The intense use of resources to combat COVID-19 causes concern in the entire transplant community because, in addition to physical limitations such as ICU beds, lack of homogeneous treatment protocols and uncertainties about the effects of immunosuppression on viral progression have significant impact on transplant surgeries. The aim of the present study is to comparatively assess the number of solid organ transplants performed in 2019 and 2020, as well as the impact of the COVID-19 pandemic on organ donation and transplant surgeries in Brazil. The last 10 years have shown increasing trend in the number of solid organ transplants, which have significantly decreased in 2020. Lung transplantations were mostly affected by the pandemic; these surgeries have been carried out only in Rio Grande do Sul and São Paulo states. Liver transplantations were the least affected ones, since the number of surgeries have only decreased by 10.8% in the first three quarters of 2020, in comparison to 2019. The number of active patients on the waiting list for heart and kidney transplantation has increased in 2020. Therefore, it is necessary developing strategies to keep the structure necessary for organ transplantation processes active and, consequently, to reduce the impacts of the pandemic on these patients.  The latter is widely expressed in human tissues, mainly those of the lower respiratory tract ,The complexity of cases has worldwide overwhelmed the public health systems,The current pandemic has significant impact on transplant proceduresThe aim of the present study was to comparatively assess the number of transplant operations performed in 2019 and 2020, as well as the impact of the COVID-19 pandemic on organ donation, in Brazil.Data referring to the timeframe between January and September in 2019 and 2020 were collected in the Brazilian Transplantation Registry (RBT - Registro Brasileiro de Transplantes), which is the official information tool used by the Brazilian Organ Transplant Association (ABTO - Associação Brasileira de Transplante de Órgãos). This paper underwent the evaluation of the Research Ethics Committee of Hospital Moriah - São Paulo, registration number 003/2021.,Transplant operations included in the current study comprised solid organs such as heart, lung, liver, pancreas and kidney, from January to September 2019 and 2020,,The state analysis has shown that the number of potential and effective donors in the country ranged from 8,469 potential donors and 2,775 effective donors in 2019 to 7,725 potential donors and 2,438 effective donors in 2020,There was an increasing trend in the number of transplants of most solid organs in the last 10 years; however, this number was significantly decreased in 2020 . This ph,Regarding donor characteristics, ABTO considers sex, age group, blood group and cause of death. It was observed a significant decrease in the number of donors due to traumatic brain injury (TBI) in 2020, although lower than in 2019,There was an increase in the number of active patients on the waiting list for heart and kidney transplantation in 20209,12.The number of organ donors during the COVID-19 pandemic has decreased in Brazil, mainly the number of donors who died due to traumatic brain injury. This factor may be associated with the decreased number of individuals on the streets - at least in the first months of the pandemic - and, consequently, with a decreased number of accidents and trauma typesnd quarter of 2020 dropped to 13.4% in the 3rd quarter. A significant drop was observed in the 2nd and 3rd quarters of 2020, in the Northeastern (8.9% and 47.6%) and Southern (64.7% and 57.1%) regions. The Southeast region, whose heart transplant rate decreased by 40.4% in the 2nd quarter of 2020, increased by 2.1% in the 3rd quarter, whereas the Midwestern region increased heart transplant rate in the latter two quarters (33.3% and 66.7%). The Federal District (8.0 pmp) stood out for liver and heart transplantation in 2020The heart transplant rate decreased by 23% in 2020, in comparison to that of 2019; the decrease of 49% observed in the 2A French study analyzed data recorded during the pandemic from March to July 2020 and observed 1,530 transplant operations, in total - 167 of them were heart transplantations. There was an increase transplant activity after the program reopened, although there was a decrease in comparison to 2019The volume of transplants from deceased donors in the USA significantly decreased in all the regions of the country in March and April 2020 - heart transplantations decreased by 43%. However, there was in the subsequent months, an increase was seen in the number of transplants due to efficient and safe actions taken by the Organ Procurement and Transplantation Network (OPTN)According to the ABTO, the number of patients on the heart transplant waiting list has slightly increased from January to September 2019 and 2020 - absolute numbers were 260 and 277, respectively. These numbers do not meet those recorded in the USA, which presented a decrease by 34.2% in the number of patients on the waiting list for heart transplantation but an increase by 35.8% in the number of patients who died on the waiting listAccording to the ABTO, lung transplantation was mostly affected by the COVID-19 pandemic; it was only performed in Rio Grande do Sul and São Paulo states. RBT data indicated a decrease in the absolute number of lung transplants from January to September 2020, in comparison to the same period in 2019 - 72 and 39 transplants, respectively. Taking into consideration the evolution over the last 10 full years, it is possible to acknowledge an increase by 61 in the number of lung transplants performed in 2010, to a peak of 121 transplants, in 2018. Based on the projection calculated by ABTO for the last months of the year (Graphic 1), there would be 52 lung transplants performed in 2020, which would represent a decrease by 49% in comparison to the previous year - these numbers are against the upward trend - with some variations - in the last decadeA study focused on evaluating transplants performed in the United States from January to April 2020 found a decrease by 40.04% in lung transplants, as well as an increase in the number of sick patients on the waiting list,The number of patients on the waiting list for lung transplantation has slightly decreased from 199 (in 2019) to 195 (in 2020). A study conducted in Italy did not find significant changes on the waiting list due to the urgent nature of lung transplantation procedures, which cannot be postponedst quarter, by 29.1% in the 2nd quarter, and by 11.9% in the 3rd quarter. The highest decrease in the number of liver transplantations was recorded in the Northeastern region (37.1%), which was followed by the Southern region (21.1%), whereas the Southeastern (decrease by 0.3%) and Mid-Western regions (increase by 3.7%) have already recovered. Liver transplantations from living and deceased donors has decreased by 11%. The Federal District alone performed more than 20 transplants per million population (pmp),,According to the ABTO, liver transplantation was the procedure least affected by the COVID-19 pandemic, since it decrease by only 10.8% in the three quarters of 2020, in comparison to the same period in 2019 - it increased by 16.9% in the 1France recorded a decrease by 22% in the number of liver transplants during the COVID-19 pandemic, as well as a sharp decrease in it during the lockdown periods. Such decrease can be explained by three reasons: most intensive care unit (ICU) beds are dedicated to critically ill patients infected with COVID-19; teams accounting for transplant operations were reassigned to take care of patients with respiratory symptoms, which hindered the logistics to harvest and transplant organs; and finally, some transplantation programs were suspended in France during the pandemic periodThe SARS-CoV-2 pandemic has led to an imbalance in the organ donation and procurement process in the USA, which resulted in decreased transplantation rates. According to data from the United Network for Organ Sharing (UNOS), there was a decrease by 25% in the number of livers from deceased donors between February and April 2020, whereas liver transplants from living donors recorded a low rate (5%), in March and AprilThe waiting list for liver transplantation in Brazil recorded a slight decrease from 1,124 patients in 2019, to 1,100 patients in 2020Based on data reported by the ABTO, the number of pancreatic transplant operations performed from January to September 2020 decreased in comparison to the number of procedures performed in the same period in 2019 - 108 and 125 transplants, respectively. Santa Catarina State recorded the highest decrease in the number of pancreatic transplants - from 11 to three transplants. São Paulo and Minas Gerais have kept the absolute number of transplants. Based on a 10-year period, the lowest transplant rate in these states was recorded in 2017 (only 113 transplants). On the other hand, there was a substantial increase in 2018 (146 transplants) and 2019 (175 transplants), which decreased again in 2020 (144 transplants)The Netherlands recorded a decrease by 67% in its services during the pandemic period - the total number of pancreatic transplants dropped to zerost quarter, decreased by 43.2% in the 2nd quarter and by 37.8% in the 3rd quarter. Interestingly, there was a higher decrease in the number of kidney transplants in the 3rd quarter in some regions due to late pandemic peak in the Southern region (54%), which was followed by the Northeastern (42%), Southeastern (30%) and Mid-Western (23%) regionsAccording to data provided by the ABTO, when comparing 2019 to the same period in 2020, the number of kidney transplantations increased by 6.5% in the 1,The total number of kidney transplants significantly decreased from January to September 2020, in comparison to the same period in 2019 - 3,486 and 4,617 transplanted kidneys, respectively. The decrease in kidney transplant rates within these nine months reached 26.2% in 2019; 18.4% of it corresponded to deceased donors and 63.7% to living donors,Based on a survey conducted with 204 transplant institutions around the world, from May to June 2020, 75% of institutions had fully stopped performing kidney transplants from living donors due to governmental or managing restrictions. The assessment of living donors has also significantly decreased due to the COVD-19 pandemic, based on concerns about the safety of living donors associated with the risk of getting infected with the virus. In addition, 59% of the institutions reported to have temporarily stopped the assessment, which led to the drop in the total number of kidney transplantsThe ABTO annual projection for 2020 had anticipated 4,646 kidney transplants and showed sharp drop in the number of transplant recipients in Brazil, despite the trend to an increased number of kidney transplants and a total number of solid organ transplants in the last 10 years. Kidney transplantation reached its maximum peak in 2019, with a total number of 6,295 transplantsThe number of patients on the waiting list for kidney transplant, according to the ABTO, increased in 2020, in comparison to the period from January to September 2019 - the absolute numbers were 25,724 and 23,630, respectivelyThe mean time spent on the waiting list for kidney transplant in the USA is three to five years and depends on several factors; patients who remain on the waiting list require kidney replacement therapy. Morbidity and mortality rates in dialysis patients are significantly higher than rates recorded for the non-dialysis population. In April 2020, the death rate of patients on the waiting list for kidney transplant in the USA increased by 43.0%, based on UNOS dataOrgan donation campaigns should be carried out to make the population aware of the importance of maintaining organ donation, as well as to educate those patients on the list waiting for organs. In addition, strategies must be developed to keep the necessary infrastructure for active organ transplantation processess, as well as to mitigate the impacts of the COVID-19 pandemic on these patients.


