Field Assessment of CRS 
I. Executive Summary and introduction 
Purpose of Assessment: USAID/DRC requested an assessment of the management and 
delivery of health services conducted in CRS-assisted health zones in order to (1) 
determine the minimum level of resources required to effectively implement the activities 
outlined in the Mission's new strategy; and (2) help enhance the grantee's performance. 
Team Composition: The Team included: Richard Greene, Team Leader, USAIDN, 
Senior Advisor to DRC and Director of HIDN; Karen Cavanaugh, USAIDN, PHR+ 
CTO and health systems specialist; Nancy McCharen, USAID/W, Africa Specialist in 
Regional and Country Support; Lina Piri Piri, USAID/Kinshasa, Activities Manager for 
the CRS Project; Dr. Denis Matshifi, Health Coordinator, CRS Kinshasa 
Methodology: Methodology included field visits to two rural health zones (Luiza and 
Luarnbo) in Kasai Occidental and meetings following an interview guide tailored to the 
three levels of health services: health centers and posts, reference hospitals, and health 
zonal offices. 
CRS Program: CRS assists three rural health zones in Bas Congo and 16 (now 23 
following the recent MOH remapping exercise) in Kasai Occidental and Kasai Oriental 
under a five year cooperative agreement that ends in September 2007. The total estimated 
cost of the grant is $8.6 million. The Kasai cooperative agreement is for five years of 
assistance (2002-7) at a total cost of $8.6 million. The purpose of the project is to reduce 
child and maternal morbidity and mortality by: 
Having local partners, MOH structures and community organizations ensure quality 
PHC in the targeted health zones. 
Making available key life -saving preventive health activities and ensuring their full 
utilized by communities. 
Ensure that communities have access to and fully utilize quality essential curative 
health services. 
Integrate essential HIV/AIDS preventive activities into PHC services. 
Accomplishments to date 
Availability of care and medicines: UNICEF medicines arrived in health centers in 
April, 2003. This one action has allowed the revitalization of essential, community￾financed services, the motivation of staff, and the reactivation of community health 
committees (COSAs) which had gone dormant from lack of resources to manage. 
Work conditions: provision of office supplies (pens, pencils, paper, registers etc.), 
motorcycles, bicycles has encouraged staff and enabled them to carry out their duties 
EPIprogram: measles and DPT coverage have increased significantly, and systems 
have been put in place to assure that the vaccinations continue. Radio 
communications have greatly facilitated reporting of both vaccinations and 
surveillance of cases at community level. 
Supervision and health information: monthly supervision of health centers on site, 
monthly meetings with head nurses at the zonal level and monthly meetings with 
selected relais have been established and allow for updating and feedback. There has 
also been an improvement in the frequency of health information reporting. 
Training of service providers, health zone managers, and BDOM staff in a variety of 
topics. 
Major Operational Problems 
Under-utilization of health services due in part to the inability to pay; 
Over-prescription of drugs and lab tests that contribute to the high costs to consumers 
Need to expand preventive services beyond EPI to include other high impact maternal 
and child services such as malaria, pneumonia treatment, and child spacing 
Inability by health zone staff to analyze and use data collected from supervision and 
the health information system. 
Inadequate planning and oversight of rehabilitation and construction projects 
Limited community participation, especially among women. 
The assessment report recommends actions to begin to address these problems and 
estimates the costs of their implementation. The team recognizes that some of these 
recommendations are already being planned or are process. 
The assessment team recommends that CRS undertake or facilitate the following steps 
to further enhance program impact: 
Basic Package of Services: 
To reduce under-five and maternal mortality, focus on achieving minimum coverage 
levels for a core package of high impact interventions that includes: 80% coverage for 
DPT3, measles and vitamin A supplementation; 65% of all pregnant women and 
infants have insecticide treated nets in their homes; 60% of all pregnant women 
receive intermittent preventive therapy for malaria; and 70% of pregnant women have 
their births attended by a trained provider in a health facility. The core package would 
also include the introduction of family planning/child spacing information and 
services (with the assistance of another USAID partner) and improved diagnosis and 
treatment of acute respiratory infections. 
To achieve these targets, provide additional support for malaria, ARI, and maternal 
health (especially for basic obstetric care). 
Ensure that health center staff and their supervisors track the above indicators and 
that they are reflected in health center performance contracts. 
Child Spacing: 
Ensure that BDOM accelerates training of personnel at all levels in the standard days 
method, providing educational materials and beads for use of the method. 
USAID should engage another partner to work with the BCZS to assure contraceptive 
supplies in health facilities, training of staff, and some quality assurance. 
To better implement its core HIVIAIDS activities (e.g., blood safety, universal 
precautions at health facilities, and awareness raising activities), distribute the 
MOH guidelines and flowcharts on blood testing, HIV diagnosis, and counseling 
and ensure that staff are trained in their use. 
If additional HIVIAIDS funds become available, in their higher risk zones, train 
hospital and health center nurses on syndromic diagnosis and treatment of STIs 
and ensure that appropriate drugs are available. 
Based on the latest epidemiologic data, USAID should review whether CRS zones 
should be targeted for more intense activities. For any CRS zones so identified, 
USAID (through an appropriate HIVIAIDS partner) should consider introducing 
in large maternities syphilis screening of pregnant women and prevention of 
mother to child transmission. 
Community Based Delivery of Information and Services 
In their program description, CRS has described a strong and participatory 
community component. Because of the program emphasis on EPI and the WHO 
training of a few of the relais, the strategie avancP work of the relais is largely 
disease surveillance and mobilization for vaccinations. 
Assure that the upcoming training of relais will prepare them for a broader role in 
working with communities, women's groups, local NGO's and in expanding the 
strategie avance' to address problems other than immunizations. The COSA 
should be trained in educational and behavior change roles as well as the 
management functions with the health center. 
BCZS work with the Head nurses to enumerate relais so that planning of training 
and provision of supplies and educational materials can be done accurately and 
gaps in coverage can be identified. 
Drug management: 
Develop guidance to limit the number and type of lab tests now being conducted 
in health centers. In addition, CRS should make fees from lab tests ineligible for 
staff primes. 
Over-prescription of drugs should be addressed in supervision protocols, refresher 
training, collaborative QA exercises, community education programs, and the new 
performance contracts to be developed between HZs and health facilities. 
