Attachment J.9.pdf

I. Health Overview

● Maternal and Newborn Health Although a high proportion of births occur in health facilities (80%), DRC has one of the highest maternal mortality rates in the world,1 with an estimated 620 deaths per 100,000 live births.2 The major causes of maternal mortality are postpartum hemorrhage, sepsis, and preeclampsia.

It is estimated that 46% of these maternal deaths were related to a woman's delayed decision in seeking healthcare in time (first delay).3

High disparities also contribute to poor maternal health outcomes. 42% of women made at least 4 antenatal care visits in rural areas compared to 61% in urban areas.4 Skilled birth attendance varies greatly, 65% to 98% of births with lower coverage in rural areas.5 Only half (50%) of women who gave birth receive a post-natal care visit two days within giving birth. 6

Poor quality of maternal health services is a persistent challenge to accelerating maternal health gains. While only 8% of maternal care facilities lack essential birth equipment and supplies7, about 90% of birth attendants had never undergone any specific training in preventing maternal and newborn mortality, such as active third stage labor management, essential newborn care, or emergency obstetric care.8 Studies found that there are major gaps in competent intrapartum care including the correct use of the partograph, provision of infection prevention during childbirth, and continuous monitoring following delivery, as well as ensuring access to obstetric equipment required during childbirth including the use of the

1 WHO, UNICEF, UNFPA, The World Bank Group, United Nations Population Division. Trends in maternal mortality:

2000 to 2017 : UNICEF, UNFPA, and The World Bank estimates. 2019 2 Ramazani IB, Ntela SM, Ahouah M, Ishoso DK, Monique RT. Maternal mortality study in the Eastern Democratic Republic of the Congo. BMC Pregnancy Childbirth. 2022 May 31;22(1):452. doi: 10.1186/s12884-022-04783-z.

PMID: 35641954; PMCID: PMC9153209.

3 Ibid 4 UNICEF: Maternal and newborn health disparities; Jan 2024 5 Brenner S, Madhavan S, Nseya CK, Sese C, Fink G, Shapira G. Competent and deficient provision of childbirth services: a descriptive observational study assessing the quality of intrapartum care in two provinces of the Democratic Republic of the Congo. BMC Health Serv Res. 2022 Apr 25;22(1):551. doi: 10.1186/s12913-022-07737-

5. PMID: 35468822; PMCID: PMC9040341

6 https://www.healthynewbornnetwork.org/hnn-content/uploads/DRC-country-profile_english-March-2024-1.pdf 7 Ecole de Santé Publique de Kinshasa (ESPK), ICF International. Évaluation des Prestations des Services de soins de Santé (EPSS) 2017–2018. Rapport Final. Kinshasa and Rockville; 2019 8 Ministère du Plan et Suivi de la Mise en oeuvre de la Révolution de la Modernité (MPSMRM), Ministère de la Santé Publique (MSP), ICF International. Deuxième Enquête Démographique et de Santé en République Démocratique du Congo (EDS-RDC II 2013–14). Rockville; 2014 partograph. One study found that deficiencies in maternal health care are mostly due to providers’ oversight rather than limited availability of equipment and supplies.9

The newborn mortality rate in the DRC is high, with 26 neonatal deaths per 1,000 live births10 and 28 stillbirths per 1000 births (2021).11 Key drivers include prematurity (34.7 percent) birth asphyxia (28.6%) and sepsis (6%).12 A large portion of neonatal deaths occur within the 48 hours after birth but only six percent of newborns in rural areas receive postnatal care (PNC) within 2 days after birth, compared to 12 percent in urban areas. Neonates born from mothers less than 20 years old are at increased risk of dying compared to neonates born from older mothers. The Neonatal Mortality Rate for younger mothers (33 neonatal deaths per 1,000 lives) is 1.2 times higher than for mothers aged 20-29 years old (28 neonatal deaths per 1,000 live births.13

The Accelerator seeks to improve equitable access, quality, and demand for (maternal, newborn, child health and adolescent) MNCAH services. Specifically, it aims at improving quality of care, improving client, and respectful care of MNCAH services, recognising that improving core competencies and skills is not enough. One needs to also improve attitudes and behaviors of health providers all along the continuum of service delivery (facility and community) to improve health outcomes.

