 3. TRAINING
Topic Attended Who administered this training?
38. Prenatal consultations No (skip to 39)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
39. Integrated Management of Childhood Illness No (skip to 40)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
40. Malaria (children under 5) No (skip to 41)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
41. Long-lasting insecticidal net (LLIN) distribution? No (skip to 42)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
42. Family planning? No (skip to 43)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
43. Reach Every District training? No (skip to 44)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
44. Administrative and human resource management? No (skip to 45)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
45. Financial management? No (skip to 46)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
46. Management ethics and patient confidentiality? No (skip to 47)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
47. Training of health care providers? No (skip to 48)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
48. Capacity-building of CODESAs? No (skip to 49)
Yes 
Internal/BCZ office 
Province/Government
The next set of questions is about the training participation and includes internal training provided by members of this health 
facility as well as training provided by provincial/government officials, USAID/IHP partners or other NGOs with which this facility 
may be affiliated. If you attended multiple trainings on the same topic, please tell us about the most recent one.
In the last calendar year (2018), did you attend training on any of the following subjects as part of your position in the health 
facility?
Baseline Report 277
USAID/IHP 
Other: ____________________ 
49. Health information management (e.g. DHIS2, SNIS, MAPEPI)? No (skip to 50)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
50. Community scorecard processes? No (skip to 51)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
51. Material resource management (medicines, supplies, 
equipment)?
No (skip to 52)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
52. Gender issues and/or the gender transformative approach? No (skip to 53)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
53. Care of victims of SGBV No (skip to 54)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
54. Supportive supervision? No (skip to 55)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
55. Team management? No (skip to 56)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
56. Planning, monitoring and evaluation? No (skip to 57)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
57. Disease prevention, health promotion and re-adaptation 
care?
No (skip to 58)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
58. Management of outbreaks, emergencies and disasters? No (skip to 59)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
59. Health research? No (skip to 60)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
60. Data analysis? No (skip to 61)
Yes 
Internal/BCZ office 
Province/Government
USAID/IHP 
Other: ____________________ 
61. Use of data for evidence-based decision-making? No (skip to 62) Internal/BCZ office 
278 The Impact of USAID’s Integrated Health Program in the DRC
Yes Province/Government
USAID/IHP 
Other: ____________________ 
iHUMAN RESOURCES INFORMATION SYSTEM (iHRIS) TRAINING
62. Did you or anyone else in this office participate in a training 
on Human Resources Management using the iHuman 
Resources Information System (iHRIS)?
No
Yes 
Don’t know
If no,  70
63. Did you participate? No
Yes 
64. How long ago was that training? 0-3 months ago
4-6 months ago
7-12 months ago 
More than 1 year ago
Don't know
65. Sometimes participants cannot attend the entire training 
workshop. How much of that workshop did you attend?
Less than half 
About half of it
All or most of it
Not applicable
66. It can be difficult to remember all of the material presented 
during training. How much do you remember of what you 
learned in the training on Human Resources Management 
using the iHRIS?
Less than half 
About half of it
All or most of it
Not applicable
67. How often do you use the material presented during that 
workshop in your day to day work?
Never 
Rarely 
Sometimes
Often 
Always
Not applicable
68. What language was the training conducted in? Swahili 
French 
Lingala 
Tshiluba
English
Other (specify) _____________
Don't know
69. Did anyone attending the training report that the language of 
the training created challenges with understanding the 
material?
No
Yes 
Don’t know
Baseline Report 279
SECTION 4: MANAGEMENT AND SUPERVISION
70. Who is your direct supervisor WITHIN the facility? Head of the facility….…..................................1
Medical specialist (please specify)………………2
Physician (general) …. .......…………………………3
Nurse A0/L2 ……………………………….................4
Nurse A1…………………………………………………….5
Nurse A2…………………………………………………….6
Nurse A3…………………………………………………….7
Midwife A0/L2 …………..…………………..............8
Midwife A1…. .........……………………………………9
Midwife A2 …. ..........………………………………..10
Midwife A3………………………………….……………11
Trained birth attendant…………………………….12
Community health worker L2 …………………..13
Community health worker G3…………………..14
Other………………………………………………………..96
_____________________________________
(Specify)
Skip if 
interviewi
ng facility 
head
71. When was the most recent time that your supervisor 
WITHIN the facility interacted with you in a 
supervisory capacity?
DO NOT READ CHOICES, BUT CIRCLE THE 
APPROPRIATE NUMBER FOR THE RESPONSE GIVEN
Today....................................1
2-7 days ago .........................2
More than 7 days ago ..........3
Not applicable ....................97
Don’t know.........................98
If N/A, 
73
72. Which activities has your supervisor WITHIN the 
facility performed in the past 30 days? 
DO NOT READ CHOICES; CIRCLE THE ANSWER(S) 
GIVEN OR WRITE IN IF “OTHER”. IF MORE THAN ONE 
ANSWER IS GIVEN, CIRCLE ALL THAT APPLY.
Checked records.......................................... 1
Checked finances ........................................ 2
Observed consultation................................ 3
Asked knowledge questions........................ 4
Provided health instruction ........................ 5
Provided administrative instruction............ 6
Provided instruction in filling HMIS............. 7
Provide feedback on job performance………8
Nothing ....................................................... 9
Other……………………………………………………...96
_____________________________________
(Specify)
280 The Impact of USAID’s Integrated Health Program in the DRC
73. What are the three biggest difficulties that you face in 
doing your job in the facility? 
How would you rank these in terms of the biggest, 
second biggest and third biggest difficulties? 
DO NOT READ CHOICES; CIRCLE THE ANSWER(S) 
GIVEN, OR WRITE IN IF “OTHER”. CIRCLE ONLY 
THREE CHOICES.
1st biggest |__|__|
2nd biggest |__|__|
3rd biggest |__|__|
Lack of trained personnel/staff…. ...............…1
Lack of knowledge…............……. .................…2
Lack of feedback of performance……………..3
Patients come to clinic too late…................…4
Inadequate transport…. ......……. .................…5
Lack of time…. .....................……. .................…6
Lack of motivation…............……. .................…7
Staff shortages…..................……. .................…8
Poor working environment…. .....................…9
Lack of supplies and drugs…. ....................…10
Lack of equipment…............……. ...............…11
Irregular/no water supply….…...................…12
Irregular/no electricity…. ....……. ...............…13
No laboratory or poor lab quality …..........…14
Lack of space in the facility….....................…15
Lack of supervision…. ..........……. ...............…16
Inadequate furniture...........…................ ……17
No problem................................................. 18
Other…………………………………………………………96
_____________________________________
(Specify)
If “No 
problem”, 
 76
74. Have you discussed the problems with your 
supervisor(s) (either within or outside the facility) 
within the last year?
IF RESPONDENT HAS NO INTERNAL OR EXTERNAL 
SUPERVISORS, CIRCLE NOT APPLICABLE
No................................................................ 0
Yes............................................................... 1
Not applicable………………………………………….97
If “Yes” or 
“N/A”, 
76
75. After these discussions did you notice any 
improvements in the problems?
No................................................................ 0
Yes............................................................... 1
Baseline Report 281
SECTION 5: PROVIDER INCOME
Now we would like to ask you some questions about your income, both from this job and any other sources of income you 
may have. These questions help us understand the strategies you use to make a living
No. Question
76. What is the total monthly net salary you are supposed to 
receive from your employment at this facility (after 
deduction and taxes etc.)? 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
If 0, 
82
77.
What was the total monthly salary you actually received
from your employment at this facility (after deduction 
and taxes etc.) for the last full month that you worked?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
78. Was your last salary payment on time? No, late……………………………………………………..0
Yes, on time .................................................1
Not yet paid……………………………………………….2
79. Have you ever received your full state salary on time?
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If no, 
82
80. Do you remember the last time that you were paid your 
full state salary on time?
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If no or 
don’t 
know, 
82
81. When was the last time that you were paid your full 
salary on time?
Month:
Year:
82. According to your contract are you supposed to receive 
a monthly hazard pay?
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If no or 
don’t 
know, 
86
83. What is the amount of hazard pay you are supposed to
receive monthly?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
84. What is the amount of monthly hazard pay you actually
received for the last full month that you worked?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
85. Was your last hazard payment on time? No, late……………………………………………………..0
Yes, on time .................................................1
Not yet paid……………………………………………….2
86. According to your contract, are you supposed to receive 
a monthly performance bonus?
No ..........................................................0
Yes..........................................................1
Don’t know…..…………………………………….98
If no, 
90
87. Are you aware of any performance criteria attached to 
this bonus? 
No ..........................................................0
Yes..........................................................1
Don’t know…..…………………………………….98
88. What is the amount of monthly performance bonus you 
are supposed to receive?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
89. What is the amount of monthly performance bonus that 
you actually received for the last full month that you 
worked? 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
282 The Impact of USAID’s Integrated Health Program in the DRC
90.
Do you receive any monthly income from user fees 
collected at the facility?
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If no or 
don’t 
know, 
92
91.
What is the amount of monthly user fees you received 
from the last full month that you worked?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
92. According to your contract, are you supposed to receive 
a housing allowance?
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If no or 
don’t 
know, 
95
93. What is the amount of monthly housing allowance that 
you are supposed to receive?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
94. What is the amount of monthly housing allowance that 
you actually received for the last full month that you 
worked?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
95. Do you receive free housing through work?
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
96.
Do you receive any of the other following allowances 
through your work? 
READ EACH POSSIBLE RESPONSE TO THE RESPONDENT. 
CIRCLE ONLY THOSE FOR WHICH THE RESPONDENT 
ANSWERED “YES”. 
MULTIPLE RESPONSES ALLOWED
Rural allowance………………………………..….…1
Transport allowance………………………..….….2
Medical allowance…………………………….….…3
Overtime allowance………………………..….....4
Uniform allowance……………………………….…5
Non-practice allowance………………………....6
None………………………………………………………7
Other (please specify)………………………..…96
_____________________________________
(Specify)
If none, 
 98
97.
FOR EACH RESPONSE CIRCLED IN QUESTION 521, POSE 
THE QUESTION: 
How MUCH do you receive for (STATE APPROPRIATE 
CATEGORY) per month?
IF UNKNOWN WRITE 99999.
Rural allowance 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Transport allowance 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Medical allowance 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Overtime allowance 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Uniform allowance 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Non-practice allowance 
|___|___|___|___|___| ___| CF
Baseline Report 283
|___|___|___|___|___| ___| USD
Other (please specify) ___________________
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
98. In the past 12 months, did you receive any per diems 
(e.g. for workshops, training or other travel)? 
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If yes, 
99
99. If yes, how much do you receive in per diems for training 
during the past year?
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
100. Do you supplement your main income with extra private 
health care work? 
No ................................................................0
Yes................................................................1
Don’t know…..………………………………………….98
If yes, 
101
101. If yes, which of these options best describes where this 
private practice is located? (SELECT ALL THAT APPLY)
Same building as main job…………………….1
At home………………………………………..........2
At home of a colleague…………………………3
In rented premises……………………………..…4
At patient/client’s home…………………….…5
Private facility…………………………………….…6
NGO facility………………………………………..…7
Other (please specify)…………………………96
_____________________________________
(Specify)
102. How much do you get paid for this private practice 
during the last month? 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
103. Do you have any additional sources of income? Yes..........................................................1
No ..........................................................2 If no, 
106
104. Can you tell me which of the additional sources of 
income you have?
Agriculture .............................................1
Livestock (elevage)………………………………2
Trade/Business ......................................3
House rent .............................................4
Gifts/contributions from family…………..5
Other……………………………………………….…96
_____________________________________
(Specify)
105. If yes to one or more of any of the above, what is the 
amount for each received in the past 30 days?
IF UNKNOWN WRITE 99999.
Agriculture 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Livestock (elevage)
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
Trade/Business 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
House rent 
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
284 The Impact of USAID’s Integrated Health Program in the DRC
Other (specify) ________________________
|___|___|___|___|___| ___| CF
|___|___|___|___|___| ___| USD
SECTION 6: PROVIDER SATISFACTION
In this part of the questionnaire we would like to ask you some questions regarding your satisfaction with your current job. All 
answers are confidential and any identifying information will be removed.
I’m now going to read you a series of statements about your level of satisfaction. Please indicate whether you are satisfied or 
dissatisfied. If you are neither satisfied nor dissatisfied, then say neutral. 
[READ FROM THE LIST/SCALE AND ASK WHICH CATEGORY APPLIES]
How satisfied or dissatisfied are you with the 
following aspects of your work?
No.
Satisfied Neutral Dissatisfied Not 
applicable
Relationships
106. Relationships with your supervisors within the facility 
107. Relationships with your supervisors outside the facility 
108. Relationships with colleagues
109. Relationships with local leaders in the community
110. Your level of respect within the community
Management
111. Management of the health facility - by the Ministry of Health or by the 
relevant management office
112. Transparency of the management of financial resources by the facility 
113. Your participation in decision-making to resolve problems in the facility 
Staffing and Workload
114. The number of staff working in the facility 
115. The description of your job role and tasks 
116. The stability of your job/contract 
Work environment
117. Availability of medicines in the health facility 
118. Availability of equipment in the health facility
119. Availability of medical supplies in the health facility 
120. The physical condition of the health facility building 
121. Your workload
122. The division of work between you and your colleagues 
123. The division of work between caring for patients and other tasks
124. The variety of your tasks 
125. Flexibility with attendance and work hours
Training and Performance
126. Your ability to provide a high quality of care to patients 
127. Your ability to meet the needs of the community
128. Your level of responsibility 
129. Your training opportunities to upgrade your skills and knowledge 
130. How you and other colleagues are selected to attend training 
131. Your ability to use skills learned from training in your work 
Baseline Report 285
132. Your opportunities for promotion 
Salary and Benefits
133. Your salary in relation to your workload 
134. Your salary in relation to your competence/skills 
135. Employment benefits (travel allowance, bonus, health care etc.) 
136. Safety and security to live and practice in the community
137. Living accommodations for your family 
138. Quality of your children’s education
Overall satisfaction
139. Overall, how satisfied or dissatisfied are you with your job?
140.
Which three of the aspects 
mentioned above, in your 
opinion, are most important in 
affecting your level of
satisfaction with your job? 
Relationships with your supervisors within the facility 
Relationships with your supervisors outside the facility 
Relationships with colleagues
Relationships with local leaders in the community
Your level of respect within the community
Management of the health facility - by the MoH or by the relevant management office
Transparency of the management of financial resources by the facility 
Your participation in decision-making to resolve problems in the facility 
The number of staff working in the facility 
The description of your job role and tasks 
The stability of your job/contract 
Availability of medicines in the health facility 
Availability of equipment in the health facility
Availability of medical supplies in the health facility 
The physical condition of the health facility building 
Your workload
The division of work between you and your colleagues 
The division of work between caring for patients and other tasks
The variety of your tasks 
Flexibility with attendance and work hours
Your ability to provide a high quality of care to patients 
Your ability to meet the needs of the community
Your level of responsibility 
Your training opportunities to upgrade your skills and knowledge 
How you and other colleagues are selected to attend training 
Your ability to use skills learned from training in your work 
Your opportunities for promotion 
Your salary in relation to your workload 
Your salary in relation to your competence/skills 
Employment benefits (travel allowance, bonus, health care etc
Safety and security to live and practice in the community
Living accommodations for your family 
Quality of your children’s education
141. Are you considering voluntarily 
leaving your current position 
within the next 12 months?
No
Yes (go to 142)
Undecided
142.
If you leave your current 
position, what will you most 
likely do? (check all that apply)
Retire/Not work
Promotion at this facility
Promotion at another health facility
Similar job at another health facility
Private clinical practice
Work with a health-related NGO
286 The Impact of USAID’s Integrated Health Program in the DRC
Work in a non-health related industry
School/other training
Other (specify) ______________________
SECTION 7: PROVIDER MOTIVATION
Please tell me whether you agree or disagree with the following statements. If you neither agree nor disagree say “neutral.”
READ FROM THE LIST/SCALE AND ASK WHICH CATEGORY APPLIES
No QUESTION Agree Neutral Disagree N/A
PRIDE
143. This health facility has a good reputation in the community 
144. It is a source of pride to get a job at this facility 
145. I am satisfied that I accomplish something worthwhile in this job 
146. Healthcare providers at this health facility pride themselves on providing good 
services to patients
FINANCIAL REWARD
147. The effort that we at this facility put into this job is reflected in our pay
148. My job offers adequate pay compared with similar jobs
149. The income I receive is a fair reflection of my skills, knowledge and training
150. The income that I receive from working at this facility more than covers my 
basic needs such as food, transport, and accommodation
151. With this job I have worries about how to support myself and my family
PERCEIVED SELF-EFFICACY
152. I am confident about my ability to handle my work
153. I effectively cope with any new challenges that occur in my work life 
154. I feel that at work things are going the way I would like them to
155. I feel that I have control of things concerning my work
156. I have received sufficient training to be able to perform my job well
COMMITMENT
157. I only do this job so that I get paid at the end of the month
158. I intend to leave this facility as soon as I can find another position 
159. I would recommend this profession to my children 
SELF-PERCEIVED CONSCIENTIOUSNESS
160. I am always reliable and dependable at work 
161. My work is consistently of a high quality
162. I am a hard worker 
163. I am always on time at work 
164. I spend my time at work on work-related activities
165. I am rarely absent from work 
166. I am careful not to make errors at work 
167. When I am not sure how to treat a patient’s condition, I look for information or 
ask for advice 
168. I do things which need to be done without being asked or told
Baseline Report 287
SECTION 8. PROVIDER ATTITUDES
No QUESTION Agree Neutral Disagree N/A
In general, at this facility…
169. Women and men are equally considered for hiring.
If disagree: which sex is preferred? |__|men |__| women
170. Women and men have the same opportunities for promotion.
If disagree: which sex is preferred? |__|men |__| women
171. Women and men have the same opportunities for training.
If disagree: which sex is preferred? |__|men |__| women
172. Women and men in the same positions perform similar tasks.
173.
Women and men in the same positions with the same training and experience 
earn the same salary.
If disagree: which sex earns more? |__|men |__| women
174. Women are given time off to deal with family responsibilities.
175. Men are given time off to deal with family responsibilities.
176. Women are given time off after the birth of a child.
177. Men are given time off after the birth of a child.
In the past 12 months…
178. I have had to turn down an opportunity for training because of family 
responsibilities.
179. I have experienced threats or verbal abuse from other staff members.
180. I have experienced physical violence (slapping, hitting, punching) from other 
staff members.
181. I have experienced other unwanted physical contact from other staff 
members.
182. I have experienced threats or verbal abuse from a patient or patient’s family.
183. I have experienced physical violence (slapping, hitting, punching) from a 
patient or patient’s family.
184. I have experienced other unwanted physical contact from a patient or patient’s 
family.
185. I have experienced threats or verbal abuse from a patient or patient’s family.
186. I have experienced physical violence (slapping, hitting, punching) from a 
patient or patient’s family.
187. I have experienced other unwanted physical contact from a patient or patient’s 
family.
288 The Impact of USAID’s Integrated Health Program in the DRC
Please tell me whether you strongly agree, agree, disagree or strongly disagree with the following statements. If you neither agree 
nor disagree say “neutral.” There are no right or wrong answers so feel free to express your thoughts openly 
READ FROM THE LIST BELOW AND ASK WHICH CATEGORY APPLIES (1-5)
No QUESTION Strongly
agree Agree Neutral Disagree Strongly
disagree
PRIDE
Patient perceptions
188. Patients I care for are not educated enough make good health decisions 
for themselves 
189. Patients I care for are not grateful for the efforts I make when I care for 
them 
190. I consider my patients to be worthy of respect no matter how poor or 
low status they are 
191. Patients often treat me without respect, so it’s hard to treat them with 
respect 
192. Patients I care for make bad decisions regarding their health no matter 
what I tell them 
193. Engaging Patients in discussions leads to better health outcomes than 
just telling them what is best for them 
194. My Patients will work hard to improve their health when they are given 
the proper information
Provider roles
195. My role is to provide clinical care, not to teach patients about how to 
take care of themselves 
196. I do not spend a lot of thought about what Patients may think about their 
experience at the clinic as I have other things to worry about 
197. An important part of my job is to communicate with Patients to make 
sure they understand their care 
198. I try hard to think about all of the Patients’ health care needs not just 
solving their immediate problem 
199. I was trained to provide clinical care, being respectful to every Patient is 
not my job 
200. When medicine is given, it is important that I explain well what it does for 
the Patient and how it helps them 
201. I think it is important to spend enough time with each Patient, even if I 
have other job demands 
202. My job is to diagnose and treat parents not to be a health educator 
Gender norms
203. A man should have the final word about decisions in his home 
204. It is the man who decides what type of sex to have with his wife 
205. A women most important role is to take care of her home and cook for 
her family 
206. If a woman has a good idea, her husband should listen even if he 
disagrees
Baseline Report 289
207. Men and women should decide together about how many children to 
have 
208. A man is expected to discipline his women 
209. Men should help take care of the children in the household 
210. There is never a good reason for a man to beat his wife 
290 The Impact of USAID’s Integrated Health Program in the DRC
PROVIDER VIGNETTES 
 
1) Do you regularly provide child health services?
a) No (skip vignette #1)
b) Yes
2) Do you regularly provide ANC?
a) No (skip vignette #2)
b) Yes
3) Do you regularly provide family planning services?
a) No (skip vignette #3)
b) Yes
 
Instructions for the data collector: Read the following scenarios to the health worker and pose questions 
about the case. The health worker should not refer to any printed materials, the internet, or discuss the 
case with anyone else.
 
Instructions for the health worker: In this exercise we will lead you through hypothetical patient case 
descriptions while asking you case management questions along the way. We want you to form an image 
of the patient presented in the case description and to imagine that this person is sitting in front of you in 
your consultation room. The answers you provide will be anonymous and will only be used for scientific 
research. You will not personally be evaluated based on your responses and the information you provide 
will not be shared with your facility’s administration. 
 