According to the latest estimate of the Food and Agriculture Organization of the United Nations, it is expected that by 2050 the world’s population will increase to 10 billion people, which will lead to a great increase in the demand for agricultural products. By this time, the world’s population will need 60–70% more animal products than it consumes today and, consequently, a high demand for feed will be required. Recently, the secondary use of the by-products of the processing industry, obtained as a result of the production of poultry meat, which can be included in the diets of farm animals, has become a popular topic in the feed industry. Russian veterinary legislation allows the use of poultry meat processing waste in the feeding of ruminants, which is consistent with EU Regulation No. 1069/2009 of 21 October 2009, which states: “Materials obtained from animals should not be fed to animals belonging to the species from which they were obtained”. Our research is developed to use a new feed (concentrate) from the remains of non-edible wastes  together with plant proteins (white lupine grain) in feeding young cattle of the Russian Ayrshire cattle. This article describes the chemical composition of protein concentrate as an alternative feed in the calves’ diet and its effect on the bacterial microbiome, nutrient digestibility and biochemical parameters of calves and heifers.p > 0.05) in group 2 by 4.4 kg (p < 0.05). Similar results were obtained at the age of 6 months of raising. Feeding 4.50% protein concentrate Agro-Matic has a positive effect on the digestibility of nutrients; in particular, there was a significant increase in the digestibility of crude protein in the PCAM + RC group (77.23 vs. 73.42%) compared with the control group. Moreover, a similar trend was found in the digestibility of nitrogen in the diet. At the age of 3 months, heifers showed a significant decrease in the concentration of ketone bodies in the second group (1.82 vs. 2.20 mmol/L) relative to the control group. Urea was significantly lower in the RC + PCAM group (5.05 vs. 6.62 mmol/L) relative to the PCAM + RC group, while acid capacity  was higher by 2.41% (p < 0.05) relative to the control. In the 10th month of age, a positive effect on the blood of heifers was observed, as in the second and the third experimental groups, β-globulin and phosphorus increased (p < 0.05), while in the second group aspartate aminotransferase decreased (p < 0.05). Consequently, replacing the rapeseed cake with the protein concentrate Agro-Matic revealed an improvement in the dynamics of growth, nutrient digestibility and nitrogen balance, and it has an effect on improving some biochemical parameters of the blood.Recently, the secondary use of by-products of the processing industry resulting from the production of poultry meat, which can be included in animal diets, has become a popular topic in the feed industry. For studying the effects of partial replacement of rapeseed cake (RC) with the by-product source of animal protein concentrate Agro-Matic (PCAM) on growth dynamics, nutrient absorption and nitrogen balance, as well as blood biochemical parameters during the growing period, a total of 48 Russian Ayrshire dairy heifers were selected for this experiment and they were divided into three experimental groups . The heifers of the control group were fed the basal diet which contained rapeseed cake (30%), while the second (RC + PCAM) and third groups (PCAM + RC) were fed the basal diet after replacing a part of the rapeseed cake with 2.25% and 4.5% of protein concentrate Agro-Matic respectively. The results showed that the weight of heifers treated with PCAM at 3 months of age exceeded the control by 2.3 kg ( Production of poultry by-product, which can be included in other animal diets, has become a popular topic in the feed industry worldwide . TogetheThe world of animal husbandry is a priority direction of development due to the greater intensity of development and growth of production ,6. Thus,The most urgent task is the introduction of harmless methods of processing biological waste, which at the same time represents a valuable secondary crude material for the production of feed ,14,15. IRussian veterinary legislation allows the use of poultry meat processing waste in the feeding of ruminants, which is consistent with EU Regulation No. 1069/2009 of 21 October 2009, which states: “Materials obtained from animals should not be fed to animals belonging to the species from which they were obtained”.The use of waste from food industries in modern feed production will ensure deep processing of food crude materials of animal and vegetable origin, reduce the cost of production of basic products through the sale of additional products, expand the range of modern feed, develop domestic livestock and poultry farming, and improve the environmental safety of food and processing workshops ,17,22,23Organic waste is characterized by a high total solids content of more than 10–15%, which mainly consist of animal proteins and fats ,24. PoulRuminants that are reared for the production of a high amount of animal products require a high intake of bypass or slowly degradable protein rich in essential amino acids ,28. ProtIn our early works devoted to the use of a new protein feed protein concentrate Agro-Matic (PCAM), which is made from poultry meat processing waste and crushed white lupine grain in feeding lactating cows ,33,34,35Bacteroidetes in cows of groups (1.0 and 1.5 kg/day) receiving protein concentrate in their diets was reduced by 1.5% and 2.9%. There were no significant differences between the control group and the groups receiving PCAM supplements and in most of the rumen microbiota, with the exception of pathogenic microorganisms such as Peptococcus and Fusobacteria; a significant decrease was noted between the control group and the groups receiving PCAM supplements [Analysis of the rumen content showed that the number of plements ,34,35.Bifidobacterium sp. and Bacillus sp., has been elevated [In experimental groups of animals, deviations from the norm for cellulolytic, amylolytic, transit and pathogenic bacteria were not detected. On the other hand, a microbiota with antimicrobial activity that stimulates animal immunity, such as elevated ,35.Poultry abattoir waste is a slowly decomposing protein in the rumen and, thus, can be an economical and rich source of insoluble protein in the diet of ruminants. This means that the use of feed based on poultry processing waste for feeding ruminants has great potential as a cleaner animal feeding product ,38,39,40This study is a part of the research of the Department of Feeding Animals Russian State Agrarian University–Moscow Timiryazev Agricultural Academy on the topic “Physiological justification of the effectiveness of the use of protein concentrate “Agro-Matic” in feeding dairy cattle” dedicated to the study of the effect of protein concentrate from poultry meat production waste in feeding young dairy cattle.The entire research process was carried out at the Vologda region (Russia) on a farm belonging to Agricultural Production Cooperative Plemzavod Maysky on dairy heifers since the transition from dairy feed to solid feed. A total of 48 Ayrshire heifers were selected for the experiment and divided into 3 experimental groups (including the control group) .When establishing groups, origin, age, live weight at birth and at 60 days of age and health status were taken into account. Before starting the study, the animals were examined by a full-time veterinarian of the farm for the presence of diseases or abnormalities in the state of health. Before the start of feeding rapeseed cake (RC) and protein concentrate Agro-Matic (PCAM), all animals were subjected to veterinary examination to ensure that all animals were healthy.The animals were clinically healthy and kept in the same conditions throughout the entire experiment. All animals were kept loose, with each group of heifers in a separate pen; the only exception was the period of the physiological experiment to determine the digestibility of basic nutrients. The animals were kept in a separate stall on a leash for 14 days before the experimental studies.After calving, the cows were transferred to the department for lactating cows, and the calves that were candidates to enter the study were fed a daily amount of colostrum through a drencher and placed in separate pens, which were balanced by live weight and date of birth. Drinking milk and other dairy products was carried out according to one approved protocol on the farm. During training and transition to the main solid feeds, the diet was carried out with an average of 45–50 days from birth. The live birth weight in the control group receiving RC was 32.90 ± 0.53 kg, in the second group receiving RC + PCAM, 32.70 ± 0.54 kg, and the third receiving PCAM, 32.60 ± 0.48 kg, respectively. The composition of concentrates for Ayrshire heifers under the study are presented in The formulation of rations was carried out according to the Feed Optima program (v. 2020.8.17251) to meet the energy and nutritional needs of heifers during the growing periods. Part of the rapeseed cake in the second (RC + PCAM) and third (PCAM + RC) groups was partially replaced by protein concentrate Agro-Matic (PCAM), which consists of white lupine grains and poultry meat waste in the amount of 2.25% (group 2) and 4.5% (group 3). The diet of the heifers was balanced, in agreement with the recommendations for feeding highly productive dairy cattle, which was distributed 2 times a day with unhindered access to water. The inclusion of all feeds was carried out by distributing pre-prepared total mixed-ration (TMR) feed mixture individually for each section.The nutritional value of daily ration of Ayrshire heifers is located in -Dry matter (AOAC 930.15);-Organic matter (AOAC 924.05);-Crude ash (AOAC 923.03);-Crude protein and nitrogen (AOAC 984.13);-Essential ether extract (crude fat) (AOCS approved procedure Am 5-04);-Crude fiber (AOCS Ba-05 standard procedure);-Calcium and phosphorus (ISO 27085:2009) .The analysis of the chemical composition of feed and products of