A systematic and contextualized assessment of the interactions between the Sustainable Development Goals and health in the Democratic Republic of Congo is currently lacking. This study aimed to characterize and classify the linkages between the Sustainable Development Goals in the DRC with a focus on health and well-being. In this semi-qualitative participatory study, 35 experts assessed 240 interactions between 16 of the 17 SDGs during a two-day workshop in Kinshasa, Democratic Republic of the Congo, using a scale from +3 (strongly promoting) to −3 (strongly restricting). SDG 16 (Peace, justice, and strong institutions) had the strongest promoting influence on other goals and was identified as a key priority for the DRC to attain the SDGs. Progress on SDG 3 (good health and well-being) was perceived as promoting progress on most SDGs, and through second-order interactions, a positive feedback loop was identified. Furthermore, progress on the other SDGs was deemed to promote progress on SDG 3, with SDG 16 having the greatest positive potential when second-order interactions were taken into account. Our results show the importance of recognizing synergies and trade-offs concerning the interactions between health and other SDGs and that it is imperative to set up structures bringing together different sectors to accelerate work towards achieving the 2030 Agenda.

To compare coverage of key child health policy indicators across provinces and to explore their association with under-five mortality and level of conflict in the Democratic Republic of the Congo. We made a secondary analysis of nationally representative data from 1380 health facilities and 20 792 households in 2017–2018. We analysed provincial-level data on coverage of 23 different indicators for improving common causes of childhood mortality, combined into mean scores for: newborn health, pneumonia, diarrhoea, malaria and safe environment. Using negative binomial regression we compared the scores with provincial-level under-five mortality. With binary logistic regression at the individual level we compared indicators (outcome) with living in a conflict-affected province (exposure). All grouped coverage scores demonstrated large ranges across the 26 provinces: newborn health: 20% to 61%; pneumonia: 26% to 86%; diarrhoea: 25% to 63%; malaria: 22% to 53%; and safe environment: 4% to 53%. The diarrhoea score demonstrated the strongest association with under-five mortality (adjusted coefficient: −0.026; 95% confidence interval: −0.045 to −0.007). Conflict-affected provinces had both the highest as well as the lowest mortality rates and indicator coverages. The odds of coverage were higher in conflict-affected provinces for 13 out of 23 indicators, whereas in provinces unaffected by conflict only one indicator had higher odds of coverage. Conflict alone is a poor predictor for child health. Ensuring that children in unaffected provinces are not neglected while addressing the needs of the most vulnerable in conflict settings is important. Prevent, protect and treat strategies for diarrhoeal disease could help improve equity in child survival.

Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera. Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners. We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0-100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation. Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an -11.6 (95% CI, -16.7 to -6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41-58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%). Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.

Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.

Setting up sustainable oxygen systems within a health facility is complex. In this paper, we propose a conceptualisation of a particular delivery model that takes a broader approach than the traditional oxygen procurement and delivery – ‘Outsourced Oxygen-to-the-Bedside’ (O2B). We explore its potential strengths and limitations using early learnings from five pilot projects in India, Kenya, Tanzania, Nigeria and Uganda. O2B models involve oxygen supply services provided by external entities that provide a minimum set of oxygen supply equipment, alongside bundles of repair, maintenance and training, and are contracted to guarantee continuous medical oxygen supply to the bedside. This market-based approach may be particularly suitable for smaller rural facilities that have limited options and capacity. Envisioned benefits of this model are the reduced mental load on facilities to manage their oxygen and distribution arrangements, whilst building local skills and knowledge to increase equipment functionality, longevity, and oxygen availability. O2B providers currently offer different variations of this service, but in all cases their main value proposition is to make oxygen access easier for facilities. Potential risks include fragmentation of existing oxygen supply solutions, and difficulties in balancing business sustainability with affordable pricing - particularly to small and under-resourced facilities. Relying on financing from individual facilities is unlikely to succeed in most contexts – particularly for poorer hard-to-reach communities. Therefore, future evaluations should focus on long-term funding solutions and cost-effectiveness of different service bundles to determine best value for money in different contexts .

Background: There is a paucity of data on causes of death in children and adolescents that can be used for public health prioritisation in settings with the highest mortality burden. We aimed to estimate the causes and circumstances around deaths for the age group 1 month to 19 years in the Western Democratic Republic of Congo. Methods: Analysis of verbal autopsy and demographic data from the Kimpese Health and Demographic Surveillance System (rural setting 200 km west of Kinshasa) was collected between September 2018 and September 2021. About 66 000 individuals were surveyed yearly using structured questionnaires. Vital events were registered and identified deaths followed up with the World Health Organization 2012 or 2016 verbal autopsy questionnaire. Verbal autopsies were analysed using the InterVA-5 algorithm to generate cause of death and circumstances of mortality categories at the population level. Individual and household characteristics relevant to child survival were compared between deceased and surviving individuals using Fisher’s exact test. Results: Overall, 166/273 (61%) of identified deaths had a complete verbal autopsy. 74% of deaths occurred in children 1–59 months of age, and 70% of all deaths were classified as due to infectious diseases. The top three causes were malaria (35%), lower respiratory infection (12%) and diarrhoeal disease (9%). 78% of deaths occurred at home, and <5% were considered inevitable. However, 70% of individuals sought healthcare in the days preceding death. Recognition (39%), emergencies (27%) and accessing care (20%) were the main contributing categories to fatal outcomes. Characteristics had low coverage (32–72% for the first dose of vaccinations and <10% for water, sanitation and hygiene). Conclusions: Results suggest a need to sensitise caregivers about care-seeking, home treatment and danger signs and improve access to health facilities, combined with improving the quality of care in facilities. Improvements in access to safe water, sanitation and vaccination coverage are also needed.