● Family Planning Use of modern contraception remains low with significant provincial disparities. It is estimated at 15.5% in 2020. An estimated 31.8 percent of women of reproductive age, or over three million women, have an unmet need for family planning. The total fertility rate is high, estimated at 6.6 children per woman. Early childbearing among adolescents 15 to 19 years old also remains high, at 13 pregnancies per 1,000 girls. Approximately 27% of adolescent girls already have been pregnant or have given birth.

Barriers to improving the modern contraceptive prevalence rate ( mCPR) include low demand, lack of information on FP and birth spacing, limited couple-centered counseling, gender barriers

9 Brenner S, Madhavan S, Nseya CK, Sese C, Fink G, Shapira G. Competent and deficient provision of childbirth services: a descriptive observational study assessing the quality of intrapartum care in two provinces of the Democratic Republic of the Congo. BMC Health Serv Res. 2022 Apr 25;22(1):551. doi: 10.1186/s12913-022-07737-

5. PMID: 35468822; PMCID: PMC9040341.

10 United Nations Inter-Agency Group for Child Mortality Estimation (2024).

11 United Nations Inter-Agency Group for Child Mortality Estimation (2023).

12 UNICEF: Maternal and Newborn Health Disparities, DRC, Jan 18, 2024 13Clarke-Deelder E, Shapira G, Samaha H, Fritsche GB, Fink G. Quality of care for children with severe disease in the Democratic Republic of the Congo. BMC Public Health. 2019 Dec 2;19(1):1608. doi: 10.1186/s12889-019-7853-3.

PMID: 31791291; PMCID: PMC6889659.

to women’s ability to seek Family Planning14, limited male involvement, and lack of access to quality, comprehensive MCH/FP services and commodities.15 The whole range of family planning options is often lacking due to contraceptive stock outs, poor quantification and distribution.

The GDRC has developed a National Family Planning Strategic Plan (NFPSP) with ambitious targets to address these persistent unmet needs and increase the contraceptive prevalence rate by 2024. The MOH has also committed to the global FP 2030 goal of ensuring universal access to sexual and reproductive health services and rights by 2030.

The NFPSP lists issues it seeks to redress to improve quality of FP services. These include:

limited coordination among all actors, limited coverage of FP services provided by the FOSA (not all FOSAs have trained FP counselors-only 60% of FOSAs have capacity to provide FP services), limited quality of services due to limited training and supervision of FP providers at facility level, regular stock out of contraceptives, Demotivation of community-based distributors due to lack of or low financial incentives (as they are officially volunteers and therefore not paid)and limited commitment and allocation of resources to create demand for FP services.

The NFPSP also recognizes that due to social, cultural and religious contexts, women, especially in rural areas, and youth, especially adolescents not married and sexually active, face many barriers that limit their autonomy to choose FP services. The Plan also calls for a greater implication and integration of FP services tailored to both men and women.

The Accelerator seeks to improve access, demand and use of family planning services, increasing male engagement, strengthening couple decision making for family planning, and improving access to family planning services for non-married sexually active women and adolescents. Young adolescent girls in the DRC are particularly vulnerable as they are often exposed to early marriages, teenage pregnancies and gender-based violence (GBV). Among unmarried sexually active young girls, only one in five use a modern contraceptive, while unmet need remains high at 48 percent among girls aged 15-19. The low use of condoms (27 percent) and family planning services (five percent), coupled with high abortion rates, puts adolescents

14 Bapolisi WA, Bisimwa G, Merten S Barriers to family planning use in the Eastern Democratic Republic of the Congo: an application of the theory of planned behaviour using a longitudinal survey BMJ Open 2023;13:e061564. doi: 10.1136/bmjopen-2022-061564= 15 Muanda MF, Ndongo GP, Messina LJ, Bertrand JT. Barriers to modern contraceptive use in rural areas in DRC.

Cult Health Sex. 2017 Sep;19(9):1011-1023. doi: 10.1080/13691058.2017.1286690. Epub 2017 Mar 3. PMID:

28276915.

at further risk.17 Only 80 out of 516 (15 percent) health zones offer a minimum package of youth-friendly sexual reproductive health rights (SRHR) services.18

● Child Health DRC remains home to one of the highest child mortality rates (less than five years old) in sub- Saharan Africa, with an estimated under-five mortality of 81 deaths per 1,000 live births according to 2021 UN estimates. About two thirds of deaths occur during the postnatal period;

malaria, diarrhea, and pneumonia are among the main causes. Declining routine immunization coverage during COVID-19 fueled more frequent outbreaks of measles, cholera, and yellow fever, contributing to child morbidity and mortality.