- First, I will give a short description of the patient and their symptoms. I want to know what questions 
you would ask the patient in order to fully understand their situation. These questions could be about 
their health, their personal characteristics, and their family. Once you have asked your questions, I 
will give you more information about the patient.
- Second, I will ask you to tell me how you would conduct your physical exam. I will tell you the results 
of the physical exam.
- Third, based on the patient’s symptoms and the physical examination, I will ask for your differential 
diagnosis. That means I would like to know which illnesses or conditions you most strongly suspect 
that the patient has.
- Fourth, I will ask you which tests you would order. I will then give you the results of the tests.
- Fifth, I will ask you for your final diagnosis of the patient.
- Sixth, you should tell me what medicines and/or treatments you would give.
- Lastly, please describe the counseling that you would give to the patient before they leave your 
office.
 
The answers you provide will be anonymous and will only be used for scientific research. You will not 
personally be evaluated based on your responses and the information you provide will not be shared with 
your facility’s administration.
 
Baseline Report 291
Vignette: Child Illness
A four-year-old boy presents with 3 days of diarrhea. His mother brought him to the hospital after he had 
a seizure at home. 
1) What questions do you ask the child’s mother? Anything else?
a) No questions
b) Consistency of stools
c) Frequency of stools
d) Progression of diarrhea (worsening or getting better)
e) Blood in stools
f) Mucous in stools
g) Temperature
h) Vomiting
i) Abdominal pain
j) Volume and frequency of eating and drinking
k) Treatments given thus far
l) Has this happened before?
m) Anyone else in household is sick?
n) Mother's marital status
o) Caretakers' occupation
p) Housing, water, and sanitation conditions
q) Family composition/number of siblings
r) Religious affiliation
s) Other (specify) ______________________________________________________
At first the diarrhea was watery 5- 10 times a day, but now it’s worse: small volume stools about 20 times 
a day, mixed with blood and mucous. He’s felt very “hot” and has been weak and listless. He has been 
consuming small amounts of soft food and water. He has not been given any treatments and this is the 
first time that he has had this type of illness. His parents are married, and his father is a teacher. He lives 
in a mud brick house with his parents and two older siblings. The family gets their water from a nearby 
spring and uses a pit latrine that they share with another family. 
2) What does your physical examination of the patient include? Anything else?
a) No examination
b) Affect/demeanor
c) Temperature
d) Heart rate
e) Respiratory rate
f) Capillary refill
g) Skin turgor
h) Abdominal palpation
292 The Impact of USAID’s Integrated Health Program in the DRC
i) Weight
j) Other (specify) ___________________________________________________________
The physical exam is notable for general apathy, a temperature of 40 heart rate 130/minute RR 
20/minute, not deep capillary refill 2 seconds skin turgor intact and a distended, tender abdomen with 
visible bowel loops. The mother reports that at his last visit he weighed 17 kg. Today he weighs 15.5 kg. 
3) What are the most likely diagnoses (i.e. the differential diagnoses??
a) Dysentery/Shigella
b) Rotavirus
c) E-Coli
d) Cryptosporidium
e) Malaria
f) Anemia
g) Others (specify) _______________________________________________
h) Don’t know
4) What tests, if any, do you order? Assume that the needed tests can be conducted at your facility.
a) No tests
b) Direct microscopic stool examination
c) Stool culture
d) Hemoglobin
e) Hematocrit
f) WBC
g) Electrolytes
h) Medical imaging
i) Other (specify) _______________________________________________
Testing indicates that the child has dysentery caused by Shigella dysenteriae type 1. 
5) Based on these results, what treatment(s) do you administer, if any? Assume that everything that is 
needed is in-stock in the facility.
a) No treatment
b) Flagyl
c) Antibiotic
d) Other medicine (specify) _______________________________________________
e) Fluids (oral)
f) Fluids (IV)
g) Treatment for fever 
h) Other (specify) _______________________________________________
6) What are the key points that you tell the child’s mother during counseling? Anything else?
a) No counseling
Baseline Report 293
b) Diagnosis
c) How the infection is transmitted
d) How to administer medicine
e) Feeding
f) Hydration
g) Hygiene
h) How to monitor/signs of worsening
i) When to bring him back for follow-up
j) Other (specify) _______________________________________________
 
294 The Impact of USAID’s Integrated Health Program in the DRC
Vignette: Antenatal care 
 
A nineteen-year-old woman comes to you for her first antenatal care visit. She is visibly pregnant and 
estimates that she is at least 20 weeks along. She has not taken a pregnancy test and did not come earlier 
because she lives far from the health center. 
1) What questions do you ask her? Anything else?
a) No questions
b) Number of pregnancies
c) Number of deliveries (live births)
d) Number of miscarriages
e) Number of children alive
f) Number of children born alive who have died
g) Timing of last menstrual period
h) History of hypertension
i) History of diabetes
j) Family health history
k) Past illnesses
l) Complaints during this pregnancy
m) Sexual history (e.g. sexual activity, number of sexual partners)
n) History of intimate partner violence and/or sexual violence
o) Marital status
p) Occupation
q) Education level
r) Family/support network
s) Religious affiliation
t) Other (specify) _______________________________________________
She tells you that this is her first pregnancy. She was vomiting at the beginning of her pregnancy but has 
not vomited for at least 3 weeks. She complains of recent mild headaches and swelling in her feet and 
ankles. There is a history of twins in her family. Her older sister died in childbirth three years ago. She does 
not know the reason. The only notable elements from her social history are that she has been married for 
a year and works on her family’s farm. 
2) What does your physical examination of the patient include? Anything else?
a) No examination
b) Height
c) Weight
d) Temperature
e) Blood pressure
f) Pulse
g) Respiratory rate
Baseline Report 295
h) Abdominal palpation
i) Breast exam
j) Fetoscope
k) Vaginal exam
l) Fundal height
m) Presence of edema
n) Other (specify) _______________________________________________
 
The woman is 1.7 m tall and weighs 73 kgs. Her blood pressure is 142/93, pulse 85 beats per minute, and 
respiratory rate is 16 breaths per minute. She does not have a fever or edema. You detect fetal movement. 
3) What tests, if any, do you order? Assume that the needed tests can be conducted at your facility.
a) No tests
b) Pregnancy test
c) Proteinuria
d) HIV
e) Syphilis
f) Malaria
g) Hemoglobin
h) Hematocrit
i) Blood grouping
j) Echography
k) Other (specify) _______________________________________________
The tests indicate that she is positive for pregnancy and proteinuria (protein/creatinine ratio of 60 
mg/mmol) and negative for HIV and syphilis. 
 
4) Based on the history, exam and test results, what is your assessment of the patient?
a) Preeclampsia
b) Healthy pregnancy
c) Other (specify) _______________________________________________
d) Don’t know
 
5) What is your next step? Assume that everything that is needed is in-stock in the facility. Indicate the 
frequency and dose if applicable.
a) No treatment
b) Transfer to hospital
c) Hypotensive drug
d) Anti-convulsive drug
e) Induction of labor
f) Other (specify) _______________________________________________
296 The Impact of USAID’s Integrated Health Program in the DRC
6) What are the key points that you would tell Thérèse during counseling? Anything else?
a) No counseling
b) Causes, symptoms, and risks of having preeclampsia
c) Referral to hospital
d) How to take medicine
e) Reduced physical activity
f) Bed rest
g) Minimize salt intake
h) Increase water intake
i) Increase protein intake
j) Signs that emergency care is needed
k) When to return for follow-up
l) Other (specify) _______________________________________________
 
Baseline Report 297
Vignette: Family planning
 
A 22-year old woman comes to the clinic on her own. She tells you that she is interested in using 
contraceptives. 
 
1) What questions do you ask her?
a) No questions
b) Menstrual history (e.g. first day of last menstrual period, length of bleeding (days), menstrual 
frequency, other patterns of uterine/vaginal bleeding)
c) Gynecologic and obstetrical history (e.g. pregnancy/-ies, recent delivery, miscarriage, or 
termination)
d) Drug history including contraceptive use (past and/or current)
e) Recent intercourse
f) Other health conditions and behaviors (e.g. allergies, breastfeeding, hypertension, smoking).
g) Marital status
h) Length of marriage
i) Education level
j) Occupation (self)
k) Occupation (husband)
l) Number of children
m) Age of youngest child
n) Pregnancy intentions (including timing and spacing if children are desired) 
o) Contraceptive preferences
p) Sexual history (e.g. sexual activity, sexual partners, past STD history)
q) History of intimate partner violence and/or sexual violence
r) Religious affiliation
s) Other (specify) _______________________________________________
You learn that she has never used any contraceptive method, aside from the occasional use of condoms. 
She has no children. Her menstrual cycle is regular, and she has no allergies or other health issues. She is 
currently married and having sex but would like to delay having children for another 3 years at least. 
 
2) Do you counsel her in choosing a contraceptive method? Assume that there are multiple methods in￾stock at your facility today.
a) No 
b) Yes (skip to Q4)
3) Why don’t you counsel her in choosing a contraceptive method? Any other reason?
a) She is married.
b) She has no children.
c) Her husband is not with her at the health center.
d) Condoms are sufficient.
298 The Impact of USAID’s Integrated Health Program in the DRC
e) Provider’s religious beliefs
f) Other (specify) _______________________________________________
4) What information do you provide when counselling her about family planning methods? Any others?
a) No counseling
b) Types of contraceptive methods available today (e.g., condoms, oral contraceptives, injectable 
contraceptives, intrauterine device (IUD), implants, etc.)
c) Types of contraceptive methods available consistently (i.e. never/rarely stocked out)
d) Duration of protection from pregnancy
e) Effectiveness of methods in preventing pregnancy 
f) Effectiveness of methods in protecting against STDs, such as HIV
g) Correct use of methods
h) Side effects including lack of periods
i) Safety of the method
j) Pain/discomfort during administration
k) Cost of methods
l) Provider’s recommendation of a specific method
m) Other (specify) _______________________________________________
5) How do you determine which family planning method to prescribe her and what factors do you 
consider when making this decision?
a) Effectiveness
b) Side effects
c) Her medical history
d) Her preferences with regard to methods
e) Her preferences with regard to timing of pregnancy/childbearing
f) Her confidence in being able to use the method correctly and consistently
g) Acceptability of method use by her husband
h) Acceptability of method use by her peers
i) Cost of method
j) Whether someone at the facility is trained and/or confident in their ability to administer the 
method
k) Availability of the method on that day
l) Other (specify) _______________________________________________
After counselling and discussion, she tells you that she would like to use the implant method. However, 
this method is not currently being offered in your clinic
6) What do you do?
a) Refer her to another clinic that provides this method
b) Tell her that she should choose another option
c) End the consultation
Baseline Report 299
d) Other (specify) _______________________________________________
She tells you that she does not want anyone to know that she is using contraception and asks that you 
keep it confidential. 
 
7) What do you do?
a) Reassure her that you will not tell anyone.
b) Encourage her to tell her husband.
c) Encourage her to tell other people.
d) Refuse to provide a method until she informs her husband.
e) Other (specify) _______________________________________________
300 The Impact of USAID’s Integrated Health Program in the DRC
IHP EVALUATION 
BUREAU CENTRAL DE LA ZONE DE SANTE (BCZS) HMIS SURVEY 
 
 
SECTION 12. HEALTH INFORMATION SYSTEM 
IDENTIFY THE PERSON PRIMARILY RESPONSIBLE FOR ENTERING DATA INTO THE DHIS2 SYSTEM TO ANSWER THIS SECTION 
Now I would like to ask you questions related to health information, specifically the DHIS2. 
NO QUESTION RESPONSE SKIP/ 
INSTRUCTIONS 
4 How many facilities are currently required to submit data to 
the BCZS?
IF UKNOWN, ENTER 999.
|__ | __ |__|
DON’T KNOW
If 0,  8
5 In the last month, how many of the [repeat number given 
above] facilities submitted data using the harmonized
reporting tool or any other form? [SHOW THE RESPONDENT 
A PHOTO OF THE CURRENT TOOL]
ALL 
SOME 
NONE 
DON’T KNOW
6 In the last month, how many facilities submitted data using 
the harmonized reporting tool? [SHOW THE RESPONDENT A 
PHOTO OF THE CURRENT TOOL]
ALL 
SOME 
NONE 
DON’T KNOW
7 Can I see the facility reports from the last month? YES, ALL OBSERVED 
YES, SOME OBSERVED 
NOT SEEN
8 In the last month, how did this office submit its weekly 
Maladie à Potentiel Epidémique (MAPEPI) to the DPS?
Hand deliver to DPS
DPS picks up
Phone call
Text message 
Radio communication
IDENTIFY THE HIGHEST-RANKING PERSON. EXPLAIN THAT SOME QUESTIONS MAY HAVE BEEN ASKED IN EARLIER INTERVIEWS WITH 
USAID IHP REPRESENTATIVES AND THAT YOU APPRECIATE THEIR TIME AND PATIENCE.
 
SECTION 1. ORIENTATION 
No. QUESTION RESPONSE SKIP/ 
INSTRUCTIONS 
1 Record the province 
2 Record the health zone 
3 Enter your data collector ID number 
Baseline Report 301
Email from office
Email from cyber café or 
other off-site location
Electronically via DHIS2
OTHER
____________________
9 To the best of your knowledge, the last time you 
encountered a MAPEPI case, how much time passed 
between when you were made aware of the MAPEPI event 
and when you were able to report to the DPS? 
DO NOT READ ANSWERS BUT CHECK THE ONE CLOSEST TO 
THE ONE GIVEN. 
IMMEDIATELY
WITIHIN 24 HOURS
THE NEXT DAY
> 2 DAYS
DON’T KNOW 
10 What are some of the reasons why an immediate or weekly 
MAPEPI report may not be submitted on time?
 
SEVERAL RESPONSES POSSIBLE. CHECK ALL THAT ARE 
MENTIONED 
 
DID NOT HAVE THE 
CORRECT FORM
NO SUPERVISION VISIT
LACK OF TRANSPORTATION
LACK OF INTERNET
LACK OF TELEPHONES
LACK OF ELECTRICITY
NO TIME TO COMPLETE 
REPORTS.
NO STAFF TO COMPLETE 
REPORTS
NOT AWARE OF 
SUBMISSION DEADLINES
OTHER
_______________________
____
Read aloud: Every BCZ office may do things differently. I am going to list a few tasks that might be performed using DHIS2 data. 
Please tell me whether you have done any of the following in the past 6 months: 
11 Generated a report with results for one or more facilities? YES
NO
DON’T KNOW
12 Generated a summary report for the health zone? YES
NO
DON’T KNOW
13 Compared results with provincial/national targets? YES
NO
DON’T KNOW
14 Compared results across different service domains? YES
NO
302 The Impact of USAID’s Integrated Health Program in the DRC
DON’T KNOW
15 Compared results over time? YES
NO
DON’T KNOW
16 Do you have a copy of the DHIS2 manual? YES, OBSERVED
YES, NOT OBSERVED
NO
DON’T KNOW
17 Have you read the DHIS2 manual? YES
NO
DON’T KNOW
If no,  19
18 How easy or difficult would you say the DHIS2 procedure 
manual is to understand?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
VERY DIFFICULT
19 THE NEXT QUESTION IS ABOUT TRAINING PARTICIPATION 
WHICH INCLUDES INTERNAL TRAINING PROVIDED BY 
MEMBERS OF THIS BCZ AS WELL AS TRAINING PROVIDED BY 
PROVINCIAL/ GOVERNMENT OFFICIALS, USAID IHP 
PARTNERS OR OTHER NGOS WITH WHICH THIS OFFICE MAY 
BE AFFILIATED.
In the last calendar year (2018), did you attend a training 
session on health information management (e.g. DHIS2, 
SNIS, MAPEPI)?
YES
NO
If no,  22
20 If yes, who administered the training [select all that apply]? Internal/BCZ office
Province/Government
USAID/ IHP
Other (specify)
_____________________
21 What topics did this training cover [select all that apply]? Completeness calculations 
and reporting
Timeliness calculations and 
reporting
Exhaustivity calculations and 
reporting
Validation rules 
Abhorrent data
Baseline Report 303
Correcting data
Other (specify)
____________________
22 Does the BCZS have written guidelines for data 
entry/compilation and data quality review and control?
YES
NO
DON’T KNOW
23 In the last month, how many feedback reports on data 
quality and performance has this office sent to health 
facilities?
IF UNKNOWN, ENTER 999. 
|__|__|__|
 
If 0,  30
24 Can I see the reports? SELECT A REPORT AT RANDOM AND 
RECORD THE FOLLOWING OBSERVATIONS.
YES, OBSERVED
NO, NOT OBSERVED
If no,  30
Was any of the following feedback included in the report?
25 Accuracy of data YES
NO
DON’T KNOW
26 Completeness of data YES
NO
DON’T KNOW
27 Timeliness of data YES
NO
DON’T KNOW
28 Positive feedback YES
NO
DON’T KNOW
29 Any other feedback? YES
_______________________
__
(SPECIFY)
NO
DON’T KNOW
30 Since October 2018, how many feedback reports on data 
quality and performance has this office received from DPS?
IF UNKNOWN, ENTER 999.
|__|__|__| If 0,  37
31 Can I see the reports? SELECT A REPORT AT RANDOM AND 
RECORD THE FOLLOWING OBSERVATIONS.
YES, OBSERVED
NO, NOT OBSERVED
If no,  37
Was any of the following feedback included in the report?
32 Accuracy of data YES
304 The Impact of USAID’s Integrated Health Program in the DRC
NO
DON’T KNOW
33 Completeness of data YES
NO
DON’T KNOW
34 Timeliness of data YES
NO
DON’T KNOW
35 Positive feedback YES
NO
DON’T KNOW
36 Any other feedback? YES
_______________________
__
(SPECIFY)
NO
DON’T KNOW
37 Does this office have a map of the health zone and if so, 
what type of map is it?
YES, COMPUTER 
GENERATED
YES, HAND-DRAWN
NO MAP
DON’T KNOW
38 Does the office display a summary of demographic 
information for the health zone (i.e. population numbers for 
each health area)?
YES
NO
DON’T KNOW
39 Does the office display more specific demographic 
information (such as population by target groups)?
YES
NO
DON’T KNOW
What kinds of actions have been taken based on DHIS2 data? 
40 Review strategy by examining service performance target 
and actual performance from month to month
YES
NO
DON’T KNOW
41 Review facility personnel responsibilities by comparing 
service targets and actual performance from month to 
month
YES
NO
DON’T KNOW
42 Mobilization/shifting of resources based on comparison 
between services
YES
NO
Baseline Report 305
DON’T KNOW
43 Advocacy for more resources by showing gaps in ability to 
meet targets
YES
NO
DON’T KNOW
Now I would like to ask you some questions related to meetings and decisions based on the DHIS2 data. 
44 How frequently does this office have routine meetings 
where the DHIS2 or facility reported data is discussed? This 
could be a separate meeting or in the routine managerial or 
administrative meetings. 
MONTHLY OR MORE OFTEN
EVERY 2-3 MONTHS
EVERY 4-6 MONTHS
LESS THAN EVERY 6 
MONTHS OR IRREGULARLY
DON’T KNOW
 