Review and reset the margins on drugs at both the health center and BDOM levels 
based on real management costs. Supervisors should routinely review the Fiches 
de Consummation of drug stores and depots to avoid abuses. 
Supervision: 
Formative supervision is performed regularly and the EPI clearly demonstrates 
that effective supervision has been provided. However, other technical and 
management areas need to effectively addressed through supervision. 
Revise existing supervision protocols to better reflect the full core package of 
services, drug and financial management, and community mobilization activities. 
Payment of perdiems should be contingent upon submission of completed 
supervision checklists. 
Training 
Offer re-trainings to increase the number of nurses trained per Health Area. 
Ensure that adequate material assistance (commodities, job aides) are made 
available to training participants when they complete instruction to permit 
immediate application of newly acquired skills. 
Study possibilities to integrate training topics as much as possible. 
Experiment with the use of quality assurance collaboratives to improve 
performance of health workers and managers. 
Financing 
Experiment with mechanisms to subsidize access to health care for the poor at 
community level, either through mutuelles de sante or through community 
subsidy hds. Work together with the MOH Sieme Direction, SANRU, the 
School of Public Health to implement and assess these experiments for broader 
application. 
Document CRS' experience with support for PHC, its cost and its impact, with a 
view toward comparing its effectiveness with other models, such as those 
supported by the World Bank or implemented by SANRU. Share information 
with MOH 5' Directorate to foster uptake of lessons learned. 
Health Information 
Now that basic health information collection is underway, train zonal and health 
facility staff to critically analyze routine information in the areas of core technical 
intervention, financing, and drug management, and service utilization with a view 
to benchmarking performance and identifying and solving problems. 
Human Resources: 
Introduce a competitive small grants program at HZ level to provide health 
centers (and local leaders) with resources for projects to improve community 
health. 
Gender: 
Although the CRS program description devotes considerable attention to gender, 
there is little evidence of gender playing a role in program implementation. 
Set gender objectives for staff composition (including for BDOM), participation 
in training, disaggregation of data by sex, male participation in reproductive 
health activities, etc. Select appropriate indicators for progress, track and report 
on them. 
CRS Management 
CRS' sub-contracts with BDOMs to support HZs in isolated rural areas. Because 
of the need to build the capacity of its local partner, there have been some delays 
in project implementation. In addition, the lack of a dedicated CRS administrative 
oficer for the project has slowed procurement and management support. 
Engage a new staff member to handle procurements, oversee rehabilitation, and 
manage project information. 
Utilize the unfilled supervisior slot and hire an additional supervisor to serve as 
on-site coordinators in the two largest BDOM offices. 
Hire a shared finance advisor to conduct analyses and design interventions to 
address financial constraints on the poor. 
Amend performance contracts (as planned) to align contract terms more closely 
with project objective (e.g coverage of core service interventions) and to reinforce 
key management practices. Use the new contracts as basis for supervision and 
provide recognition and awards for meeting performance expectations. 
Foster community participation and appropriate designs. Ensure appropriate and 
transparent contracting arrangements. CRS should approve all designs and 
contracts over a minimum level. 
Optimal Number of Zones for CRS Support: At present, the Mission budgets 
approximately $2,000,000 per year for the two CRS grants (with a total value of 
$2,150,000 with the CRS matching contribution). Assuming no increases in Mission 
budgets, the Assessment team recommends that CRS provide the following levels of 
support: 
Full support to the 18 originally targeted zones (two remaining in Bas 
Congo and 16 in the Kasais). Each zone would receive approximately 
$70,000 of support per year including CRS management costs (excluding 
NICRA). This level of support is consistent with present budgets. 
Partial support ($25,000 per zone per year covering supervision, 
management training, information systems, etc.) to the 7 Kasai zones that 
were created following the MOH remapping exercise. 
After the NICRA is paid, there would be less than $100,000 available to 
begin to cover the cost of some of the recommended actions of this 
assessment. 
The team believes that with the present funding available for CRS, it would be better to 
provide a package of support of about $70,000 per zone ('resent projections) than to 
dilute assistance and cover more zones. 
Costs of Proposed Recommendations: 
The actions proposed in this assessment will cost approximately $20,500 per zone per 
year to implement (about a 22% increase in present cost estimates). The total additional 
annual cost is estimated at approximately $370,000 per year. 
11. The Basic Package of Services 
A. The core set of high impact intervention 
Observations: According to its proposal, CRS plans to support a core service package 
that includes child health interventions (immunization, malaria prevention and control, 
vitamin A supplementation); maternal health (ANC, attended births), and selected 
HIVIAIDS interventions (e.g., safe blood transfusion, universal precautions). CRS also 
plans to provide lesser levels of support for exclusive breastfeeding (through community 
education), growth monitoring (through provision of scales and growth cards), nutrition 
promotion (through introduction of positive deviance programs in demonstration health 
areas). In addition, CRS expects to support the implementation of several national level 
interventions including semi-annual vitamin A supplementation and directly observed 
treatment strategy (DOTS) to control TB. 
Issue: CRS has made an excellent start improving vaccination services (with DPT3 
coverage increasing from a baseline of about 30% (for DPT3) to an estimated 50%, as 
well as helping to sustain relatively high vitamin A coverage. However, in order to 
achieve public health impact and reduce child mortality, other core interventions need to 
be implemented at scale. In addition, there appears to be a total lack of family planning 
services. 
Recommendations: 
To reduce under-five mortality and to begin to address maternal mortality, CRS needs 
to concentrate upon achieving minimum coverage levels for a core package of high 
impact interventions that are feasible to implement in the DRC. Consistent with the 
Mission strategy and PMP, the list of key interventions and their targets are as 
follows: 
DPT3 and measles vaccination coverage exceeding 80%; 
Semi-annual vitamin A supplementation coverage exceeding 80%; 
65% of all pregnant women and infants have insecticide treated nets in their 
homes (denominator: All pregnant women and infants in CRS zones). 
60% of all pregnant women receive intermittent preventive therapy (denominator: 
All pregnant women in CRS zones); 
70% of pregnant women have their births attended by a trained provider in a 
health facility. 
The core package would also include the introduction of family planninglchild 
spacing information and services (with the assistance of another USAID partner) 
and improved diagnosis and treatment of acute respiratory infections. 