the balance experiment was carried out in the laboratory of the Northwest Research Institute of Dairy and Pasture Animal Husbandry named after A.S. Emelyanov which is considered as a separate division of the Vologda Scientific Center of the Russian Academy of Sciences . Feed samples and products of the balance experiment were taken in accordance with the ISO 6498:2012 standard “Animal feed and they were similarly subjected to chemical analysis according to the AOAC methods” . The cheNitrogen in urine is nitrogen according to the Kjeldahl method (AOAC 984.13).During the study, the following parameters were taken into account: daily weight gain and absolute live weight at birth at the age of 3, 6 and 10 months. The following indicators were measured during the study:The live weight (g) was determined by a control individual weighing of heifers 1 time per month from the moment of birth.W1 is the live weight of heifers at the end of the growing period  and W0 is the live weight of heifers at the beginning of the growing period . Absolute gain  is the increase in live weight over the period of the experiment, which was determined using Equation (1):W2 is the live weight of heifers at the end of the growing period (g), W1 is the live weight of heifers at the beginning of the growing period (g), t2 is the age of heifers at the end of the growing period (day) and t1 is the age of heifers at the beginning of the growing period (day).The average daily gain  was calculated by weighing the results, which was determined using Equation (2):Feed costs per 1 kg of live weight gain (kg) were calculated by dividing the amount of feed consumed over the entire period of the experiment by the live weight gain of heifers during the growing period.The use of nutrients and the use of nitrogen in diets were established based on the results of balance experiments conducted at the age of 3 months in accordance with the methodological recommendations of the Federal Research Center for Animal Husbandry named after Academician L.K. Ernst (2016) . For thiTo compile an average sample, animal feed, leftovers and excrement were taken every day and stored in glass jars. Feed several times a day as the feed mixture was distributed and consumed, the remains of the feed from the previous day were weighed 1 time in the morning of the next day during the entire period of the experiment to calculate nutrient intake.Feces and urine were collected in individual tanks, from which an average sample was subsequently taken 2 times a day for chemical analysis. To preserve the secretions, a 10% solution of hydrochloric acid and toluene was added to them in the calculation of 10% HCl and 0.5% toluene by weight of the average sample. The added amount of preservatives was taken into account when determining the dry matter content .At the end of the experiment, the samples were dried in a drying cabinet at a temperature of 65 °C for several days and crushed for further chemical analysis. The chemical composition of the litter was analyzed similarly to the methods presented in The digestibility coefficient  of each nutrient in the diet was evaluated using Equation (3):g, and then stored at a temperature of +4 °C to determine the biochemical parameters of blood. Biochemical blood parameters were analyzed in a certified independent veterinary laboratory . In the blood of calves, the following parameters were measured:-Glucose—calorimetrically with ortho-toluidine according to Gultman in the modification of Hivarinen-Nikkel;-Pyruvic acid—according to the modified Freedman and Haugen method;-Non-esterified fatty acids (NEFA)—calorimetrically;-Ketone bodies—by the iodometric method;-Total protein—by the refractometric method;-Urea—calorimetrically;-Calcium spectrometric titration;-Phosphorus—colorimetric method, reserve alkalinity according to Nevodov in Lebedev modification;-ALT—UV-kinetic method;-AST—dinitrophenylhydrozone method;-Carotene (mg%)—colorimetrically.Throughout the experiment, blood samples (9 mL) were taken from the tail vein of heifers aged 3 and 10 months. Samples were taken from the caudal vein 3 h after morning feeding. They were collected in a test tube with coagulant activator  to obtain blood serum. Blood serum was obtained after blood sampling and centrifugation of blood samples for 15 min, 3000× p < 0.05) of the treated groups [The results are expressed as the means ± standard errors. Before running the statistical analysis, data were subjected to Shapiro–Wilk and Levene tests to test the normality and homogeneity of the data. Before processing percentile data, an arcsine transformation was used. Analysis was performed on both non-transformed and transformed data. However, the results were similar in both analyses; therefore, the non-transformed data were used. Data were statistically analyzed using the statistical analysis program SPSS, 2017 . One-wayd groups .The statistical model was as follows:1st = rapeseed cake (RC);2nd = rapeseed cake (RC) and protein concentrate Agro-Matic (RC + PCAM); 3rd = protein concentrate Agro-Matic and rapeseed cake (RC) (PCAM + RC); and Eij is a random deviation due to unexplained sources of variation.p < 0.05) that in the control group at 3 months of age by 3.37 kg in the second group and by 5.00 kg in the third group. The same trend was obtained at the ages of 6 and 9 months of heifer raising and differences were significant between heifers receiving Agro-Matic protein concentrate as part of the diets and the control group. Moreover, absolute body gain and average daily gain recorded significant differences between the RC + PCAM, PCAM + RC and CON groups in the different periods 1–3 and 3–6 months of age, while the differences were (p > 0.05) during the period of 6–9 months.The data presented in The digestibility of nutrients of Ayrshire heifers when different levels of Agro-Matic protein concentrate were included in their diets is presented in p < 0.05), and the animals of the second group in terms of digestibility of the ether extract (EE) were lower than the control by 2.7% (p < 0.05), respectively. The best protein digestibility was noted in the group where the animals were fed the maximum level of high-protein concentrate Agro-Matic (PCAM), exceeding the control by 3.81%. The coefficients of digestibility of crude fiber and nitrogen-free extract did not differ significantly between the groups. Referring to the previous results obtained in The results showing the indicators of nitrogen balance in the body of Ayrshire heifers are presented in p < 0.05) (86.09 vs. 79.15 g) respectively.According to the obtained data on nitrogen balance at the age of 3 months, the introduction of protein concentrates Agro-Matic (PCAM) had a positive effect on nitrogen balance when compared to the control heifers. Thus, the introduction of protein concentrates into the diet contributed to a more efficient use of protein in the diet, due to a more efficient digestion of nitrogen in PCAM + RC by 8.77% . However, in terms of the urea content in the ROC + PCAM group, there were higher levels relative to the control group (p > 0.05) and the third group (p < 0.05). In the group of heifers receiving the maximum level of PCAM (4.50%) in the compound feed, the urea content in the blood was significantly lower by 1.57 mmol/L, compared to the second group and the control (p > 0.05). The alkaline reserve of blood in young dairy heifers who consumed the highest level of protein concentrate, showed an increase in blood alkalinity of 424.67 mg%, versus 414.67 mg% in the control group. So, the increase in this indicator relative to the control group was 2.41%, respectively.According to the results obtained, it was noted that the introduction of protein concentrate (PCAM) into the compound feed in the second group had a positive effect on some biochemical blood parameters. In the body of young heifers (at the age of 3 months) in the second group, which received a minimum amount (2.25%), the total content of ketone bodies decreased from 2.20 mmol/L in the control group to 1.82 mmol/L (Results of blood biochemistry which were conducted at 10 months of raising are given in p > 0.05) was observed, and in the third group (PCAM + RC) an increase of 0.32 mmol/L (p < 0.05) was observed, respectively. On the other hand, the concentration of aspartate aminotransferase in the blood of RC + PCAM heifers was lower than the control group and  and the difference was significant.According to the results obtained for the 2nd period of the study at 10 months of age, the introduction of protein concentrate contributed to an increase in the content of β-globulins due to the introduction of PCAM. The increase in the supplemented groups RC + PCAM and PCAM + RC was 0.26 g/L and 0.28 g/L relative to the control, respectively. With respect to the phosphorus level, a similar trend was found where, in the second group (RC + PCAM), with comparison to the control, an increase of 0.18 mmol/L  in comparison with the control one. The best protein digestibility was noted in the group where the animals were fed the maximum level of PCAM, exceeding the control by 3.81%, and the coefficients of digestibility of crude fiber did not differ between the groups. In similar studies conducted by Kamalak et al. (2005) it was shown that animal protein sources, such as poultry abattoir waste with a low ability to decompose, can be used to increase the amount of byproduct protein . Kazemi-Bohnert et al. (1998) reported that the loss of nitrogen in the rumen when feeding poultry processing waste was 1.4%, nitrogen was isolated with productivity in diets containing poultry abattoir waste of 55% versus 25% for soybean meal . Kim et The rearing of heifers is a key issue on dairy farms, because these animals ensure the maintenance and renewal of the herd ,59. Thusp < 0.05). Similar results were obtained by Vosooghi-poostindoz et al. (2014) [p < 0.05) by the level of crude protein in the diet.In our studies, no clinical signs of acidosis were registered, a decrease in feed intake or diarrhea were not observed in any of the experimental animals, and blood counts corresponded to normal values for the species. Regarding urea content at the age of 3 months, the content of the maximum level of PCAM + RC decreased (. (2014)  who repoIt is known that ammonia released during the decomposition of food or endogenous urea in the rumen contributes to maintaining the physiological pH in the rumen . In our However, it is necessary to note a decrease in the level of ketone bodies in the blood serum of heifers at the age of 3 months, where there was a significant decrease in the concentration of ketone bodies in the blood, which indicates a more favorable level and course of energy and lipid metabolism in animals. On the other hand, the levels of liver enzymes, albumin, total protein, glucose, calcium, phosphorus and carotene were within normal values. Despite this, the introduction of protein concentrate did not significantly affect the content of total protein or albumins in the blood during the growing period. 