Very limited progress has been made to reduce malnutrition as a significant underlying cause of child mortality in the DRC. Nationally, 43% of children aged 0-59 months suffer from chronic malnutrition, while 23% experience severe malnutrition. Additionally, 8% suffer from acute malnutrition and 3% from the severe form; 23% are underweight, and 7% experience severe underweight. The on-going global food security crisis and insecurity are exacerbating food insecurity among children. While the essential package of health services includes nutrition specific services, often the health providers lack the skills and knowledge to prevent and address malnutrition both in children, adolescent and women during pregnancy. Limited counseling and understanding of optimal Infant and young child feeding practices contribute to child’s malnutrition.

The MOH uses integrated community case management of childhood illnesses (iCCM) as the cornerstone of its equity-based approach to extend management of uncomplicated cases of malaria, acute respiratory infection, diarrhea, and moderate malnutrition to hard-to-reach children. However, a study of 321 health facilities in five provinces of the DRC: Equateur, Bandundu, Katanga, North Kivu, and South Kivu revealed that many challenges in the implementation of iCCM, including insufficient training of IMCI and the fragmentation of the health sector funding in different provinces, which contribute to increased health inequities.

The same study found that only 41% of the children in the catchment area of the survey were taken to a health facility. Most of the health providers (63%) did not collect enough information for an accurate diagnosis across childhood’s illnesses (pneumonia, malaria, fever). Secondly, in the case that health workers collected the most relevant information, they often fail to correctly diagnose the disease and severity. Most worrying some, even when the diagnosis was made correctly, providers often fail to give the appropriate medication. This was particularly the case for malaria. Less than one-fifth of severely ill children were referred to urgently needed inpatient care.16

● Nutrition Food security and malnutrition continue to worsen throughout the DRC, more than 37 million people are suffering from malnutrition due to poverty, unavailability of nutrient-rich foods, lack of access to health and nutrition services, inappropriate feeding and care practices for young children and mothers, and poor water, sanitation, and hygiene practices. In 2023, UNICEF reported that 1.6 million children aged five years or younger suffered from GAM (global acute malnutrition), with 520,000 of them suffering from severe acute malnutrition.17 Nearly 900,000 children under the age of five and more than 400,000 pregnant and lactating women are likely to be acutely malnourished. The long-term impacts of malnutrition are significant and considerably increase maternal and child mortality rates and decrease cognitive and learning abilities of families, communities and individuals.18

In alignment with the DRC’s National Nutrition Strategic Plan and the DRC’s Country Roadmap for Global Action Plan, USAID is scaling up high-impact, nutrition-specific and nutrition-sensitive interventions in the provinces with the highest levels of malnutrition to address both the direct and underlying causes of malnutrition. USAID plans to use funds to emphasize integrated, locally led health, nutrition, and livelihoods programming in ways that build resilience among families and communities. This will include creative approaches to elevate nutrition and other outcomes, such as using Vitamin A supplementation outreach to screen for children who have missed their measles vaccinations and refer them to health centers. Nutrition programming will prioritize the continuum of care for the management of acute malnutrition in target provinces to reduce the rate of morbidity and mortality linked to malnutrition, focusing on children under 5 and pregnant women, with an emphasis on the 1,000-day window from pregnancy to the child’s second birthday.

In response to the growing needs to address malnutrition in DRC, the Accelerator will work in close collaboration with other USAID Multi-Sector Nutrition investments (i.e. Feed the Future) and also other donors’ investments (i.e., UNICEF and others) to improve the quality of nutrition specific services provided through health services (facility to community). Where feasible, the Accelerator will also promote nutrition-sensitive actions to improve care practices of young

16 Ibid 17 https://data.unicef.org/topic/nutrition/malnutrition/ 18 A.Akilimali, S.Banga, M.Oduoye, C. Biama, A. Munyangi, E. Byiringrio, et al., Malnutrition among under-five children in Democratic Republic of the Congo: A plague of the health system, Annal of Medicine and Surgery 82 (2022) https://doi.org/10.1016/j.amsu.2022.104260 https://data.unicef.org/topic/nutrition/malnutrition/ https://doi.org/10.1016/j.amsu.2022.104260 children, food intake and prevent disease through improved adoption of key healthy behaviors, delivered through health and community systems.