45 Is an official record of management meetings maintained? YES
NO
DON’T KNOW
46 Have the DHIS2 or facility data been used to make 
decisions?
YES
NO
DON’T KNOW
47 Has any follow-up action taken place regarding the decisions 
made during the previous meetings?
YES
NO
DON’T KNOW
306 The Impact of USAID’s Integrated Health Program in the DRC
IHP EVALUATION
BUREAU CENTRAL DE LA ZONE DE SANTE (BCZS) SURVEY
IDENTIFY THE HIGHEST-RANKING PERSON. EXPLAIN THAT SOME QUESTIONS MAY HAVE BEEN ASKED IN EARLIER INTERVIEWS WITH 
USAID IHP REPRESENTATIVES AND THAT YOU APPRECIATE THEIR TIME AND PATIENCE.
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1 Record the province
2 Record the health zone
3 Enter your data collector ID number
4 Enter the facility ID number
5 Identify the highest-ranking person. Explain that some questions may have been asked in earlier interviews with 
USAID IHP representatives and that you appreciate their time and patience.
6
Have you read him/her the consent script? |_| No
|_| Yes
If no,  7
7 If no, why?
8
Did the respondent agree? |_| No
|_| Yes
If no,  9
9
If no, what was the reason? |_| No office members present 
at time of visit
|_| Office members absent for 
a long period of time
|_| Deferred
|_| Refused
|_| Office vacant or not an 
address
|_| Office destroyed
|_| Office not found
|_| Other (specify) _________
Go to 10 & 11 
and end survey
10 Take a photograph of the front of the facility
11 Record the GPS coordinates of the health zone office
Baseline Report 307
SECTION 2. BASIC INFORMATION
First, I would like to ask you some general questions about you. 
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
12 Record the sex of the participant MALE
FEMALE
01
02
13 Are you the head of this health zone 
office?
 ☐ Yes ☐ No 
14 What is your position in this office? HEALTH ZONE CHIEF MEDICAL OFFICER
MEDICAL DIRECTOR OF HGR
DIRECTOR OF NURSING
HEALTH ZONE ADMINISTRATOR/MANAGER
HEALTH ZONE NURSE SUPERVISOR OF PRIMARY 
HEALTH CARE 
PHARMACIST
SANITATION TECHNICIAN
COMMUNITY HEALTH ANIMATOR
NUTRITIONIST
OTHER__________________
OTHER__________________
OTHER__________________
01
02
03
04
05
06
07
08
09
10
11
12
13
15 What is the highest level of education 
you have received?
NO SCHOOLING
PRIMARY
SECONDARY
UNIVERSITY
01
02
03
04
If University, 
16
16 Do you have a master’s degree? ☐ Yes ☐ No If Yes,  17
17 In what subject is your master’s 
degree(s)? (check all that apply)
PUBLIC HEALTH
PUBLIC ADMINISTRATION
BUSINESS ADMINISTRATION
OTHER__________________
01
02
03
04
18 How many years have you worked in 
this office (in any capacity)?
Less than 1 year
1
2
3
4
5
6
7
8
9
10+
DON’T KNOW
00
01
02
03
04
05
06
07
08
09
10
-98
If don’t know, 
 20
19 For how many years have you held 
the position of {q14} in this office?
Less than 1 year
1
2
00
01
02
308 The Impact of USAID’s Integrated Health Program in the DRC
3
4
5
6
7
8
9
10+
DON’T KNOW
03
04
05
06
07
08
09
10
-98
20 For how many years in total have you 
worked as a ${q11a}, whether at this 
office or another BCZ?
Less than 1 year
1
2
3
4
5
6
7
8
9
10+
DON’T KNOW
00
01
02
03
04
05
06
07
08
09
10
-98
TRAINING
The next set of questions is about the training participation and includes internal training provided by members of this BCZ 
as well as training provided by provincial/government officials, USAID/IHP partners or other NGOs with which this office 
may be affiliated.
In the last calendar year (2018), have you or anyone in this office attended training on any of the following subjects as part 
of your position in the health zone office?
21 Prenatal consultations? ☐ Yes ☐ No If no,  24
22 Did you attend this training? ☐ Yes ☐ No If no,  24
23
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
24 Integrated Management of Childhood Illness? ☐ Yes ☐ No If no,  27
25 Did you attend this training? ☐ Yes ☐ No If no,  27
26
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
27 Malaria (children under 5)? ☐ Yes ☐ No If no,  30
Baseline Report 309
28 Did you attend this training? ☐ Yes ☐ No If no,  30
29
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
30 Long-lasting insecticidal net (LLIN) 
distribution? ☐ Yes ☐ No If no,  33
31 Did you attend this training? ☐ Yes ☐ No If no,  33
32
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
33 Family planning? ☐ Yes ☐ No If no,  36
34 Did you attend this training? ☐ Yes ☐ No If no,  36
35
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
36 Reach Every District (zone) training? ☐ Yes ☐ No If no,  39
37 Did you attend this training? ☐ Yes ☐ No If no,  39
38
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
39 Vaccine Safety Training? ☐ Yes ☐ No If no,  42
40 Did you attend this training? ☐ Yes ☐ No If no,  42
41
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
42 Administrative and human resource 
management? ☐ Yes ☐ No If no,  45
43 Did you attend this training? ☐ Yes ☐ No If no,  45
44
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
45 Financial management? ☐ Yes ☐ No If no,  48
46 Did you attend this training? ☐ Yes ☐ No If no,  48
310 The Impact of USAID’s Integrated Health Program in the DRC
47
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
48 Management ethics and patient 
confidentiality? ☐ Yes ☐ No If no,  51
49 Did you attend this training? ☐ Yes ☐ No If no,  51
50
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
51 Training of health care providers? ☐ Yes ☐ No If no,  54
52 Did you attend this training? ☐ Yes ☐ No If no,  54
53
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
54 Capacity-building of CODESAs? ☐ Yes ☐ No If no,  57
55 Did you attend this training? ☐ Yes ☐ No If no,  57
56
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
57 Health information management (e.g. DHIS2, 
SNIS, MAPEPI)? ☐ Yes ☐ No If no,  61
58 Did you attend this training? ☐ Yes ☐ No If no,  61
59
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
60
What topics did this health information management training cover?
☐ Completeness calculations and reporting ☐ Timeliness calculations and reporting
☐ Exhaustivity calculations and reporting ☐ Validations rules ☐ Aberrant data
☐ Correcting data ☐ Other (specify)____________________ 
61 Community scorecard processes? ☐ Yes ☐ No If no,  64
62 Did you attend this training? ☐ Yes ☐ No If no,  64
63
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
Baseline Report 311
64 Material resource management (medicines, 
supplies, equipment)? ☐ Yes ☐ No If no,  67
65 Did you attend this training? ☐ Yes ☐ No If no,  67
66
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
67 Gender issues and/or the gender 
transformative approach? ☐ Yes ☐ No If no,  70
68 Did you attend this training? ☐ Yes ☐ No If no,  70
69
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
70 Supportive supervision? ☐ Yes ☐ No If no,  73
71 Did you attend this training? ☐ Yes ☐ No If no,  73
72
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
73 Team management? ☐ Yes ☐ No If no,  76
74 Did you attend this training? ☐ Yes ☐ No If no,  76
75
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
76 Planning, monitoring and evaluation? ☐ Yes ☐ No If no,  79
77 Did you attend this training? ☐ Yes ☐ No If no,  79
78
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
79 Disease prevention, health promotion and re￾adaptation care? ☐ Yes ☐ No If no,  82
80 Did you attend this training? ☐ Yes ☐ No If no,  82
81
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
312 The Impact of USAID’s Integrated Health Program in the DRC
82 Management of outbreaks, emergencies and 
disasters? ☐ Yes ☐ No If no,  85
83 Did you attend this training? ☐ Yes ☐ No If no,  85
84
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
85 Health research? ☐ Yes ☐ No If no,  88
86 Did you attend this training? ☐ Yes ☐ No If no,  88
87
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
88 Data analysis? ☐ Yes ☐ No If no,  91
89 Did you attend this training? ☐ Yes ☐ No If no,  91
90
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
91 Use of data for evidence-based decision￾making? ☐ Yes ☐ No If no,  94
92 Did you attend this training? ☐ Yes ☐ No If no,  94
93
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Province/Government ☐ USAID/IHP ☐ Other: ___ ☐ Other: __ 
☐ Other: __
iHuman Resources Information System (iHRIS) Training
94 Did you or anyone else in this office 
participate in a training on Human Resources 
Management using the iHuman Resources 
Information System (iHRIS)?
☐ Yes
☐ No
☐ Don’t know
If no,  101
95 How long ago was that training? ☐ 0-3 months ago
☐ 4-6 months ago
☐ 7-12 months ago 
☐ More than 1 year ago
96 Sometimes participants cannot attend the 
entire training workshop. How much of that 
workshop did you attend?
☐ Less than half 
☐ About half of it
☐ All or most of it
If N/A,  101
Baseline Report 313
SECTION 3. BASIC INFRASTRUCTURE 
Now I would like to ask you some questions related to the basic infrastructure of this office. If the answer to the question is yes, 
please show me the room/equipment, and where applicable, verify the functionality.
NO Questions and filters YES SKIP
101
RECORD OBSERVATION OF THE MAIN MATERIAL OF THE FLOOR NATURAL FLOOR
EARTH/SAND
DUNG
RUDIMENTARY FLOOR
WOOD PLANKS
PALM/BAMBOO
FINISHED FLOOR
PARQUET OR POLISHED 
WOOD
VINYL OR ASPHALT STRIPS
11
12
21
22
31
32
☐ Not applicable
97 It can be difficult to remember all of the 
material presented during training. How much 
do you remember of what you learned in the 
training on Human Resources Management 
using the iHRIS?
☐ Less than half 
☐ About half of it
☐ All or most of it
☐ Not applicable
98 How often do you use the material presented 
during that workshop in your day to day work?
☐ Never 
☐ Rarely 
☐ Sometimes
☐ Often 
☐ Always
☐ Not applicable
99 What language was the training conducted in? ☐ Swahili 
☐ French 
☐ Lingala 
☐ Tshiluba
☐ English
☐ Other
_________________________
100 Did anyone attending the training report that 
the language of the training created
challenges with understanding the material?
☐ Yes
☐ No
314 The Impact of USAID’s Integrated Health Program in the DRC
CERAMIC TILES
CEMENT
CARPET
OTHER
________________________
(SPECIFY)
33
34
35
96
102
RECORD OBSERVATION OF THE MAIN MATERIAL OF THE ROOF NATURAL ROOFLING
NO ROOF
THATCH/PALM LEAF
SOD
RUDIMENTARY ROOFING
MAT
PALM/BAMBOO
WOOD PLANKS
CARDBOARD
FINISHED ROOFING
METAL
WOOD
CALAMINE/CEMENT FIBRE
CERAMIC TILES
CEMENT
OTHER
________________________
(SPECIFY)
11
12
13
21
22
23
24
31
32
33
34
35
96
103
RECORD OBSERVATION OF THE MAIN MATERIAL OF THE 
EXTERIOR WALLS
NATURAL WALLS
NO WALLS
BAMBOO/CANE/PALM/ 
TRUNK
DIRT
RUDIMENTARY WALLS
BAMBOO WITH MUD
STONE WITH MUD
UNCOVERED ADOBE
PLYWOOD
CARDBOARD
REUSED WOOD
FINISHED WALLS
CEMENT
STONE WITH LIME/CEMENT
BRICKS
CEMENT BLOCKS
COVERED ADOBE
WOOD PLANKS
11
12
13
21
22
23
24
25
26
31
32
33
34
35
36
Baseline Report 315
OTHER
________________________
(SPECIFY)
96
104 Does this office have cell phone reception? RECORD OBSERVATION
☐ Yes
☐ No
If no,  107
105 How would you rate the ease of connectivity to the nearest health 
centre?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
VERY DIFFICULT
01
02
03
04
106 How would you rate the ease of connectivity to the furthest health 
centre?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
VERY DIFFICULT
01
02
03
04
107 Does this office have electricity? RECORD OBSERVATION
☐ Yes
☐ No
If no,  113
108 What is the main source of electricity?
MAIN POWER
SOLAR POWER
GENERATOR
OTHER (SPECIFY)
01
02
03
96
109
On a typical 8-hour work day, how many hours is electricity 
available at this office? [Provide drop-down list with options ‘0’ 
through ‘8’]
|__|__|__|
110 Is electricity functioning now? (CHECK TO SEE IF ELECTRICITY CAN 
BE TURNED ON.) RECORD OBSERVATION
☐ Yes
☐ No
111 Are there power cuts (excluding electricity supplied by a generator 
backup) during the hours when the facility is open?
☐ Yes
☐ No
If no,  113
112 What is the average duration of power cuts?
|__|__|__| Minutes
|__|__|__| Hours
|__|__|__| Days
113
Does this office have a generator for electricity?
This may be a back-up or stand-by generator. RECORD 
OBSERVATION
☐ Yes
☐ No
If no,  115
114 Is the generator functional and is there fuel today? RECORD 
OBSERVATION
☐ Yes
☐ No
In the last month, how often have power cuts interfered with:
115 Cold chain maintenance?
☐ ALWAYS
☐ OFTEN
☐ SOMETIMES
☐ RARELY
☐ NEVER
Reference 111 
and ask if yes; 
otherwise, 
120
316 The Impact of USAID’s Integrated Health Program in the DRC
116 DHIS2 reporting?
☐ ALWAYS
☐ OFTEN
☐ SOMETIMES
☐ RARELY
☐ NEVER
117 Other: ______________________
☐ ALWAYS
☐ OFTEN
☐ SOMETIMES
☐ RARELY
☐ NEVER
118 Other: ______________________
☐ ALWAYS
☐ OFTEN
☐ SOMETIMES
☐ RARELY
☐ NEVER
119 Other: ______________________
☐ ALWAYS
☐ OFTEN
☐ SOMETIMES
☐ RARELY
☐ NEVER
120 Is there a functional solar panel? RECORD OBSERVATION
☐ Yes
☐ No
If no,  122
121 Is there a functional battery for solar panel? RECORD 
OBSERVATION
☐ Yes
☐ No
122 Does this office have a radio? RECORD OBSERVATION
☐ Yes
☐ No
123 Does this office have a calculator? RECORD OBSERVATION
☐ Yes
☐ No
124
How many functional computers are there at the office and of 
which type? RECORD OBSERVATION
IF THE RESPONDENT DOESN’T KNOW THE NUMBER FOR A TYPE 
OF COMPUTER, WRITE “99” IN THE BOX.
BCZ OWNED (NOT PERSONAL) 
DESKTOP |__|__|
BCZ OWNED (NOT PERSONAL) 
LAPTOP |__|__|
PERSONAL LAPTOP |__|__|
125
How many functional printers are there at the office? RECORD 
OBSERVATION |__|__|
126 In general, does this office have access to the internet? 
☐ Yes
☐ No
127 Do you have the following sources of internet? Check all that apply
128 Modem using commercial telephone network (VODACOM, AIRTEL, 
etc.)
☐ Yes
☐ No
If yes,  129
Baseline Report 317
129 Is it functioning? RECORD OBSERVATION
☐ Yes
☐ No
130 V-Sat antenna?
☐ Yes
☐ No
If yes,  131
131 Is it functioning? RECORD OBSERVATION
☐ Yes
☐ No
132 Personal mobile/wifi hotspot? ☐ Yes
☐ No
If yes,  133
133 Is it functioning? RECORD OBSERVATION
☐ Yes
☐ No
134 Other source of internet? SPECIFY__________________
☐ Yes
☐ No
135 Was internet connectivity provided by USAID/IHP?
☐ Yes
☐ No
136 How common is it for people at this office to rely on their own 
personal mobile hotspot?
☐ ALWAYS
☐ OFTEN
☐ SOMETIMES
☐ RARELY
☐ NEVER
137
In a typical 8-hour work day, how many hours does the internet at 
the office work, not including personal mobile hotspots? [Provide 
drop-down list with options ‘0’ through ‘8’]
|__|__|
138
Can you log into the DHIS2 system for me so that I can see whether 
it is working?
Check all that apply.
☐ YES, OBSERVED
☐ NO, NO WORKING 
COMPUTER
☐ NO, NO ELECTRICITY
☐ NO, NO INTERNET
☐ NO, SLOW INTERNET
☐ NO, FORGOT USERNAME
☐ NO, FORGOT PASSWORD
☐ NO, REFUSED
☐ NO, OTHER REASON:
________________________
(SPECIFY)
318 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 4. GENERAL STAFFING
Now I have some questions about staffing for this BCZ. 
Please tell me how many people currently work in the following positions as members of this health zone management team and 
whether they are male or female. Please include all persons who work in this BCZ, whether in a full-time, part-time or volunteer 
capacity. 
USE THIS INFORMATION TO COMPLETE COLUMNS a, b AND c. IF THE INFORMATION IS UNKNOWN, MARK COLUMN d AND LEAVE 
COLUMNS a, b AND c BLANK.
ASK TO SEE THE STAFF ROSTER. FOR EACH QUALIFICATION, RECORD THE NUMBER OF PEOPLE WHO ARE ACTUALLY PRESENT THE 
DAY OF THE INTERVIEW. USE THIS INFORMATION TO COMPLETE COLUMN e.
139 Does this BCZ currently employ a Health Zone Chief 
Medical Officer? ☐ Yes ☐ No ☐ Don’t know If yes, 
140
140 Is the MCZ male or female? ☐ Male ☐ Female
141 Does this health zone currently employ a Medical 
Director of the HGR? ☐ Yes ☐ No ☐ Don’t know If yes, 
142
142 Is the physician director male or female? ☐ Male ☐ Female
143 Does this health zone currently employ a Director of 
Nursing? ☐ Yes ☐ No ☐ Don’t know If yes, 
144
144 Is the Director of Nursing male or female? ☐ Male ☐ Female
145 Does this health zone currently employ a Health Zone 
Administrator/Manager? ☐ Yes ☐ No ☐ Don’t know If yes, 
146
146 Health Zone Administrator/Manager No. staff
|__|__|__|
No. female
|__|__|__|
No. male
|__|__|__|
147 Does this health zone currently employ a Health zone 
Nurse Supervisor of Primary Health Care ☐ Yes ☐ No ☐ Don’t know If yes, 
148
148 Health zone Nurse Supervisor of Primary Health Care No. staff
|__|__|__|
No. female
|__|__|__|
No. male
|__|__|__|
149 Does this health zone currently employ a Pharmacist ☐ Yes ☐ No ☐ Don’t know If yes, 
150
150 Pharmacist No. staff
|__|__|__|
No. female
|__|__|__|
No. male
|__|__|__|
151 Does this health zone currently employ a Sanitation 
Technician ☐ Yes ☐ No ☐ Don’t know If yes, 
152
152 Sanitation Technician No. staff
|__|__|__|
No. female
|__|__|__|
No. male
|__|__|__|
153 Does this health zone currently employ a Community 
Health Animator ☐ Yes ☐ No ☐ Don’t know If yes, 
154
154 Community Health Animator No. staff
|__|__|__|
No. female
|__|__|__|
No. male
|__|__|__|
155 Does this health zone currently employ a Nutritionist ☐ Yes ☐ No ☐ Don’t know If yes, 
156
156 Nutritionist No. staff
|__|__|__|
No. female
|__|__|__|
No. male
|__|__|__|
157
Does this office have a designated person to 
enter/compile DHIS2 data reports from health 
facilities?
☐ Yes ☐ No ☐ Don’t know
158 Does the district have a designated person to review 
and control the quality of data entry/compilation? ☐ Yes ☐ No ☐ Don’t know
Baseline Report 319
SECTION 6. SOURCES AND USES OF FUNDING
Now I would like to ask you some questions about sources and uses of funding for this BCZ office.
No. QUESTION RESPONSE
SKIP/ 
INSTRUCTIONS
What is the total amount of operational funds (i.e. 
funds not passed on to another organization) 
received from the following sources in the last 
calendar year (2018)?:
159 Ministry of health/Provincial health office/Health 
zone office |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
160 USAID/IHP |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
161
Other NGO’s or FBO’s: Cordaid, Memisa, 
Foundation Damien, save the Children, Rescue, IRC, 
Caritas, Sanru, Chemonics, MCSP
|__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
162 User fees |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
163 Community financing (e.g. mutuelles) |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
164 Other health insurance program? |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
165 Any other sources of funding? ☐ Yes ☐ No 
166 Other 1 (specify) ____________________________ |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
167 Other 2 (specify) ____________________________ |__ __ __ __ __ __ __ __ __ __| ☐ FC ☐ USD 
What percentage of operational funds was spent 
on the following during the last calendar year 
(2018)?
168 Savings |__ __ __| % 
169 Building/grounds improvements |__ __ __| % 
170 Equipment (vehicles, computers, etc.) |__ __ __| % 
171 Utilities and communication (electricity, water, 
phone credit, internet, etc.) |__ __ __| % 
172 Medical supplies |__ __ __| % 
173 Drugs |__ __ __| % 
174 Transport |__ __ __| % 
175 Salaries and primes |__ __ __| % 
176 Training |__ __ __| % 
177 Any others? ☐ Yes ☐ No 
320 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 7. USER FEES
Now I would like to ask you a few questions about user fees in this health zone’s health centers and hospitals.
NO QUESTION RESPONSE SKIP/INSTRUCTIONS
180 Does this office have guidelines that facilities 
should follow on the user fees that should be 
charged to patients?
IF YES, ASK TO SEE THE GUIDELINES AND TAKE A 
PICTURE
YES, GUIDELINES OBSERVED 
YES, NOT OBSERVED 
NO GUIDELINES RECEIVED
01
02
00
181 To the best of your knowledge, where do the 
user fee guidelines come from?
National MoH
DPS
BCZ/MCZ alone
MCZ with mayor and community
Integrated Health project
Other (specify)
Don't know
01
02
03
04
05
96
99
182 Are health facilities supposed to post the fee 
schedule where patients can see it? 
YES
NO
DON’T KNOW
01
02
98
183 Are all designated health facilities in this health 
zone supposed to charge the same user fee for 
the same service?
YES
NO
DON’T KNOW
01
00
99
184 Does the health zone provide a different fee 
schedule for patients who are considered 
indigent? 
YES
NO
DON’T KNOW
01
00
99
185 Does this office have guidelines on the 
EXEMPTION OF payment for indigent patients?
IF YES, ASK TO SEE THE GUIDELINES
YES, GUIDELINES OBSERVED 
YES, NOT OBSERVED 
NO GUIDELINES RECEIVED
01
02
00
186 To the best of your knowledge, where do the 
exemption guidelines come from?
National MoH
DPS
BCZ/MCZ alone
MCZ with mayor and community
Integrated Health project
Other (specify)
Don't know
01
02
03
04
05
96
99
187 Who are considered indigent? Meaning, what 
are the criteria for the user fee exemption?
CIRCLE ALL THAT ARE MENTIONED
ELDERLY 01 Reference 184 and 
ask if yes.
ORPHANED 02
WIDOW WITHOUT A SOURCE OF 
INCOME
03
PHYSICALLY HANDICAPED WITHOUT 
A SOURCE OF INCOME
04
178 Other 1 (specify) ____________________________ |__ __ __| % 
179 Other 2 (specify) ____________________________ |__ __ __| % 
Baseline Report 321
REFUGEE/INTERNALLY DISPLACED 
PERSON NOT YET INTEGRATED INTO 
THE COMMUNITY
05
OTHER _____________________ 96
DON’T KNOW 99
188 Are health facilities supposed to have lists of 
people who are considered indigent?
YES
NO
DON’T KNOW
01
02
99
Reference 184 and 
ask if yes.
If 188 is no,  192
189 Who is supposed to participate in the process of 
identifying the individuals on this list?
CIRCLE ALL THAT ARE MENTIONED
The respondent
Health centre staff
CODESA members
Other community leaders
Other BCZ staff
DPS staff
Dirigeants
National MoH
Other ____________________
Don't know
01
02
03
04
05
06
07
08
-96
-98
190 Are CODESAs supposed to approve these lists? YES
NO
DON’T KNOW
01
02
99
191 How often are these lists supposed to be
updated?
DO NOT READ ANSWERS BUT CHECK THE ONE 
CLOSEST TO THE RESPONSE GIVEN
Every 1-5 months
Every 6 months
Every 7-11 months
Once a year or less
Never
Other _____________________
Don't know
01
02
03
04
05
-96
-98
192 Do health facilities in this health zone always 
require payment before providing labour and 
delivery services?
YES
NO
DON’T KNOW
01
02
98
193 Do health facilities in this health zone always 
require payment before treatment of emergency 
cases?
YES
NO
DON’T KNOW
01
02
98
194 Generally speaking, how do health facilities 
handle cases in which a patient cannot pay for 
services? CHECK ALL THAT APPLY.
No services are given
The patient can pay in-kind
The patient can give a 
guarantee
The patient is treated for 
free/reduced cost
the patient is not discharged 
until they can pay
The patient is refused services 
in the future
Nothing, no recourse
Other (specify)
Don't know
00
01
02
03
04
05
06
-96
-98
322 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 8. COMMUNITY FUNDING INITIATIVES
NO QUESTION RESPONSE SKIP/
INSTRUCTIONS
195 Are there any mutuelles operating in this health zone? YES…………………………………….
NO……………………………………..
DON’T KNOW…………………….
01
00
99
If no,  201
196 How many mutuelles are operating in this health zone?
|____|____|____|
197 Does this office keep a list of all mutuelles? YES…………………………………….
NO……………………………………..
DON’T KNOW…………………….
01
00
99
198 Does this office keep a list of the members of ALL mutuelles? YES…………………………………….
NO……………………………………..
DON’T KNOW…………………….
01
00
99
199 Do health areas in your health zone participate in these 
mutuelles?
YES
NO
DON’T KNOW
01
00
99
If no,  201
200 How many health areas in this health zone participate in these
mutuelles?
A SMALL NUMBER OF 
HEALTH AREAS 
PARTICIPATE.
HALF OF ALL HEATH AREAS 
PARTICIPATE
ALMOST ALL HEALTH AREAS 
PARTICIPATE
ALL HEALTH AREAS 
PARTICIPATE
01
02
03
04
201 Do health facilities require permission from the BCZ in order to 
offer fee reductions to members of the mutuelles?
YES
NO
DON’T KNOW
01
00
99
If no,  204
202 How many of the health facilities in this health zone have been 
given permission to offer fee reductions to members of
mutuelles?
ALL HEALTH FACILITIES
SOME HEALTH FACILITIES
NO HEALTH FACILITIES
DON’T KNOW
01
02
03
99
203 What services are covered by this fee reduction?
CIRCLE ALL THAT ARE MENTIONED. 
GENERAL OUTPATIENT 01
IMMUNIZATION FOR 
CHILDREN 02
ANTENATAL CARE 03
NORMAL DELIVERIES 04
DELIVERIES BY CAESAREAN 
SECTION 05
POSTNATAL CARE 06
FAMILY PLANNING 
COUNSELING 07
TUBERCULOSIS TREATMENT 08
Baseline Report 323
STIs TREATMENT 09
COMMUNITY AND 
OUTREACH SERVICES 10
GENERAL INPATIENT 
MEDICAL SERVICES 11
GENERAL INPATIENT 
SURGICAL SERVICES
ALL SERVICES
OTHER 
_________________
(SPECIFY)
DON’T KNOW
12
13
96
99
IMMUNIZATION FOR 
CHILDREN 02
ANTENATAL CARE 03
NORMAL DELIVERIES 04
DELIVERIES BY CAESAREAN 
SECTION 05
POSTNATAL CARE 06
FAMILY PLANNING 
COUNSELING 07
TUBERCULOSIS TREATMENT 08
STIs TREATMENT 09
COMMUNITY AND 
OUTREACH SERVICES 10
GENERAL INPATIENT 
MEDICAL SERVICES 11
GENERAL INPATIENT 
SURGICAL SERVICES
ALL SERVICES
OTHER ________________
(SPECIFY)
DON’T KNOW
12
13
96
99
204 Do you or someone from the BCZS conduct supervision visits 
specifically for health areas participating in the mutelles?
YES
NO
DON’T KNOW
01
00
99
Reference 195 and 
ask if yes.
If 204 is no,  207
205 How often are supervision visits supposed to be made per site? MONTHLY OR MORE OFTEN
EVERY 2-3 MONTHS
EVERY 4-6 MONTHS
LESS THAN EVERY 6 
MONTHS OR IRREGULARLY
DON’T KNOW
01
02
03
04
99
324 The Impact of USAID’s Integrated Health Program in the DRC
206 On average, how many visits were made in the last 6 months for 
each site?
IF UNKNOWN, ENTER 99. |__|__|
SECTION 9. SUPPORT FROM USAID/IHP
NO QUESTION RESPONSE SKIP/
INSTRUCTIONS
Capacity building
207 Has this office ever completed a 
Participatory Institutional Capacity 
Assessment and Learning (PICAL) 
assessment, facilitated by someone 
from USAID, IHP or Abt Associates?
[ ] Yes
[ ] No (SKIP TO xxx)
[ ] Don’t know
If no,  212
208 For the last PICAL assessment, which 
members of the health zone 
management team participated?
Check all that apply
HEALTH ZONE CHIEF MEDICAL 
OFFICER
MEDICAL DIRECTOR OF HGR
DIRECTOR OF NURSING
HEALTH ZONE 
ADMINISTRATOR/MANAGER
HEALTH ZONE NURSE SUPERVISOR 
OF PRIMARY HEALTH CARE 
PHARMACIST
SANITATION TECHNICIAN
COMMUNITY HEALTH ANIMATOR
NUTRITIONIST
209 How long ago was most recent PICAL 
assessment?
[ ] 0-3 months ago
[ ] 4-6 months ago 
[ ] 7-12 months ago 
[ ] More than 1 year ago
[ ] Don’t know
If don’t know,  211
210 Did the office receive its “PICAL score” 
as a result of that assessment?
[ ] Yes
[ ] No (SKIP TO xxx)
[ ] Don’t know
If yes,  211
211 What was the score? ____________________________
Baseline Report 325
SECTION 10: MANAGEMENT AND SUPERVISION 
LEADERSHIP
In this part of the questionnaire, I would like to know what you would do in certain situations regarding the health zone office. I will 
read you a series of scenarios. For each scenario, I will read 4 possible responses that you might have. Please select the response that 
most closely matches what you would do in this specific situation. You can only select one response for each scenario. There are no 
correct or incorrect answers - we just want to know how you would approach each situation.
INTERVIEWER: EACH RESPONSE IS CODED BETWEEN 1 AND 4. RECORD APPROPRIATE CODE ACCORDING TO RESPONDENT'S 
RESPONSE.
NO SCENARIOS 1 2 3 4 RECORD RESPONSE 
(RANGE 1-4)
212 Scenario 1: The 
performance of 
your staff is 
improving. 
You stress their 
responsibilities 
and standards.
You take no 
particular 
additional action.
You give positive 
feedback and 
make staff feel 
involved in the 
achievements.
You emphasize 
the importance of 
deadlines and 
tasks.
213 Scenario 2: 
Members of your 
staff have been 
unable to solve a 
problem over the 
past month, 
though they have 
been trying to 
address it.
You call a meeting 
and together try 
to solve the 
problem.
You let your staff 
address this 
problem on their 
own.
You give them 
direction and 
instructions on 
how to solve the 
problem.
You encourage 
the group to solve 
the problem on 
their own, and 
you are available 
when needed to 
discuss.
214 Scenario 3: You 
are considering a 
major change in 
how things are 
done in the 
office.
You collaborate 
with your staff to 
develop the 
needed changes. 
You announce 
your vision for the 
changes and 
implement a clear 
plan. 
You ask your staff 
to develop and 
implement their 
own plan for 
change.
You consult with 
your staff, but 
direct the 
changes yourself.
215
Scenario 4: The 
performance of 
your staff has 
been falling in 
recent months.
You ask your staff 
to rethink their 
direction and 
goals and come 
up with a plan 
together.
You ask for 
suggestions from 
your staff on 
what to do, and 
you formulate a 
specific plan to 
meet objectives.
You redefine 
goals clearly and 
supervise 
whether these 
are being met 
closely.
You allow your 
staff freedom to 
set their own 
goals and do not 
push them.
216
Scenario 5: Your 
staff are no 
longer working 
together as an 
effective team.
You discuss ideas 
as a group and 
identify how to 
work better 
together.
You let your staff 
work out their 
issues on their 
own.
You act quickly 
and decisively to 
get the team back 
on track.
You make 
yourself available 
to discuss any 
issues and 
support your 
team to work out 
their own 
problems.
AUTONOMY
In this part of the questionnaire I would like to ask you some questions regarding how work is organized and how decisions are made 
in this health zone office. All answers are confidential.
326 The Impact of USAID’s Integrated Health Program in the DRC
I am now going to read you a series of statements about decision-making and authority in this facility. Please tell me whether you 
agree, are neutral, or disagree.
RESPONSE CODE 
RECORD 
RESPONSE 
AGREE 1
NEUTRAL 2
DISAGREE 3
NOT APPLICABLE (N/A) 4
217 I am able to allocate my HZ budget according to how it is needed. There is enough flexibility in my 
budget.
218 I am able to assign tasks and activities to staff as needed to achieve the outcomes I want in the HZ office. 
There is enough flexibility to use staff to address needs.
219 The District Health Management Team supports my decisions and actions for doing a better job in my 
office.
220 I have choice over who I allocate for what tasks.
221 I have choice over what services are provided in the facilities within this HZ.
222 I have enough authority to obtain the resources I need (drugs, supplies, funding) to meet the needs of 
my facilities within this HZ.
223 The policies and procedures for doing things are clear to me.
224 The policies and procedures for doing things are useful tools for the challenges I face in providing 
services and reporting on activities.
225 The District Health Management Team provides adequate feedback to me about my job and the 
performance of my facility.
INTERNAL MANAGEMENT
NO QUESTION RESPONSE SKIP/ 
INSTRUCTIONS
226 Does this office have routine meetings 
for reviewing managerial or 
administrative matters? 
YES
NO
DON’T KNOW
01
02
99
If no,  241
227 In 2018, how often did meetings to 
discuss the managerial and 
administrative matters take place?
MONTHLY OR MORE OFTEN
QUARTERLY
TWICE A YEAR
ANNUALLY 
IRREGULARLY
NEVER
DON’T KNOW
01
02
03
04
05
06
99
228 Are meeting minutes available? YES
NO
DON’T KNOW
01
00
99
If no,  240
229 Can I see the meeting minutes from 
2018 until now?
OBSERVED
NOT OBSERVED
01
00
If no,  240
230 RECORD THE NUMBER OF MEETINGS 
THAT HAVE BEEN HELD SINCE 
OCTOBER 2018.
|__|__|__|
Which members of the BCZ attend these meetings and how often? Who attends the routine meetings?
Baseline Report 327
231 Health Zone Chief Medical officer 75-100%
50-74%
25-49%
1-24%
01
02
03
04
232 Medical Director of the HGR 75-100%
50-74%
25-49%
1-24%
01
02
03
04
233 Director of Nursing 75-100%
50-74%
25-49%
1-24%
01
02
03
04
234 Health zone Administrator/Manager 75-100%
50-74%
25-49%
1-24%
01
02
03
04
235 Health zone Nurse Supervisor of Primary 
Health Care
75-100%
50-74%
25-49%
1-24%
01
02
03
04
236 Pharmacist 75-100%
50-74%
25-49%
1-24%
01
02
03
04
237 Sanitation Technician 75-100%
50-74%
25-49%
1-24%
01
02
03
04
238 Community Health Animator 75-100%
50-74%
25-49%
1-24%
01
02
03
04
239 Nutritionist 75-100%
50-74%
25-49%
1-24%
01
02
03
04
240 What types of decisions are made in 
these meetings?
SEVERAL ANSWERS POSSIBLE. DO NOT 
READ THE ANSWERS BUT CHECK ALL 
MENTIONED
SCHEDULING OF ACTIVITES IN THE HZ.
ALLOCATING FINANCIAL RESOURCES.
ALLOCATING TECHNICAL RESOURCES
DEFINING PROGRAMMATIC PRIORITIES
COORDINATING STRATEGIES WITH DONORS
HUMAN RESOURCES MANAGEMENT
CONFLICT RESOLUTION
01
02
03
04
05
06
07
241 Do you or does someone from this 
office make supervision visits to health 
facilities?
YES
NO
DON’T KNOW
01
00
99
If no,  224
242 Are supervision reports available? YES
NO
DON’T KNOW
01
00
99
If no,  224
243 Can I see the most recent report? OBSERVED
NOT OBSERVED
01
00
328 The Impact of USAID’s Integrated Health Program in the DRC
EXTERNAL SUPERVISION
LEVEL FROM WHICH 
THE SUPERVISOR 
CAME
In 2018, how 
many times did 
the supervisor 
from [LEVEL] 
visit this office 
for the purpose 
of management 
or supervision 
of routine and 
non-routine 
activities?
Do you know 
the date 
(month and 
year) of the 
most recent 
visit by a 
supervisor from 
the [LEVEL]?
When did a 
supervisor from 
the [LEVEL] last 
visit?
What topic was 
discussed at the last 
visit?
CHECK ALL THAT APPLY
After the last visit, did 
the supervisor send 
you a report based on 
his/her findings?
a. b. c. d. e.
244 Provincial 
Office
0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Don't know
YES
NO (skip to d)
DON’T KNOW
MONTH _______
YEAR _______
DON’T KNOW
QUALITY OF CARE …..01
MANAGEMENT ……...02
RECORD KEEPING …..03
DATA REPORTING …..04
DATA USE ……………....05
N/A………………………….96
DON’T KNOW………….98
YES
NO
DON’T KNOW
245 National-/ 
Central-level 
authorities
0
1
2
3
4
5
6
7
8
9
10
11
12 or more
Don't know
YES
NO (skip to d)
DON’T KNOW
MONTH _______
YEAR _______
DON’T KNOW
QUALITY OF CARE …..01
MANAGEMENT ……...02
RECORD KEEPING …..03
DATA REPORTING …..04
DATA USE ……………....05
N/A………………………….96
DON’T KNOW………….98
YES
NO
DON’T KNOW
246 IHP officials 0
1
2
3
4
5
6
7
8
9
YES
NO (skip to d)
DON’T KNOW
MONTH _______
YEAR _______
DON’T KNOW
QUALITY OF CARE …..01
MANAGEMENT ……...02
RECORD KEEPING …..03
DATA REPORTING …..04
DATA USE ……………....05
N/A………………………….96
DON’T KNOW………….98
YES
NO
DON’T KNOW
Baseline Report 329
SECTION 11. STAKEHOLDER COORDINATION & COLLABORATION
The next questions are about different kinds of interactions your BCZ may have with other health zone offices.
NO QUESTION RESPONSE SKIP/ INSTRUCTIONS
Community Engagement
247 Are there any CODESAs functioning in this area? YES
NO
DON’T KNOW
01
00
99 If no,  250
248 How many CODESAs are functioning in this area?
If unknown, enter 999.
|__|__|__|
249 How many CODESAs submitted a report to this office 
within the last 30 days?
If unknown, enter 999.
|__|__|__|
250 Are you aware of a program called the community 
scorecard?
YES
NO
01
00
If no,  254
251 Have facilities/health areas in your health zone
participated in a community scorecard meeting?
YES
NO
DON’T KNOW
01
00
99
If no,  253
252 How many health areas in this health zones 
participate in the community scorecard processes?
A SMALL NUMBER OF 
HEALTH AREAS PARTICIPATE
HALF OF ALL HEATH AREAS 
PARTICIPATE
ALMOST ALL HEALTH AREAS 
PARTICIPATE
ALL HEALTH AREAS 
PARTICIPATE
01
02
03
04
253 Have you received a report about the community 
scorecard activity from at least one health area in 
your health zone?
YES
NO
DON’T KNOW
01
02
99
Communication
254 How often do you communicate with different 
CODESAs?
[ ] One a month
[ ] Every 3 months 
[ ] Twice a year
[ ] Once a year
[ ] Other: 
_____________________
[ ] Don’t know
255 Since October 2018 when the IHP project was 
implemented, would you say this BCZ had more, less, 
or about the same amount of communication with 
CODESAs?
[ ] MORE
[ ] LESS
[ ] ABOUT THE SAME
[ ] DON’T KNOW
10
11
12 or more
Don't know
330 The Impact of USAID’s Integrated Health Program in the DRC
256 How many other health zone offices does this BCZ 
communicate with for professional reasons at least 
quarterly? 
[____] [____][____] 
257 How often do you communicate with other health 
zone offices?
[ ] One a month
[ ] Every 3 months 
[ ] Twice a year
[ ] Once a year
[ ] Other: 
_____________________
[ ] Don’t know
258 Since October 2018 when the IHP project was 
implemented, would you say this BCZ had more, less, 
or about the same amount of communication with 
other health zone offices?
[ ] MORE
[ ] LESS
[ ] ABOUT THE SAME
[ ] DON’T KNOW
Please tell me how often you or someone from your organization did each of the following things as part of their day-to-day 
work in 2018?
259 Do you or does someone from your office attend 
Comités de Gestion (COGE) meetings?
[ ] Yes
[ ] No
If no, continue to next 
table.
260 How many times were these meetings held in 2018? [__] 01
[__] 02
[__] 03
[__] 04
[__] 05
[__] 06
[__] 07
[__] 08
[__] 09
[__] 10
[__] 11
[__] 12 or more
[__] Don’t know
261 How many times have you or someone from your 
office contributed ideas or lessons learned at COGE 
meetings?
[__] 01
[__] 02
[__] 03
[__] 04
[__] 05
[__] 06
[__] 07
[__] 08
[__] 09
[__] 10
[__] 11
[__] 12 or more
[__] Don’t know
Baseline Report 331
262 How many times have you or someone from your 
office served as a COGE meeting facilitator or guest 
speaker?
[__] 01
[__] 02
[__] 03
[__] 04
[__] 05
[__] 06
[__] 07
[__] 08
[__] 09
[__] 10
[__] 11
[__] 12 or more
[__] Don’t know
263 How many times have you or someone from your 
office worked with other HZ officials at COGE 
meetings to influence decision-making or 
development of strategies?
[__] 01
[__] 02
[__] 03
[__] 04
[__] 05
[__] 06
[__] 07
[__] 08
[__] 09
[__] 10
[__] 11
[__] 12 or more
[__] Don’t know
332 The Impact of USAID’s Integrated Health Program in the DRC
This next section includes questions about specific local-level entities and organizations your BCZ has worked with to strengthen institutional capacity and improve health of 
Congolese citizens. By “work with” we mean both informally, for example through exchange of information, and formally, for example by attending the same training or 
workshop. The term “local-level entities” includes other health zone offices in addition to government enterprises other than the Ministry of Health (e.g. Ministry of Finance, 
Ministry of Education) and private sector partners. “Organizations” refers to all non-governmental institutions that have provided technical, financial or other support. (RECORD 
THE NUMBER corresponding to the chosen response) 
Over the last 6 months 
how many 
organizations and 
other local-level 
entities have you 
worked with to help to 
achieve goals related 
to strengthened 
capacity and improved 
health outcomes?
Enter number|__|__|
If none,  264
Over the last 6 months 
how frequently have you 
worked with this 
organization?
In the last 6 months, 
how often did your 
office share or exchange 
information with THIS 
ORGANIZATION?
In the last 6 months, 
how often did your 
organization jointly plan, 
implement or monitor 
an activity, event, or 
service with THIS 
ORGANIZATION? 
In the last 6 months, 
how often did your 
office receive technical 
assistance from THIS 
ORGANIZATION to 
strengthen skills in data 
analysis, use and 
reporting? 
In the last 6 months, 
how often did your 
office receive financial or 
other support from THIS 
ORGANIZATION to build 
institutional capacity?
Does your office have a 
formal relationship with 
THIS ORGANIZATION, 
through a contract, 
memorandum of 
understanding or some 
other written document 
describing your 
partnership?
Write the name of 
each organization 
below.
1= Never
2= Once, twice, or just a 
few times 
3= Monthly
4= Weekly
5= Daily
1= Never 
2= Once, twice, or just a 
few times 
3= Monthly
4= Weekly
5= Daily
1= Never 
2= Once, twice, or just a 
few times 
3= Monthly
4= Weekly
5= Daily
1= Never 
2= Once, twice, or just a 
few times 
3= Monthly
4= Weekly
5= Daily
1= Never 
2= Once, twice, or just a 
few times 
3= Monthly
4= Weekly
5= Daily
1= YES
0= NO
2= DON’T KNOW
Baseline Report 333
SECTION 12. HEALTH INFORMATION SYSTEM
IDENTIFY THE PERSON PRIMARILY RESPONSIBLE FOR ENTERING DATA INTO THE DHIS2 SYSTEM TO ANSWER THIS SECTION
Now I would like to ask you questions related to health information, specifically the DHIS2.
NO QUESTION RESPONSE SKIP/ 
INSTRUCTIONS
264 How many facilities are currently required to 
submit data to the BCZS?
IF UKNOWN, ENTER 999.
|__ | __ |__|
DON’T KNOW
265 In the last month, how many of the [repeat number 
given above] facilities submitted data using the 
harmonized reporting tool or any other form? 
[SHOW THE RESPONDENT A PHOTO OF THE 
CURRENT TOOL]
ALL 
SOME 
NONE 
DON’T KNOW
01
02
00
99
266 In the last month, how many facilities submitted 
data using the harmonized reporting tool? [SHOW 
THE RESPONDENT A PHOTO OF THE CURRENT 
TOOL]
ALL 
SOME 
NONE 
DON’T KNOW
01
02
00
99
267 Can I see the facility reports from the last month? YES, ALL OBSERVED 
YES, SOME OBSERVED 
NOT SEEN
01
02
00
268 In the last month, how did this office submit its 
weekly Maladie à Potentiel Epidémique (MAPEPI) 
to the DPS?
Hand deliver to DPS
DPS picks up
Phone call
Text message
Radio communication
Email from office
Email from cyber café or other off-site 
location
Electronically via DHIS2
OTHER ____________________
01
02
03
04
05
06
07
08
96
269 To the best of your knowledge, the last time you 
encountered a MAPEPI case, how much time 
passed between when you were made aware of 
the MAPEPI event and when you were able to 
report to the DPS? 
DO NOT READ ANSWERS BUT CHECK THE ONE 
CLOSEST TO THE ONE GIVEN.
IMMEDIATELY
WITIHIN 24 HOURS
THE NEXT DAY
> 2 DAYS
DON’T KNOW 
01
02
03
04
98
270 What are some of the reasons why an immediate 
or weekly MAPEPI report may not be submitted on 
time?
SEVERAL RESPONSES POSSIBLE. CHECK ALL THAT 
ARE MENTIONED
DID NOT HAVE THE CORRECT FORM
NO SUPERVISION VISIT
LACK OF TRANSPORTATION
LACK OF INTERNET
LACK OF TELEPHONES
LACK OF ELECTRICITY
NO TIME TO COMPLETE REPORTS.
NO STAFF TO COMPLETE REPORTS
NOT AWARE OF SUBMISSION DEADLINES
OTHER ___________________________
01
02
03
04
05
06
07
08
09
96
334 The Impact of USAID’s Integrated Health Program in the DRC
Read aloud: Every BCZ office may do things differently. I am going to list a few tasks that might be performed using DHIS2 data. 
Please tell me whether you have done any of the following in the past 6 months:
271 Generated a report with results for one or more 
facilities?
YES
NO
DON’T KNOW
01
00
99
272 Generated a summary report for the health zone? YES
NO
DON’T KNOW
01
00
99
273 Compared results with provincial/national targets? YES
NO
DON’T KNOW
01
00
99
274 Compared results across different service domains? YES
NO
DON’T KNOW
01
00
99
275 Compared results over time? YES
NO
DON’T KNOW
01
00
99
276 Do you have a copy of the DHIS2 manual? YES, OBSERVED
YES, NOT OBSERVED
NO
DON’T KNOW
01
02
00
99
277 Have you read the DHIS2 manual? YES
NO