6.The levels of globulins, phosphorus and alkaline reserve in the plasma increased as the amount of protein concentrate increased. The addition of protein concentrates at the age of 3 months from the moment of birth did not affect the activity of transaminases, which indicated that damage to hepatocytes did not occur. However, the activity of aspartate aminotransferase synthesized in the liver was changed by the interaction between the levels of protein concentrate, so at this age there was a significant decrease in its content compared to the blood content of the control group receiving only plant protein sources. The decrease in the content of aminotransferase is probably reduced due to insufficient synthesis of vitamin BMoreover, an increase in the reserve alkalinity of the blood was noted at the beginning of raising, probably due to the intake of alkaline elements with protein concentrate and their better assimilation, which is probably indirect evidence of a reduction in the risks of subacute lactic acidosis in these animals.Partial replacement of rapeseed cake with the by-product source of animal protein Agro-Matic concentrate in various amounts in the diet of Ayrshire dairy heifers showed a positive effect on growth dynamics, improved digestibility of nutrients and nitrogen retention without deterioration of the general health status of animals. Therefore, we recommend supplementation with the by-product source of animal protein Agro-Matic concentrate into the diets of heifers at an appropriate dose of 4.5% during the period of 3 to 6 months of the raising stage.


In the range of 293–353 K and 5–30 MPa, the snapshot of palmitic acid distribution in CO2 shows that the molecular chain of palmitic acid in high-density CO2 system is more straight and more dispersed than that in low-density CO2 system. The radial distribution function further clearly shows that the solubility of palmitic acid in CO2 decreases with the increase of temperature and increases with the increase of pressure, which is consistent with the fatty acid solubility data reported in the literature and the setting rules of supercritical CO2 extraction process conditions. As the temperature decreases and the pressure increases, the interaction energy between palmitic acid and CO2 increases, which is conducive to overcoming the intermolecular force of palmitic acid and promoting dissolution. The solubility parameters of palmitic acid and CO2 can better reflect the trend of palmitic acid solubility changing with temperature and pressure, which can play a guiding role in the determination of process conditions and even the development of new processes.In this study, molecular dynamics simulation was used to explore the interaction characteristics of palmitic acid and CO It haet al. [et al. [2 extraction to recover the lipid part of cake by-product from Brazil nut beverage, and evaluated the effects of pressure and temperature on the yield, oil recovery rate, fatty acid distribution and small amounts of lipid compounds. Mouahid et al. [−1) on the efficiency of supercritical CO2 extraction of Argan oil using response surface methodology. On the whole, the effects of temperature and pressure on oil extraction rate and component selectivity can be largely attributed to the interaction between fatty acids and high-pressure CO2, as the composition of oil is the esterification of fatty acids. Although some scholars have studied the solubility data of fatty acids in supercritical carbon dioxide for a long time, the data are relatively limited, and the solubility data of fatty acids in liquid carbon dioxide near the critical region is even more scarce [At present, using experimental methods to study the effects of supercritical carbon dioxide extraction process conditions, such as temperature, pressure, etc., on oil extraction rate and different components, especially for new experimental materials, is still the current research hotspot. Lasekan & Abdulkarim  used supet al.  measured [et al.  carried d et al.  investige scarce ,12. MoreMolecular dynamics (MD) simulation technology can complete the characterization and analysis of molecular characteristics that cannot be achieved at the experimental level, intuitively providing information on the conformational changes of molecules during the simulation process and the interactions between different components, thus providing strong theoretical support for microscopic mechanism analysis. As an important means of studying micro mechanisms, MD simulation has been widely applied in fields such as chemical engineering, materials science and engineering, and biomedicine –16.In terms of chemical composition, oils are esters formed by advanced fatty acids and glycerol. Glycerol esters are esters formed by the esterification of one molecule of glycerol and three molecules of fatty acids, also known as triglycerides. The properties of glycerol esters mainly depend on the properties of the fatty acids in the composition. According to the different saturations of C-H bonds, fatty acids are divided into saturated fat fatty acids and unsaturated fat fatty acids. According to the different length of carbon chain, it can be divided into short-chain fatty acid (with the number of carbon atoms less than six), medium-chain fatty acids (with the number of carbon atoms more than six but less than 12) and long-chain fatty acids (with the number of carbon atoms more than 12). Most common fatty acids in daily life are medium-chain and long-chain fatty acids, such as oleic acid, linoleic acid, palmitic acid, etc. Different fatty acids participate in different metabolism and play different physiological functions in the human body, and selective intake is of great significance for regulating physical health ,18. AlthIn this study, palmitic acid was taken as a typical example, and the interaction between palmitic acid and high pressure carbon dioxide was studied from a microscopic perspective by means of molecular dynamics simulation. The microscopic mechanism of fatty acid dissolution was analysed in depth, providing theoretical support for determining and optimizing process conditions of super/subcritical carbon dioxide extraction, and providing new solutions for the application of super/subcritical fluid technology in fatty acid-related products beyond experiments.. 22 and fatty acids are both based on condensed phase optimized molecular potential for atomic simulation studies (COMPASS), which is an ab initio force field widely applicable to organic and inorganic material systems [Etotal includes bonding energy and non-bonding energy, and the function expression is as follows:All simulations in this study were calculated using the Amorphous Cell and Forcite modules of Materials Studio 2017 . The force field parameters of CO systems ,20.The tEbond, Eangle, Etorsion, Eoop, Ecross, EvdW, Ecoulombic, respectively, represent the energy components of bond stretching, angular bending, dihedral angle torsion, out of plane interaction and cross coupling, short distance van der Waals interaction, and long distance electrostatic interaction. The first five terms form the bonding potential, while the last two terms form the non-bonding potential. The vdW interaction is represented by the Lennard–Jones 96 function, while the electrostatic interaction is calculated by the Coulomb equation and described by the following equations, respectively.In equation (2.1), −1) Å e−2 is the unit conversion factor, D0 is the depth of the potential well, iq and jq are partial charges of atoms i and j, respectively, R is the distance between atoms, R0 is the Lennard–Jones radius, and ε is the relative dielectric constant.In equations (2.2) and (2.3), C = 332.0647  database at that temperature and pressure. And the 100 pure palmitic acid molecules system was established based on the actual palmitic acid density of 0.852 g cm−3.Firstly, palmitic acid molecule and CO−5 kcal mol−1, the convergence of force was 0.001 kcal mol Å−1, and the convergence of displacement was 1.0 × 10−5 Å. Finally, the molecular dynamics equilibrium of NPT ensemble was carried out under the conditions of 293–353 K and 5–30 MPa in a time step of 1 fs. Considering the saving of computing resources and good conservation of energy, the integrator adopted the Verlet velocity algorithm. Andersen temperature control method and Berendsen pressure control method were used. The electrostatics was calculated by Ewald method with Ewald accuracy of 1.0 × 10−5 kcal mol−1, while van der Waals was calculated by atom-based method with cut-off distance of 18.5 Å. In general, the system reaches equilibrium when the standard deviation of the energy, temperature and density requirements of the system is less than 10%. At around 100 ps, both the density and energy have converged, indicating that the system has reached equilibrium. In order to obtain more accurate data results, the simulation process has been extended to 1000 ps. Taking the mixed system of eight palmitic acid molecules and 1000 CO2 molecules at 293 K and 10 MPa as an example, the energy, temperature and density fluctuations observed during molecular dynamic simulation are shown in Then, the smart algorithm  was used. 3. 