Fidelity of implementation of the strategy to mobilize the for-profit private sector in the fight against malaria in Kinshasa, DR Congo
This mixed-methods case study conducted in Kinshasa, DR Congo, found that the strategy to mobilize the for-profit private sector for malaria control was largely implemented as planned with a 70.2% completion rate, despite challenges such as funding constraints and regulatory limitations that necessitated contextual adaptations to ensure coherence.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the Democratic Republic of Congo, malaria remains a relentless public health challenge, affecting a vast portion of the population and causing significant loss of life. While the government runs a national health system, a large share of the country's medical care actually happens in private clinics and pharmacies that operate for profit. Because so many people rely on these private providers, health officials realized that to truly control the disease, they needed to bring these independent businesses into the national plan. This approach involves a concept known as implementation fidelity, which simply asks whether a health program is being carried out exactly as its designers intended. If a plan is brilliant on paper but fails in practice because the steps were skipped or changed, the program cannot succeed. Understanding the gap between the plan and the reality on the ground is essential for fixing broken systems and saving lives.
Researchers set out to examine how well a specific strategy to mobilize these for-profit private providers was working in Kinshasa, the capital city. The goal was to see if the program was being delivered with the right content, at the right frequency, to the right number of people, and with high enough quality. The team, led by Eddy Kieto and colleagues from universities in Canada and the Congo, conducted a detailed study. While data collection took place between January 2024 and February 2025, the assessment focused on the degree of fidelity of the implementation of this strategy during the period from 2020 to 2024. They did not just look at numbers; they visited six different health zones and six private medical facilities known for high malaria rates. The researchers interviewed managers, doctors, pharmacists, and even pregnant women who use these services. They compared what the program planners had scheduled against what was actually happening in the clinics, looking for signs of success and reasons for any shortfalls.
The study found that the strategy was largely being followed, but with important gaps. Overall, about 70 percent of the planned activities were completed. The researchers broke this down into four key areas to see where the program was strong and where it struggled. The quality of the services provided was the strongest point, with about 72.5 percent of the care meeting the required standards. Training sessions for private clinic owners and staff were generally well-received and helped correct bad habits, such as the overuse of medicines. However, the program struggled with the "dose," or the amount of work actually done compared to what was planned. Only about 61 percent of the intended activities, such as the frequency of visits and the volume of supplies distributed, were carried out. Similarly, the "scope," or how many people and clinics were reached, covered only about 57 percent of the target group.
Several real-world obstacles explained why the program could not reach 100 percent of its goals. The most significant factor was a sharp reduction in funding. The program originally needed about 7 million dollars every three years to run fully, but the available budget was cut to between 2 and 3 million. This money shortage forced organizers to reduce the number of training sessions and cut back on the frequency of visits by medical representatives. The pandemic also left a lasting mark, disrupting supply chains and making it difficult for staff to travel safely due to traffic and security issues in the city. Furthermore, the private clinics themselves are often unstable; many open and close quickly, or their staff change frequently, which makes it hard to keep a consistent program running. Despite these challenges, the study noted that the program adapted well to these difficulties. For example, when official rules about who could sell diagnostic tests were unclear, local authorities issued temporary permissions to keep clinics working.
A critical finding was that while the clinics were doing a good job following medical rules, the people they served often did not know about the support available to them. When the researchers spoke with pregnant women, none of them knew that the government and international partners were helping to lower the cost of malaria treatment in these private clinics. This lack of awareness means that even though the clinics are ready to help, patients might not seek care or might not understand why they are getting a discount. The study also highlighted that the visits from medical representatives, who are supposed to guide the clinics, were irregular. Some clinics reported not seeing a representative for a whole year, which weakened the connection between the health authorities and the private providers.
The researchers concluded that the strategy to bring private businesses into the fight against malaria is working, but it is not perfect. The program has successfully improved the quality of care in many private clinics and has managed to stay active despite severe financial and logistical hurdles. However, to make the program truly effective for everyone, it needs more stable funding and better communication with the patients. The study suggests that the public and private sectors must work even closer together to ensure that the support reaches the people who need it most. By understanding exactly where the plan falls short, health officials can make the necessary adjustments to ensure that the fight against malaria continues to move forward, even in a complex and changing environment.
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