To even a casual observer, the problems of rapid population growth are painfully evident in Kinshasa, a teeming city of 10 million and the capital of the Democratic Republic of the Congo (DRC). The effects of ravaging poverty and poor governance have taken their toll, yet the streets are filled with young Kinois (residents of Kinshasa) peddling their wares, hoping for a better future. Where would one even begin to make a dent?
The Tulane School of Public Health and Tropical Medicine returned to the DRC in 2011 to take up where it left off 20 years ago promoting family planning as a means of reducing maternal mortality, decelerating rapid population growth, and alleviating the hardship associated with excessive childbearing. With a grant from the Bill and Melinda Gates Foundation, the school began to systematically assess how best to jumpstart family planning activities in a country where the government (at the time) considered family planning to be a low priority. It began in Kinshasa, where some major donors and implementing agencies are located and where change was more likely to happen than in the outlying rural areas.
In this vast central African country, Tulane is up against enormous odds. The DRC ties for last place among 186 countries on the Human Development Index, a composite statistic of life expectancy, education, and income indices used to rank countries into four tiers of human development. The barriers to family planning here are numerous: cultural (children are a man’s wealth), religious (a large segment of the population is Catholic), economic (even minimal fees may make contraception unaffordable to the poor), and social (a lingering fear that contraceptive use will allow women too much freedom). Add to those obstacles the great value placed on high fertility and the relatively few alternative roles for women, and the hurdles family planning faces might seem insurmountable.
Yet, the tide seems to be shifting, albeit slowly, as the government is becoming more aware of how family planning could significantly impact the country’s future, observes Dr. Jane Bertrand, who has been at the helm of Tulane’s family planning initiative in Kinshasa since 2011. Bertrand is the Neal A. and Mary Vanselow Professor and Chair of the Department of Global Health Systems and Development.
Tulane’s initial involvement with the DRC dates back to 1978, when the country was called Zaire. The school began work there by providing technical and financial support to the fledging Nutrition Planning Center. That assistance led the way for two health initiatives in the 1980s, both funded by the United States Agency for International Development (USAID): the establishment of the Kinshasa School of Public Health, and a program of operations research for family planning, directed by Jane Bertrand. The Bertrands lived in Kinshasa with their two children from 1986 to 1989 while managing these efforts. (The public health experience must have left an imprint; Their daughter received her master’s of public health from SPHTM in 2012.)
A NEW HOPE
The country now known as the Democratic Republic of the Congo has been down on its luck since its independence in 1960. King Leopold’s Ghost by Adam Hochschild goes back even further, providing a riveting account of the abuses suffered by the Congo Free State since its establishment as a Belgian colony in 1908. When the country regained independence 1960, it was left to fend for itself with only a handful of trained doctors, administrators, engineers, teachers, and other essential personnel to build a country. Moreover, the Belgians retained control over much of the mineral wealth of the country. In 1965 President Mobutu Sese Seko rose to power and renamed the country Zaire, bringing relative political stability from 1965 to the early 1990s (it’s a wide time span (+ or -) that these years refer to) at the price of repressive measures and little investment in the welfare of the population.
Following Mobuto’s fall from power, the country experienced more than a decade of political turmoil and social disruption, in the midst of which the country became known as the Democratic Republic of the Congo. Donors withdrew or drastically reduced their funding for development projects in the war-torn region. “Embassies closed and expats left the country. It was considered a wasteland, untenable for development work,” Bertrand said. “Only in 2005 did the political upheaval begin to subside to the degree that donors started to return and re-engage.”
When Bertrand returned to Kinshasa in 2011, only a handful of other agencies were working in family planning at the time. “It really was starting from point zero,” Bertrand said. “Although a few organizations were working in family planning, there was little or no coordination among them.”
Her task as principal investigator of the Gates-funded project was to determine what did exist and how family planning could be strengthened. Working in collaboration with the National Program on Reproductive Health (PNSR), Bertrand and her colleagues began to systematically learn as much as possible about “the black box of family planning in Kinshasa,” as she calls it. In partnership with the Kinshasa School of Public Health, the team conducted a survey designed to identify every health facility and pharmacy in Kinshasa that distributed contraception.
It organized a national meeting on family planning in the DRC. It developed a ‘first of its kind” website (www.familyplanning-drc.net) in French and English that assembled all pertinent information about family planning in the DRC: organizations, donors, policies, contraceptive flows, service sites, survey results, publications, an interactive map of all family planning sites in Kinshasa, and more. With this information in hand and in collaboration with the PNSR, Tulane orchestrated the formation of the Kinshasa Family Planning Coalition to better coordinate family planning service delivery activities. Most recently, this team has worked with more than 100 Congolese collaborators to develop the first ever Strategic Plan for Family Planning in the DRC: 2014-2020.
Dr. Thibaut Mukaba, a family planning expert who has seen the transformation in the DRC over the past several years, is impressed with the progress the school and its team have made. “Tulane University brought new energy to the family planning program in the DRC,” said Mukaba, who is USAID’s family planning and reproductive health specialist for the DRC. “Beside the big players—USAID and UNFPA [the United Nations Population Fund]—Tulane University has reinvigorated the national family planning committee. The increased coordination among stakeholders is now showing some concrete results.”
A HOME BASE
In Kinshasa (as in other international sites), Tulane projects operate as Tulane International LLC (TILLC), housed in the Congolese version of an office park. Like most business offices in Kinshasa, armed guards man the gated entries and 8-foot walls surrounding the premises of a one-story compound. Occupying four small offices and a galley kitchen, the project staff is settling in to these new digs. A coat of fresh yellow paint brightens the walls, while a fine dusting from recently sanded dry wall has floated to the tile floor.
