This case study presents a novel rural rotation (RR) program in rural Haut Katanga province of the Democratic Republic of the Congo (DRC). Health systems continue to grapple with how to ensure a robust rural health workforce despite long-standing WHO recommendations on rural education, regulation, financing, and support as key measures to improve health equity [
1]. In DRC, where most people reside in rural areas, supporting human resources for health (HRH) interest in rural practice is central to health system strengthening and providing healthcare for all [
2]. Access to care needs in Haut Katanga are compounded by a higher than national average HIV prevalence and larger rural population. We describe the rationale, steps taken, and methods used to implement the RR program for nursing students in Haut Katanga, a province heavily impacted by HIV and AIDS. The results of two academic years as well as the challenges faced, lessons learned, and persistent health system constraints are provided.
DRC context and challenges
DRC, a country with a historically high burden of disease, political instability and low health system use, gained independence in 1997 and has received United States President’s Emergency Plan for AIDS Relief (PEPFAR) funding since 2003 [
3,
4]. DRC is a country of over 2 million square kilometers that borders seven sub-Saharan African countries. Decades of violent conflict and instability have taken a devastating toll on the country’s economy, human resources, and infrastructure, and coupled with a largely rural population, present several challenges to providing equitable access to healthcare [
2]. The health workforce, of which 45% are nurses, is concentrated in the capital Kinshasa and provincial urban areas [
5].
The DRC health system is divided into three major levels including the central level led by the Ministry of Health, the intermediate level—including provincial health hospitals and oversight of programs at the level of health zones. The intermediate level, while maintaining a degree of decentralized control in health service inspection and implementation remains beholden to national policies and directives. Most preventive and curative care is provided through over 500 health zones, 300 general reference hospitals and over 8000 health centers. Health centers are staffed by five-member team led by an advanced level (A1) and secondary level (A 2) trained nurse. A laboratorian, receptionist and logistics/maintenance staff member round out the rural team.
Maldistribution of health workers continues to challenge achievement of universal health coverage and the Sustainable Development Goals (SDGs). Improving access to care is essential to achievement of the SDGs, particularly SDG 3 (good health and wellbeing) and 10 (reduced inequalities) United Nations [
6]. Nurses, as primary care providers, are central to improving access to care and reducing inequity. Although nurses are the largest health workforce globally and, in the DRC, recruitment and retention of nurses into rural areas remains a challenge. This challenge persists despite the existence of policies to recruit and retain rural health workers [
6‐
8].
The DRC health system is also tasked to respond to a generalized HIV epidemic with an estimated prevalence of 1.2% among adults aged 15 to 49. An estimated 404,894 people are living with HIV, and around 10,535 people die from AIDS-related conditions each year [
9]. The HIV epidemic has drastically impacted two of DRC’s most populous provinces, with general population prevalence estimates of 1.6% in Kinshasa and 2.6% in Haut Katanga [
10].
Support to HIV service delivery scale-up in Haut Katanga
ICAP at Columbia University (ICAP) initiated a comprehensive program of support for HIV care and treatment (C&T) services in DRC in 2010. Since then, ICAP has worked hand-in-hand with the Programme National de Lutte contre le SIDA (PNLS) to expand availability, quality, and uptake of adult and pediatric HIV care and treatment in DRC with an emphasis on expanding prevention of mother-to-child transmission (PMTCT) activities, building laboratory networks for disease monitoring, integration of HIV and tuberculosis (TB) services, improvement of infrastructure, prevention among key populations (KP) in Kinshasa and Haut Katanga provinces. The program has expanded from 10 sites in 2010 to 240 public and private hospitals, health centers, and TB clinics as of September 2014. ICAP currently supports the health ministry in 199 sites.
Support to nurse strengthening in Haut Katanga
With PEPFAR funding through the United States Health Resources and Services Agency (HRSA), in 2017, ICAP was awarded the Resilient and Responsive Health Systems (RRHS) project to continue strengthening HRH in DRC. Using the World Health Organization (WHO) conceptual framework for HRH development, the first 2 years of the RRHS project built on extensive HRH capacity-building and infrastructure improvements for student nurses and midwives through the HRSA-funded Nursing Education Partnership Initiative (NEPI) and Global Nursing Capacity Building Program (GNCBP) [
11,
12]. NEPI focused on nurses’ readiness for clinical practice through curricula reform and development of innovative pedagogy including use of skills labs and simulation-based training. Over the past 2 years, HRSA and ICAP have leveraged these pre-service strengthening efforts to shift focus to in-service capacity-building and addressing wider HRH limitations affecting epidemic control specifically in largely rural Haut Katanga province.
Given the volume of people living in rural areas and HIV service needs therein, a collaborative effort between the MoH, Ministry of Education (MoE), ICAP and HRSA has yielded a RR program to increase nursing student and community health worker (CHW) exposure to rural health needs as well as rural clinical practice and community engagement prior to graduation, entry to practice, and employment. Additional strategies, not presented here, included the development of a telementoring program to bridge rural health centers with urban specialists and trainers as well as assistance with national registration of nurses.