3.12 can be considered as gradual diffusion of palmitic acid molecules from palmitic acid molecular group to surrounding CO2. If the actual situation is modelled, the reductive dissolution process can be more realistic to a certain extent. However, this study is more concerned about the interaction between palmitic acid and CO2 molecules after the system is balanced. Therefore, regardless of temperature and pressure conditions, Amorphous Cell was used to distribute eight palmitic acid molecules almost evenly in a cell filled with CO2, which can greatly save the computational resource consumption caused by the non-equilibrium process of dissolution to phase equilibrium. According to the different solubility of palmitic acid in high pressure CO2 under different temperature and pressure conditions, it can be determined that the system thus established is not a balanced real system. After deep equilibrium under 1000 ps NPT ensemble, fatty acid molecules show different degrees of dispersion in the cell. The distribution snapshot after equilibrium is shown in 2 density, the solubility of palmitic acid under different temperature and pressure conditions can be judged visually.The dissolution process of palmitic acid solid in high pressure CO2 can be easily obtained. At the same time, density analysis was conducted on pure CO2 systems under different temperature and pressure conditions after deep equilibrium. The simulation results and the actual density in the NIST Chemistry WebBook are shown in With the help of the NIST Chemistry WebBook , the act2 density. By contrast, under the low CO2 density, palmitic acid is intertwined and aggregated. This also shows that the solubility of palmitic acid in high density CO2 is greater than that in low density CO2, which generally conforms to the basic general knowledge that the solubility of oil in high pressure CO2 increases with the increase of CO2 density and decreases with the decrease of CO2 density. When the system is large enough, the distribution of palmitic acid will be more clear, but it is limited by computing resources. In order to clarify the interaction characteristics of palmitic acid and CO2, quantitative analysis was carried out from the perspectives of radial distribution function, interaction energy, solubility parameters, etc.From . 3.2r from a given particle to the average distribution probability density. The calculation of the radial distribution function g(r) is shown in equation (3.1). The location and size of the radial distribution function peak can reflect the variation of intermolecular bonding strength with distance, which means that the microscopic distribution details of palmitic acid can be linked with the macroscopic solubility. The radial distribution function (RDF) is a description of the local distribution of other groups around a group in the shell. It refers to the ratio of the probability density of another particle at the distance N represents the number of group A between the distance r and r + dr from the reference group B, ρ represents the average number density of group A.In equation (3.1), d2 extraction and separation process conditions [It can be seen from nditions ,24. Howe. 3.32, the interaction energy was calculated. The interaction energy can reflect the binding strength between palmitic acid and CO2. The larger the absolute value is, the stronger the interaction between the two substances will be, which means the better solubility of palmitic acid in CO2. Its expression is shown in the following equation:Einter is the interaction energy between CO2 and palmitic acid, E2CO+C16:0 is the total energy of the system, E2CO is the CO2 energy in the system, and EC16:0 is the palmitic acid energy in the system.In order to further clarify the interaction between palmitic acid and CO2 and fatty acids is strengthened. It is conducive to palmitic acid overcoming the binding between its own molecules and diffusing to the surrounding CO2, increasing its solubility in CO2. Under the same pressure, with the increase of temperature, the interaction energy decreases, which means that the interaction between CO2 and palmitic acid weakens. The binding between its own molecules is adverse to the diffusion of palmitic acid into CO2, thus reducing the solubility of palmitic acid in CO2. In the field of supercritical fluid extraction, this can be used to select lower temperature and higher pressure as the extraction process conditions. On the contrary, at high temperature and low pressure, the interaction energy is low and the solubility is poor, which can be used to achieve the separation of fatty acids and CO2.After deep equilibrium of the system, the interaction energy under various temperature and pressure conditions is shown in . 3.42 under different temperature and pressure conditions, the solubility parameters of palmitic acid and CO2 in the range of 293–353 K, 5–30 MPa were calculated by molecular dynamics method. In addition, in order to verify the correctness of molecular dynamics calculation, the group contribution method was used to calculate the solubility parameters of palmitic acid.The solubility parameter can reflect the solubility characteristics between different substances. In order to clearly characterize the solubility difference of palmitic acid in CO1/2 at 298 K and 0.1 MPa will be used for subsequent analysis.The solubility parameters of palmitic acid at normal temperature and pressure, 293–353 K, 5–30 MPa were calculated by molecular dynamics method. The results are shown in δ is the solubility parameter. δd, δp and δh are the dispersion force, polarity force and hydrogen bonding force components of the solubility parameters, respectively, and the calculated values are 16.464, 0.07133 and 5.9000 MPa1/2. The solubility parameter of palmitic acid is 17.489 MPa1/2, which is similar to that calculated by molecular dynamics simulation, indicating the reliability of the simulation method.The group contribution method is the most widely used theoretical method to calculate the solubility parameters. Since Small first proposed calculating the solubility parameters based on the structure of substances in 1953 , a varie2, the better the solubility of palmitic acid in CO2. On the contrary, the larger the difference between the solubility parameters, the poorer the solubility of palmitic acid in CO2. The solubility parameter difference D was defined to be equal to the solubility parameter of palmitic acid minus the solubility parameter of CO2, and the solubility parameter difference under different temperature and pressure conditions is shown in 2 is extremely low under low pressure. The separation of fatty acids and their compounds from CO2 at low pressure, even without increasing the temperature, will be significant. In fact, the supercritical fluid extraction of oils and fats also adopts the depressurization separation method. Under the pressure of 10 MPa, the difference in solubility parameters changes significantly around 313 K, such as sharply increasing from 6.234 MPa1/2 at 293 K to 15.194 MPa1/2 at 333K, indicating the theoretical feasibility of isobaric extraction and separation. That is to say, liquid CO2 in the near critical zone is used for extraction, and the separation of fatty acids is achieved only by raising the temperature without changing the pressure. This will greatly overcome the huge energy consumption of the pressure reduction separation process of supercritical carbon dioxide extraction technology, which is also a major factor limiting the promotion of supercritical fluid technology.According to the principle of similar solubility parameters, the smaller the difference between the solubility parameters of palmitic acid and CO2 [2 at 298 K is very high. Raising the temperature while maintaining the same pressure results in a significant change in solubility, especially at 20 MPa, indicating the possibility of oil extraction and separation under equal pressure. This is also consistent with the results of molecular dynamics simulation of the interaction between palmitic acid and CO2 to a certain extent. These all demonstrate the feasibility of using molecular dynamics simulation to guide the determination of the approximate range of process conditions and even the development of new processes. Molecular simulation technology will have a wider application in super/subcritical fluid extraction.Combined with the existing solubility data of canola oil in CO2 , as show. 42 system, pure palmitic acid system, and the mixed system of CO2 and palmitic acid in the range of 293–353 K, 5–30 MPa. The microscopic mechanism of the interaction between palmitic acid and CO2 was analysed. The error between the simulated density results of the pure CO2 system and the NIST database is small, and the error between the simulated solubility parameters of the pure palmitic acid system and the theoretical calculation results based on the group contribution method is also small, which proves the correctness of the simulation method. The snapshot of the micro distribution of palmitic acid under different temperatures and pressures shows that the molecular chain of palmitic acid is more straight and the molecules are more dispersed in high density CO2. Relatively, at low density, fatty acids undergo entanglement and aggregation. The radial distribution function further clearly shows that the dispersion of palmitic acid in CO2 gradually decreases with the increase of temperature, and increases with the increase of pressure. With the increase of temperature, the interaction energy between palmitic acid and CO2 decreases, and the solubility of palmitic acid decreases under the constraint of its own molecular force. With the increase of pressure, the interaction energy between palmitic acid and CO2 increases, which is conducive to overcoming the interaction between palmitic acid molecules and promoting dissolution. This is consistent with the solubility data of fatty acids reported in the literature and the setting rules of supercritical CO2 extraction process conditions. The solubility parameters of palmitic acid and CO2 can better reflect the trend of solubility changing with temperature and pressure. The solubility parameters of palmitic acid and CO2 vary sharply from 293 to 333 K at 10 MPa, providing theoretical support for the isobaric extraction and separation using liquid CO2 in the near critical region, and the existing solubility data of canola oil also provide experimental support. It can be seen that molecular simulation technology can play a guiding role in determining process conditions and developing new processes.The molecular dynamics simulation method was used to construct pure CO