This newly established office houses five SPHTM projects. The largest is part of the Access to Primary Health Care Project, which is financed by the United Kingdom’s Department for International Development to strengthen health systems in rural areas. Dr. David Hotchkiss, JP Morgan Chase Professor of Health Care Finance, is the technical lead on this project, for which Tulane is the subcontractor responsible for operations research and impact evaluation. The other four projects focus specifically on family planning. Two are funded by the Gates Institute at Johns Hopkins: Advance Family Planning (for advocacy work) and Performance Monitoring and Accountability 2020 (measuring contraceptive dynamics using cellphone technology), with a third supported by the Futures Institute (Track 20, to strengthen the national health information system). The most recent—a $1.7 million grant from the David and Lucille Packard Foundation—focuses on strengthening family planning service delivery and creating demand in Kinshasa.
To date, the school has received $3.5 million for its family planning activities in the DRC, with prospects for expanded activity moving forward. Dr. Arsene Binanga, a Congolese physician, serves as director of Tulane’s Family Planning Projects.
To keep tabs on every facet of these projects, Bertrand commutes to Kinshasa a minimum of four times a year. Even as she departs Kinshasa after a two-week stint, she has already set in stone her return dates in six weeks and scheduled back-to-back meetings. Back in her New Orleans office at the Tulane School of Public Health, separated from Kinshasa by seven time zones and 8,100 miles, Bertrand continues daily strategy sessions with the Kinshasa team in support of family planning project activity underway in the DRC. “We communicate largely by Skype and email,” Bertrand said. “Fortunately, the internet access is fairly good.”
DRY DIRT PATHS, CUTTING EDGE TECHNOLOGY
The funding has also enabled Tulane to conduct valuable research that has set the stage for family planning initiatives. A study directed by the Kinshasa School of Public Health used cell phone technology for collecting data on women’s contraceptive use and availability of contraceptive products in health facilities throughout Kinshasa. Upon completing an interview, the interviewer would transmit the data (similar to sending a text message) to a server enabling Tulane researchers to have real-time access from anywhere in the world served by the internet. Dr. Julie Hernandez, faculty at Tulane’s Payson Center, used the geocoded data to develop interactive mapping of all health facilities in Kinshasa delivering family planning services. Combined with data on contraceptive uptake by women in Kinshasa, this information provides an unparalleled platform on which to strengthen family planning programming.
The arduous legwork behind these studies requires interviewers to go door-to-door to collect data under the blazing sun or in drenching rain along dirt paths in rambling low-income neighborhoods. Dr. Philip Anglewicz, assistant professor in the Department of GHSD, experienced this challenge first-hand, mapping thousands of households in 60 “quartiers” in a city of 10 million people.
The researchers used cutting-edge Android cell phone technology, with the devices customized in French and Lingala, the local language in Kinshasa. The technology helped the family planning team to leap-frog over traditional and cumbersome data collection options and provided results within weeks versus months. “Many people in our field are surprised to learn that we are testing some of the most innovative technologies available here in the DRC. It makes this work all the more rewarding,” said Bertrand.
The logistics to get such technology into interviewers’ hands in time for the scheduled survey start date called Bertrand’s take-charge penchant for troubleshooting into play. First, the devices were only available for purchase in France. To avoid bureaucratic snags with DRC customs officials and serpentine shipping delays, it initially appeared that she might have to make a fast dash to pick them up herself during a brief layover in Paris on her way back from Kinshasa to the U.S. When that shortcut option didn’t work out, she arranged to have the phones shipped to the U.S. and hand-carried by a colleague heading back to Kinshasa on the next scheduled trip.
For decades, the DRC government gave little priority to the country’s problems related to population growth, or family planning. But in 2012 the situation began to turn the corner with several encouraging signs of the government’s commitment to support and strengthen family planning programming. Most recently, the DRC made a very significant public declaration of commitment in Addis Ababa at the Third International Conference on Family Planning, which offered a platform for countries that had not yet pledged to do so.
The Tulane team worked for weeks with the Ministry of Health and other key figures to coax out an agreement on the ticklish phrasing of a mere 150-word declaration.
Additional signs of government support for family planning include a first-ever allocation of $800,000 to purchase contraceptives in 2013, with an even larger pledge for 2014. Previously, no financial support had been allotted. Moreover, the DRC government has officially approved the Strategic Plan, with the goal to increase contraceptive use by 1.5 percentage points a year from now to 2020. “These signs (of the DRC government support) give donors further interest in supporting family planning in the DRC,” Bertrand said.
Stepping back from the day-to-day operations, Bertrand reflects on the long-term goal of curbing rapid population growth; she recognizes that it is still a long way off. Currently, women in the DRC have an average of 6.3 children, although in Kinshasa this number is down to approximately four children. “Even if overnight we were to bring the average child birth rate to two children per household, it would still be 60 years before the country had a zero population growth,” she said, citing a demographic fact known as population momentum. However, this kind of change can happen in a lifetime. In the 1960s, for example, women in Latin America had an average of six children. Today, it is close to around 2.2. Says Bertrand about the DRC, “I’m not discouraged. You have to start somewhere.”
There is a new momentum for family planning in the DRC, which was on display when the Minister of Health launched the Strategic Plan for Family Planning: 2014-2020 at a Tulane-organized event on February 13, 2014. It exemplifies the extent to which the DRC government is backing the work of family planning organizations, said USAID’s Mukaba. “Tulane University has played a pivotal role in all stages of this strategy development. Thanks to the enhanced partnership that we are building with the DRC government, USAID is optimistic about the implementation of the new family planning strategy,” he said.
– Sharon Donovan