DON’T KNOW
01
00
99
278 How easy or difficult would you say the DHIS2 
procedure manual is to understand?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
VERY DIFFICULT
01
02
03
04
279 THE NEXT QUESTION IS ABOUT TRAINING 
PARTICIPATION WHICH INCLUDES INTERNAL 
TRAINING PROVIDED BY MEMBERS OF THIS BCZ AS 
WELL AS TRAINING PROVIDED BY PROVINCIAL/ 
GOVERNMENT OFFICIALS, USAID IHP PARTNERS OR 
OTHER NGOS WITH WHICH THIS OFFICE MAY BE 
AFFILIATED.
In the last calendar year (2018), did you attend a 
training session on health information 
management (e.g. DHIS2, SNIS, MAPEPI)?
YES
NO
01
00
280 If yes, who administered the training [select all that 
apply]?
Internal/BCZ office
Province/Government
USAID/ IHP
Other (specify) _____________________
01
02
03
96
281 What topics did this training cover [select all that 
apply]?
Completeness calculations and reporting
Timeliness calculations and reporting
Exhaustivity calculations and reporting
Validation rules 
Abhorrent data
Correcting data
Other (specify) ____________________
01
02
03
04
05
06
96
Baseline Report 335
282 Does the BCZS have written guidelines for data 
entry/compilation and data quality review and 
control?
YES
NO
DON’T KNOW
01
00
99
283 In the last month, how many feedback reports on 
data quality and performance has this office sent to 
health facilities?
IF UNKNOWN, ENTER 999.
|__|__|__|
GO TO 151
284 Can I see the reports? SELECT A REPORT AT 
RANDOM AND RECORD THE FOLLOWING 
OBSERVATIONS.
YES, OBSERVED
NO, NOT OBSERVED
01
00
Was any of the following feedback included in the report?
285 Accuracy of data YES
NO
DON’T KNOW
01
00
99
286 Completeness of data YES
NO
DON’T KNOW
01
00
99
287 Timeliness of data YES
NO
DON’T KNOW
01
00
99
288 Positive feedback YES
NO
DON’T KNOW
01
00
99
289 Any other feedback? YES
_________________________
(SPECIFY)
NO
DON’T KNOW
01
00
99
290 Since October 2018, how many feedback reports 
on data quality and performance has this office 
received from DPS?
IF UNKNOWN, ENTER 999.
|__|__|__|
GO TO 158
291 Can I see the reports? SELECT A REPORT AT 
RANDOM AND RECORD THE FOLLOWING 
OBSERVATIONS.
YES, OBSERVED
NO, NOT OBSERVED
01
00
Was any of the following feedback included in the report?
292 Accuracy of data YES
NO
DON’T KNOW
01
00
99
293 Completeness of data YES
NO
DON’T KNOW
01
00
99
294 Timeliness of data YES
NO
DON’T KNOW
01
00
99
295 Positive feedback YES
NO
01
00
336 The Impact of USAID’s Integrated Health Program in the DRC
DON’T KNOW 99
296 Any other feedback? YES
_________________________
(SPECIFY)
NO
DON’T KNOW
01
00
99
297 Does this office have a map of the health zone and 
if so, what type of map is it?
YES, COMPUTER GENERATED
YES, HAND-DRAWN
NO MAP
DON’T KNOW
01
02
03
99
298 Does the office display a summary of demographic 
information for the health zone (i.e. population 
numbers for each health area)?
YES
NO
DON’T KNOW
01
00
99
299 Does the office display more specific demographic 
information (such as population by target groups)?
YES
NO
DON’T KNOW
01
00
99
What kinds of actions have been taken based on DHIS2 data?
300 Review strategy by examining service performance 
target and actual performance from month to 
month
YES
NO
DON’T KNOW
01
00
99
301 Review facility personnel responsibilities by 
comparing service targets and actual performance 
from month to month
YES
NO
DON’T KNOW
01
00
99
302 Mobilization/shifting of resources based on 
comparison between services
YES
NO
DON’T KNOW
01
00
99
303 Advocacy for more resources by showing gaps in 
ability to meet targets
YES
NO
DON’T KNOW
01
00
99
Now I would like to ask you some questions related to meetings and decisions based on the DHIS2 data.
304 How frequently does this office have routine 
meetings where the DHIS2 or facility reported data 
is discussed? This could be a separate meeting or in 
the routine managerial or administrative meetings. 
MONTHLY OR MORE OFTEN
EVERY 2-3 MONTHS
EVERY 4-6 MONTHS
LESS THAN EVERY 6 MONTHS OR 
IRREGULARLY
DON’T KNOW
01
02
03
04
99
GO TO 169
305 Is an official record of management meetings 
maintained?
YES
NO
DON’T KNOW
01
02
99
306 Have the DHIS2 or facility data been used to make 
decisions?
YES
NO
DON’T KNOW
01
00
99
307 Has any follow-up action taken place regarding the 
decisions made during the previous meetings?
YES
NO
DON’T KNOW
01
00
99
Baseline Report 337
Thank you for the time.
Interview End Time: Hour |___|___| Minutes |___|___|
338 The Impact of USAID’s Integrated Health Program in the DRC
IHP EVALUATION
DIVISION PROVINCIAL DE LA SANTÉ (DPS) SURVEY
IDENTIFY THE HIGHEST-RANKING PERSON ON THE DAY OF THE INTERVIEW. EXPLAIN THAT SOME QUESTIONS MAY HAVE BEEN ASKED 
IN EARLIER INTERVIEWS WITH USAID/IHP REPRESENTATIVES AND THAT YOU APPRECIATE THEIR TIME AND PATIENCE.
SECTION 1. ORIENTATION
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
1 Record the province
2 Enter your data collector ID number
3 Enter the facility ID number
4 Identify the highest-ranking person. Explain that some questions may have been asked in earlier interviews with 
USAID IHP representatives and that you appreciate their time and patience.
5 Have you read him/her the consent script? |_| No
|_| Yes
If no,  6
6 If no, why?
7 Did the respondent agree? |_| No
|_| Yes
If no,  8
8 If no, what was the reason?
|_| No office members present 
at time of visit
|_| Office members absent for 
a long period of time
|_| Deferred
|_| Refused
|_| Office vacant or not an 
address
|_| Office destroyed
|_| Office not found
|_| Other (specify) _________
Go to 9 & 10
and end survey
9 Take a photograph of the front of the office
10 Record the GPS coordinates to six decimal places
Baseline Report 339
SECTION 2. BASIC INFORMATION
First, I would like to ask you some general questions about you. 
No. QUESTION RESPONSE SKIP/
INSTRUCTIONS
11 Record the sex of participant ☐ Male ☐ Female 
12 Are you the head of this DPS? ☐ Yes ☐ No 
13 What is your position in this office? CHEF DE DIVISION
SECRETARY
OFFICE CHIEF OF RESOURCE 
MANAGEMENT
OFFICE CHIEF OF TECHNICAL 
SUPPORT 
OFFICE CHIEF OF INSPECTION AND 
CONTROL
OFFICE CHIEF OF HEALTH 
INFORMATION
OFFICE CHIEF OF HYGIENE AND 
PUBLIC SANITATION
OFFICE CHIEF OF HEALTH SCIENCES 
TRAINING
OTHER _____________________
01
02
03
04
05
06
07
08
96
14 For how many years have you held this position in this office? Less than 1 year
1
2
3
4
5
6
7
8
9
10+
Don't know
00
01
02
03
04
05
06
07
08
09
10
98
15 What is the highest level of education you have received? No schooling
Primary
Secondary
University
01
02
03
04
If University, 
 16; 
otherwise, 
 18 
16 Do you have a master’s degree? ☐ Yes ☐ No If no,  18
17 In what subject is your master’s degree(s)? (check all that 
apply)
Public health
Public administration
Business administration
Other (specify) _________________
01
02
03
96
340 The Impact of USAID’s Integrated Health Program in the DRC
18 How many years have you worked in this office (in any 
capacity)?
Less than 1 year
1
2
3
4
5
6
7
8
9
10+
Don't know
00
01
02
03
04
05
06
07
08
09
10
98
19 For how many years have you held the position of [refer to 
response in Q13] in this office?
Less than 1 year
1
2
3
4
5
6
7
8
9
10+
Don't know
00
01
02
03
04
05
06
07
08
09
10
98
20 For how many years in total have you worked as a [refer to 
response in Q13] , whether at this office or another DPS?
Less than 1 year
1
2
3
4
5
6
7
8
9
10+
Don't know
00
01
02
03
04
05
06
07
08
09
10
98
TRAINING
The next set of questions is about training participation and includes internal training provided by members of this DPS as well as 
training provided by central/government officials, USAID/IHP partners or other NGOs with which this office may be affiliated.
In the last calendar year (2018), have you or anyone in this provincial office attended training on any of the following subjects?
21 Prenatal consultations? ☐ Yes ☐ No If no,  24
22 Did you attend this training? ☐ Yes ☐ No If no,  24
23 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
Baseline Report 341
24 Integrated Management of Childhood Illness? ☐ Yes ☐ No If no,  27
25 Did you attend this training? ☐ Yes ☐ No If no,  27
26 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
27 Malaria (children under 5)? ☐ Yes ☐ No If no,  30
28 Did you attend this training? ☐ Yes ☐ No If no,  30
29 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
30 Long-lasting insecticidal net (LLIN) distribution? ☐ Yes ☐ No If no,  33
31 Did you attend this training? ☐ Yes ☐ No If no,  33
32 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
33 Family planning? ☐ Yes ☐ No If no,  36
34 Did you attend this training? ☐ Yes ☐ No If no,  36
35 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
36 Reach Every District (zone) training? ☐ Yes ☐ No If no,  39
37 Did you attend this training? ☐ Yes ☐ No If no,  39
38 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
39 Vaccine Safety Training? ☐ Yes ☐ No If no,  42
40 Did you attend this training? ☐ Yes ☐ No If no,  42
41 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
42 Administrative and human resource management? ☐ Yes ☐ No If no,  45
43 Did you attend this training? ☐ Yes ☐ No If no,  45
44 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
45 Financial management? ☐ Yes ☐ No If no,  48
342 The Impact of USAID’s Integrated Health Program in the DRC
46 Did you attend this training? ☐ Yes ☐ No If no,  48
47 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
48 Management ethics and patient confidentiality? ☐ Yes ☐ No If no,  51
49 Did you attend this training? ☐ Yes ☐ No If no,  51
50 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
51 Training of health care providers? ☐ Yes ☐ No If no,  54
52 Did you attend this training? ☐ Yes ☐ No If no,  54
53 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
54 Capacity-building of CODESAs? ☐ Yes ☐ No If no,  57
55 Did you attend this training? ☐ Yes ☐ No If no,  57
56 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
57 Health information systems (e.g. DHIS2, SNIS, MAPEPI)? ☐ Yes ☐ No If no,  60
58 Did you attend this training? ☐ Yes ☐ No If no,  60
59 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
60 Community scorecard processes? ☐ Yes ☐ No If no,  63
61 Did you attend this training? ☐ Yes ☐ No If no,  63
62 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
63 Material resource management (medicines, supplies, 
equipment)? ☐ Yes ☐ No If no,  66
64 Did you attend this training? ☐ Yes ☐ No If no,  66
65 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
66 Gender issues and/or the gender transformative approach? ☐ Yes ☐ No If no,  69
Baseline Report 343
67 Did you attend this training? ☐ Yes ☐ No If no,  69
68
If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
69 Supportive supervision? ☐ Yes ☐ No If no,  72
70 Did you attend this training? ☐ Yes ☐ No If no,  72
71 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
72 Team management? ☐ Yes ☐ No If no,  75
73 Did you attend this training? ☐ Yes ☐ No If no,  75
74 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
75 Planning, monitoring and evaluation? ☐ Yes ☐ No If no,  78
76 Did you attend this training? ☐ Yes ☐ No If no,  78
77 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
78 Disease prevention, health promotion and re-adaptation 
care? ☐ Yes ☐ No If no,  81
79 Did you attend this training? ☐ Yes ☐ No If no,  81
80 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
81 Management of outbreaks, emergencies and disasters? ☐ Yes ☐ No If no,  84
82 Did you attend this training? ☐ Yes ☐ No If no,  84
83 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
84 Health research? ☐ Yes ☐ No If no,  87
85 Did you attend this training? ☐ Yes ☐ No If no,  87
86 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
87 Data analysis? ☐ Yes ☐ No If no,  90
344 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 3. BASIC INFRASTRUCTURE 
NO Questions and filters SKIP
93
RECORD OBSERVATION OF THE MAIN MATERIAL OF THE FLOOR NATURAL FLOOR
EARTH/SAND
DUNG
RUDIMENTARY FLOOR
WOOD PLANKS
PALM/BAMBOO
FINISHED FLOOR
PARQUET OR POLISHED 
WOOD
VINYL OR ASPHALT STRIPS
CERAMIC TILES
CEMENT
CARPET
OTHER
________________________
(SPECIFY)
11
12
21
22
31
32
33
34
35
96
94
RECORD OBSERVATION OF THE MAIN MATERIAL OF THE ROOF NATURAL ROOFLING
NO ROOF
THATCH/PALM LEAF
SOD
RUDIMENTARY ROOFING
MAT
PALM/BAMBOO
WOOD PLANKS
CARDBOARD
FINISHED ROOFING
METAL
WOOD
CALAMINE/CEMENT FIBRE
11
12
13
21
22
23
24
31
32
33
88 Did you attend this training? ☐ Yes ☐ No If no,  90
89 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
90 Use of data for evidence-based decision-making? ☐ Yes ☐ No If no,  93
91 Did you attend this training? ☐ Yes ☐ No If no,  93
92 If yes, who administered the training: [select all that apply] 
☐ Internal/HZ office ☐ Central/Government ☐ USAID/IHP ☐ Other: __________________________
Baseline Report 345
CERAMIC TILES
CEMENT
OTHER
________________________
(SPECIFY)
34
35
96
95
RECORD OBSERVATION OF THE MAIN MATERIAL OF THE 
EXTERIOR WALLS
NATURAL WALLS
NO WALLS
BAMBOO/CANE/PALM/ 
TRUNK
DIRT
RUDIMENTARY WALLS
BAMBOO WITH MUD
STONE WITH MUD
UNCOVERED ADOBE
PLYWOOD
CARDBOARD
REUSED WOOD
FINISHED WALLS
CEMENT
SOTEON WITH LIME/CEMENT
BRICKS
CEMENT BLOCKS
COVERED ADOBE
WOOD PLANKS
OTHER
________________________
(SPECIFY)
11
12
13
21
22
23
24
25
26
31
32
33
34
35
36
96
96 Does this office have cell phone reception? RECORD OBSERVATION ☐ Yes ☐ No If no,  99
97 How would you rate the ease of connectivity to the nearest health 
center?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
VERY DIFFICULT
01
02
03
04
98 How would you rate the ease of connectivity to the furthest health 
center?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
VERY DIFFICULT
01
02
03
04
99 Does this office have electricity? RECORD OBSERVATION ☐ Yes ☐ No If no,  105
100 What is the main source of electricity?
Main power
Solar power
Generator
Other (specify) ___________
01
02
03
96
101 On a typical 8-hour work day, how many hours is electricity 
available at this office? |__| hours
346 The Impact of USAID’s Integrated Health Program in the DRC
102 Is electricity functioning now? (CHECK TO SEE IF ELECTRICITY CAN 
BE TURNED ON.) RECORD OBSERVATION ☐ Yes ☐ No 
103 Are there power cuts (excluding electricity supplied by a generator 
backup) during the hours when the office is open? ☐ Yes ☐ No If no,  105
104 What is the average duration of power cuts? |__|__| hours
|__|__| days
105
Does this office have a generator for electricity?
This may be a back-up or stand-by generator. RECORD 
OBSERVATION
☐ Yes ☐ No 
Refer to 100 and 
answer if 
Generator, then 
 106; 
otherwise, 
107
106 Is the generator functional and is there fuel today? RECORD 
OBSERVATION ☐ Yes ☐ No 
107 In the last month, how often have power cuts interfered with:
108 Cold chain maintenance?
Never 
Rarely 
Sometimes
Often 
Always
Don't know
Not applicable (N/A)
01
02
03
04
05
98
97
Refer to 103 and 
answer if yes; 
otherwise, 
110
109 DHIS2 reporting?
Never 
Rarely 
Sometimes
Often 
Always
Don't know
Not applicable (N/A)
01
02
03
04
05
98
97
110 Is there a functional solar panel? RECORD OBSERVATION ☐ Yes ☐ No 
If yes,  111; 
otherwise, 
112
111 Is there a functional battery for solar panel? RECORD 
OBSERVATION ☐ Yes ☐ No 
112 Does this office have a radio? RECORD OBSERVATION ☐ Yes ☐ No 
113 Does this office have a calculator? RECORD OBSERVATION ☐ Yes ☐ No 
114
How many functional computers are there at the office and of 
which type? RECORD OBSERVATION
IF THE RESPONDENT DOESN’T KNOW THE NUMBER FOR A TYPE 
OF COMPUTER, WRITE “99” IN THE BOX.
DPS OWNED (NOT PERSONAL) 
DESKTOP |__|__|
DPS OWNED (NOT PERSONAL) 
LAPTOP |__|__|
PERSONAL LAPTOP |__|__|
115
How many functional printers are there at the office? RECORD 
OBSERVATION |__|__|
116 In general, does this office have access to the internet? ☐ Yes ☐ No 
117 Do you have the following sources of internet? Check all that apply
Baseline Report 347
118 Modem using commercial telephone network (VODACOM, AIRTEL, 
etc.) ☐ Yes ☐ No If yes,  119
119 Is it functioning? RECORD OBSERVATION ☐ Yes ☐ No 
120 V-Sat antenna? ☐ Yes ☐ No If yes,  121
121 Is it functioning? RECORD OBSERVATION ☐ Yes ☐ No 
122 Personal mobile/wifi hotspot? ☐ Yes ☐ No If yes,  123
123 Is it functioning? RECORD OBSERVATION ☐ Yes ☐ No 
124 Other source of internet? SPECIFY__________________ ☐ Yes ☐ No 
125 Was internet connectivity provided by USAID/IHP? ☐ Yes ☐ No 
126 How common is it for people at this office to rely on their own 
personal mobile hotspot?
Never 
Rarely 
Sometimes
Often 
Always
Don't know
Not applicable (N/A)
01
02
03
04
05
98
97
127 In a typical 8-hour workday, how many hours does the internet at 
the office work, not including personal mobile hotspots? |__| hours
128
Can you log into the DHIS2 system for me so that I can see whether 
it is working?
Check all that apply.
Yes, observed
No, no working computer
No, no electricity
No, no internet
No, slow internet
No, forgot username
No, forgot password
No, refused
No, other reason (specify)
______________________
01
02
03
04
05
06
07
99
96
SECTION 4. GENERAL STAFFING
Now I have some questions about staffing for this DPS. 
Please tell me how many people currently work in the following positions/units as members of this provincial management team 
and whether they are male or female. Please include all persons who work in this DPS, whether in a full-time, part-time or 
volunteer capacity.
Does this DPS currently employ a or have employees in the… No. Staff No. Male No. Female
129 Chef de Division
☐ Yes
☐ No (go to 130)
☐ Don’t know (go to 130)
|__|__|__| |__|__|__| |__|__|__|
130 Secretary
☐ Yes
☐ No (go to 131)
☐ Don’t know (go to 131)
|__|__|__| |__|__|__| |__|__|__|
131 Office of Resource Management ☐ Yes
☐ No (go to 132) |__|__|__| |__|__|__| |__|__|__|
348 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 5. HEALTH INFORMATION SYSTEM
IDENTIFY THE PERSON PRIMARILY RESPONSIBLE FOR ENTERING DATA INTO THE DHIS2 SYSTEM TO ANSWER THIS SECTION
Now I would like to ask you questions related to health information, specifically the DHIS2.
NO QUESTION RESPONSE SKIP/ 
INSTRUCTIONS
139 How many health zones are currently required 
to submit DHIS2 reports to the DPS?
IF UKNOWN, ENTER 999.
|__ | __ |__| If 0,  145
140 In the last month, how many of the [repeat
number given above] health zones submitted 
their DHIS2 reports on time? 
ALL 
SOME 
NONE 
DON’T KNOW
01
02
00
98
If none,  142
141 Can I see the health zone reports from the last 
month?
Not observed
Observed
00
01
142 In the last month, how did this office submit its 
weekly Maladie à Potentiel Epidémique 
(MAPEPI) to the Central Level (Disease Control 
Directorate)? 
Hand deliver to DPS
DPS picks up
Phone call
Text message
Radio communication
Email from office
Email from cybercafé or other off-site 
location
Electronically via DHIS2
Other (specify)_____________________
01
02
03
04
05
06
07
08
96
☐ Don’t know (go to 132)
132 Office of Technical Support 
☐ Yes
☐ No (go to 133)
☐ Don’t know (go to 133)
|__|__|__| |__|__|__| |__|__|__|
133 Office of Inspection Control
☐ Yes
☐ No (go to 134)
☐ Don’t know (go to 134)
|__|__|__| |__|__|__| |__|__|__|
134 Office of Health Information
☐ Yes
☐ No (go to 135)
☐ Don’t know (go to 135)
|__|__|__| |__|__|__| |__|__|__|
135 Office of Hygiene and Public Sanitation 
☐ Yes
☐ No (go to 136)
☐ Don’t know (go to 136)
|__|__|__| |__|__|__| |__|__|__|
136 Office of Health Sciences Training 
☐ Yes
☐ No (go to 137)
☐ Don’t know (go to 137)
|__|__|__| |__|__|__| |__|__|__|
137
Does this office have a designated person to 
enter/compile DHIS2 data reports from health 
facilities?
YES
NO
DON’T KNOW
01
00
99
138
Does the district have a designated person to review 
and control the quality of data entry/compilation?
YES
NO
DON’T KNOW
01
00
99
Baseline Report 349
143 To the best of your knowledge, the last time 
you encountered a MAPEPI case, how much 
time passed between when you were made 
aware of the MAPEPI event and when you were 
able to report to the Central Level (Disease 
Control Directorate)? 
DO NOT READ ANSWERS BUT CHECK THE ONE 
CLOSEST TO THE ONE GIVEN.
Immediately
Within 24 hours
The next day
> 2 days
Don't know
01
02
03
04
98
144 What are some of the reasons why an 
immediate or weekly MAPEPI report may not 
be submitted on time?
SEVERAL RESPONSES POSSIBLE. CHECK ALL 
THAT ARE MENTIONED
Did not have the correct form
No supervision visits
Lack of transportation
Lack of internet
Lack of telephones
Lack of electricity
No time to complete reports
No staff to complete reports
Not aware of submission deadlines
Other (specify)_______________________
01
02
03
04
05
06
07
08
09
96
Read aloud: Every DPS office may do things differently. I am going to list a few tasks that might be performed using DHIS2 data. 
Please tell me whether you have done any of the following in the past 6 months:
145 Generated a report with results for one or more 
health zones?
No
Yes
Not applicable (N/A)
Don’t know
00
01
97
98
146 Generated a summary report for the province? No
Yes
Not applicable (N/A)
Don’t know
00
01
97
98
147 Compared results with provincial/national 
targets?
No
Yes
Not applicable (N/A)
Don’t know
00
01
97
98
148 Compared results across different service 
domains?
No
Yes
Not applicable (N/A)
Don’t know
00
01
97
98
149 Compared results over time? No
Yes
Not applicable (N/A)
Don’t know
00
01
97
98
150 Do you have a copy of the DHIS2 manual? YES, OBSERVED
YES, NOT OBSERVED
NO
DON’T KNOW
01
02
00
98
151 Have you read the DHIS2 manual? No
Yes
Not applicable (N/A)
Don’t know
00
01
97
98
If no,  152
152 How easy or difficult would you say the DHIS2 
procedure manual is to understand?
VERY EASY
SOMEWHAT EASY
SOMEWHAT DIFFICULT
01
02
03
350 The Impact of USAID’s Integrated Health Program in the DRC
DON’T KNOW 98
153 Does the district have written guidelines for 
data entry/compilation and data quality review 
and control?
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
154 In the last month, how many feedback reports 
on data quality and performance has this DPS
sent to health zone offices?
IF UNKNOWN, ENTER 999.
|__|__|__| If 0,  161
155 Can I see the reports? SELECT A REPORT AT 
RANDOM AND RECORD THE FOLLOWING 
OBSERVATIONS.
YES, OBSERVED
NO, NOT OBSERVED
01
00
If no,  161
Was any of the following feedback included in the report?
156 Accuracy of data No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
157 Completeness of data No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
158 Timeliness of data No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
159 Positive feedback No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
160 Other feedback No
Yes (specify) __________________________
Not applicable (N/A)
Don't know
00
01
97
98
161 Since October 2018, how many feedback 
reports on data quality and performance has 
this office received from Central Level (Disease 
Control Directorate)? 
IF UNKNOWN, ENTER 999.
|__|__|__| If 0,  168
162 Can I see the reports? SELECT A REPORT AT 
RANDOM AND RECORD THE FOLLOWING 
OBSERVATIONS.
YES, OBSERVED
NO, NOT OBSERVED
01
00
If no,  168
Was any of the following feedback included in the report?
163 Accuracy of data No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
164 Completeness of data No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
Baseline Report 351
165 Timeliness of data No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
166 Positive feedback No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
167 Other feedback No
Yes (specify) __________________________
Not applicable (N/A)
Don't know
00
01
97
98
168 Does this office have a map of the province and 
if so, what type of map is it?
YES, COMPUTER GENERATED
YES, HAND-DRAWN
NO MAP
DON’T KNOW
01
02
03
98
169 Does the office display a summary of 
demographic information for the province (i.e. 
number of health zones; population numbers 
for each health area)?
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
170 Does the office display more specific 
demographic information (such as population 
by target groups)?
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
What kinds of actions have been taken based on DHIS2 data?
171 Review strategy by examining service 
performance target and actual performance 
from month to month
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
172 Review facility personnel responsibilities by 
comparing service targets and actual 
performance from month to month
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
173 Mobilization/shifting of resources based on 
comparison between services
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
174 Advocacy for more resources by showing gaps 
in ability to meet targets
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
Now I would like to ask you some questions related to meetings and decisions based on the DHIS2 data.
175 How frequently does this office have routine 
meetings where the DHIS2 or facility reported
data is discussed? This could be a separate 
meeting or in the routine managerial or 
administrative meetings. 
Monthly or more often
Every 2-3 months
Every 4-6 months
Less than every 6 months or irregularly
Don't know
01
02
03
04
98
GO TO 166
176 Is an official record of management meetings 
maintained?
No
Yes
Not applicable (N/A)
00
01
97
352 The Impact of USAID’s Integrated Health Program in the DRC
Don't know 98
177 Have the DHIS2 data been used to make 
decisions?
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
178 Has any follow-up action taken place regarding 
the decisions made during the previous 
meetings?
No
Yes
Not applicable (N/A)
Don't know
00
01
97
98
SECTION 6. SOURCES AND USES OF FUNDING
Now I would like to ask you some questions about sources and uses of funding for this DPS office.
No. QUESTION RESPONSE
SKIP/ 
INSTRUCTIONS
What is the total amount of operational funds (i.e. funds not 
passed on to another organization) received from the following 
sources in the last calendar year (2018)?
179 Ministry of health/Provincial health office |__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
180 USAID/IHP |__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
181 Other NGO’s or FBO’s: Cordaid, Memisa, Foundation Damien, 
save the Children, Rescue, IRC, Caritas, Sanru, Chemonics, MCSP
|__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
182 User fees |__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
183 Other health insurance program? |__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
184 Other 1 (specify) ________________________________ |__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
185 Other 2 (specify) ________________________________ |__|__|__|__|__|__|__|FC
|__|__|__|__|__|__|__|USD
What percentage of operational funds was spent on the 
following during the last calendar year (2018)?
186 Savings |__|__|__| %
187 Building/grounds improvements |__|__|__| %
188 Equipment (vehicles, computers, etc.) |__|__|__| %
189 Utilities and communication (electricity, water, phone credit, 
internet, etc.)
|__|__|__| %
190 Medical supplies |__|__|__| %
191 Drugs |__|__|__| %
Baseline Report 353
192 Transport |__|__|__| %
193 Salaries and primes |__|__|__| %
194 Training |__|__|__| %
195 Other 1 (specify) ______________________________ |__|__|__| %
196 Other 2 (specify) ______________________________ |__|__|__| %
SECTION 7. SUPPORT FROM USAID/IHP
NO QUESTION RESPONSE SKIP/
INSTRUCTIONS
Capacity building
197 Has this office ever completed a Participatory 
Institutional Capacity Assessment and Learning 
(PICAL) assessment, facilitated by someone 
from USAID, IHP or Abt Associates?
[ ] Yes
[ ] No
[ ] Don’t know/ not sure
If no,  202
198 For the last PICAL assessment, which members 
of the DPS participated?
Check all that apply
CHEF DE DIVISION
SECRETARY
OFFICE CHIEF OF RESOURCE MANAGEMENT
OFFICE CHIEF OF TECHNICAL SUPPORT 
OFFICE CHIEF OF INSPECTION AND CONTROL
OFFICE CHIEF OF HEALTH INFORMATION
OFFICE CHIEF OF HYGIENE AND PUBLIC SANITATION
OFFICE CHIEF OF HEALTH SCIENCES TRAINING
OTHER _______________________
199 How long ago was most recent PICAL 
assessment?
[ ] 0-3 months ago
[ ] 4-6 months ago 
[ ] 7-12 months ago 
[ ] More than 1 year ago
[ ] Don’t know
200 Did the office receive its “PICAL score” as a 
result of that assessment?
[ ] Yes
[ ] No
[ ] Don’t know
If no,  202
201 What was the score? ____________________________
354 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 8: MANAGEMENT AND SUPERVISION 
LEADERSHIP
In this part of the questionnaire, I would like to know what you would do in certain situations regarding this DPS. I will read you a
series of scenarios. For each scenario, I will read 4 possible responses that you might have. Please select the response that most
closely matches what you would do in this specific situation. You can only select one response foreach scenario. There are no correct 
or incorrect answers -we just want to know how you would approach each situation.
INTERVIEWER: EACH RESPONSE IS CODED BETWEEN 1 AND 4. RECORD APPROPRIATE CODE ACCORDING TO RESPONDENT'S 
RESPONSE.
NO SCENARIOS 1 2 3 4 RECORD RESPONSE 
(RANGE 1-4)
202 Scenario 1: The 
performance of 
your staff is 
improving. 
You stress their 
responsibilities 
and standards.
You take no 
particular 
additional action.
You give positive 
feedback and 
make staff feel 
involved in the 
achievements.
You emphasize 
the importance of 
deadlines and 
tasks.
203 Scenario 2: 
Members of your 
staff have been 
unable to solve a 
problem over the 
past month, 
though they have 
been trying to 
address it.
You call a meeting 
and together try 
to solve the 
problem.
You let your staff 
address this 
problem on their 
own.
You give them 
direction and 
instructions on 
how to solve the 
problem.
You encourage 
the group to solve 
the problem on 
their own, and 
you are available 
when needed to 
discuss.
204 Scenario 3: You 
are considering a 
major change in 
how things are 
done in the 
office.
You collaborate 
with your staff to 
develop the 
needed changes. 
You announce 
your vision for the 
changes and 
implement a clear 
plan. 
You ask your staff 
to develop and 
implement their 
own plan for 
change.
You consult with 
your staff, but 
direct the 
changes yourself.
205 Scenario 4: The 
performance of 
your staff has 
been falling in 
recent months.
You ask your staff 
to rethink their 
direction and 
goals and come 
up with a plan 
together.
You ask for 
suggestions from 
your staff on 
what to do, and 
you formulate a 
specific plan to 
meet objectives.
You redefine 
goals clearly and 
supervise 
whether these 
are being met 
closely.
You allow your 
staff freedom to 
set their own 
goals and do not 
push them.
206 Scenario 5: Your 
staff are no 
longer working 
together as an 
effective team.
You discuss ideas 
as a group and 
identify how to 
work better 
together.
You let your staff 
work out their 
issues on their 
own.
You act quickly 
and decisively to 
get the team back 
on track.
You make 
yourself available 
to discuss any 
issues and 
support your 
team to work out 
their own 
problems.
AUTONOMY
In this part of the questionnaire I would like to ask you some questions regarding how work is organized and how decisions are 
made in this DPS. All answers are confidential.
Baseline Report 355
I am now going to read you a series of statements about decision-making and authority in this facility. Please tell me whether you 
feel these are true always, often, sometimes, rarely or never.
RESPONSE CODE 
RECORD 
RESPONSE 
ALWAYS 1
OFTEN 2
SOMETIMES 3
RARELY 4
NEVER 5
207 I am able to allocate my DPS budget according to how it is needed. There is enough flexibility in my 
budget.
208 I am able to assign tasks and activities to staff as needed to achieve the outcomes I want in the DPS 
office. There is enough flexibility to use staff to address needs.
209 The Central Level Office/Minister of Health supports my decisions and actions for doing a better job in 
my office.
210 I have choice over who I allocate for what tasks.
211 I have choice over what services are provided in the facilities within the health zones.
212 I have enough authority to obtain the resources I need (drugs, supplies, funding) to meet the needs of 
the facilities within my health zones.
213 The policies and procedures for doing things are clear to me.
214 The policies and procedures for doing things are useful tools for the challenges I face in providing 
services and reporting on activities.
215 The Central Level Office/Minister of Health provides adequate feedback to me about my job and the 
performance of my facilities/health zones.
INTERNAL MANAGEMENT
NO QUESTION RESPONSE SKIP/ 
INSTRUCTIONS
216 Does this office have routine meetings 
for reviewing managerial or 
administrative matters? 
YES
NO
DON’T KNOW
01
02
99
If no,  230
217 In 2018, how often did meetings to 
discuss the managerial and 
administrative matters take place?
MONTHLY OR MORE OFTEN
QUARTERLY
TWICE A YEAR
ANNUALLY 
IRREGULARLY
NEVER
DON’T KNOW
01
02
03
04
05
06
98
If never or don’t 
know,  230
218 Are meeting minutes available? YES
NO
DON’T KNOW
01
00
98
If no,  230
219 Can I see the meeting minutes from 
2018 until now?
OBSERVED
NOT OBSERVED
01
00
If no,  230
220 RECORD THE NUMBER OF MEETINGS 
THAT HAVE BEEN HELD SINCE 
OCTOBER 2018.
|__|__|__|
356 The Impact of USAID’s Integrated Health Program in the DRC
Which members of the DPS attend these meetings and how often? Who attends the routine meetings?
221 CHEF DE DIVISION 75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
222 SECRETARY 75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
223 OFFICE CHIEF OF RESOURCE 
MANAGEMENT
75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
224 OFFICE CHIEF OF TECHNICAL SUPPORT 75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
225 OFFICE CHIEF OF INSPECTION AND 
CONTROL
75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
226 OFFICE CHIEF OF HEALTH 
INFORMATION
75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
227 OFFICE CHIEF OF HYGIENE AND PUBLIC 
SANITATION
75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
228 OFFICE CHIEF OF HEALTH SCIENCES 
TRAINING
75-100%
50-74%
25-49%
1-24%
Don’t know
Not applicable (N/A)
01
02
03
04
98
97
229 What types of decisions are made in 
these meetings?
Scheduling of activities in the health zone
Allocating financial resources
01
02
Baseline Report 357
SEVERAL ANSWERS POSSIBLE. DO NOT 
READ THE ANSWERS BUT CHECK ALL 
MENTIONED
Allocating technical resources
Defining programmatic priorities
Coordinating strategies with donors
Human resources management
Conflict resolution
03
04
05
06
07
230 Do you or does someone from this 
office make supervision visits to health 
zone offices?
YES
NO
DON’T KNOW
01
00
99
If no,  233
231 Are supervision reports available? YES
NO
DON’T KNOW
01
00
99
If no,  233
232 Can I see the most recent report? OBSERVED
NOT OBSERVED.
01
00
EXTERNAL SUPERVISION
LEVEL FROM WHICH 
THE SUPERVISOR 
CAME
In 2018, how 
many times did 
the supervisor 
from the 
[LEVEL] visit this 
office for the 
purpose of 
management or 
supervision of 
routine and 
non-routine 
activities?
Do you know 
the date 
(month and 
year) of the 
most recent 
visit by a 
supervisor from 
the [LEVEL]?
When did a 
supervisor from 
the [LEVEL] last 
visit?
What topic was 
discussed at the last 
visit? 
CHECK ALL THAT APPLY
After the last visit, did 
the supervisor send 
you a report based on 
his/her findings?
233 National-/ 
Central-level 
authorities
☐ 0
☐ 1
☐ 2
☐ 3
☐ 4
☐ 5
☐ 6
☐ 7
☐ 8
☐ 9
☐ 10
☐ 11
☐ 12 +
☐ Don’t know
☐ No 
☐ Yes
☐ Don’t know
Month: ______
Year: ______
☐ Quality of care
☐ Management
☐ Record keeping
☐ Data reporting
☐ Data use
☐ Don’t know
☐ No 
☐ Yes
☐ Don’t know
234 IHP officials ☐ 0
☐ 1
☐ 2
☐ 3
☐ 4
☐ 5
☐ 6
☐ 7
☐ 8
☐ No 
☐ Yes
☐ Don’t know
Month: ______
Year: ______
☐ Quality of care
☐ Management
☐ Record keeping
☐ Data reporting
☐ Data use
☐ Don’t know
☐ No 
☐ Yes
☐ Don’t know
358 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 9. STAKEHOLDER COORDINATION & COLLABORATION
The next questions are about different kinds of interactions your DPS may have with other provincial offices.
NO QUESTION RESPONSE SKIP/ INSTRUCTIONS
Communication
235 How often do you communicate with different health 
zone offices?
[ ] Monthly or more often
[ ] Quarterly
[ ] Twice a year
[ ] Annually
[ ] Irregularly
[ ] Don't know
236 Since October 2018 when the IHP project was 
implemented, would you say this DPS had more, less, 
or about the same amount of communication with 
health zone offices?
[ ] MORE
[ ] LESS
[ ] ABOUT THE SAME
[ ] DON’T KNOW
237 How many other provincial offices does this DPS 
communicate with for professional reasons at least 
quarterly?
|__|__|__|
If 0,  239
238 How often do you communicate with other provincial
offices?
[ ] Monthly or more often
[ ] Quarterly
[ ] Twice a year
[ ] Annually
[ ] Irregularly
[ ] Don't know
239 Since October 2018 when the IHP project was 
implemented, would you say this DPS had more, less, 
or about the same amount of communication with 
other provincial offices?
[ ] MORE
[ ] LESS
[ ] ABOUT THE SAME
[ ] DON’T KNOW
Please tell me how often you or someone from your organization does each of the following things as part of their day-to￾day work.
240 Do you or does someone from your office attend 
technical or partner review meetings?
[ ] Yes
[ ] No
If no, go to Section 10
241 How many times have these meetings been held? [ ] 0
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6
[ ] 7
[ ] 8
[ ] 9
☐ 9
☐ 10
☐ 11
☐ 12 +
☐ Don’t know
Baseline Report 359
[ ] 10
[ ] 11
[ ] 12 or more
[ ] Don't know
242 How many times have you or someone from your 
office contributed ideas or lessons learned at these 
technical or partner review meetings?
[ ] 0
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6
[ ] 7
[ ] 8
[ ] 9
[ ] 10
[ ] 11
[ ] 12 or more
[ ] Don't know
243 How many times have you or someone from your 
office served as a meeting facilitator or guest 
speaker?
[ ] 0
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6
[ ] 7
[ ] 8
[ ] 9
[ ] 10
[ ] 11
[ ] 12 or more
[ ] Don't know
244 How many times have you or someone from your 
office worked with other DPS officials at these
meetings to influence decision-making or 
development of strategies?
[ ] 0
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6
[ ] 7
[ ] 8
[ ] 9
[ ] 10
[ ] 11
[ ] 12 or more
[ ] Don't know
360 The Impact of USAID’s Integrated Health Program in the DRC
SECTION 10. CAPACITY BUILDING 
This next section includes questions about specific local-level entities and organizations your DPS has worked with to strengthen institutional capacity and improve health of 
Congolese citizens. By “work with” we mean both informally, for example through exchange of information, and formally, for example by attending the same training or 
workshop. The term “local-level entities” includes other health zone offices in addition to government enterprises other than the Ministry of Health (e.g. Ministry of Finance, 
Ministry of Education) and private sector partners. “Organizations” refers to all non-governmental institutions that have provided technical, financial or other support.
List the organizations 
and other local-level 
entities with whom 
you have worked over 
the last 6 months to 
help achieve goals 
related to 
strengthened capacity 
and improved health 
outcomes.
Over the last 6 months 
how frequently have you 
worked with this 
organization?
In the last 6 months, 
how often did your 
office share or exchange 
information with THIS 
ORGANIZATION?
In the last 6 months, 
how often did your 
organization jointly plan, 
implement or monitor 
an activity, event, or 
service with THIS 
ORGANIZATION? 
In the last 6 months, 
how often did your 
office receive technical 
assistance from THIS 
ORGANIZATION to 
strengthen skills in data 
analysis, use and 
reporting? 
In the last 6 months, 
how often did your 
office receive financial or 
other support from THIS 
ORGANIZATION to build 
institutional capacity?
Does your office have a 
formal relationship with 
THIS ORGANIZATION, 
through a contract, 
memorandum of 
understanding or some 
other written document 
describing your 
partnership?
Responses 1=Never
2=Once, twice, or just a 
few times 
3=Monthly
4=Weekly
5=Daily
1=Never
2=Once, twice, or just a 
few times 
3=Monthly
4=Weekly
5=Daily
1=Never
2=Once, twice, or just a 
few times 
3=Monthly
4=Weekly
5=Daily
1=Never
2=Once, twice, or just a 
few times 
3=Monthly
4=Weekly
5=Daily
1=Never
2=Once, twice, or just a 
few times 
3=Monthly
4=Weekly
5=Daily
0 = NO
1 = YES
98 = DON’T KNOW
Thank you for the time.
Interview End Time: Hour |___|___| Minutes |___|___|
Baseline Report 361
In-depth Interview Guide
General
What in your view are the major obstacles to health service utilization? How do these factors vary 
across health zones and regions? 
How would you describe the present quality of health services offered in this facility? What are the 
deficits and how could quality be improved? 
Availability of quality, integrated facility-based health services
What comprises the basic package of health services? What services does your facility provide? What 
services are devoted to child health?
Has an assessment of the availability of quality, integrated health services been carried out in this 
facility? If so, when and what were the results and follow up actions? 
Have any of the facility staff received training or attended a workshop in the past year? If so, what did 
this entail? How would you assess the training received?
To what extent are treatment protocols available for different childhood diseases? How are these 
protocols used? Are there any other tools such as service flowcharts and technical guidelines which 
health providers in this center follow? When were these tools introduced? Do you feel that these tools 
are useful? Why or why not?
To what extent are child health services integrated in respect to either treatment or preventive care? 
Can you please give me some examples of integration of these services? How could integration be 
improved? 
Availability of quality, integrated community-based health services
How would you describe the community-based health services in your area? Has there been an
assessment of the CODESAs in this area? Do the CODESAs receive any training, technical assistance or 
mentoring? What is the current role of the CODESAs in this area? How many CODESAs are female?
How many CHWs are presently active? How many of the active CHWs are female and how recently did 
they become CHWs? As CHWs, what does their work entail? Have the CHWs received any recent 
training or attended competency workshops? If so, what did the training entail and how would you 
assess the training received?
What are the community-based organizations and structures in place to promote health care and 
provide services? What types of activities do they engage in? Do they have adequate materials to carry 
out these activities? What are some of the strengths and weaknesses of these activities? To what 
