DEMOCRATIC REPUBLIC OF THE CONGO Last update: 27 July 2004 The Present Context • The installation of the transitional national government in July 2003, following the peace agreement of December 2002, formally ended 7 years of civil conflict. • In September a brigade-strength UN (“MONUC”) contingent for Ituri armed with a new Chapter VII mandate replaced the EU- led Artemis force. • The international community is cautiously optimistic, and has recently launched major reconstruction programmes. • There are concerns that the peace in the east of the country is not stable and there is expectation for further consolidation of the peace process and the holding of elections. • Humanitarian needs are likely to continue to exist while the capacity of agencies to deliver humanitarian services is often inadequate to meet all the needs, mostly due to the size and inaccessibility of many parts of the country, aggravated by continuing insecurity and instability in the east of the country. • In addition, natural disasters—including volcano eruptions in the East, droughts in the South, and flooding of the Congo River—further add to the vulnerability of the population. Main Public Health Issues and Concerns Health status • Mortality rates found in mostly eastern DRC continue to be above emergency thresholds. It is estimated that millions of people have died in excess to normal baseline mortality rates for sub-Saharan countries. Childhood mortality is at least double the normal rate, indicating that the severity of the crisis is still in emergency conditions. Most of these excess deaths are attributable to malaria and other common diseases, rather then directly due to violence. • Maternal mortality rates in the east of the country are estimated to be above 1,800 per 100,000 live births. • The principal public health concerns in the DRC are communicable diseases such as malaria, tuberculosis, and diarrhoeal diseases (including cholera). Malaria accounts for 45% of childhood death. Acute respiratory infections (ARI), diarrhoea and measles are other important causes of morbidity and mortality among children • Control of epidemics is one of the highest priorities in DRC, as the country faces almost every possible outbreak. Most important are cholera and measles, but include pertussis and (re)emerging pathogens such as Marburg, Ebola, Trypanosomiasis and plague.
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DEMOCRATIC REPUBLIC OF THE CONGO Last update: 27 July 2004
The Present Context
• The installation of the transitional national government in July 2003, following the peace agreement of December 2002, formally ended 7 years of civil conflict.
• In September a brigade-strength UN (“MONUC”) contingent for Ituri armed with a new Chapter VII mandate replaced the EU-led Artemis force.
• The international community is cautiously optimistic, and has recently launched major reconstruction programmes.
• There are concerns that the peace in the east of the country is not stable and there is expectation for further consolidation of the peace process and the holding of elections.
• Humanitarian needs are likely to continue to exist while the capacity of agencies to deliver humanitarian services is often inadequate to meet all the needs, mostly due to the size and inaccessibility of many parts of the country, aggravated by continuing insecurity and instability in the east of the country.
• In addition, natural disasters—including volcano eruptions in the East, droughts in the South, and flooding of the Congo River—further add to the vulnerability of the population.
Main Public Health Issues and Concerns
Health status
• Mortality rates found in mostly eastern DRC continue to be above emergency thresholds. It is estimated that millions of people have died in excess to normal baseline mortality rates for sub-Saharan countries. Childhood mortality is at least double the normal rate, indicating that the severity of the crisis is still in emergency conditions. Most of these excess deaths are attributable to malaria and other common diseases, rather then directly due to violence.
• Maternal mortality rates in the east of the country are estimated to be above 1,800 per 100,000 live births.
• The principal public health concerns in the DRC are communicable diseases such as malaria, tuberculosis, and diarrhoeal diseases (including cholera). Malaria accounts for 45% of childhood death. Acute respiratory infections (ARI), diarrhoea and measles are other important causes of morbidity and mortality among children
• Control of epidemics is one of the highest priorities in DRC, as the country faces almost every possible outbreak. Most important are cholera and measles, but include pertussis and (re)emerging pathogens such as Marburg, Ebola, Trypanosomiasis and plague.
