Reporting completeness and timeliness
While data completeness was 100% at the provincial and health zone levels, the lower data completeness seen in the health facilities, at 86%, suggests that improvements are still needed at the lower levels to ensure complete data is feeding into the disease reporting structure. Even with health zones submitting surveillance data for each reportable disease and condition, disease incidence is likely to be underreported due to health facilities needing to report more complete data. A previous review of IDSR disease surveillance data in the DRC shows that discrepancies between IDSR reported morbidity and actual morbidity are common among the IDSR weekly reported diseases (18). Nevertheless, the average data completeness observed is a slight improvement from the 2016 IDSR assessment in DRC, with 100% at the provincial level, 82% at the health zone level, and 70% within health centers (6). With only 58% of health facilities reporting COVID-19 disease data in January 2021, this indicates that the disease reporting system needs to be faster to fully incorporate reporting for new disease threats across all geographic areas.
The timeliness of weekly data reporting was high at 100% at the provincial level and 97% at the health zone level. Yet, timeliness was low at the health facility level, with considerable variability. These results may be explained by country directives focused on providing support to ensure timely reporting at the higher levels. This is a vast improvement from the 2016 IDSR assessment in DRC, where the timeliness of data reporting at the provincial level was 17% and 79% at the health zone level (6). The 2018 DRC Joint External Evaluation reports combined completeness and promptness of weekly surveillance data reporting at the provincial level to be an average of 80% (19). The recurrence of public health emergencies and the perception focusing on the importance of complete and timely data in the framework of the IDSR have likely contributed to the improved indicators in disease data reporting.
Data analysis and interpretation
In general, data analysis efforts are carried out at the provincial and health zone levels, with dissemination to the lower levels of the bulletins produced every week. The 2016 IDSR evaluation in DRC noted similar results with analyses occurring at the central, provincial, and health zone levels, and primarily focused on disease trends (81% of provinces graphed disease trends), more so than demographic characteristics (19% of provinces developed demographic tables) or location (13% of provinces developed maps) (6). The results of our assessment also showed that graphs displaying disease trends were more commonly produced than other types of analyses, and more types of analyses could be conducted at the provincial level than at lower levels. Although not much change has occurred with respect to data analysis efforts concentrated at the higher levels of the health system, and lower levels benefiting from receiving these analyses, the availability of computer tools at lower levels seen in this assessment suggests there is an opportunity for increasing analysis capabilities at all levels with additional training and support.
Response
The functionality of the RRTs needs to improve, which could be linked to the high turnover of trained personnel and the lack of standardization of the RRTs in accordance with the guidelines of the 3rd edition of the IDSR. The low functionality of RRTs was previously identified in the 2016 IDSR evaluation in DRC, as less than one-third (31%) of provinces assessed and roughly one in ten (9.7%) health zones had functioning RRTs (6). North Kivu province has RRTs at the provincial level and in 41% of health zones. However, at both levels, the teams face challenges responding to alerts within 24 hours due to logistical, operational, and financial constraints. The issue was also raised in the 2018 DRC Joint External Evaluation, with DRC scoring a 1, the lowest possible score out of 5, for both emergency preparedness and response planning and for the ability to activate an emergency response (19). Recommended priority actions of the Joint External Evaluation included establishing emergency response teams at all levels of the health system and the development and dissemination of Standard Operating Procedures for public health emergencies (19). Even among the health zones with functional RRTs, SOPs, and preparedness and response plans are not widely available, and RRT functionality continues to be an ongoing challenge.
Infrastructure and equipment
Limited telecommunication infrastructure, limited electricity supply, and the lack of sustainable energy sources were documented as challenges by the IDSR task force meeting in 2017 in Uganda, which have remained consistent in this assessment (20). Among the recommendations from the 2016 IDSR evaluation in the DRC, an emphasis was put on enhancing the timely sharing of information through electronic IDSR reporting (5), but this comes at the high cost of upgrading equipment, infrastructure, and network coverage in order to do so. The persistence of telecommunication network coverage gaps, especially in remote, hard-to-reach, and epidemic-prone areas, limits the timely sharing of surveillance data and information for early warning and emergency response. For example, during the 2021 meningitis outbreak in Tshopo, a neighboring province, unstable telecommunication network coverage, and inadequate diagnostic capacity were among the main challenges cited for surveillance and emergency response (21).