● Immunization:

The current GDRC plan for revitalizing routine immunization (RI), the Mashako Plan 2.0, has the ambitious goal of ensuring that 75 percent of children under five are fully vaccinated by the national health system on a routine basis, and free of charge, by 2023. However, to date, full immunization coverage remains low.

The Government of DRC’s Mashako Plan succeeded in increasing immunization coverage for several years, but then routine immunization coverage backslid during the COVID-19 pandemic. A joint-donor immunization coverage survey that USAID supported in 2021 found that only 42% of children (1.8 million) are fully vaccinated: 1 in 8 children have never been vaccinated (“zero dose”), and 1 in 2 children have not completed their vaccination schedule (“under vaccinated”). DRC continues to face regular vaccine-preventable disease outbreaks, notably measles and polio, which are mostly due to inadequate immunization coverage. A USAID Global Health Bureau priority for maternal and child health funding is identifying and vaccinating zero-dose and under-vaccinated children.

● Tuberculosis The Democratic Republic of the Congo is among the 30 global high burden countries listed for TB, TB/HIV and MDR/RR-TB. The NSP promotes scaling up effective interventions to reduce gaps of missing TB cases and how best to increase TB case notification with two main strategies: 1) Passive Case Finding (PCF) which consists of screening TB within all entry doors in all TB Diagnostic Setting (CDT) with their Satellite health Settings (CT). 2) and Active Case Finding (ACF) which include a wide range of strategies to raise awareness about TB and TB screening, diagnosis and referrals to treatment. Both strategies work with community participation through RECOs, Civil Society Organizations (CSO) and Community Based Organizations (CBO) who work closely with Health care providers to address the TB epidemic.

The Accelerator must work in close collaboration with other USAID TB investments (TB LONS) in synergy with other donors for instance the Global Fund, Action Damien, CHAI to improve TB notification and decreased mortality with the PNLT as the space of coordination of the fight against Tuberculosis. The Accelerator will support social and behavior implementation to improve TB detection and patient compliance to treatment regimen. .

● Malaria Malaria is the leading cause of mortality and morbidity in DRC with 97% of the population living in areas with stable malaria transmission lasting 8-12 years. Indeed, 40% of all hospital visits are due to malaria. In 2023, there were 27.7 million malaria cases in DRC that resulted in 22,224 malaria deaths. Globally, the DRC carries the second highest malaria burden, and malaria incidence per 1,000 population in the country is 224/1,000 populations. Among children less than five years old, the malaria prevalence in the USAID Accelerator Activity targeted province is estimated at 14% of children in Sud-Kivu, 41% in Kasai Central and more than half of all children in Tanganyika and Lomami (54%).19 DRC continues to struggle to achieve targets in malaria intervention coverage and burden reductions. USAID, under PMI, supports the DRC’s National Malaria Strategic Plan, with the objective to reduce malaria morbidity by 70 percent and malaria mortality by 50 percent from 2021 levels. USAID focuses on optimizing coverage and quality implementation for core prevention and treatment interventions, in addition to cross-cutting interventions such as surveillance, monitoring and evaluation; social and behavior change (SBC); and supply chain.

Malaria case management services are provided at different levels of the healthcare delivery system through national guidelines. All suspected malaria cases are supposed to be tested by malaria rapid diagnostic test (mRDT). The NMCP case management objective is to treat 100 percent of confirmed malaria cases according to the national guidelines at all levels of care, including at the community level.

In line with the World Health Organization (WHO) guidelines, the DRC’s national strategy includes provision of ITNs at the first ANC visit, a minimum of four doses of intermittent preventive treatment of malaria in pregnant women (IPTp) starting at 13 weeks gestational age, and effective case management of malaria. A study in DRC has shown that delivering IPTp by CHWs (c-IPTp)20 is an effective complementary approach to antenatal care clinics that can increase IPTp coverage by providing a greater access of pregnant women to IPTp, and increasing the required doses.