• The EPI program has low coverage, with for example only 40% of children vaccinated against measles. Environmental health conditions—such as lack of sanitation, indoor air pollution, inadequate hygiene and insufficient water supplies—increase the potential for ill health. High levels of malnutrition heighten susceptibility to disease, particularly aggravating the health predicament of children under five.
• Conflict-related injuries are on the increase, particularly after recent surge in violence. Gender-based violence in conflict areas, , although mostly undocumented, remains the greatest threat to women's reproductive/sexual health and their emotional well-being.
• The poor health status can further be attributed to high levels of poverty, displacement and limited access to adequate health services.
The Health System
• Conflict and collapsed infrastructure have resulted in a severely weakened health system with insufficient capacity to meet the needs of the population. In many areas, the health system functions as if it were private and patients can not afford to seek assistance.
• Most people buy drugs of dubious quality in the many private pharmacies. In areas supported by international NGOs, acceptable consultation rates of between 0.5-1 consultations per person per year are reached.. Different forms of user fees and cost recovery schemes are being introduced ranging from 'symbolic' flat fees of 0,125 US$ to 50% of costs recovered, sometimes risking to decrease access to services for the indigents.
• In most cases, health workers have not received salaries from the MoH for decades. In particular doctors left the periphery and went to the cities, or were employed by international agencies. Many nurses stayed and started working for themselves. The health worker education system does not function well anymore, with concerns about the qualifications of staff.
• Access to secondary level of care is still a serious unresolved problem. This level receives the least international support compared to the first line health centers. Capacity for emergency surgical procedures or treatment of severe illnesses is very limited, or patients have no access due to the high costs as procedures are often not subsidised. Emergency obstetric procedures like caesarean section can induce or further increase poverty of families.
Main Sector Priorities
• Detection and control of epidemics in the entire country
• Emergency assistance to IDPs and returnees
• To ensure equitable access to basic health services in targeted health zones most affected by the conflict and/or with proven mortality rates above the emergency threshold
− Scaling up the minimum package of services including expanding immunization coverage.
− Access to secondary level care for severely ill patients and acute surgical procedures.
− Search an adequate solution to remove the barrier of user fee issues with the MoH, NGOs and donors
• Increased efforts to control malaria; increased access to effective curative treatment and prevention through insecticide treated bednets, targeting conflict areas with the longest transmission season.
• Improved access to reproductive health programmes, including emergency Obstetric Care.
• To address Gender Based Violence and provide curative treatment and counselling to victims of rape.
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• HIV/AIDS prevention program to control the epidemic in its early phase
• Reduce malnutrition in areas with high acute malnutrition rates. Integrate nutritional services in the PHC system in areas where acute malnutrition rates have decreased below emergency thresholds
• Advocacy to gain access to isolated areas, rapid assessments and emergency support based on findings to newly accessible areas remains a top priority.
• The humanitarian approach is to support the existing health structures. Particularly in areas where there is no longer active conflict, strategies need to be adopted that make communities less dependent on external aid and that allow transition and handover to development partners, and further strengthen the capacities of the national health authorities in management and supervision:
• Support to the Bureaux Inspection Provinciale (BIPs), Bureaux Centrales des Zones de Sante (BCZS) and the Committees de Santes (CoSa's) using perfomance based contracts
• Increase the percentage of costs for the population only if signs of improved purchase power through socio economic surveys, to guaranteeing equitable access for the poorest, acknowledging that many parts of the country will continue to face an economic crisis.
• Maintaining accomplishments achieved through the humanitarian programs • More funds are being pledged from development donors, but implementation is likely to be delayed, awaiting further consolidation of the peace process and the elections next year.
Other priority Humanitarian Needs Alleviate or prevent human suffering while helping vulnerable communities in the DRC to live a life with dignity. This overarching goal is translated into three axes:
• Preserve lives through life saving interventions; • Reduce vulnerabilities within affected communities; • Maximise coordination mechanisms and facilitate the transition from relief to
development.