The above indicators should be tracked by every health center and health zone 
through the UNICEF designed wall chart that will soon be distributed. 
Recognition should be provided when these public health indicators are reached or 
sustained for the year. 
Health center performance contracts should be modified to include these five core 
indicators. 
Supervisors should monitor progress on these indicators during their monitoring visits 
using a standard checklist to be developed. 
In addition to these core indicators, CRS should: 
Facilitate measles vaccination campaigns (when the Kasais are targeted) to achieve 
high coverage rates and help ensure that planned follow-up campaigns are conducted. 
Promote the use of WHO-recommended diagnosis and treatment recommendations 
for child pneumonia (as outlined in the ordinograrnme) in all health facilities. 
Facilitate the efforts of another organization (perhaps SANRU) to introduce a 
package of family planning information and services. 
Malaria control activities: 
Background: Routine utilization of key preventive health services provides opportunities 
to increase access and use of key malaria interventions. - for instance, 60% of pregnant 
women make at least one visit to a formal ANC and about the same percentage of infants 
complete their DPT series - providing an important opportunity to provide insecticide 
treated nets (ITNs) and intermittent presumptive treatment (IPT), as well as key messages 
on malaria prevention and care. 
Recommendations: 
To achieve the public health targets for ITNs and IPT in section I1 above, CRS plans to 
fully exploit the high utilization rate of key preventive services. It is recommended that: 
CRS provide a long-lasting ITN to all pregnant women at the time of their first 
ANC visit and an additional ITN to the mothers of all infants that complete their 
DPT3 injection. These nets should be provided as part of the standard CPN and 
CPS services at no additional cost to the client. 
CRS should fully implement intermittent presumptive treatment of pregnant 
women with SP including the provision of a special stock of SP for this purpose. 
Key messages on care and prevention should be provided at all points of contact. 
CRS and SANRU should produce a job aide to succinctly communicate 
guidelines (presently being reviewed by CDC and the national program) on the 
treatment of severe malaria. 
Due to its importance, CRS should aim to fully launch malaria activities during 
the upcoming year. 
Immunization 
With SANRU, develop a one page job aide summarizing the most important 
elements of the recently approved national immunization guidelines. Key 
information such as the upper age limit for vaccinations and the open vial policy 
(how long an opened vial can be used) should be included. 
Continue implementation of the "reaching every zone" program. Broaden the 
impact of the program by adding malaria and perhaps one other intervention to 
the health center microplans (to be done on a trial basis). 
Vitamin A: Continue to facilitate the program of semi-annual vitamin A 
supplementation with the objective of sustaining greater than 80% coverage. Support the 
provision of vitamin A to postpartum women (at the new recommended dose of 400,000 
IU) and to selected categories of sick children (e.g., post measles). 
Maternal Health: The percent of pregnant women giving birth at a health facility in 
CRS zones is fairly high (in many places over 60%). This provides an opportunity to 
deliver quality maternal health services at scale. 
Recommendations: 
Improve the quality of ANC services by providing adequate supplies of iron-folate 
and mebendazole for deworming at the time of each visit (free of charge) and helping 
the women develop birth preparedness plans. 
Include recognition of danger signs and symptoms of pregnancy complications in 
community education materials. 
Labor and delivery: Health providers should be trained in active management of the 
third stage of labor, an intervention that helps prevent postpartum hemorrhage, 
consisting of immediate ocytocin, controlled cord traction, and uterine massage. In 
addition, the partogram should by introduced to better address obstructed or 
prolonged labor. 
CRS and SANRU should review the appropriateness of including ergometrine as an 
essential drug during child birth. 
Acute Respiratory Infections (helping health providers implement the MSP guidance on 
child pneumonia in the ordinogramme). 
Introduce timers in all health centers and hospitals to permit providers to 
accurately count respirations in order to diagnose child pneumonia; 
Design and distribute a job aide for child pneumonia that includes instructions for 
diagnosis and treatment. 
Child spacing 
Observations: We encountered the head nurse in the Centre de Sante de Ngovo "close 
by" the health center working alongside the community making bricks - an estimated 
20,000 being required for construction of the maternity. His wife is a member of the 
COSA, and when asked about family planning, she proudly declared that they had a 
planned family. However, no center offers child spacing services or products, other than 
condoms which are provided through the national HIVIAIDS program. If a woman (or 
man) were to ask about family planning, they would be counseled, the calendar method 
explained, and referred to Lwiza or other BCZS. As one gentleman informed us, "on 
nous conseil de respecter le cycle, mais il y a toujours des imprevus", that is to say, they 
advise us to respect the cycle, but there are always unplanned moments. 
Issues 
These are very hard to reach areas. If the health system under the supervision of the 
BDOM does not provide child spacing services, they simply are not available for men 
and women who might be interested in using them. If provider attitudes are not 
supportive, this becomes an additional barrier to the cost and effort necessary for 
couples to space their births. 
Even the standard days method is not well understood nor available to women either 
post-parturn or during other consultations. CRS materials and lessons from their pilot 
zone for the standard days method will prove useful in introducing the method in their 
other zones. 
Recommendations 
CRS should provide reference and resource material on the standard days method to 
BDOM and BCZS staff, and introduce the discussion on child spacing. BDOM needs 
to accelerate training of personnel at all levels in the standard days method. 
USAID should consider using another partner to work with the BCZS to assure 
contraceptive supplies in health facilities, training of staff and some quality 
assurance. 
Recommendations 
Ensure that BDOM accelerates training of personnel at all levels in the standard days 
method, providing educational materials and beads for use of the method. 
USAID should engage another partner to work with the BCZS to assure contraceptive 
supplies in health facilities, training of staff, and some quality assurance. 
B. Other important interventions that will receive limited support: 
Some potentially important interventions are not ready to be implemented effectively at 
scale because of level of difficulty, lack of funding, or other constraints. These include 
positive deviance nutrition promotion, therapetic feeding programs, and exclusive 
breastfeeding. Other interventions are already integrated into most health facilities and 
will receive only limited additional support (e-g., oral rehydration therapy, growth 
monitoring). Finally, any additional support for TB to CRS supported health zones will 
be provided under the direction of the National TB Program. 
HIVIAIDS: The CRS program supports a limited set of HIVIAIDS activities consisting 
of ensuring blood transfusion safety, universal precautions at health facilities, and 
awareness raising activities (including counseling training for health providers). HIV 
tests provided by CRS are being used by hospitals for both screening blood and 
diagnosis. 