The need to expose and engage nursing students in rural healthcare
An increase in the use of telemedicine globally has expanded access to quality healthcare services regardless of a patient’s proximity to physical medical care/clinic services [
13,
14], diminishing healthcare disparities in rural settings. However, many countries, including those in sub-Saharan Africa, still struggle with gaps in healthcare access for rural populations. Common themes seen among the extant literature include lack of funds to enhance rural healthcare, lack of medical professionals among rural populations, and lack of technology available for use in rural areas [
15]. Current scholarship identifies various issues faced in attempting to close these gaps between rural and urban health settings and describes various interventions that have been used globally, in sub-Saharan Africa, and more specifically in DRC. In particular, the evolving role of nurses in supporting—and advancing—rural healthcare in such contexts is explored in-depth as is the need to actively recruit nurses to areas by demonstrating the career advantages that such experiences and expertise bring. This, exposure, in turn, will be valued more by student nurses and will, as a result, increase their willingness/interest in rural placement [
16].
An interesting healthcare paradox exists in rural settings, compared to urban ones, no matter where one looks in the world: rural communities in which some of the most numerous, complex, and diverse healthcare needs exist are precisely those served least by HRH. Despite the prevalence of unmet rural healthcare needs, healthcare providers tend to remain in wealthier, better resourced, urban areas [
17]. A retrospective review of 174 nations and the rural “deficits” in health coverage showed that four basic inequities exist when comparing rural versus urban healthcare: lack of rights to healthcare (i.e., fewer entitlement programs in rural areas), shortages of rural HRH, unequal funding for rural health protection (and for preventative healthcare), and high out-of-pocket costs for rural populations forced to pay for their own health services [
18] These deficits were seen in very poor rural areas throughout regions of Africa including countries such as Zambia, Nigeria, South Africa and Kenya.
These inequities, alone, however, are not the only reasons for higher incidence and prevalence of some infectious diseases (e.g., malaria), malnutrition, and less preventative care in rural areas. Social determinants of health also come into play including access to education, food and social support [
19]. Given social and economic inequities, few rural areas send students to medical and nursing schools; thus, fewer return to serve these areas [
15]. Yet where a medical professional student comes from is highly correlated with where that student will practice upon graduation [
20]. Attempts to improve recruitment from rural areas—via incentives and increased access to education—have resulted in mixed, or at best only short-term results and improvements [
21]. In addition, poor road networks and physical distances from patients to care centers—as well as the social factors and pressures in some rural communities—also prevent patients from seeking health care early or often. Social exclusion from urban areas, not to mention the social pressures to seek guidance from local/rural “healers,” are strong forces that may keep patients from seeking life-saving care [
22].
Rural determinants of health result in relatively lower health indicators and indices; for example: greater numbers of stillbirths and higher infant mortality in Central Africa [
23], greater child malnutrition and inequitable food security among families across most low-income countries [
24], and larger family sizes [
25]. If rural determinants of health are not addressed proactively, poor rural health outcomes can pose serious health risks to urban areas—and their healthcare systems and populations, especially after conflict and/or national disasters when (rural) healthcare services are often depleted, and rural urban migration ensues [
26]. For example, when an Ebola patient traveled from a small Liberian town to an urban center to seek better care during civil unrest and to escape pressures to utilize local healers, this patient’s travels resulted in several downstream infections closer to an urban center [
27].
Failure to address rural healthcare staffing and care provision leads to underreporting of diseases, such as Buruli ulcer in DRC [
28], lack of appropriate and basic diagnostic services such as radiology in across sub-Saharan Africa [
29], and inadequate communication networks and sharing of best practices from urban to rural settings—from healthcare providers and thought-leaders in DRC [
16]. Several interventions have been proposed—including e-health information sharing and application deployment through smartphones in Ghana [
30], e-health solutions for rural clinics in South Africa [
31], Ghana, Tanzania, and Burkina Faso [
32], and improved clinic leadership training for rural healthcare leaders in South Africa [
33], yet multipronged HRH development is needed to improve health, avert pandemics and sustain hard won gains in HIV scale-up [
12].
In 2019 with support from HRSA, ICAP launched a telementoring program in DRC to help address some of disparities and lack of knowledge transfer from urban to rural settings [
34]. While successfully launched and currently being scaled up to, telementoring does not address insufficient supply of health care workers in rural areas able to drive health promotion, disease prevention and treatment. Therefore, a combination approach to strengthening rural health is needed.
Engaging students in rural contexts while increasing their familiarity and understanding of rural health needs allows students to experience the breadth of health services provided in rural areas and opportunities to expand knowledge and skills. Under the mentorship and supervision of experienced rural clinicians, students are exposed to a broader array of healthcare challenges than may be seen in urban settings where care is divided between many units and specialized services. This level of exposure to health issues, symptomatology, and engagement in all aspects of care from health history, point of care laboratory investigations, diagnosis and follow up can rapidly build clinical competence. Students live in and absorb more varied cultural environs and may establish early career leadership and managerial success on a scale more demonstrable than in urban settings where one is “lost in the crowd” of the larger healthcare workforce. Exposing nursing students to the opportunities in rural setting scan create more HRH who are willing to work in rural settings after graduating [
35].