Zinc Introduction in D.R. Congo Improves and Revitalizes Diarrhea Case Management
In DR Congo, the introduction of zinc for the treatment of diarrhea has provided an opportunity to revitalize diarrhea case management for the Ministry of Health and its partners, including: USAID/BASICS, CRS, GTZ, HKI, IRC, MSH, UNICEF, WHO, and AXxes.
Zinc for the treatment of diarrhea was first introduced in DR Congo by IRC in 2004 in the Kabare health zone. USAID/BASICS and Management Sciences for Health began working with the Ministry of Health in 2006 to develop a national strategy, using experience in Madagascar as a basis. A key element of the strategy was establishing a task force to advocate a revitalization approach that included the introduction of zinc. An innovative approach was using an existing technical working group of partners who, since 2004, had been involved in the introduction of an integrated community case management intervention that included pneumonia, malaria, and diarrhea, as well as a nutrition component. Developing a task force for introduction of zinc and revitalization of diarrhea management within the context of an existing technical working group had three distinct strategic advantages. First, members were already working together and had momentum to move faster on revitalization activities. Second, despite a lack of availability of zinc in DR Congo, the group had included zinc (as well as low-osmolarity oral rehydration solution) in the integrated community case management package, and had advocated its acquisition. Finally, given that UNICEF was an active member of the group, procurement of zinc was made possible even before product registration had occurred. Ultimately, UNICEF ordered 3.5 million zinc tablets, which arrived in the country in December 2006.
The larger task force held its first meeting in April 2007, using the opportunity to identify priority areas for action and to develop a work plan. Three working sub-groups were formed to work in parallel on products, a literature review and qualitative study, and training materials. Within two months, zinc and low-osmolarity oral rehydration solution were registered, paving the way for utilization in country. Notably, though, zinc was included on the essential drug list much later because the review of the list occurs at a time set date.
Concurrent with the task force increasing the availability of low osmolarity ORS and zinc, the need for training large numbers of health workers was also addressed. Recognizing that different health workers have different training needs, three training approaches were employed:
- Health workers already trained in IMCI received a one-day day orientation on new protocols, as well as refresher training in IMCI.
- Health workers not yet trained in IMCI, but already scheduled for such were provided with near-immediate training,
- Health workers not yet trained in IMCI and not scheduled for such attended a 2-day session that focused on diarrhea case management, as well as systematic assessment of children presenting with any symptom illness at a health facility.
At the community level, when zinc became available, active community health workers were briefed during a post-training follow-up meeting and new community health workers had zinc incorporated into their diarrhea training.
It was critical that, during the time that implementation was moving forward, the task force worked concurrently on reviewing and revising the national policy on diarrhea case management. As a result, the Ministry of Health adopted a national policy on diarrhea revitalization and also approved zinc for the treatment of diarrhea in May 2008.
These efforts in policy development and implementation of zinc generated so much interest among partners and MOH officials that it quickly became apparent that the 3.5 million tablets procured by UNICEF would not be sufficient. To be responsive to the increased demand for zinc, the MOH and partners undertook three actions:
- Representatives from the private sector and central medical stores were invited to two meetings aimed at gaining their participation in zinc supply.
- Zinc distribution was restricted to targeted health zones, allowing a continuous availability there while efforts were being undertaken to expand supply nationally.
- A price level was set to ensure access to zinc through adequate resupply of stocks as it became more widely used.
Zinc is currently being used for diarrhea treatment in 100 out of 515 districts in DR Congo, with extension to hard-to-reach areas through community case management in 43 health zones. These efforts are now being supplemented with increased monitoring of efforts through studies and development of health education messages through the media of posters, radio and TV spots, and dramas.
The team has planned to launch the revitalization of diarrhea case management in DR Congo through a national day under the leadership of the Minister of health. Preparations began months ago. The main missing piece is zinc. One way UNICEF is supporting this large-scale event is through the ordering of 60 million tablets of zinc, which are slated for delivery soon. Once in country, the zinc will be put in place in all provinces, then final arrangements will be made for the national launch. To say the very last, partners are anxious for that day to come.