The USAID Accelerator Activity will support the NMCP 2024-2028 objectives. It seeks to strengthen the health system and improve the skills and behaviors of health workers in providing malaria services (case management, IPTp, in addition to cross-cutting interventions such M&E, SBC and supply chain), to strengthen referral systems across the pyramid of care from the community and health centers levels to referral hospitals per national malaria

19 PMI: U. S. President’s Malaria Initiative. DRC Country Profile-2023 https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2023/12/FY-2024-DR-Congo-Country-Profile.pdf 20 Gonzalez R et al: The impact of community delivery of intermittent preventive treatment of malaria in pregnancy on its coverage in four Sub-Saharan Countries-a quasi-experimental multi-center evaluation. The Lancet Global Health, Volume 11, issue 4, E566-E574, April 2023 https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00051-7/fulltext#seccestitle10 https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2023/12/FY-2024-DR-Congo-Country-Profile.pdf https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00051-7/fulltext#seccestitle10 treatment guidelines that will result in an improved health and socio-economic conditions of households and communities.21 Since malaria cases start at the household level, making correct early decisions is key, including seeking prompt care when children have a fever. In DRC, studies have shown that often parents of sick children will resort to self-medication or revert to unconventional treatment.22 There is a need to support efforts to improve the effectiveness and quality of malaria health services at community level, which will involve integrating CHWs in the elimination of malaria by improving community care sites and recognizing and promoting the RECOs 23.Other barriers to malaria control include limited knowledge effective malaria treatment at community and household’s levels24, understanding of the consequences of malaria, religious and cultural beliefs and economic considerations including easy access to poor quality antimalarials in the private sector.25 26 USAID Accelerator Activity will scale up SBC interventions targeting women of reproductive age and their partners to promote prompt care seeking behaviors for children with fever, early and complete ANC attendance, sleeping every night under an insecticide treated bed net, and IPTp uptake. The Activity will support efforts to treat children with severe malaria using Rectal Artesunate (RAS) as pre-referral treatment, based on lessons learned from the CARAMAL Project.27 The USAID Accelerator Activity includes support for MOH to scale up the introduction of the malaria vaccine by strengthening the capacity of health workers to deliver and counsel on the new vaccine.

● Zoonotic diseases and emerging public health outbreaks

The risk of emerging infectious disease and future pandemics are increasing. Rapid population growth, land-use, climate change, globalization, unsafe livestock farming practices and wildlife

21 Bavurhe RF, Akilimali A, Muhoza B, Biamba C, Oduoye MO, Masimango G, Cakwira H, Balume A, Rusenyi RB, Kibukila F, Nyakio O. What are the challenges and the possible solutions to fight Malaria in the Democratic Republic of Congo? New Microbes New Infect. 2023 Jun 14;54:101160. doi: 10.1016/j.nmni.2023.101160. PMID:

37416864; PMCID: PMC10320575.

22 Katumbo A.M., Tshiningi T.S., Sinanduku S., Mudisu L.K., Mulunda P., Mukuku O., Luboya O.N., Malonga F.K. The practice of self-medication in children by their mothers in Lubumbashi, Democratic Republic of Congo. J. Adv.

Pediatrics Child Health. 2020;3:27–31 23 World Health Organization Integrated Community Case Management of Malaria. [(accessed on 14 July 2020)];2017 24 https://www.researchgate.net/publication/364158123_Self-medication_and_Anti-malarial_Drug_Resistance_in_the_Democratic_Republic_of_the_Congo_DRC_A_silent_threat 25 Ntamabyaliro NY, Burri C, Lula YN, Ishoso D, Engo AB, Ngale MA, Liwono JY, Mukomena ES, Mesia GK, Mampunza SM, Tona GL. Knowledge of Antimalarials and Health Seeking Behaviour of Households in Case of Suspected Malaria in Democratic Republic of the Congo. Trop Med Infect Dis. 2021 Aug 26;6(3):157. doi:

10.3390/tropicalmed6030157. PMID: 34462413; PMCID: PMC8406087.