Access to universal health coverage is a fundamental right that ensures that even the most disadvantaged receive health services without financial hardship. The Democratic Republic of Congo is among the poorest countries in the world, yet healthcare is primarily made by direct payment which renders care inaccessible for most Congolese. Between 2017 and 2021 a purchasing of health services initiative (Le Programme de Renforcement de l’Offre et Développement de l’accès aux Soins de Santé or PRO DS), was implemented in Kongo Central and Ituri with the assistance of the non-governmental organization Memisa Belgium. The program provided funding for health system strengthening that included health service delivery, workforce development, improved infrastructure, access to medicines and support for leadership and governance. This study assessed the social and health impacts of the PRO DS Memisa program using a health impact assessment focus. A documentary review was performed to ascertain relevant indicators of program effect. Supervision and management of health zones and health centers, use of health and nutritional services, the population’s nutritional health, immunization levels, reproductive and maternal health, and newborn and child health were measured using a controlled longitudinal model. Positive results were found in almost all indicators across both provinces, with a mean proportion of positive effect of 60.8% for Kongo Central, and 70.8% in Ituri. Barriers to the program’s success included the arrival of COVID-19, internal displacement of the population and resistance to change from the community. The measurable positive impacts from the PRO DS Memisa program reveal that an adequately funded multi-faceted health system strengthening program can improve access to healthcare in a low-income country such as the Democratic Republic of Congo. Access to healthcare is a fundamental right for all populations, including the most disadvantaged. According to data from the Democratic Republic of Congo’s (DRC) 2014 Demographic and Health Survey (DHS), more than 50% of the population had an economic well-being index in the lowest quintiles . CongoleAlthough some progress has been made in recent years, the health situation in the DRC is dire. Indeed, according to figures from the 2014 DRC’s statistical yearbook, the infant and child mortality rate was 65 per thousand, the infant mortality rate 41 per thousand, only 70.6% of children aged 12–23 months had full immunization coverage, and nearly 59% of children under 5 years of age were stunted due to malnutrition. These findings confirm the precarious economic and health status of the population. Moreover, according to the 2014 RDC’s DHS survey, more than 97% of men and 93% of women aged 15–49 had no medical insurance. Over 60% of the population did not access health services due to lack of finances, and 28.8% due to the inability to travel to receive care. This level of poverty reflects an existing financial inaccessibility which is undoubtedly the main problem in accessing healthcare services. Based on 2020 World Bank data for the DRC, health expenditures represented 4.1% of the gross domestic product (GDP). Of total current health expenditures, domestic government spending accounted for 16.1%, external funding 37.5%, out-of-pocket payments represented 39.7%, and private health insurance 6.7%.To address the issue of affordability, country governments have considered appropriate health financing systems that can improve access to healthcare. Several methods currently being developed in the DRC include subsidized flat-rate pricing; purchasing health services approach; performance-based financing; community-based health insurance and direct payment. Direct payment for healthcare is still the most predominant form of financing as it makes care in healthcare facilities marketable. However, this is contrary to the principles of universal health coverage (UHC) as advocated by the WHO  as it leOne attempt to provide better healthcare coverage in the DRC was The Program for Strengthening the Supply and Developing Access to Health Care (Le Programme de Renforcement de l’Offre et Développement de l’accès aux Soins de Santé or PRO DS), financed by the European Union and implemented between 2017 and 2021 by the NGO Memisa Belgium (PRO DS Memisa) in the provinces of Kongo Central and Ituri in the DRC. Memisa is a non-governmental medical organization based in Belgium that supports access to universal health coverage for vulnerable populations worldwide. Their aim is to improve the quality of healthcare with a focus on maternal and child health. Memisa is most active in African countries, and especially in the DRC, a former Belgian colony. Memisa Belgium’s initiatives in the DRC include (a) providing infrastructure for healthcare in the form of newly built or renovated health clinics; (b) providing health supplies including medicine, equipment and blood banks; (c) offering training and support for those with malnutrition; (d) employing over 50 local professionals; and (e) providing ongoing medical training for healthcare professionals. Memisa Belgium advocates for Congolese to be aware of their own right to healthcare and works in collaboration with the Ministry of Health to recognize the needs of the population. Finally, Memisa also provides financial support by ensuring there are systems in place (copayments or solidarity funds) to ensure access to care.Memisa’s objective in the DRC was to facilitate access to UHC, particularly for the most vulnerable, to participate in the fight against poverty and encourage health equity by providing a health service purchasing approach to healthcare and the management of malnutrition. Purchasing healthcare services is a strategic purchasing policy that includes a bundle of services that can vary widely, consisting of a series of elements that importantly include: "purchased" results ; associated performance bonuses; mechanisms for verification and cross-checking of results; governance and accountability structure; and any related support . The success of this approach is strongly based on the involvement of the various stakeholders that include governments, suppliers and patients  and suffThis study aims to assess the social impacts of, and changes brought about by, the PRO DS Memisa program, a strategic purchasing policy to strengthen healthcare systems. It evaluates the program in the provinces of Kongo Central and Ituri.The initial contract for PRO DS Memisa (PRO DS Memisa 1) implementation was signed on March 1, 2017, between the European Union's Cooperative Food Empowerment Directive (COFED) and the NGO Memisa for a period of 42 months. It had three objectives: (1) to improve the population’s quality of health in targeted health zones (HZ) and to ensure its sustainability; (2) to integrate humanitarian interventions in the health zones and (3) to improve the institutional capacity of the Ministry of Public Health at the central level and provincial level . The initial contract was extended for 7 months until March 31, 2021, to integrate the quality assessment of health zones, health centers (CS) and a nutrition component in both provinces. In addition, due to COVID-19 and the urgent health measures implemented by other partners, a second PRO DS Memisa 2 contract was signed for a 19-month period spanning April 1, 2021 to September 30, 2022. This phase of the program focused on the intensification of activities to achieve objectives 1 and 3 described above. Figure Objective 1) To improve the population’s quality of health in the targeted HZ and to ensure its sustainability.Objective 2) To integrate the HZ supported by humanitarian and vertical interventions.Objective 3) To improve the institutional capacity of the Ministry of Public Health at the central level and provincial level.PRO DS Memisa was implemented in three of 31 HZ in Kong Central province and seven of the 36 HZ in Ituri province. The HZ chosen represented areas with very poor healthcare services and were identified under the 11th European Union funding. The main actors in each of the two provinces were: the DPS, the general referral hospitals (HGR) in each HZ , and all CS responsible for a geographic region in the zones concerned. Contracts were signed between the regional offices and the DPS, and with the public utility institutions of the health services procurement fund (Utilité publique de fonds d’achat de services de santé or EUP-FASS). In Kongo Central, the EUP-FASS was supported by MUSAKIS (Mutuelle de santé de Kisantu). Together with the DPS, an advising physician, the EU, and technical assistants, MUSAKIS acted as an EUP-FASS under the name MUSAKIS-FASS within the framework of this project. The role of the MUSAKIS-FASS in Kongo Central and the EUP-FASS in Ituri was to contract with the HZ and CS to verify and pay their invoices. To fulfill the nutritional objectives of PRO DS Memisa 1 and PRO DS Memisa 2, contracts were signed between the regional offices and organizations for the preparation and distribution of local food. Finally, under calls for open contracts, relevant organizations were contracted to build, rehabilitate, and equip general hospitals and health centers.In both Ituri and Kongo Central, a Memisa operating grant made it possible for the DPS to strengthen its ability to supervise the 10 targeted HZ and plan and oversee initiatives being put into place. DPS staff received a salary bonus and specific emergency activities were carried out. The program supported the DPS in improving the quality of care and services offered in these zones through: (1) quality assessment, management ; (2) training, upgrading skills and providing internships; (3) facilitating the development of community initiatives and recruiting community outreach workers.The MUSAKIS FASS in Kongo Central and EUP-FASS in Ituri entered into contracts with the HZ, HGR and CS for the purchase of services between September 1st, 2017, and July 31st, 2022, to carry out the program’s activities.For the HZ, the HGR and health zone management team (ECZ), these contracts stipulated that the program provide: (1) supervision and guidance at the management level for the ECZ and management supervision for the HZ; (2) management of the EZS and top-up/supplementary remuneration; (3) purchase of services for the HGR in the form of third-party payments; (4) a bonus for the HGR depending on the quality of care and; (5) a co-payment to supplement the total cost of care for the most disadvantaged patients in the HGR (maximum 5% of the budget). The budget for the ECZ (points 1 and 2 above) was allocated as follows: 50% for supplementary remuneration; 35% for the purchase of medication, laboratory reagents and medical consumables paid directly to the relevant medicine distribution centers in the program's HZ; 10% for ECZ operating costs; and 5% for reserves/savings.The CS were initially responsible for: (1) the purchase of services at the agreed fixed cost for prenatal and preschool consultations and vaccinations for pregnant women and children aged 0–5 years; (2) the purchase of services via third-party payment at the agreed fixed cost for childbirth and delivery; (3) the purchase of services via third-party payment at a flat-rate cost for childbirth, delivery and postnatal care; (4) co-payment coverage for indigent women (maximum 5%); (5) co-payment coverage for indigent pregnant women (maximum 3%); and (6) offering a quarterly bonus according to the level of quality of care provided. Health centers receive a sum of $0.5 per health area resident based on the area’s 2019 population.n = 486,020)  in Kongo Central and the population of the seven HZs   in Ituri.The direct beneficiaries of PRO DS Memisa were the HZ; the two DPS of Kongo Central and Ituri; the EUP-FASS of Ituri and the MUSAKIS-FASS in Kongo Central; the CAAMEKI  and the CADIMEBU (Ituri); the population of the three HZs . All population statistics are from 2020.Health impact assessments are defined as: “a combination of procedures, methods and tools that systematically judges the potential, and sometimes unintended, effects of a policy, plan, program or project on the health of a population and the distribution of those effects within the population” . By moniTo meet the objective of the study, we focused on the health and social outcomes brought about by PRO DS Memisa, measuring levels of supervision provided to health centers, changes in health and nutritional status of the population and involvement and uptake of the program in the community. To measure effect, this study used a controlled longitudinal model to compare between areas that were served by PRO DS Memisa and those that were not.At each stage of the study the following research questions were analyzed:(i)Who are the stakeholders?(ii)Who was affected by the project (beneficiaries)?(iii)Who had an impact on the project?(iv)What do we expect to change for the intended beneficiaries?In step 1, to define the scope of the analysis:(i)What are the project’s resources or inputs?(ii)What are the activities carried out within the framework of this project?(iii)What are the results or products of this project?In step 2, to produce a map of outcomes based on stakeholder meetings:(i)How does one measure the changes observed?(ii)What is the quantified result of this observed change?In step 3, we define the results indicator:(i)What would have happened without the action of the project?(ii)How much of the change is outside of the project’s effects?(iii)Can the result diminish or increase over time?In step 4, we consider the possible impact of the PRO DS Memisa program:This study is a retrospective study incorporating a documentary review and a secondary analysis of longitudinal quantitative data comparing the 10 health zones supported and the 49 health zones not supported by the PRO DS Memisa program.At the start of the study an analysis grid was developed to guide the documentary review. This grid’s content has been validated by researchers and field teams and made it possible to collect information on the available resources, the activities carried out, and the results that were expected and achieved. Documents underwent content analysis based on the theoretical framework of health impact assessments that made it possible to construct the chain of potential effects of the program. The research team and the implementation team identified relevant existing documents to analyze; all documents were provided by Memisa. A total of 48 documents were consulted for Kongo Central and 31 for Ituri. Some documents were common to the two provinces, in particular project documents such as annual reports and signed contracts. The complete list of documents is available in supplementary file1.Tbefore); (2) in the first year of the program (baseline in 2017) (Tbaseline); (3) during the first 36 months of PRO DS Memisa 1  (TPRO DS 1); (4) during the final 9 months of PRO DS Memisa 1 while in transition to PRO DS Memisa 2  (TPRO DS 2); (5) during the most recent 6 months of PRO DS Memisa 2  (TPRO DS 3).The secondary data were obtained from the annual reports of the provincial health division , the PRO DS Memisa reports, and the national health information systems (systèmes nationaux d’information sanitaire or SNIS) from all HZ in both provinces. Figure In line with PRO DS Memisa objectives, 74 indicators for Central Kongo and 65 for Ituri were identified and collapsed into six impact domains: 1) Supervision and management of health zones and health centers; (2) Use of health and nutritional services; (3) Nutritional health; (4) Immunization; (5) Reproductive and maternal health; and (6) Newborn and child health  health zones and non-PRO DS (non PRO DS) health zones, and for the periods before the program began, and at baseline (Tbefore and Tbaseline), denoted Ind before, and PRO DS times 1,2 and 3, since  denoted Indsince. The rate of change or percentage impact (% impact) was defined as follows:Quantitative analyses of the effects of the program were carried out in two phases. As noted above, indicators were identified from the SNIS, the Memisa PRO DS activity reports, and the DPS. A causal change of relationships was interpreted from these indicators Fig. . EstimatAnalyses were performed using Microsoft Excel and SPSS-26 software.The organizational structure and main activities of PRO DS Memisa in both provinces is shown in Fig. comité de develppement de l’aire de santé or CODESA) meetings with recorded minutes, and weekly HZ management team meetings. These increases were 15%, 56%, and 56%, respectively in the three PRO DS Memisa HZ compared to the non-PRO DS HZ.In the province of Kongo Central, PRO DS Memisa contributed to an increase in the amount of health center supervision, health region development committee  which then grew to an 85.1-fold increase in further referrals to another UNTA. The was also a 26.9-fold increase in admissions to an UNTA with a concordant 4.3-fold increase admitted to intensive therapeutic nutrition units (UNTI).In Kongo Central, the effects on health and nutrition services seen from program implementation in the three PRO DS Memisa HZ compared to the non-PRO DS HZ are presented in Table The proportion of cases referred to hospital increased by 41%;Curative service use increased by a factor of 1.2;There was a 35% increase in attendance in preschool consultations;The average hospital length of stay decreased by 29%;Hospital bed occupancy rate decreased by 91%;In Ituri, the effects on health and nutrition services seen from program implementation in the seven PRO DS versus non-PRO DS HZ are presented in Table A strong response was witnessed in the use of nutritional services: referrals and counter-referrals to UNTAs increased by 31% and 1.02-fold respectively, while referrals to UNTIs increased by 76%. Finally, there was an increase of 7.1-fold in admissions to UNTIs.The number of people cured of malnutrition increased 12.7-fold;Deaths in UNTAs and nutritional supplemental units were reduced by 15% and 2%, respectively;There was reduced attrition from nutritional supplemental units and UNTIs by 1.9-fold, and 1.6-fold, respectively.In Kongo Central, the comparative effects seen on nutritional health from program implementation in PRO DS HZ compared to the non-PRO DS HZ included:Deaths within UNTIs reduced by 15.9-fold;The number of people cured of malnutrition increased by 4.5-fold;Women being screened at the nutritional supplemental unit increased by 11.1-fold;Death rates in UNTA and nutritional supplemental unit reduced by 15% and 2%, respectively;Attrition from the nutritional supplemental unit reduced 1.3-fold.In Ituri, the comparative effects seen on nutritional health from program implementation in the seven PRO DS HZ versus non-PRO DS HZs included:In Kongo Central, the program improved overall immunization coverage in the three PRO DS HZ compared to non-PRO DS HZ. Increases ranged from 16 to 45% higher in immunization coverage rates , and a 35% decrease in the Penta 1-Penta 3 dropout rate; almost all immunization indicators were positive.In Ituri, the program improved overall immunization coverage in the seven PRO DS HZ compared to non-PRO DS HZ. Increases ranged from 0.17-fold to 1.2-fold in vaccine coverage rates .The number of pregnant women who consulted prenatal services increased 5.65-fold;Coverage rates increased for Prenatal Consultation 1 (1.5-fold) and Prenatal Consultation 4 (1.1-fold), as well as for assisted delivery (1.7-fold);Pregnancy related edema, with or without complications reduced by 62.5-fold and 30.0-fold, respectively;An increase of 1.63-fold in the use of oral progestin-only pills as a method of contraception.In Kongo Central Table , the proHospital mortality rates (of stays over 48 h) was reduced 17.2-fold;The number