Sector Actors
Please see Annex 3
Disclaimer
The emergency country profiles are not a formal publication of WHO and do not necessarily represent the decisions or the stated policy of the Organization. The presentation of maps contained herein does not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or areas or its authorities, or concerning the delineation of its frontiers or boundaries.
Contact Details (Country code 243)
Minister of Health Dr Y. Sitolo Monsieur le Ministre de la Santé publique Ministère de la Santé publique 4310, boulevard du 30 juin
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3088 Kin 1 Kinshasa Gombé République démocratique du Congo Tel. 243 12 33216; 243 12 33213; 243 12 33214 WHO Representative Dr Leonard Tapsoba T: +243 88 40789 E-mail: [email protected] UN Resident Coordinator Mr. Herbert M Cleod UN Resident & Humanitarian Coordinator UNDP Resident Representative Kinshasa +243 12 33 424 / 81 880 4637 / 880 4603 (T) +243 884 36 75 (Fax)
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Annex 1: Health Profile - DRC1
General Indicators Population (2004) 58 million Refugees2 415,000 Internally Displaced Persons3 3.4 million Healthy life expectancy at birth m/f (years) 41/46 GNI (Gross National Income) per capita (US $, 2002)4 90 Infant Mortality rate (deaths/1000 live births) 127 Under-five mortality rate (deaths/1000 live births) 212 Total adult literacy m/f % (2000) 76/55 Population using improved drinking water sources 45% Population using adequate sanitation facilities 21% UNDP's Human Development Index ranking5 168/177 Health Systems Profile Total expenditure on health as % of GDP 3.5 Total per capita health expenditure (US $) 5 Nurses rate per 100,000 population 44.2 Physicians rate per 100,000 population 6.9 Hospital Beds per 1000 population 1.4 Tuberculosis Prevalence per 100,000 511 Mortality rate per 100,000 57 HIV/AIDS Adult prevalence of HIV/AIDS (15-49 years) 4.9% Estimated number of adults living with HIV/AIDS (2001) 1.3 million Reported number of people receiving antiretroviral therapy 2500 Orphans due to AIDS 800,000 Malaria Mortality rate per 100,000 452 Immunization (2002)6 BCG 48% DPT3 40% Measles 40% Polio 40% Pregnant women receiving tetanus vaccine 35% Women's Health Total fertility rate 6.7 % of antenatal care coverage 30-80 %of skilled attendant at delivery 20-60 Maternal mortality ratio 1837
1 WHO/CDS baseline statistics unless indicated otherwise 2 http://www.unhcr.org.uk/info/briefings/statistics/#world 3 http://www.db.idpproject.org/Sites/idpSurvey.nsf/wCountries/Democratic+Republic+of+the+Congo 4 The World Bank Annual Report, 2003 5 UNDP World Report 2004 6http://www.unicef.org/infobycountry/drcongo_statistics.html
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Annex 2: Health Sector Health system description
The country is divided in 11 provinces, with each a 'Bureau Inspection de Province', lead by a 'Medecin Inspecteur de Province'. The structure of this bureau resembles that of the ministry of health's 9 'Directions'. The provinces are divided in Zones de Sante' with each a Bureau central de Zone de Sante, headed by a Medecin Chef du Zone. The health zones correspond with what is often referred to as districts, with a general referral hospital and 20-30 health centers. Some have health posts in addition. In total, there are 400 hospitals (1 general hospital per 180,397 inhabitants), 5078 health centres (1 HC per 10,218 inhabitants). Average population per health zone used to be 200.000, but recently the number of zones has been increased from 308 to 515. Most of the new zones are 'virtual' as there are no funds to construct the required infrastructures or pay for the staff. A national health policy and action plan exists. In Mai 2004, a roundtable was organised by the MoH bringing all health stakeholders together to plan for implementation and scaling up of the health system.
The administrative structures (BCZdS and BIP) continued to exist though, even if they were not functioning as they should. In areas supported by international agencies, the BCZdS often get direct financial budget support and/or a percentage of the revenues of the health centres is to be given to them. In return, performance based contracts are often introduced, for example specifying supervisory responsibilities and the delivery of health surveillance reports. The 'medecin chef du Zone' is often also working as a doctor in the referral hospital.