Observations: Discussions with the staff at the Luiza Reference Hospital indicated that: 
Patients are tested without their knowledge, consent or counseling 
Hospital staff are alerted to patients who test positive so that they can take the proper 
precautions 
Family members are also notified when a patient tests positive 
Hospital staff have no idea what happens to those people when they leave, or the 
social implications of a positive diagnosis, or even of having been tested. 
Issues: 
MSP guidelines on blood testing, HIV diagnosis, and counseling have not been 
disseminated or applied in CSR supported hospitals. 
Recommendations: 
To better implement its core HIVIAIDS activities (e.g., blood safety, universal 
precautions at health facilities, and awareness raising activities), distribute the 
MOH guidelines and flowcharts on blood testing, HIV diagnosis, and counseling 
and ensure that staff are trained in their use. 
Include in the supervision checklist for hospitals and health centers verification of 
implementation of universal precautions. 
Make it a priority to use some of the rehabilitation funds for the building or 
rehabilitation of incinerators at referral hospitals and safe disposal pits at health 
centers. 
If additional HIVIAIDS funds become available, in their higher risk zones, train 
hospital and health center nurses on syndromic diagnosis and treatment of STIs 
and ensure that appropriate drugs are available. 
Based on the latest epidemiologic data, USAID should review whether CRS zones 
should be targeted for more intense activities. For any CRS zones so identified, 
USAID (through an appropriate HIVIAIDS partner) should consider introducing 
in large maternities syphilis screening of pregnant women and prevention of 
mother to child transmission. 
111. Community Based Delivery of Information and Services 
Observations: Although the CRS Project is intending to expand into additional areas, the 
main focus to date has been on increasing utilization of EPI services. Health Centers 
have well organized programs which provide for immunizations within centers on a 
weekly basis and at health posts in the strategie avance' on a monthly basis. Community 
relais seem to be competent in promotion of EPI and community mobilization for 
vaccinations, though it is not clear how many relais are actually functional. The COSA 
seem to be primarily involved in logistic and management questions, and very little in 
terms of expressing community needs, organizing educational activities or in defining 
quality of services. 
Local NGO's other than church groups exist. The Profam women's groups are 
widespread. In Lueta where an influx of Congolese repatriated from Angola have 
increased needs for emergency assistance, an NGO has formed to provide help to 
"Personnes Oprimes". It currently has 15 members, each contributing 1500 fc ($4) a 
month to provide emergency relief. The BDOM in Luiza carries a considerable 
responsibility for emergency relief as well. 
For the most part, community participation centers around making bricks for health 
center and health post construction, and providing the labor to build. The BCZS told us 
that they pass through the village chefs to reach the population, and through commanders 
to reach military when they encounter resistance. However, we did not find any 
systematic attempt to work with other local NGO's or women's groups other than the 
COSA. The COSA has primarily a management role with regards to the health center 
rather than an educational role with the community. 
We did not see flip charts in the centers, though we were told that EPI flip charts have 
been (or will be provided). There were also wall posters in most places relating to TB, 
community surveillance, cases of paralysis, malaria treatment, malaria spraying, 
coughing (TB), vitamin A, MONUC, ABC, but none related to child spacing. 
CRS uses a performance improvement contract at two levels: between BDOM and 
BCZS, and BCZS and the COSNCentre de Sante. This process engages the partners in 
carrying out their activities to achieve agreed upon objectives. Committee members and 
health staff on both sides must participate in the development of the contract and sign it. 
Issues: 
In their program description, CRS has described a strong and participatory 
community component. Because of the program emphasis on EPI and the WHO 
training of a few of the relais, the strategie avance' work of the relais is largely 
disease surveillance and mobilization for vaccinations rather than preventive or 
educational activities. 
Although some relais have received WHO surveillance training, most have not been 
trained. It is not even known how many relais are functioning in some health zones. 
BCZ "animateurs" hold monthly meetings with relais, but only 1 or 2 per health area. 
Relais seem to receive more effective supervision fiom the BCZS animateur than 
from the health center in their area. 
The Performance Improvement Contracts are helpful in focusing attention and 
making certain specific actions an obligation on the part of both parties. However, 
some of the entries are not easily defined nor measured, and completion of certain 
tasks does not necessarily trigger a response from the other party. It was not clear if 
or how contracts are monitored for performance. 
Recommendations 
Assure that the upcoming training of relais will prepare them for a broader role in 
working with communities, women's groups, local NGO's and in expanding the 
strategie avance' to address problems other than immunizations. The COSA should 
be trained in educational and behavior change roles as well as the management 
functions with the health center. 
Carry out an enumeration of relais, identified by sex, to be able to effectively plan for 
trainings and to provide the necessary registers and educational materials. This 
census can be carried out at health center level, using the "messengers" who are 
already on staff and the strategy avance outings for vaccinations. It is sufficient for 
health center staff to meet and plan based on their list of villages covered, and then 
for the BCZS to aggregate the data at the monthly meeting of infirmiers chefs. 
The monthly reports to BCZS need to include questions about relais and other 
community and IEC work. 
Build a community participation strategy which more effectively involves women, 
which addresses client satisfaction and community defined quality and which works 
with local NGO's and groups to provide educational activities. This can be done 
through inclusion of community participation themes in the other trainings being 
developed, and does not need to be the objective of a separate, costly set of trainings. 
It should be included in the infirmier chefs meeting as well as the monthly meetings 
of relais. 
CRS, BDOM and BCZS in developing the training plans for the relais should explore 
social marketing as a strategy for increasing utilization of services, and determine if 
relais have a role in socially marketing certain products in their villages 
As the second year ends, review contracts to discuss progress, monitoring in the 
future, identify clear indicators, and the relationship between the actions of each 
party. Current contracts are more like workplans than contracts. 
111. Management Systems 
A. Drug management: 
CRS supports a drug management system that consists of: 
pharmacies at health centers and hospitals that are managed by health facility 
staff; 
Drug depots at Health Zonal offices that resupply the health facilities; 
Drug facilities managed by the regional BDOM offices that service a number 
of health zones; 
Resupply of BDOM depots through the PATS-supported CODEPAK drug 
supply centers in Kananga and Mbuji Mayi. 