of women who relapsed postpartum with complications was reduced 2.3-fold;Pregnancy related edema, with or without complications was reduced 1.9-fold and 17.0-fold, respectively.In Ituri Table , the proIn Kongo Central, the PRO DS program improved indicators related to the health of newborns and children in the three PRO DS HZ compared to non-PRO DS HZ. The greatest impact was a 19.4-fold reduction in cases of children under the age of five suffering from acute malnutrition, followed by a 5.2-fold reduction in babies and children aged 6–59 months with moderate acute malnutrition, a result of the integrated management of acute malnutrition national program . Other indicators of improvement were seen in children under the age of 5 years with: diarrhea treated with oral hydrating solution (OHS) and zinc; pneumonia treated with antibiotics; malaria treated according to the national protocol, and in low-birth-weight and very low-birth-weight (under 2500 g) newborns, the proportion of babies aged 6–23 months who continued to be breastfed, and in attendance rates at preschool medical consultations , pneumonia (treated with antibiotics) and malaria . Improvements were seen in the number of live births, the proportion of newborns put to the breast within 1 h of birth, the proportion of babies under 6 months who were exclusively breastfeeding, the proportion of babies aged 6–23 months who continued breastfeeding, the proportion of babies and children aged 6–59 months with severe acute malnutrition, and the proportion of newborns who received five components of essential newborn care and three examinations in the first 6 days of life the onset of the COVID-19 pandemic in March 2020. Program activities slowed down because of public health measures that had to be respected.(ii)the growing insecurity and the internal displacement of several populations from HZ in Ituri rendered the fixed CS fees inappropriate as they were indexed to the size (number) of the population, which was in constant flux.(iii)the withdrawal of the local bonus and occasionally the meager funding due to a large number of beneficiaries  as well as the insignificant salary supplement due to an increase in staff being assigned in the health zones and health centers supported by PRO DS Memisa.(iv)the precarious nature of the zonal pharmacies that were to ensure drugs stored in Kongo Central would be packaged and repackaged.(v)there was resistance to the paradigm shifts and signing of agreements that would introduce a comprehensive approach to patient care.The analysis of documents highlighted difficulties that were encountered during program implementation in the two provinces. As well, weaknesses were identified in the PRO DS MEMISA program that may help explain unachieved results. The main findings were:(i)The application of a fixed fee in health centers without considering the movement of populations;(ii)The same payments (fees) were made to health centers and to the referred health centers, even though the latter function as hospitals;(iii)A lack of clarity in defining indigent persons without a study to identify the criteria for indigence;(iv)The lack of training for healthcare personnel;(v)Poor integration of Water, Sanitation and Hygiene (WASH) into development programs;(vi)Weak community participation that hindered integration of the community liaison officers in the health centers;(vii)Failure to consider family history as documented in the family medical history files;(viii)The lack of equipment for buildings .Based on observations of our research team in the field and from those who were collecting data, certain weaknesses in the PRO DS Memisa program were identified. These included:The objective of this study was to evaluate the social impact of the PRO DS Memisa program that aims to strengthen healthcare systems in the DRC.In the following paragraphs, we discuss the results obtained by PRO DS Memisa in relation to (1) the supervision and management of the HZ and CS; (2) the use of health and nutritional services; (3) nutritional health; (4) immunization; (5) reproductive and maternal health; (6) newborn and child health; and (7) program weaknesses and limitations.Supervision and Management of Health ZonesThe health purchasing approach deployed by Memisa through the PRO DS program in supported HZ made it possible to measurably improve the supervision of CS by the HZ management teams in Central Kongo, the holding of ECZ and CODESA meetings. These findings corroborate those of other studies , 13. SupIn Ituri, on the other hand, no changes were observed in CS supervision or in the overall management of the HZ. During the PRO DS implementation period, Ituri experienced increasing insecurity, which sometimes made it difficult for the HZ management team to travel to health areas. The PRO DS program improved CODESA performance, and ultimately the community participation which is recognized in population health as an essential driver of sustainable improvement .Health Services UtilizationAt the health service level, the purchase of services improved rates of postoperative infections and hospital referrals, the average hospital length of stay, rates of bed occupancy, curative service use (primary care and treatments), attendance at prenatal consultations, and hospital mortality in those admitted more than 48 h prior. These results have been obtained in similar programs , 17, 18.Nutritional Health and Use of Nutritional ServicesThe program's positive effect on the recovery of malnourished individuals, reduction in deaths in UNTAs and UNTIs, and reduced attrition from UNTAs and UNTIs corroborate the findings of other programs –23. NimpImmunizationVaccination indicators improved because of the program, in particular the increased rates of vaccination coverage for BCG, PCV-13, VAA Pentavalent 1 and Pentavalent 3 and VAR and reduced rates of booster shot attrition for Penta 1-Penta 3. Vaccination is an important component supported by the program, being recognized as one of the pillars of infant mortality prevention. These results corroborate those obtained in similar studies , 25, 26 Reproductive and Maternal HealthThe positive effects of the program are largely reflected in reproductive and maternal health outcomes. In Kongo Central, there was a substantial increase in prenatal consultation and reduction in pregnancy related edema (with or without complications). In Ituri, the program resulted in reduced hospital mortality, and lower rates of pregnancy related complications or relapse of edema. Effects were not observed for the number of pregnant women who: consulted prenatal services, received a third dose of folic acid or tetanus vaccines, or who consulted for prenatal consultations #1 and #4. The coverage rate for assisted delivery was also not significantly affected by the program.Newborn and Child HealthIn Kongo Central, the program brought about a reduction in the number of acutely malnourished children under the age of five, and a reduction in the number of moderately malnourished children aged 6–59 months. In Ituri, fewer low-birth-weight babies were born, and there was a reduction in the number of acutely malnourished children under the age of five. Other indicators of newborn and child health were not significantly affected by the program. PRO DS has supported PCIMA, which promotes community involvement and leadership in malnutrition prevention and management strategies. This approach has proven to be effective and corroborates the results of other studies .Barriers Encountered During PRO DS Program ImplementationA series of barriers and limitations were identified for program implementation and success. The first of these was the appearance of the COVID-19 pandemic, which slowed program activities and adversely affected the achievement of certain indicators, including those related to maternal and child health , 31. TheThis study has several limitations. This work is an analysis of secondary data, which unlike primary data analysis, may have more inherent bias –40. To mThis study demonstrated measurable positive health impacts from the PRO DS Memisa comprehensive and integrative health system strengthening program in the DRC where living conditions remain far below world standards. Further work should evaluate the medium- and long-term effects of this and similar programs to be able to gauge sustainability, scalability and future investment requirements. Qualitative studies implemented alongside quantitative analyses may provide a deeper understanding of the barriers that exist to the implementation and uptake of health-based initiatives.In the absence of any existing policy for the sustainability for the PRO DS Memisa program at the end of its mandate, the following ten elements deserve to be capitalized on to ensure comprehensive, high-quality healthcare for the population through the provision of services and by strengthening nutrition: (1) Maintain the comprehensive care approach through the purchase of services, the third party payer, and flat-rate pricing (confirm the flat-rate pricing beforehand); (2) Maintain a high-quality approach acquired by the HZ and CS and maintain intensive supervision of the DPS; (3) Maintain the banking system and rigor in the administrative and financial management in the health centers and health zones; (4) Continue to develop the management, operational action and drug management plans; (5) Encourage community dynamics to strengthen the supply and promote mutual aid to continue the same strategy; (6) Preserve what has been achieved by maintaining equipment, built facilities, rolling stock, etc.; (7) Maintain the internal and external hygiene of the hospital and healthcare centers through a high-quality approach; (8) Keep the principle of distribution key with progressive adjustments of the proportions in four categories: medication, operations, additional remuneration, and provisions; (9) Encourage a principle of cooperation between the HZ in the management of medication supply at the regional distribution centers that serve the provinces; and (10) Raise awareness for, interact with and educate the population through community.