extent are these activities coordinated? What are some needed changes to improve their work?
Do you have functioning iCCMs in this area? If so, what services related to child health care are 
available and how often are services offered? What medications, supplies, equipment and tools are 
available to provide services? Are CHWs permitted to prescribe medications for child illnesses, such as 
antibiotics? Are the services sufficient to meet the population needs? What are some of the challenges 
in providing community-based services? 
362 The Impact of USAID’s Integrated Health Program in the DRC
Are facility-based workers involved in any community outreach activities or training of community 
workers? Please explain. 
Is community monitoring such as community scorecard approaches carried out in this area? If so, how 
does this work and who is involved? What is the overall purpose of community monitoring? 
Referral systems from community-based platform to health centers to reference hospitals
What are the current referral processes from the community and health center level to higher facilities? 
What types of health conditions require referral to a higher facility? Which workers have the authority 
to make a referral? How is tracking of referrals or counter referrals conducted? To what extent are 
mobile phones used to monitor referrals?
Are specific guidelines in place for referrals and counter referrals? If so, what are some of the 
recommendations regarding referrals? 
At present, when do referrals generally occur? What are some of the barriers that hinder acceptance to 
referrals? How are patients transported to referral facilities? Are there any mechanisms set up to assist 
community members with transport?
What training have CHWs received regarding referrals? What about the facility-based providers?
Health provider attitudes and interpersonal skills at the facility and community levels 
How would you describe facility-based health provider relations with patients? Are there aspects of the
health provider-patient interaction that needs improvement? Do you feel that facility-based providers 
are generally respectful towards and sensitive to the needs of caregivers of young children? Are there 
any instances where you or your colleagues exhibit behavior with caregivers that you feel is 
inappropriate or could be improved? Please explain. Why do you feel that these occurrences occur?
How would you describe CHW relations with community members? Are there aspects of the CHW￾patient interaction that needs improvement? Do you feel that CHWs are generally respectful towards 
and sensitive to the needs of caregivers of young children? Are there any instances that you can recall 
when CHWs exhibited behavior with caregivers that you felt was inappropriate? Please explain. Why do 
you feel that these occurrences occur?
We all know that certain behaviors or health conditions may evoke negative responses in the 
community. Are there types of patients (e.g. pregnant adolescent girls, HIV-infected patients, poor 
patients, children with disabilities) or medical conditions (SGBV, HIV, fistula, etc) you see in the health 
center or community that may cause health care providers to show less sensitivity or compassion? 
Please explain. 
How does the sex of the provider and patient impact on health provider-patient interactions? How can 
this be explained, is it related to cultural issues, power, economics? How does the age of the provider 
and patient impact on health provider-patient interactions?
Why do you think that some health providers have negative attitudes towards patients? How does this 
affect community members health care seeking behavior? How do you think that health provider 
attitudes and behaviors could be improved? Have you ever participated in a group session when health 
Baseline Report 363
provider attitudes and behaviors have been discussed? Have you ever received training focused on 
health provider behaviors and ways to improve provider-client interactions? 
Are there ways to report negative attitudes or practices carried out by health providers? In other parts 
of the country, hotlines have been set up to allow for reporting of negative health provider behaviors 
and practices. Does anything like that exist in this area? If so, do people use the hotline? If not, do you 
think that people would be willing to use the hotline? Why or why not? Might there be any concerns 
about retaliation for reporting bad behavior or practices?
Availability of innovative financing approaches
What are some of the biggest barriers to health care seeking for child health services? To what extent 
do user fees dictate careseeking for treatment of childhood illness? What about for preventive care 
such as well baby visits and vaccinations? 
Have any assessments been carried out in this health facility or area to explore possible ways to finance 
health care so that costs for poorer members of the population would be reduced? Are any strategies 
presently used to reduce costs for vulnerable members of the population who cannot afford health 
care? If so, how does this work? Is it effective in increasing demand for services?
Do you know of health financing initiatives (e.g. vouchers, mutual, emergency funds, etc.) introduced to 
make health care costs more affordable and to increase demand for services? What about cost recovery 
schemes? How do you feel that these initiatives would work in this context?
Basic facility infrastructure and equipment to ensure quality services
What year was this facility constructed? Has your health facility ever been renovated? If so, why was 
this facility chosen to be renovated? Please explain what exactly was done. 
Do you feel that any renovations are presently needed in this facility? If so, what exactly would you like 
to see renovated? Have you taken any initiatives to make sure that these renovations are done? If so, 
what did you do? Who, if anybody, did you contact? Do the personnel in the central health zone know 
that you feel that these renovations are needed?
Is basic equipment available in this health facility? When you are in need of equipment, what is done? 
Who do you contact/how is it obtained? When was the last time you received health care equipment? 
Is there any equipment that you do not have that you feel is needed to carry out essential health care? 
Is there any equipment that you do not have that you feel is needed to carry out essential child health 
care?
What do you do when health equipment needs repair? Who do you contact and how are repairs 
financed? How is the health facility equipment maintained? 
Collaboration between central and decentralized levels through sharing of best practices and 
contributions to policy dialogue
Do you participate in any forums or working groups such as meetings with the DPS or zonal offices that 
facilitate exchanges of lessons learned from the field? If so, what forums do you participate in, how 
regularly do you participate and what transpires during these meetings? Are you encouraged to share 
364 The Impact of USAID’s Integrated Health Program in the DRC
field experiences of best practices or challenges during these meetings? If so, how is this information 
used?
Are there other ways that you disseminate or share field experiences with other government workers or 
implementing partners such as NGOs or UN agencies? Do you feel that these exchanges are important? 
Why or why not? How could they be improved? 
Have you participated in meetings that focus on the development of community activities? To what 
extent have these interactions affected community activities?
Are you able to receive information that helps you to be more effective in your work? Are you satisfied 
with the information that you receive or would you like to receive more information? Do you have any 
suggestions regarding ways to receive information that would allow you to be better informed? 
Has any research been carried out in this area related to health services? If so, how was the research 
used or disseminated? Do you feel that research related to the health services offered would be 
beneficial? Why or why not? 
Practice of priority healthy behaviors at the individual, household and community levels
How is information about curative or preventive health care for young children related to malaria, 
diarrhea or pneumonia or child vaccinations disseminated? When and what type of information is 
shared in the facility? What about at the community level? 
Have you ever invited community members to the health center to learn about the facilities being 
offered? If so, please explain. 
Do CHWs, CODESAs or other health center staff ever visit people’s homes to provide information on 
child health? If so, how often are home visits conducted? What type of information is shared and who 
in the household do they share it with? 
Are there other ways that information on child health care is disseminated? For instance, are
community meetings ever led by health workers or community leaders? If so, how often and what 
information is provided? 
Are any campaigns related to child health care offered? If so, how often and what services are 
provided? Who in the community is eligible to receive these services? 
Are there any local community organizations or groups providing information on child health care? Is 
information ever shared in schools or churches? If so, please describe who is involved and the type of 
information shared.
Are there other ways that information on child health care is disseminated such as through the 
television, radio or mobile phone? If so, what type of information is provided? What do you think about 
this venue and the type of information provided? 
To what extent is research used to follow and reach out to specific cases in the community? Do you 
ever use more personalized messaging approaches to reach out to patients or caregivers? 
What type of treatment is offered to children suffering from malaria, diarrhea or pneumonia? Are there 
other places where community members can receive treatment for these illnesses? Is treatment for 
Baseline Report 365
these illnesses offered at the community level? What are some of the challenges you face in offering 
treatment for these childhood illnesses?
What about preventive care for these illnesses? For instance, are you involved in distribution of 
insecticide treated nets? How and how often are nets for young children distributed? Who is eligible to 
receive a net? What are some of the challenges you face in providing nets for young children?
How are child vaccinations offered? What vaccinations are offered and how often? Who is eligible to 
receive vaccinations? What are some of the challenges you face in providing essential vaccinations for 
young children?
What can you tell us about Champion Communities? Do you have any Champion Communities in this 
area? 
Have you or any of the health staff ever been invited to participate in community discussions about 
barriers community members face in accessing the health center? How about discussions around the 
practice of healthy behaviors such as rapid treatment for diarrhea, vaccinations for young children, or 
placing children under a net at night? If so, what exactly was discussed?
Do you know how the messages related to healthy behaviors disseminated during well baby visits, 
community meetings or home visits were developed? During your time working in the health center or 
at the community level, have these messages changed or been modified in any way? Please explain. 
What do you think about the content of these messages? How would you suggest that the messages be 
improved? 
Staff motivation and needs
What motivates health facility employees to perform their work well? What sort of potential is there for 
work advancement? How are employees compensated? How do you feel about the way that employees 
are compensated? What is needed to improve job performance? 
What are the capacity building needs in your health facility? How do you think that training 
opportunities would strengthen work performance? To what extent do you think that health center 
staff are satisfied with their work? Why do you feel this way? 
What motivates community workers to carry out their work? What is needed to improve their 
performance?
What are the capacity building needs of community health workers including CODESA and CHWs? How 
do you think that training opportunities would strengthen their work performance? To what extent do 
you think that community health workers are satisfied with their work? Why do you feel this way? 
What mechanisms are presently set up to ensure transparency and accountability in the health center? 
How effective are these mechanisms? How might they be improved? Are funds or resources ever 
misused to compensate for poor pay? 
366 The Impact of USAID’s Integrated Health Program in the DRC
Key Informant Guide
General questions
How would you describe the health systems in the DR Congo? What are the strengths of the health 
systems? What are the weaknesses?
What should the role of the government be in the provision of health care? How would you describe 
the way the government is fulfilling that role? What needs to be done to improve the government’s role 
in strengthening health systems so that they are better meet the needs of the population?
Overall, what are the primary needs related to institutional strengthening and support to DRC health 
systems and service delivery? How do you see these needs being fulfilled?
Where does the decentralization of health care stand in the DRC? What is needed to ensure that health 
systems decentralization is carried out as planned?
Institutional and individual capacities to plan, lead, execute, and monitor health action plans
National level
How would you describe the capacity of health personnel to plan, implement and monitor health 
services at the different levels? 
What are the necessary steps to build capacity to plan, implement and monitor health services at the 
provincial, zonal and facility level? What organizations need to be involved to ensure that these steps 
be followed? What is your role or your organization’s role to ensure that these steps be carried out?
What challenges do you anticipate facing related to building institutional and individual capacities? How 
can these challenges be addressed?
Provincial and zonal levels
How would you describe a well-functioning provincial or zonal office? How does your office meet that 
description? What are some of the strengths and weaknesses in regard to the functioning of your 
office? What about your role in the office, how do you see your strengths and weaknesses in regard to 
contributing to a well-functioning office setting?
What do you see as the primary capacity building needs in this office? Have you or the office ever 
undergone an assessment such as PICAL to identify capacity building needs?
How would you describe the office organization? Who is in charge and what is the hierarchy of 
command? 
How would you describe a good leader? What are the skills needed to provide effective leadership? Do 
you feel that you or others in this office possess those skills? Why or why not? 
In this office, how do you plan health activities? Is there a set schedule for the development of health 
action plans? Who is involved in developing health plans and what are their roles? What needs to be 
considered when developing a health action plan? 
Baseline Report 367
How does your office ensure implementation of health plans? What steps are involved in overseeing a 
health plan is carried out as envisioned and who is involved? What are some of the challenges in 
implementing a health plan and how are they addressed? 
How does your office monitor health services? What are some of the challenges in monitoring health 
services? What do you do with the monitoring information? How does the information collected inform 
decision making?
What are management needs in your office setting? Who takes on management roles? What are some 
of the challenges your office faces in managing the office? What are your needs in regarding to 
improving capacity of management skills? 
Have you or others in your office ever participated in peer-to-peer learning during provincial or health 
zone meetings? If so, what did this entail?
What do you know about performance-based financing? Have you ever participated in RBF workshops 
or been involved in RBF efforts? If so, please explain. 
Transparency and oversight in health service financing and administration
National level
What are the key actions needed to improve transparency and oversight in health service financing and 
administration at the zonal, facility and community level?
What in your view is needed to improve capacity in administrative and financial management at the 
different levels? 
How do you define general inspection? What is the role of general inspection in regard to strengthening 
transparency and accountability? How is general inspection carried out now? What activities will be 
implemented over the course of the project aimed at strengthening general inspection? What do you 
anticipate in regard to challenges in implementing these activities?
What actions are needed to increase transparency and report abuse? What do you know about the 
fraud and complaints hotline? How does this work and to what extent it could be effective in addressing 
corruption? 
For the IGS, what is your role in terms of coaching, regulation and supervision of the IPS in the provinces
in financial management? How often do you make visits? How many visits have you made over the past 
year? Do you feel that these visits are effective in supporting capacity building? How could these visits 
be improved? 
Provincial and zonal level
How does financial management in your office work? What sort of training and assistance have staff 
members received in regard to financial management and budget planning? What are some of the 
challenges in regard to financial management and budget planning? How does this affect the 
functioning of your offices and health care delivery? What are your needs in regard to improving 
financial management? 
368 The Impact of USAID’s Integrated Health Program in the DRC
How does administrative management in your office work? What sort of training has been received in 
regard to administrative management? What are some of the challenges in regard to administrative 
management? How does this affect the functioning of your offices and health care delivery? What are 
your needs in regard to improving administrative management? 
What is the role of CACs and the CODESAs in regard to administrative and financial management? How 
could these actors be involved to improve transparency and accountability of the healthcare system? 
Why do you think that corruption is such a big problem in the health care systems? What is presently 
being done to address fraud and corruption? How could oversight of fraud and corruption be 
improved? What do you know about the fraud and complaints hotline? How does this work and to 
what extent it could be effective in addressing corruption? 
How do you define general inspection? How is general inspection being conducted? What is the role of 
general inspection in improving accountability? 
CSO and community structures to provide health systems oversight
What in your view is the role of community members in the oversight of health services? How could 
their involvement be improved? 
To what extent do community members and organizations participate in the identification of health 
problems and the needs of local populations? Do you view their participation as important? Why or 
why not? 
What mechanisms could be used to ensure greater dialogue between community members and health 
providers and community participation in health care planning, implementation, and monitoring? What 
are some of the challenges in ensuring greater community involvement? What community monitoring 
tools presently exist and how are they used? 
To what extent are women involved in decision making in communities? Do you view women’s 
involvement in decision making related to health care important? Why or why not? What approaches 
could be used to facilitate greater female involvement? 
At the provincial and zonal level, when was the last time an assessment of CODESAs was conducted? 
What is the present role of CAC and CODESA in the oversight of health services? When was the last time 
the CACs and CODESA were trained or received technical assistance and what did this entail? Have 
CODESAs in this area been trained to carry out community assessments? If so, how are these 
assessments being used? 
Have any of the health zones in this area been awarded community grants for facility improvements or 
emergency transportation plans? 
Have community organization and CODESA ever received training on gender issues?
Stakeholder coordination at the provincial and zonal levels
How would you describe coordination of health activities by different stakeholders at the provincial and 
zonal levels? Why is this important to the functioning of the health system? What are some 
Baseline Report 369
recommendations regarding ways to improve coordination? What resources are needed to make those 
improvements?
At the provincial and zonal levels, what coordination meetings are presently held at the provincial, zonal 
and community levels? How often are these meetings held? How would you describe the meeting 
management in regard to organization, documentation and follow up? Have any changes in the 
management recently occurred? What is discussed during these meetings? Is the financial and 
technical support adequate to carry out these meetings regularly? 
Disease surveillance and strategic information gathering
How is disease surveillance presently carried out? What are some of the strengths and weaknesses 
related to disease surveillance? Are there challenges related to capacity or the availability of technical 
resources and equipment? How would you describe the data quality (comprehensiveness, promptness, 
and accuracy) and what needs to be done to improve the quality of data collected during surveillance? 
How is routine data collection in health facilities presently carried out? What are some of the strengths 
and weaknesses related to routine data collection? Are there challenges related to capacity or the 
availability of technical resources? How would you describe the data quality (comprehensiveness, 
promptness, and accuracy) and what needs to be done to improve the quality of routine data collection? 
How would you describe the capacity of personnel at the provincial and zonal levels to collect, transmit, 
analyze, interpret data collected through surveillance (e.g. Maladie a Potential Epidemique) or routine 
data collection (e.g. DHIS2) to inform decision making? What sort of technical training or other support 
have they received in the past? What is expected of health center staff in regard to reporting of data 
during monthly zonal meetings or quarterly provincial data reviews? What in your view is needed to 
improve use of the data collected to inform health service planning? 
To what extent has mobile phone-based reporting been introduced?
How is reporting of community health worker activities done? What are the needs in regard to 
community reporting?
At present, how is data validation carried out? Are meetings or technical sessions carried out at the 
provincial level to validate the data? If so, how often and who attends? 
Management and motivation of human resources in health
What triggers the recruitment of health personnel? How are health personnel presently recruited? How 
is gender considered when recruiting or deploying staff to another area? Do you think that gender 
should be a primary consideration related to staff recruitment? Have you ever been advised to recruit 
more women in the health services? If so, were the recommendations followed? Why or why not?
To what extent are resource management tools such as iHRIS and the DHIS2 data used for staff 
recruitment, recruitment based on real needs, and the available budget for recruitment? What other 
systems are available to assess needs and manage staff recruitment? What do you know about the data 
quality audit processes to identify and remove ghost workers and ensure current staff are on payroll?
370 The Impact of USAID’s Integrated Health Program in the DRC
What if any incentives (both positive and negative) are presently offered to motivate personnel or 
discourage bad practices? Do you consider these motivators effective? What other motivators would 
you like to see considered? 
At the provincial and zonal level, how are job descriptions and roles developed? What if any coaching or 
supervision takes place to ensure that staff are fulfilling their roles? What approaches or tools are used 
to support supervisions?
Availability of essential commodities
How would you describe the supply chain for drugs and essential products down to the health facilities 
and communities? What are some of the weaknesses in the system that need to be addressed? How is 
the coordination of the supply chain stakeholders and how does this effect the efficiency of distribution? 
How would you describe the national and provincial supply chain data management, quantification, 
procurement and distribution? What are the major challenges and how can they be addressed? What 
training has been received regarding supply chain management including forecasting needs, 
distribution, tracking and inventory management of supplies and drugs?
At the zonal and health facility level, have any assessments been conducted of the supply chain? What
is the capacity at the zonal level to report, forecast and quantify supply chain needs? What are the 
major bottlenecks in getting essential supplies to health zones? Where are the supplies stored and what 
are the storage conditions?
What is the capacity at the health facility level to manage inventory and report needs for supplies on a 
regular basis? What training have zonal and facility level staff received on quantification of supply chain 
needs and reporting and inventory management? What stock and data management tools are 
available? 
What supervisory visits are undertaken at the zonal and health facility level to ensure that supply chain 
management, quantification and requisition is carried out?
How is transport of essential medicine from health zones to health facilities presently conducted? Is 
private or public transport used? How are transport costs supported? Have there been any recent 
changes in transport of supplies?
Collaboration between central and decentralized levels
How is information sharing related to program activities and lessons learned currently carried out? 
What are the weaknesses and strengths in the current mechanism to share information?
What meetings or workshops do you currently participate in that allow you to coordinate activities and 
share information that could potentially impact on national policies and strategies? Are these forums 
sufficient or could they be improved?
Staff motivation and needs
What motivates government health employees to perform their work well? What sort of potential is 
there for work advancement? How would you assess the way that government officials are 
compensated? What is needed to improve job performance? 
Baseline Report 371
What are the capacity building needs in your offices? How do you think that training opportunities 
would strengthen work performance? To what extent do you think that people in your office are 
satisfied with their work?
372 The Impact of USAID’s Integrated Health Program in the DRC
Focus Group Discussion Guide
General
When was the last time you went to the health center to access services? What was the reason for your 
visit? When did you last go to the health center to obtain health services for your young child? What 
services were obtained? 
Why did you select the health center for care? What are some of the challenges in obtaining care at the 
health center? 
What health services are offered at the health center for young children?
How would you describe the child health care services offered at the health center? How could the 
quality be improved? 
Practice of priority healthy behaviors at the individual, household and community levels/use of facility 
and community-based health services
Where do you get information about health care for young children such as treatment or prevention 
related to malaria, diarrhea or pneumonia or child vaccinations? If the health center is mentioned, 
when is information shared? What type of information is shared? How often do you receive this type of 
information? To what extent do you follow the advice provided? Why or why not?
Have you ever been invited to the health center to learn about the facilities being offered? If so, please 
explain. 
Do people ever come to your home providing information on child health? If so, who are these people 
and how often do they visit? What type of information do they share and who in the household do they 
share it with? To what extent do you follow the advice provided? Why or why not?
Are there other ways that you receive information on child health care? For instance, do you ever 
participate in community meetings where information is disseminated by health workers or community 
leaders? If so, how often and what information is provided? Has this information changed any of your 
behaviors or practices related to child health care? If so, please give us an example.
Are any campaigns related to child health care offered in your area? If so, how often and what services 
are provided? Who in the community is eligible to receive these services?
Do you know of any local community organizations or groups providing information on child health 
care? Is information ever shared in schools or churches? If so, please describe who shares the 
information and the type of information presented.
Are there other ways that you have received information on child health care? How many of you have a 
television? Radio? Mobile phone? Have you even received information related to child health through 
any of the television, radio or phone? If so, what type of information have you received? What do you 
think about the way this information was provided? What do you think about the content of the 
information? Has this information changed any of your behaviors or practices related to child health 
care? If so, please give us an example.
Baseline Report 373
Where do you generally get treatment for your children when they have malaria? Diarrhea? 
Pneumonia? Are there other places where you can receive treatment for these illnesses? Are there 
treatment services offered at the community level through the health center? What guides decision 
making related to careseeking and who in your household is involved?
What do you know about child vaccinations? How often do you have your children vaccinated? Where 
does your child get vaccinated? Are there any challenges to getting your young children vaccinated? 
Please explain. 
Do you have a net in the household? If so, when and where did you get it? How and by whom is it 
used? 
Sociocultural barriers to the use of health services and the practice of key healthy behaviors
Have any of you ever been invited to participate in community discussions about the use of the health 
center and barriers in accessing the health center? How about discussions around the practice of 
healthy behaviors such as rapid treatment for diarrhea, vaccinations for young children, or placing your 
child under a net at night? If so, what exactly was discussed?
What in your view are the biggest obstacles to using the health facilities for treatment of childhood 
illnesses? How many of you attend well baby visits? Why or why not? Why do certain members of your 
community choose not to attend these sessions? 
Are most young children in your community fully vaccinated? What are some of the challenges 
caregivers face in getting their young children vaccinated?
How often and by whom are nets distributed? Who is eligible to receive nets when they are 
distributed? Do most people in your community place young children under nets at night? Why or why 
not? 
374 The Impact of USAID’s Integrated Health Program in the DRC
Observation of the health center infrastructure and supplies
Yes No Comments
Has the health center been 
renovated within the last 
five years?
Is electricity available in the 
health center?
Is there a separate area of 
the building where child 
health services are 
provided?
Is an infant treatment table 
available?
Is an infant scale and salter 
weighing scale with 
trousers available?
Is a weighing scale and 
height measure available?
Are growth monitoring kits 
available?
Is sterilizing equipment 
available?
Does the health provider 
have key instruments such 
as a stethoscope, 
thermometer, and timer? 
Are essential medications 
available such as zinc, ORS, 
amoxicillin, ACTs and other 
malaria drugs?
Are treated mosquito nets 
available?
Are rapid diagnostic kits for 
malaria available?
Are all essential 
vaccinations available?
Is there a refrigerator which 
is functioning?
Are fee schedules posted?
Baseline Report 375
Are there educational 
materials such as posters on 
the walls?
Are there BCC 
materials/aides for the 
health workers to use?
Is there evidence of 
activities to discourage 
fraud and increase 
transparency such as a 
hotline or a complaint box?
We plan to take photographs of the exterior and interior of the health facilities, equipment and 
materials to record conditions in the health centers. Photographs will not be taken of clientele including 
caregivers and children observed during the health provider-caregiver interactions. 
376 The Impact of USAID’s Integrated Health Program in the DRC
Interviewer and interview location
I. Identify of research assistant First name Last name Date
Research assistant ……………………………… ……………… ….../……/……
II. Place of interview
Reference hospital/Health center or post …………………………………………………………………………………….
Name of structure …………………………………………………………………………………….
Background information on the health provider observed
Age ______ years
Maximum schooling attained
 Primaire
 Secondaire
 Supérieur
Training of the health worker observed
Title
 Physician
 State nurse
 Midwife
 Other …………………………….
Years working in this position ______ Years
Participation in training focusing on treatment for 
childhood illnesses?
 Yes
 No
If yes, how recently?
Illnesses focused on during the training?
 ARI
 Diarrhea
 Malaria
 Others ………………………….….. 
Length of time of last training attended?
 1 day or less
 2 – 4 days
 More than 4 days
Observations of health provider/caregiver interaction
Baseline Report 377
Waiting area and triage
Yes No Comments
At the hour that treatment 
services became available, 
were caregivers waiting to 
see the health worker?
Was there a designated 
waiting area for caregivers 
and sick children?
Was this area separate from 
the area where well baby 
services are carried out?
Were there seats available 
and were there enough 
seats for all of the 
caregivers and patients?
Was triage carried out to 
ensure that more serious 
cases were examined first?
Did caregivers have to wait 
more than 15 minutes 
before the child was seen 
for treatment?
Was the waiting area clean 
and orderly?
Were there educational 
materials such as posters on 
the walls of the waiting 
area?
Were sick children (other 
than those who were seen 
earlier due to the 
seriousness of their 
condition) seen in the order 
that they arrived at the 
health center?
Were any 
caregivers/children sent 
away without being 
treated?
378 The Impact of USAID’s Integrated Health Program in the DRC
Health provider interactions with the caregiver and child
Yes No Comments
Did the health worker greet 
the caregiver?
Did the health worker ask
for the name of the child?
Did the health worker ask 
questions regarding the 
presence of fever and the 
duration?
Did the health worker ask 
questions on the presence 
of cough and the duration?
Did the health worker ask 
questions on the presence 
of diarrhea, frequency and 
duration and whether there 
is mucus or blood in the 
stool?
Did the health worker ask 
questions about the 
treatment given prior to 
bringing the child to the 
health facility?
Did the health worker 
determine the age and 
weight of the child?
Did the health worker 
physically examine the 
child?
Did the health worker 
follow a treatment protocol 
when diagnosing the illness 
and providing treatment 
recommendations?
Did the health worker 
explain the diagnosis and 
treatment regimen?
Did the health worker 
provide medication or a 
prescription?
In the case of diarrhea, did 
the health worker provide 
ORS sachets and zinc 
tablets? 
In the case of diarrhea, did 
the health worker provide 
Baseline Report 379
counseling on the 
administration of ORS and 
zinc?
Did the health worker 
provide counseling on 
feeding the young child
?
Did the health worker 
request that the caregiver 
return to the health facility
immediately if illness signs 
worsen?
Did the health worker ask 
questions to confirm that 
the caregiver understood 
the diagnosis and home 
treatment and ask the 
caregiver whether s/he had 
any additional questions
?
Did the caregiver ask the 
health provider any 
questions?
Did the caregiver appear to 
understand the information 
provided by the health 
worker?
Did the health provider 
request that the caregiver 
bring the child back for a 
follow up visit?
Was the session 
interactive?
Was the health worker 
respectful towards the 
caregiver and the child?
Was the consultation 
carried out in a setting 
where privacy was maintained?
Other comments/observations
380 The Impact of USAID’s Integrated Health Program in the DRC
Appendix 3. Evaluation Team Members
Evaluation team
David Hotchkiss, PhD is a Professor in the Department of Global Community Health and Behavioral 
Sciences at the Tulane School of Public Health and Tropical Medicine. His current research focuses on 
the monitoring and evaluation of health systems strengthening strategies in low- and middle-income 
countries including: health care financing mechanisms; health workforce strategies; and routine health 
information systems. Dr. Hotchkiss has been conducting health systems research in the DRC since 2013. 
As principle investigator, he is responsible for overseeing all phases of the evaluation, including research 
design, data collection, data analysis, and report writing.
Janna Wisniewski, PhD is a Research Assistant Professor in the Department of Health Policy and 
Management at the Tulane School of Public Health and Tropical Medicine. Dr. Wisniewski specializes in 
operations research and evaluation of health system strengthening projects and has been conducting 
research in the DRC since 2015. As a co-investigator, she is responsible for overseeing activities and 
analysis related to the quantitative component of the study, including the training of supervisors and data 
collectors responsible for the facility, health zone office, and provincial health office surveys, the 
compilation and analysis of DHIS2 data, and writing reports based on the study findings.
Lauren S. Blum, PhD, MPH is an Adjunct Professor at the Tulane School of Public Health and Tropical 
Medicine and a consultant to D4I. Dr. Blum has over 20 years of experience designing, implementing, 
and analyzing qualitative research focusing on sociocultural factors and behaviors related to child and 
maternal health and nutrition, infectious disease transmission, and WASH in low-income communities in 
Africa and Asia. Since 2013, she has collaborated with Tulane University on evaluations of health 
systems strengthening projects in the DRC. Dr. Blum has worked in the DRC over a period spanning 
several decades and speaks French. Dr. Blum is responsible for overseeing all activities and analysis 
related to the qualitative research. 
Paul Lusamba Dikassa, MD, PhD is a Professor in the Department of Epidemiology and Biostatistics at
the School of Public Health, University of Kinshasa. He has been conducting research for several years in
DRC. As co-investigator, he participated in the elaboration of the evaluation protocol. On the ground, he
is additionally responsible for organizing and coordinating the local research team and supervising the
field activities related to this project, including the pretesting of the quantitative data collection
instruments and the training of field supervisors and data collectors. Paul Lusamba also participates in
the drafting of study reports.
Eva Silvestre, PhD is a Clinical Assistant Professor in the department of Global Community Health and
Behavioral Sciences and has worked in the areas of HIV prevention, treatment, and communication,
reproductive health, health information systems strengthening, and technology use in healthcare settings.
She has experience using both quantitative and qualitative methods for program evaluation. She has
worked both domestically and internationally, including living in Ethiopia working with a Regional
Health Bureau to improve data quality and use and working with community organizations in New
Orleans. Her work currently focuses on health information system strengthening in low- and middle￾income countries. She is currently the principal investigator for MEASURE Evaluation and Data 4
Impact.
Baseline Report 381
Charles Stoecker, PhD is an Associate Professor in the Department of Health Policy and Management at 
the Tulane School of Public Health and Tropical Medicine. Dr. Stoecker holds a doctorate in economics 
and functions as an applied econometrician on the research team. He brings experience with practical 
applications of differences-in-differences models, propensity score matching models, doubly robust 
estimators, and issues of multiple imputation to the project.
Matt Worges, MSc is a doctoral candidate in the department of Tropical Medicine at the Tulane School 
of Public Health and Tropical Medicine. Mr. Worges' current and previous work has involved critical 
evaluation of survey methodologies used in low-resource settings, monitoring and evaluation of projects 
designed to improve malaria diagnostics, and conducting broad assessments of the state of malaria case 
management practices at health facilities in low and middle income countries. As a team member on the 
D4I project, he is responsible for coding baseline survey questionnaires in Open Data Kit, monitoring the 
data collection process and reporting out issues to the field-based supervisors in near real-time, managing
incoming data streams to construct databases, and contributing to the analysis and interpretation of those
data.
 