The total markup of drugs from CADIMEK is 30%. All initial stocks of drugs came 
from UNICEF donations. 
Issues: 
Health facilities are in need of periodic supplements of drugs in order to keep 
from raising prices and to cover cost of indigent services; 
The existing registers fiche de consummation) that document use of drug 
revenues for approved resupply costs (e.g., transport to drug depot) are not 
consistently used nor reviewed by supervisors. 
There appears to be inadequate monitoring of drug stocks and decapitalization of 
most pharmacies. 
Lab tests are over-prescribed and appear to be used as a revenue generating 
device. 
There appears to be serious over-prescription of drugs that drives up the costs of 
health care for consumers and depresses health facility utilization. 
Recommendations: 
USAID should verify with UNICEF that requested drug donations (four 
increments for each health facility on a sliding scale) will be provided through the 
life of the project. If UNICEF is unable to provide the remaining drugs, USAID 
should plan now to procure the needed stocks. The options for doing this are as 
follows: provide funds to UNICEF obtaining any needed waivers perhaps in a 
cost share arrangement; order drugs directly through a mission purchase order 
obtaining USAIDIW waivers; obtain permission from CRS' Regional Contracting 
Officer to purchase drugs directly from approved sources. In addition, CRS needs 
to review its calculation of the quantities of drugs provided in each increment and 
make any needed adjustments. 
Once the planned four increments of drugs are provided to health centers, CRS 
should consider providing additional donations only to those facilities that 
demonstrate solid drug management (e.g., low decapitalization, good prescription 
practices). 
CRS and SANRU should conduct a review of health center laboratory tests 
conducted in USAID-supported zones and establish guidance that will reduce the 
number of unneeded lab tests. At the same time, fees from lab tests should be 
considered part of drug revenues and reserved for reorder of reagants. This 
measure will reduce incentives to prescribe lab tests by making the hnds 
generated an ineligible source for staffprimes. 
To address the over-prescription of drugs, CRS should ask Health Zonal 
supervisors to review the health center drug dispensary sheets and compare 
prescription patterns to what is in the ordinogramme. In addition, supervisors 
should routinely compare the physical stocks and stock cards for at least three 
drugs during health center visits. These measures should be elements in the 
supervision checklist that the Assessment Team recommends developing. In 
addition, over-prescription of drugs should be addressed in scheduled refresher 
training, collaborative QA exercises, community education programs, and the new 
performance contracts to be developed between HZs and health facilities. 
CRS should introduce simple forms to document the use of drug revenues for 
transport and other approved drug resupply costs to improve accountability of 
these funds. CRS should review and reset the margins on drugs at both the health 
center and BDOM levels based on real management costs. 
B. Supervision: 
Observations: The CRS Project has done an excellent job of making supervision regular 
and effective at all levels that the team visited. Staff in all project health centers reported 
monthly supervision visits, and the one non-project health center reported a last visit in 
May of 2003. BCZS and BDOM staff carry out supervision visits together. The PEV 
program is effectively supervised. 
Within health centers, the Centre de SantC de Lueta was particularly noteworthy in that 
the Head Nurse holds staff meetings every morning to discuss cases from the night before 
or any other needs in the health center. This affords supportive and corrective 
supervision, and assures that the Head nurse is well able to assure satisfactory provision 
of services. 
Supervision of BDOM and in turn of rehabilitation of structures has been problematic in 
certain circumstances. BDOM provides primarily a coordination, administrative and 
logistics role with technical support mostly to the PEV program. The maternity 
rehabilitation at the Lwiza hospital clearly would have benefited from greater technical 
direction and participation from beneficiaries. It is CRS role to supervise BDOM both in 
the plan and design of such work as well as the implementation phase. This maternity 
has been constructed with about 20 small cells with a high window - no water, and toilets 
and showers located at some distance. For a single nurse on duty at the night it would be 
impossible to provide good observation of patients. A larger, multiple bed room with a 
nurse station, lighting and ventilation might be better for both the women and the nurses. 
Issues 
Better supervision of rehabilitation projects and more involvement of beneficiaries to 
assure best use of resources for the desired outcome 
Supervision of relais (see community approach) by the closest health center 
Recommendations 
Formative supervision is performed regularly and the EPI clearly demonstrates that 
effective supervision has been provided. However, other technical and management 
areas need to be effectively addressed through supervision. 
Revise existing supervision protocols to better reflect the full core package of 
services, drug and financial management, and community mobilization activities. 
Ensure that the revised supervision protocols are used during supervision visits. 
C. Training 
Observations: CRS provides a series of trainings throughout the life of the project. 
These trainings primarily target the personnel at different levels of health structures 
(BCZS', General Referral Hospitals and Health Centers) as well as the technical staff of 
the partner BDOM~. Since the beginning of this project, the following trainings have 
been conducted: 
and HC 
Technical staff of 
- TRAINING 
Primary Health Care Management 
Vaccination techniques BCZS, Referral HC I and HC 
TRAINING TARGET 
Technical staff of 
BCZS, Referral 
Hospital, Referral HC 
Malaria case management 
Treatment algorithms including 
IMCI principles 
Technical staff of 
BCZS, Referral 
Hospitals, Referral HC 
and HC 
Technical staff of 
BCZS, Referral 
Hospitals, Referral HC 
and HC 
# OF PARTICIPANTS ___I 
Blood transfusion safety and 
universal precautions 
' BCZS (Bureau Central de la Zone de Santt) is the Central Ofice of the Health Zone. 
BDOM (Bureau Diocesain des Oeuvres Mkdicales) means Diocesan Medical Office. 
Hospital and Referral 
Health Center 
transfusing staff 
For all trainings CRS collaborates closely with MOH agencies and programs at the 
national and provincial level as well as with other international agencies (e.g. BASICS) 
to assure training content is compliant with national policies and standards. In addition, 
pre- and post-tests conducted during the trainings reveal that the participants adequately 
understood the training topics. 
In December 2003, the MOH restructured the Health Zones in the Sankuru District, 
thereby creating three Health Zones from the original eight supported by this project. 
Although these newly created Health Zones did not benefit from the hll complement of 
material support during the current fiscal year due to budgetary constraints, the BCZS, 
hospital and health center staff from these "daughter Health Zones" were included in all 
trainings in order to reinforce their technical capacity until more material assistance is 
possible. 