26 https://www.researchgate.net/publication/364158123_Self-medication_and_Anti-malarial_Drug_Resistance_in_the_Democratic_Republic_of_the_Congo_DRC_A_silent_threat 27 https://malariajournal.biomedcentral.com/articles/10.1186/s12936-023-04737-6 https://www.researchgate.net/publication/364158123_Self-medication_and_Anti-malarial_Drug_Resistance_in_the_Democratic_Republic_of_the_Congo_DRC_A_silent_threat https://www.researchgate.net/publication/364158123_Self-medication_and_Anti-malarial_Drug_Resistance_in_the_Democratic_Republic_of_the_Congo_DRC_A_silent_threat https://www.researchgate.net/publication/364158123_Self-medication_and_Anti-malarial_Drug_Resistance_in_the_Democratic_Republic_of_the_Congo_DRC_A_silent_threat https://www.researchgate.net/publication/364158123_Self-medication_and_Anti-malarial_Drug_Resistance_in_the_Democratic_Republic_of_the_Congo_DRC_A_silent_threat https://malariajournal.biomedcentral.com/articles/10.1186/s12936-023-04737-6 trade provide multiple opportunities for pathogens to evolve into new forms, making spillover from animals to humans more frequent and intense.28 It is estimated that 75% of emerging infectious human diseases have an animal origin.29

Recent, multiple infectious disease outbreaks in DRC including cholera, monkeypox, yellow fever, meningitis and Covid 19, Ebola is a reminder of the impact of these threats and the urgent needs to build DRC’s capacities to prevent, detect and respond to these public health threats. Responding to emerging infectious diseases requires a multi-sectoral approach as for example, animal disease outbreaks can threaten food security, disrupt local economics, lead to human disease outbreaks, and erode social fabrics in vulnerable societies.30

DRC Global Health Security success depends upon collaboration among the health, the security, the environmental and the agriculture and animal health sectors. USAID/DRC has supported the country’s efforts to establish structures and systems to strengthen the One Health Approach.

The Accelerator aims at strengthening the existing One Health Structures at provincial level, and also build capacity of Provinces, build one health platform at territorial level (CTCUS=Comite Territorial de coordination Une Sante), Health Zones and health workers at facility and community capacity to prevent, identify and respond to virus outbreaks; to strengthen community-based surveillance systems where RECOs and ACSA (Agent Communautaire de Santé Animale),together, are the first point of contact with the population they serve. It is important to note that USAID/DRC has already invested in all these domains: 1) strengthening coordination between human, animal, and environment health at provincial level, One Health Provincial Platform; 2) Strengthening community engagement; 3) strengthening community-based surveillance systems; 4) supporting IPC both at facilities and communities.31

A strong health system will ensure everyone can access high-quality healthcare without financial difficulty.

28 https://www.woah.org/en/what-we-do/global-initiatives/one-health/ 29 Ibid 30 Global Health Security Agenda Framework 2024. https://globalhealthsecurityagenda.org/wp-content/uploads/2022/11/ghsa2024-framework.pdf

31 Through USAID funding a qualitative study on the social-cultural, and individual determinants of prevention and response risk behaviors to the six priority zoonotic diseases. Message dissemination has been strengthened through interactive voice responses and modules using the 42502 hotline. USAID supported the establishment of six additional provincial-level One Health Coordination Committees (OHCC) (Kasai Oriental, Haut Katanga, Sud Kivu, Kasai, Sankuru, and Sud Ubangi) https://globalhealthsecurityagenda.org/wp-content/uploads/2022/11/ghsa2024-framework.pdf https://globalhealthsecurityagenda.org/wp-content/uploads/2022/11/ghsa2024-framework.pdf

Many people who live in this country where the health systems for providing services are underfunded and overstretched, experience dramatic consequences such as: (1) no access to a basic health facility as healthcare facilities do not exist where they are most needed. This is especially true in rural and remote areas where the distance to travel to a facility – or the cost to do so – is too great.

(2) Facilities that do exist are understaffed and under-resourced. This means they cannot provide high-quality culturally appropriate healthcare or vital services such as those for mental health.

(3) Poor quality services give rise to mistrust and suspicion, which deter people from seeking healthcare when it is needed.

(4) Service users are charged a fee for seeking healthcare to fill the funding gap. This pushes many people into poverty or again deters people from seeking healthcare when it is needed.

And so on.

The above weaknesses highlighted across all program areas have as an underlying cause, a weak health system.