Disclosure of Conflict of Interest for USAID Evaluation Team Members 
Name
Title
Organization
Evaluation Position? Team Leader Team member
Evaluation Award Number (contract 
or other instrument)
USAID Project(s) Evaluated (Include 
project name(s), implementer 
name(s) and award number(s), if 
applicable)
I have real or potential conflicts of 
interest to disclose.
Yes No
If yes answered above, I disclose the 
following facts:
Real or potential conflicts of interest may include, 
but are not limited to:
1. Close family member who is an employee of the 
USAID operating unit managing the project(s) 
being evaluated or the implementing
organization(s) whose project(s) are being 
evaluated.
2. Financial interest that is direct, or is significant 
though indirect, in the implementing 
organization(s) whose projects are being 
evaluated or in the outcome of the evaluation.
3. Current or previous direct or significant though 
indirect experience with the project(s) being 
evaluated, including involvement in the project 
design or previous iterations of the project.
4. Current or previous work experience or seeking 
employment with the USAID operating unit 
managing the evaluation or the implementing 
organization(s) whose project(s) are being 
evaluated.
5. Current or previous work experience with an 
organization that may be seen as an industry 
competitor with the implementing 
organization(s) whose project(s) are being 
evaluated.
6. Preconceived ideas toward individuals, groups, 
organizations, or objectives of the particular 
projects and organizations being evaluated that 
could bias the evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the information for any purpose other than that for which it was furnished. 
Signature
Date
Appendix 4. Signed Disclosures of Conflicts of Interest
Disclosure of Conflict of Interest for USAID Evaluation Team Members 
Name
Title
Organization
Evaluation Position? Team Leader Team member
Evaluation Award Number (contract 
or other instrument)
USAID Project(s) Evaluated (Include 
project name(s), implementer 
name(s) and award number(s), if 
applicable)
I have real or potential conflicts of 
interest to disclose.
Yes No
If yes answered above, I disclose the 
following facts:
Real or potential conflicts of interest may include, 
but are not limited to:
1. Close family member who is an employee of the 
USAID operating unit managing the project(s) 
being evaluated or the implementing
organization(s) whose project(s) are being 
evaluated.
2. Financial interest that is direct, or is significant 
though indirect, in the implementing 
organization(s) whose projects are being 
evaluated or in the outcome of the evaluation.
3. Current or previous direct or significant though 
indirect experience with the project(s) being 
evaluated, including involvement in the project 
design or previous iterations of the project.
4. Current or previous work experience or seeking 
employment with the USAID operating unit 
managing the evaluation or the implementing 
organization(s) whose project(s) are being 
evaluated.
5. Current or previous work experience with an 
organization that may be seen as an industry 
competitor with the implementing 
organization(s) whose project(s) are being 
evaluated.
6. Preconceived ideas toward individuals, groups, 
organizations, or objectives of the particular 
projects and organizations being evaluated that 
could bias the evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the information for any purpose other than that for which it was furnished. 
Signature
Date
Janna Wisniewski Research Assistant Professor Data for Impact 7200AA18LA00008
USAID’s Integrated Health Program in the Democratic 
Republic of the Congo
Janna Wisniewski 03/31/2020
Disclosure of Conflict of Interest for USAID Evaluation Team Members 
Name Lauren S. Blum 
Title Medical Anthropologist 
Organization Data for Impact 
Evaluation Position? D Team Leader Ii] Team member 
Evaluation Award Number (contract 7200AA 18LA00008 or other instrument) 
USAID Project(s) Evaluated {Include USAID's Integrated Health Program in the Democratic project name(s), implementer Republic of the Congo name(s) and award number(s), if 
applicable) 
I have real or potential conflicts of D Yes Ii] No 
interest to disclose. 
If yes answered above, I disclose the 
following facts: 
Real or potential conflicts of interest may include, 
but are not limited to: 
1. Close family member who is an employee of the 
USA/0 operating unit managing the project(s) 
being evaluated or the implementing 
organization(s) whose project(s) are being 
evaluated. 
2. Financial interest that is direct, or is significant 
though indirect, in the implementing 
organization(s) whose projects are being 
evaluated or in the outcome of the evaluation. 
3. Current or previous direct or significant though 
indirect experience with the project(s) being 
evaluated, including involvement in the praject 
design or previous iterations of the project. 
4. Current or previaus wark experience ar seeking 
employment with the USAID aperating unit 
managing the evaluatian or the implementing 
organization(s) whose project(s) are being 
evaluated. 
5. Current or previous work experience with an
organization that may be seen as an industry 
competitor with the implementing 
organization(s) whose project(s) are being 
evaluated. 
6. Preconceived ideas toward individuals, groups, 
organizations, or objectives of the particular 
projects and organizations being evaluated that 
could bias the evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the informa io other than that for which it was furnished. 
Signature 
Date April 2, 2020 
 