Issues 
During the planning, realization and evaluation of these trainings, CRS identified the 
following issues: 
Facilitation: Securing the commitment of training facilitators was at times 
challenging due to competing obligations on the part of the facilitators and 
difficulties in reaching the training sites. 
Number of nurses (IT) trained: Although all of the Health Areas (AS) were 
covered by these trainings, financial and logistical constraints permitted only one 
IT to be trained per AS. 
Equipment to apply training concepts: The scarcity of certain types of material 
assistance was a hindrance in applying training concepts/techniques in the field. 
Integration of trainings: In Sankuru health zones, trainings of malaria case 
management and treatment algorithms including IMCI principles were integrated 
during five days instead of six as previously planned. This experience allowed the 
project to save time and money. 
Recommendations: 
The following recommendations have been identified by CRS to address the 
abovementioned issues. 
Compile a list of potential training facilitators from national and/or provincial 
level for future trainings. 
Coordinate with SANRU to have a standardized contract between training 
facilitator and CRS or SANRU. 
Ensure sufficient time and resources to adequately plan trainings well in advance 
and make provisions for unforeseen circumstances. 
Offer re-trainings to increase the number of IT trained per Health Area. 
Ensure that adequate material assistance (e-g. ITBN, SP, HIV test kits, etc.) is 
made available at the operational level to enable training participants to apply 
their newly acquired skills and knowledge once they return to their place of work. 
Study possibilities to integrate multiple topics during trainings sessions. 
D. Financing: 
Observations: The CRS Kasai primary health care project is undertaking interventions 
that impact favorably on the financing of primary health care. First and foremost, by 
rehabilitating facilities and providing them with basic drugs, equipment, supplies and 
vehicles, the project increases the availability and quality of services. Participating health 
centers experience increases in utilization leading to increased revenues and increased 
staff bonuses. Also, the project trains health staff in primary health care management and 
the use of standard protocols. This training contributes to more efficient case 
management and reduces the costs associated with over-prescribing of drugs and lab 
tests. By strengthening zonal supervision of health centers, the project increases 
transparency and accountability. Both increased patient revenues and increased oversight 
are likely to contribute to reducing negative practices such as supplementary employment 
or underreporting of patient income. 
The Kinshasa School of Public Health indicates an interest in working collaboratively on 
the issue of access to services by the poor in rural areas. Additional experiences that may 
provide lessons are those of the BDOM in Kinshasa under Sister Close Benedicte and the 
experience in Bwamanda. Dr. Munyanga of the SPH will lead the initiation of a new 
pgram in health system management to train economists with support from the MOH and 
the Dutch NGO CORDET. 
Issues: 
Congo's primary health care system is severely undercapitalized. Health centers 
have practically no medical, laboratory, or office supplies or equipment; furniture, 
drugs, or vehicles. They operate out of rudimentary facilities not served by 
running water, electricity, functional roads, radio or telephone, and poorly 
illuminated and ventilated. 
Health workers, while nominally civil servants, function as concession holders, 
with the authority to earn income from patient fees. Health center staff retain 
60% of revenues from patient fees (excluding drug sales) as staff bonuses. Some 
health staff work fewer days in health facilities to earn income elsewhere. 
Severe undercapitalization means health centers cannot meet patient needs, so 
people use their services less. With fewer patients, health centers are inclined to 
provide each patient with more and more expensive services in order to raise 
money. 
The price of health services is a serious constraint for the poor and for households 
with seasonal income or limited cash. This is especially problematic for labor and 
delivery services. At $2.70 per normal delivery, this is one of the most expensive 
services that primary health centers provide.3 While some of the poor opt not to 
use services, others end up pawning household items to the health center until 
they can pay their debts. Thus health centers are full of clothes, radios and even 
guns that patients leave until they can pay their bills. Often months go by without 
patients being able to retrieve their belongings. Because 60% of patient fees go to 
pay health center staff, each $10 not collected from patients effectively means a 
3 A recent MOH study estimates average rural household daily income at $0.23. 
16 
$6 cut in staff salaries. The financing system does not make any formal provision 
for fee exemptions4. With limited flow of information and limited supervision, it 
is not clear whether low patient revenues are a result of low utilization, staff 
underreporting of patient income, or non-payment by poor patients. 
Neither health center staff nor zonal supervisors fully exploit financial 
information routinely collected and reported through the SNIS. 
Recommendations 
Assess the impact of indigents on overall primary health care financing and 
develop experimental options with communities to subsidize the poor (possibly 
based on agricultural products rather than cash). Build on community 
organization(s) that already collect funds for shared purposes. Develop 
collaborative network with CRS, BDOMs, SANRU, MOH 5th Directorate, World 
Bank and School of Public Health to explore this challenge together. Develop 
capacity in at least one of these organizations (possibly School of Public Health) 
to provide technical assistance in this area. 
o Test feasibility of mutuelles de sante in rural zones. Participate in 
November Bamako meeting of Concertation. 
o Set up community fimd to subsidize services for the poor. Explore 
Yangala and Micope health zone experiences for lessons learned. 
Document the content and cost of CRS core service package and its impact on 
health services. Share lessons learned with MOH and partners. CRS can build on 
the work SANRU has done in this area based on PHRplus technical assistance. 
Improve analysis of financial information at health center and zonal level and 
benchmark performance to foster greater accountability. 
Help BDOMs and health zones with business planninglfundraising to diversify 
their funding sources by attracting resources fiom additional sources such as the 
Global Fund, the World Bank MAP, foundations and churches. 
E. Health Information: 
Observations 
Primary health care staff keep surprisingly good records considering their circumstances. 
In the absence of prepared forms, typewriters, writing supplies or carbon for copies, their 
improvised registers of patient consultations, fees, drug stocks, laboratory tests and 
inventories of goods and equipment are generally thorough and up-to-date. They submit 
monthly reports to zonal authorities following the structure of the Systeme National 
d'lnformation Sanitaire (SNIS). The SNIS provides thorough information on health 
services, human resources, drugs and finances. For the Expanded Program for 
Immunizations, the health center staff set annual targets and track monthly progress with 
graphic wall charts. 
