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Background: There is often collateral damage to health systems during epidemics, affecting women and girls the most, with reduced access to non-outbreak related services, particularly in humanitarian settings. This rapid case study examines sexual and reproductive health (SRH) services in the Democratic Republic of the Congo when the COVID-19 hit, towards the end of an Ebola Virus Disease (EVD) outbreak, and in a context of protracted insecurity. Methods: This study draws on quantitative analysis of routine data from four health zones, a document review of policies and protocols, and 13 key-informant interviews with staff from the Ministry of Public Health, United Nations agencies, international and national non-governmental organizations, and civil society organizations. Results: Utilization of SRH services decreased initially but recovered by August 2020. Significant fluctuations remained across areas, due to the end of free care once Ebola funding ceased, insecurity, number of COVID-19 cases, and funding levels. The response to COVID-19 was top-down, focused on infection and prevention control measures, with a lack of funding, technical expertise and overall momentum that characterized the EVD response. Communities and civil society did not play an active role for the planning of the COVID-19 response. While health zone and facility staff showed resilience, developing adaptations to maintain SRH provision, these adaptations were short-lived and inconsistent without external support and funding. Conclusion: The EVD outbreak was an opportunity for health system strengthening that was not sustained during COVID-19. This had consequences for access to SRH services, with limited-resources available and deprioritization of SRH.
A mixed-methods approach that used a largely retrospective (rapid) case study design was adopted to gather qualitative and quantitative secondary information as well as the views of stakeholders about how SRH policies, protocols and practices were adapted in response to COVID-19. Data sources included a document review, key-informant interviews, quantitative secondary data analysis, and knowledge embedded within the research team. Documents included in the document review were found through a purposeful online search (generally and specifically using the database of the Cellule d’Analyse en Sciences Sociales (CASS) [16], as well as shared by International Rescue Committee (IRC) staff in DRC and key-informants. The document review included 17 documents and included existing laws, policies, and protocols for SRH in DRC and North Kivu (n = 4); descriptions of COVID-19 policy response and adaptations (n = 4); presentations from Health Cluster meetings (n = 1); other reports and analyses of the COVID-19 effects on SRH and on the health system in DRC (n = 2); and reports on SRH and on the health system of North Kivu before COVID-19 (n = 6). In addition, quantitative data from four health zones (Goma, Karisimbi, Beni, and Mweso) in North Kivu were extracted from DRC’s District Health Information Software-2 (DHIS2) database for the period between 2019 and 2020 and shared with the study team. The indicators reviewed were maternal deaths, antenatal care visits, skilled birth attendance, and new consultations. Twenty-three key informants were purposefully identified from the five following groups: representatives of United Nations (UN) agencies, Ministry of Public Health (MSP), international non-governmental organizations (INGOs), national non-governmental organizations (NNGOs), and civil society organizations (CSOs). The overall number of respondents captured covered a high proportion of key actors and these five groups were selected to represent the main stakeholders involved in delivery of health services in the province, with a target of five organizations from each group, with the exception of the UN, which only had three relevant agencies to include. The respondents approached for interviews were those responsible for reproductive health within their organizations. A list of the representatives of main actor’s organizations in each of these categories was initially prepared by IRC staff in Goma with the aim of five per category. A total of 23 key informants were selected and contacted. Interviews were successfully scheduled with 13 of those key informants, of whom only one was female (Table (Table11). Key informants contacted and interviewed An information sheet and consent form in French were provided to the respondents at the time of scheduling interviews with all information needed for the interview. The informed consent was collected for all the interviewees including consent to recording of interviews or taking notes. Investigators conducted interviews with key-informants in French—two of the interviewers do not have working relationship with the respondents (LSH and MPB), while one (CM) does. Additionally, the research team included investigators from both academic institutions (MPB, WM) and an implementing agency (NGO) (LSH, CM, JK), and from both the outside (LSH, MBP, WM) and inside the country (CM, JK). The mix of insiders and outsiders with iterative discussions between researchers at data collection and analysis stages, including reflections on researchers’ positionality, were chosen to strengthen the rigor and trustworthiness of our qualitative findings [17] by allowing for both external and internal perspectives on the context. Each interview lasted about 1-h and was done either remotely using Whatsapp or Microsoft Teams or in person, between December 2020 and January 2021 guided by a semi-structured interview guide which focused on understanding the response to COVID-19 in terms of changes to SRH services, actors responsible for those changes, as well as on unpacking the decision processes on changes and their implementation at different levels of the health system and their impact (Additional file 1: Annex 1). While interviews were not transcribed or translated, detailed notes were taken given the rapid approach of the case study. Illustrative quotations used in the results section below were transcribed and translated by the authors based on the audio recordings. Quantitative secondary data were reviewed for trends between 2019 and 2020 using Microsoft Excel to address the question on the impact of COVID-19 on utilization of SRH services and on SRH outcomes for women and girls. Data was also triangulated with reports and other information to compare trends in North Kivu with those at the national level and interpret those trends against the COVID-19 epidemic data and other key factors, such as changes in funding levels. Interviews and documents were analyzed using thematic analysis [18, 19]. A series of themes/codes were developed building on the aims of the study but allowing space for revisions during analysis to accommodate emerging themes (Additional file 1: Annex 2). Codes were applied to interviews’ field notes and documents using an Excel-based extraction matrix. Findings from each source were carefully integrated and triangulated, and results of the data analysis, document review and interviews were analyzed and written up jointly to allow for complementarity between data sources. The preliminary results of the study were discussed between researchers as well as shared with participants during a Health Cluster SRH sub-working group meeting in Goma for their feedback. Furthermore, the final report was sent to participants.