Disclosure of Conflict of Interest for USAID Evaluation Team Members 
Name Paul Samson Lusamba Dikassa 
Title Professor 
Organization Data for Impact 
Evaluation Position? □ Team Leader � Team member
Evaluation Award Number (contract 7200AA 18LA00008 or other instrument) 
USAID Project(s) Evaluated {Include USAID's Integrated Health Program in the Democratic project name(s}, implementer 
name(s) and award number(s), if Republic of the Congo 
applicable} 
I have real or potential conflicts of LJ Yes ■ No
interest to disclose. 
If yes answered above, I disclose the 
following facts: 
Real or potential conflicts of interest may include, 
but are not limited to: 
1. Close family member who is an employee of the 
USAID operating unit managing the project(s)
being evaluated or the implementing
organization(s) whose project(s) are being 
evaluated. 
2. Financial interest that is direct, or is significant 
though indirect, in the implementing 
organization(s) whose projects are being 
evaluated or in the outcome of the evaluation.
3. Current or previous direct or significant though
indirect experience with the project(s) being
evaluated, including involvement in the project 
design or previous iterations of the project. 
4. Current or previous work experience or seeking
employment with the USA/0 operating unit
managing the evaluation or the implementing 
organization(s) whose project(s) are being 
evaluated. 
5. Current or previous work experience with an 
organization that may be seen as an industry
competitor with the implementing
organization(s) whose project(s) are being
evaluated. 
6. Preconceived ideas toward individuals, groups, 
organizations, or objectives of the particular 
µrujecls u11u uryu11i,uliu11s /Jei11y evuluuleci llrul
could bias the evaluation.
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the information for any purpose other than that for which it was furnished. 
Signature 
Date 
Disclosure of Conflict of Interest for USAID Evaluation Team Members
Name Eva Silvestre
Title Tulane team lead
Organization Data for Impact
Evaluation Position? Team Leader Team member
Evaluation Award Number (contract
or other instrument) 7200AA18LA00008
USAID Project(s) Evaluated (Include 
project name(s), implementer 
name(s) and award number(s), if
applicable)
USAID’s Integrated Health Program in the Democratic 
Republic of the Congo
I have real or potential conflicts of
interest to disclose.
Yes No
If yes answered above, I disclose the 
following facts:
Real or potential conflicts of interest mayinclude, 
but are not limited to:
1. Close family member who is an employee ofthe 
USAID operating unit managing the project(s) 
being evaluated or the implementing 
organization(s) whose project(s) are being 
evaluated.
2. Financial interest that is direct, or issignificant 
though indirect, in the implementing 
organization(s) whose projects are being 
evaluated or in the outcome of the evaluation.
3. Current or previous direct or significant though 
indirect experience with the project(s) being 
evaluated, including involvement in the project 
design or previous iterations of the project.
4. Current or previous work experience or seeking 
employment with the USAID operating unit 
managing the evaluation or the implementing 
organization(s) whose project(s) are being 
evaluated.
5. Current or previous work experience with an 
organization that may be seen as anindustry
competitor with the implementing 
organization(s) whose project(s) are being 
evaluated.
6. Preconceived ideas toward individuals, groups, 
organizations, or objectives of the particular 
projects and organizations being evaluatedthat
could bias the evaluation.
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the information for any purpose other than that for which it was furnished.
Signature Eva A. Silvestre Digitally signed by Eva A. Silvestre
DN: cn=Eva A. Silvestre, o=Tulane University, ou=Global Community Health & Behavioral
Sciences, email=esilvest@tulane.edu, c=US 
Date: 2020.04.03 11:18:34 -05'00'
Date 4/3/2020 
 