The CRS Project has begun to cultivate a culture of information in the primary health 
care system in the Kasais through training, population surveys, technical assistance and 
4 The system does allow for exemption fiom payments for drugs, through the use of the rumeur form. 
17 
the provision of formats. Thanks to project efforts, health center staff now have a clearer 
idea of their catchment areas and target populations. They track laboratory tests and drug 
use and post their fee schedules. Once the MOH finalizes reporting formats, CRS plans 
to reproduce and distribute them. EPI information is particularly well managed. Overall, 
health centers submit timely and complete reports to zonal authorities who in turn 
maintain up-to-date consolidated reports. 
Issues 
Neither health center staff nor zonal authorities fully exploit available information 
to identify trends, spot potential or actual problems or benchmark progress. 
The severe scarcity of inputs such as carbon paper, paper and formats poses a real 
constraint to good data collection and reporting. Health centers do not retain 
copies of the reports they submit that would allow them to analyze their own 
information. With the exception of the EPI program, health centers do not use 
any graphic techniques for analyzing or presenting information. 
Recommendations 
Provide each health center with ample supplies of paper, carbon paper and writing 
supplies. Establish a practice of retaining copies of all reports submitted. 
Ensure the use of the new UNICEF graphic tools modeled on those used for EPI 
for other key services such as prenatal, delivery, vitamin A, and malaria 
prevention (coverage of ITNs and IPT). Train health center staff to establish 
expected values, identify and find the reasons for deviations and develop 
solutions. 
At the zonal level, work with authorities to establish benchmarks for health center 
services and to analyze reports for variations from these benchmarks. Use the 
observations about these reports as the basis for supervision visits. 
F. Human Resources 
Observations 
At the zonal level, Congo's primary health care system is not overstaffed based on 
observations of staffing patterns in Luiza, which has 13 1 staff to serve 122,127 people. 
Overall, 30% of all nurses and both of Luiza's two physicians work at the reference 
hospital. The health centers operate with a total of 93 staff, including only one nurse or 
auxiliary for every 2 100 people. 
Lulza. ConQo PHC Staffing 
per 2003 Zonal SNlS Reporl 
to serve population of 122.1 27 
BEST AVAILABLE 
Luiza Health Center Staffing 
per 2003 SNlS 
I Mas. O, 0% , , Managers 1, 1% 
Malnlenance Stan 17 18% 
A2 Nurses 22 24% 
Admm Stan 17 18% 
A3 Nurses, 30, 33% 
The CRS project is improving health worker skills and motivation. The pro-ject has 
provided staff with training as discussed elsewhere in this report. Most health center staff 
demonstrate awareness and indicate use of up-to-date practices in these areas. 
By offering supervision, access to training, drugs, equipment and the possibility of 
rehabilitation, the project provides staff with tangible evidence that things can improve, 
thereby substantially improving motivation. Health center staff have had such limited 
access to support that the CRS project support makes a tremendous difference for them. 
In one center, staff recounted the exact date and time their first shipment of CRS￾provided drugs arrived last year. 
Issues 
Hospital staff productivity is extremely low.. with 2 physicians and 25 nurses 
producing fewer than 3000 patient days of service in 2003. On any given day, 
this 108 bed hospital had fewer than 8 inpatients.5 
Health center staff productivity is also low, with health centers frequently 
reporting fewer than 10 patient visits a day. This is likely due to both the very 
low availability of complementary inputs and financial constraints on demand. 
Production of services seems to be increasing with the project, as staff training 
and complementary inputs improve and health center prices decline. 
Because of the dearth of support over long periods of time, health workers and the 
communities they serve are not accustomed to identifying their needs and taking 
steps to improve services. Health workers have no outside incentive to take 
special initiative. 
' This may reflect underreporting of service production by hospital staff who stand to benefit 
financiallyfiom such a practice. 
BEST AVAILABLE 20 
Recommendations 
Establish competitive grants fund that the BDOM would manage in collaboration 
with the zonal office to allow health centers to carry out projects with community 
support to improve health. 
Use performance contracts to reward health center teams for good performance 
IV. Gender: 
Observations: Although gender is highlighted in the CRS program document, there is 
little evidence on the ground of attention to gender in activities. It was noted that for a 
maternal and child health project, none of the 1 1 BDOM staff are women. It is not clear 
how many relais are women, though the intention was to identify teams including one 
man and one woman of whom one would be literate. There was no evidence of focus on 
male participation in project activities, and in the one case of maternal mortality 
discussed, the cause identified was a husband who was unwilling to provide the money so 
the woman could deliver in Lwiza. Participation by women's groups, discussions at 
community level to address problems and active participation by men would seem to be 
useful in achieving project objectives. 
Issues 
Project staffing and positions at all levels should involve women and men more 
equitably 
Consultation and participation by women in rehabilitation of maternities and facilities 
which serve primarily women and children would benefit the project 
Recommendations 
Set gender objectives for staff composition (including for BDOM), participation in 
training, disaggregation of data by sex, male participation in reproductive health 
activities, etc. Select appropriate indicators for progress, track and report on them. 
USAIDIDRC has requested a gender tdy, scheduled in July, 2004, to assist with 
identifying appropriate gender indicators in the strategy. 
V. CRS Management 
Background: The CRS office is located in Kinshasa and there are no provincial/district 
level offices in the country. However, the Kasai Project is implemented in remote rural 
areas by three BDOMs (Luiza, Kole, and Tshumbe). Because of the size of the country 
and poor means of communication (poor roads, few airports, inadequate telephone 
system), it is hard to for the CRS Office in Kinshasa to closely supervise the three 
BDOMs which manage the project. In addition, the CRS administrative/logistics staff in 
Kinshasa is unable to provide the three BDOMs with the management support they need. 
Financial management: Project spending from October 2002 through June 2004 
including pending requisitions is about $1.65 million, of which about 1 1% is for direct 
CRS operations, about 22% for the operation of 4 BDOMs and about 5 1% for goods and 
services for the 18 health zones. FY02 and FY03 obligations of about $2.5 million leave 
the project with a pipeline as of July 2004 of $850,000 of which $236,000 is in use as 
operating cash. Because BDOM operations are such a significant share of total project 
costs, CRS needs to ensure that BDOM costs match the value they add to the health 
zones. CRS needs to ensure that project goods and services reach the health zones to the 
greatest extent possible. To do so, it would be helpful if CRS would track expenditures 
by principal beneficiary and by purpose (e.g., training, supervision, rehabilitation, etc.) as 
well as by spending site. 