In the context of DRC, outbreaks often occur in remote areas with poor road infrastructure, and mobility often requires a combination of different types of transportation (car, motorbike, canoe, etc.). Inadequate transportation was noted at each level of the health system.
For disease reporting and investigation to improve, particularly in more remote areas, the challenges of communicating quickly and having means of transportation within each health zone will need to be addressed.
eIDSR reporting
The DRC began implementing electronic surveillance data reporting through DHIS2 in 2014. However, to date, the DHIS2 rollout has yet to be fully implemented below the health zone level (22). Additional equipment and training will be needed to improve functionality at the health area and health facility levels.
In the DRC’s 2018 Joint External Evaluation of the International Health Regulation capacity, the DRC scored a 1, the lowest score meaning no capacity, for the use of electronic systems in surveillance data reporting, and the findings of this assessment do not show improved capacity since then (19). As a result, DHIS2 is still not effectively used for routine disease surveillance across DRC.
From a geographic perspective, the country is vast, with 519 health zones and 10,067 health areas, making efforts to provide equipment and electronic surveillance training down to the health area level countrywide challenging and costly. Network coverage is also patchy, further complicating rapid disease reporting. As the electronic surveillance system is not fully operational, traditional reporting channels continue to be used in parallel, potentially increasing the workload of surveillance staff. While other countries, namely Guinea, have successfully implemented DHIS2 for surveillance and transitioned out of the paper-based reporting system (23), the challenges are of a different scale within the DRC because of the vastness of the country. The IDSR task force recommended in 2017 that a dedicated budget line be set for electronic surveillance by 2018 (20). However, the funds may not be efficiently used in the absence of a national strategic e-surveillance plan, which was still lacking at the time of this evaluation.
Border health integration into the surveillance system
The Ministry of Public Health in the DRC has a program dedicated to the surveillance and control of public health threats at points of entry. This program, among other missions, conducts routine disease surveillance at points of entry, so integration with the mainstream disease surveillance system is critical. This component was included in this assessment to evaluate how NPBH works with the surveillance and response system, including alerting and information transfer. In the previous IDSR evaluation conducted in 2016, at the provincial level, NPBH was listed as a member of the provincial surveillance cell in North Kivu, however, the performance of surveillance activities by NPBH in North Kivu was not evaluated (6). The 2018 DRC Joint External Evaluation recommended that a cooperative agreement between the public health surveillance system and border authorities be established, and a system for the referral and transfer of ill travelers be developed (19).
The results of the present evaluation indicate that in some HZs where NPBH operates, suspect cases are reported to the health zone offices and referred to health facilities within the health zone. Information also goes from the provincial health office to NPBH based on a formal agreement. Though detailed travel data is not systematically collected from patients in health facilities, it is collected during the investigation of suspect disease cases by the rapid response teams. NPBH sometimes carries out the investigation for cases detected at points of entry. At the time of this assessment, the NPBH data management system is not integrated with the mainstream surveillance data system. Projects supported by different partners are ongoing to address this limitation at priority points of entry. This information can be used to assist in the management of data relevant to information sharing between agencies.
Limitations
The sampling of health zones and health facilities was not random, which may limit the generalizability and applicability of the findings to the whole of North Kivu province and the country at large. The findings reported here may be an overestimation since the North Kivu province has received significant support post-Ebola compared to other provinces. The geographic scope of this assessment was also limited due to security and accessibility issues present in many of the health zones in North Kivu. Violence is an ongoing threat in many areas. Also, some health zones identified as lower performing health zones in the province could only be reached by helicopter or several days of dangerous overland transportation and were not assessed. North Kivu province, which is a communicable disease hotspot, shares common borders with Uganda and Rwanda. The points of entry in this province are among the most frequented countrywide. However, surveillance activities at points of entry were not specifically assessed. It is also possible that repeated and prolonged disease outbreaks have made disease surveillance in North Kivu more effective than in other provinces.