Disclosure of Conflict of Interest for USAID Evaluation Team Members 
Name Charles Stoecker 
Title Associate Professor 
Organization Data for Impact 
Evaluation Position? □ Team Leader � Team member
Evaluation Award Number (contract 7200AA 18LA00008 or other instrument) 
USAID Project{s) Evaluated {Include USAID's Integrated Health Program in the Democratic project name(s), implementer 
name(s) and award number(s), if Republic of the Congo 
applicable) 
I have real or potential conflicts of D Yes ■ No
interest to disclose. 
If yes answered above, I disclose the 
following facts: 
Real or potential conflicts of interest may include, 
but are not limited to: 
1. Close family member who is an employee of the 
USAID operating unir managing the project(s) 
being evaluated or the implementing 
organization(s) whose project(s) are being 
evaluated. 
2. Financial interest that is direct, or is significant
though indirect, in the implementing
organization(s) whose projects are being 
evaluated or in the outcome of the evaluation.
3. Current or previous direct or significant though
indirect experience with the proiect(s) beina 
evaluated, including involvement in the project 
design or previous iterations of the project. 
4. Current or previous work experience or seeking
employment with the USAID operating unit
managing the evaluation or the implementing
organization(s) whose project(s) are being
evaluated.
5. Current or previous work experience with an 
organization that may be seen as an industry
competitor with the implementing
organization(s) whose project(s) are being
evaluated.
6. Preconceived ideas toward individuals, groups,
organizations, or objectives of the particular
projects and organizations being evaluated that 
could bias the evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the information for any purpose other than that for which it was furnished. 
Signature 
Date 
Charles Stoecker 
3-31-2020
Disclosure of Conflict of Interest for USAID Evaluation Team Members 
Name Matt Worges 
Title Tulane University 
Organization Data for Impact 
Evaluation Position? □ Team Leader � Team member
Evaluation Award Number (contract 7200AA 18LA00008 or other instrument) 
USAID Project(s) Evaluated {Include USAID's Integrated Health Program in the Democratic project name(s), implementer 
name(s) and award number(s), if Republic of the Congo 
applicable) 
I have real or potential conflicts of D Yes ■ No 
interest to disclose. 
If yes answered above, I disclose the 
following facts: 
Real or potential conflicts of interest may include, 
but are not limited to: 
1. Close family member who is an employee of the
USAID operating unit managing the project(s)
being evaluated or the implementing
organization(s) whose project(s) are being
evaluated. 
2. Financial interest that is direct, or is significant 
though indirect, in the implementing 
organization(s) whose projects are being
evaluated or in the outcome of the evaluation.
3. Current or previous direct or significant though
indirect experience with the project(s) being
evaluated, including involvement in the project 
design or previous iterations of the project.
4. Current or previous work experience or seeking
employment with the USAID operating unit
managing the evaluation or the implementing 
organization(s) whose project(s) are being 
evaluated. 
5. Current or previous work experience with an 
organization that may be seen as an industry
competitor with the implementing
organization(s) whose project(s) are being
evaluated. 
6. Preconceived ideas toward individuals, groups, 
organizations, or objectives of the particular 
projects and organizations being evaluated that
could bias the evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this 
disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, 
then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and 
refrain from using the information for any purpose other than that for which it was furnished. 
Signature Matthew Scott Worges 
Date 04/03/2020 

This publication was produced with the support of the 
United States Agency for International Development 
(USAID) under the terms of the Data for Impact (D4I) 
associate award 7200AA18LA00008, which is 
implemented by the Carolina Population Center at the 
University of North Carolina at Chapel Hill, in partnership 
with Palladium International, LLC; ICF Macro, Inc.; John
Snow, Inc.; and Tulane University. The views expressed 
in this publication do not necessarily reflect the views of 
USAID or the United States government.
TRE-20-28 D4I
ISBN 978-1-64232-246-0 
Data for Impact 
University of North Carolina at Chapel Hill
123 West Franklin Street, Suite 330
Chapel Hill, NC 27516 USA
Phone: 919-445-9350 | Fax: 919-445-9353
D4I@unc.edu
http://www.data4impactproject.org