Issue: 
The lack of CRS staff in the field results in inadequate supervision of BDOM offices. 
The overburdened CRS administrative staff cannot handle the project's management 
needs in a timely fashion. 
Recommendations: 
CRS' sub-contracts with BDOMs to support HZs in isolated rural areas. Because 
of the need to build the capacity of its local partner, there have been some delays 
in project implementation. In addition, the lack of a dedicated CRS administrative 
officer for the project has slowed procurement and management support. 
Engage a new staff member to handle procurements, oversee rehabilitation, and 
manage project information. 
Utilize the unfilled supervisior slot and hire an additional supervisor to serve as 
on-site coordinators in the two largest BDOM offices. 
Hire a shared finance advisor to conduct analyses and design interventions to 
address financial constraints on the poor. 
Amend performance contracts (as planned) to align contract terms more closely 
with project objective (e.g coverage of core service interventions) and to reinforce 
key management practices. Use the new contracts as basis for supervision and 
provide recognition and awards for meeting performance expectations. 
Foster community participation and appropriate designs. Ensure appropriate and 
transparent contracting arrangements. CRS should approve all designs and 
contracts over a minimum level. 
Because BDOM operations are such a significant share of total project costs, CRS 
needs to ensure that BDOM costs match the value they add to the health zones. 
CRS needs to ensure that project goods and services reach the health zones to the 
greatest extent possible. To do so, it would be helpful if CRS would track 
expenditures by principal beneficiary as well as by cost center. The Kinshasa 
School of Public Health indicates an interest in building capacity in the area of 
improvement collaboratives for quality assurance. Professor Okito has worked in 
quality assurance. 
Other Recommendations: 
Quality Assurance: suggest experimentation with the use of collaboratives to achieve and 
spread quality improvements. Collaboratives use teams of providers (from as many as 30 
facilities or units) to analyze how they provide care and then develop and test potential 
improvements. The teams volunteer to work on a single area of care (such as malaria or 
over-prescription of drugs) and to share their results with the entire collaborative on a 
regular basis (usually monthly). This approach would potentially work well in health 
zones where monthly meetings of the chiefs of all health facilities already take place. 
The Kinshasa School of Public Health indicates an interest in building capacity in the 
area of improvement collaboratives for quality assurance. Professor Okito has worked in 
quality assurance. 
Coordination with SANRU: CRS should hold regularly scheduled meetings with 
SANRU, the MOH, and other PHC implementers to share best practices and 
approaches and to resolve common problems together. 
Collaboration with the MOIUDEP: CRS should take actions to improve its 
collaboration and relations with the DEP. Possibilities include inviting DEP staff 
on selected supervision trips, making sure the DEP receives copies of project 
reports, and meeting periodically with the directorate. 
Review of project indicator targets: At project midpoint based on progress 
achieved, CRS and USAID should review project indicator targets and make any 
needed revisions. 
Oversampling of PHC-supported zones in upcoming MISC survey: US AID 
should discuss with UNICEF, the MOH, and other partners the possibility of 
oversampling the donor-assisted health zones during the upcoming UNICEF 
Multiple Indicator Cluster Survey scheduled for 200516. 
VII. Optimal Number of Zones for CRS Support: At present, the Mission budgets 
approximately $2,000,000 per year for the two CRS grants (with a total value of 
$2,150,000 with the CRS matching contribution). Assuming no increases in Mission 
budgets, the Assessment team recommends that CRS provide the following levels of 
support: 
Full support to the 18 originally targeted zones (two remaining in Bas 
Congo and 16 in the Kasais). Each zone would receive approximately 
$70,000 of support per year including CRS management costs (excluding 
NICRA). This level of support is consistent with present budgets. 
Partial support ($25,000 per zone per year for supervision, management 
training, health information, etc.) to the 7 Kasai zones that were created 
following the MOH remapping exercise. 
After the NICRA is paid, there would be $100,000 available to begin to 
cover the cost of some of the recommended actions of this assessment. 
The team believes that with the present funding available for CRS, it would be better to 
provide a package of support of about $70,000 per zone (present projections) than to 
dilute assistance and cover more zones. 
Costs of Proposed Recommendations: 
The actions proposed in this assessment will cost approximately $20,500 per zone per 
year to implement (about a 22% increase in present cost estimates). The total additional 
annual cost is estimated at approximately $370,000 per year. 
Assessment of CRS Kasai PHC Revitalization Project 7/04 
Estimated Costs of Recommended Actions 
Total Additional Annual Additional 
Item Basis of estimate Cost Cost 
Insecticide treated nets 
(ITNs) already budgeted $0 $0 
SP for intermittent 
~resum~tive tratment $1 200/zone/100.000 
(IPT) popln.1year $64,800 $21,600 
Guides for severe 
malaria and EPI $1,500 $500 
Timers and guides for 
ARI diagnosis $5000/zone $90,000 $30,000 
Iron-folate, training, job 
aides for maternal 
health $1 35,000 $45,000 
AIDS already budgeted 
child spacing already budgeted 
Community component already budgeted 
Introduce, disseminate 
new lab test policy $3,000 $1,000 
New supervision guide $5OO/zone $9,000 $3,000 
New SNlS form and 
training $1 500Izone $27,000 $9,000 
Training already budgeted 
Document cost 
effectiveness of project 
approach $1 0,000 $3,333 
Studies to review drug 
margin and spending 
on indigents $5,000 $1,667 
Refresher training of 
health zone staff to 
improve data analysis 
and supervision $20,000 $6,667 
Fund for special 
projects $3000/zonelyear $162,000 $54,000 
2.5 FTEs CRS new 
mgmt. staff with support 
costs (2 supervisors, 
0.5 finance) $25,00O/FTElyear $1 87,500 $62,500 
Business plans for 
BDOMs $30,000 $30,000 $1 0,000 
30 days of short term 
technical assistance 
(for contracts, etc.) $1 0001day fully loaded $30,000 $10,000 
development cost of $50,000 included in 
mutuelles de sante & mission mgmt.; School of 
indigent funds Public Health pipeline $0 $0 
Net additional costs $774,800 $258,267 
Total additional costs (with 30% indirect costs) $1,007,240 $335,747 
Net additional costs per zone $43,044 $14,348 
Total additional costs per zone (with 30% indirect costs) $55,958 $18,653