The Health Centres (HC) are to provide a prioritised Minimum Package of Activities (PMA) including basic curative treatment for both out and inpatients and preventive programs including Antenatal Care and the Expanded Program on Immunisations; HCs are staffed by nurses, reference hospitals ideally with a doctor. Health centres are to have community based 'Committees de Sante', often consisting of up to 30 people who are to be involved in community mobilisation and other preventive programs.
Churches traditionally have been providing up to half of the health services in the DRC. With zero state investment and minimal or no state contribution to running cost (see below), Churches relied on their external partners for investment and on the patients to cover the cost of treatment and other running cost. In addition to the public and church run health facilities, there is a flourishing market of unregulated private pharmacies and traditional healers.
The role of the private for-profit sector with regard to drug supply is overwhelming: it supplies at present 80% of the drug market. With the help of external aid (FEDECAM) however, 30 Regional Distribution Centres (CDR) are planned throughout the country to be operational by the end of 2004, covering the needs for essential drugs for 38% of the Congolese population. Crucial factors for their success include adequate supervision and training of BCZSs in management, improving the rational drug use at health facility and community level, subsidised purchases and the commitment of NGO working in these areas to purchase via the CDR.
The Ministry of health has not been able to financially support most of the provinces over the last decades. Since the independence in 1960, hardly any investments were made in the infrastructure. Staff has received no salaries from the MoH. Health services, if not run by a Church-based organisation, became the responsibility of the community and/or were 'self-managed'. This system, which had become a de facto private system with full cost-recovery to finance the income of the health staff and medicines, had already produced a high rate of economic exclusion before the war, resulting in very low consultation rates (less than 0,1 consultation per person per year). During the war, health structures suffered from looting, lack of material and drainage of human resources. Many doctors went to the larger cities or were recruited by international agencies. Many nurses stayed in their areas and started working for themselves, sometimes using the existing health facility. The health workers education system does not function well and there are concerns about the qualifications of staff. Some are self trained, and/or receive training from NGOs.
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Health sector objectives to address concerns:
• Strengthen capacity of the health system to prevent, detect and control epidemics
• To expand access to the minimum package of activities in health centres
• To bring more coherence in user fees mechanisms, retaining equitable access
• Increase access to effective malaria treatment and rapidly increase the capacity of preventive programs (distribution of insecticide treated bednets). Prioritising areas with the longest transmission season
• Reduce maternal mortality by increased access to Emergency Obstetric Care
• Scaling up HIV prevention programs
• Monitor nutritional status in high risk areas and among vulnerable populations, reduce childhood malnutrition rates if above emergency thresholds.
• More effective advocacy and interventions for the protection of populations, in particular to prevent SGBV, and ensure access to counselling and treatment of rape victims
• In transition areas, building on achievements of the humanitarian programs, strengthen the capacity of national partners to manage and supervise the health services.
• Ensuring that priorities are agreed upon between health partners and improving the framework for health coordination and joint planning
Summary of gaps and challenges:
• The security situation remains a cause for humanitarian needs and a constraint to implement programs. There are still many areas to which there is no or only sporadic access.
• In these and other areas that do not receive support from international NGOs, access to adequate health services remains very low, mainly as they function as private services, recovering 100% of the costs.
• Given the low amount of financial resources available in the MoH, and the fact that few of these arrive in the periphery of the country, support to the functioning of the public health system will continue to fall on the shoulders of external donors.
• Adequate and effective support to secondary level of health services is identified as one of the important gaps.
• The high poverty levels and limited opportunities for economic growth remain a constraint for humanitarian agencies to withdraw from areas that are in transition. Development agencies are not yet ready to take over programs.
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Annex 3: Principal agencies providing health assistance
Maniema CARE, Merlin, CARITAS, Concern, ACF, COOPI
North Katanga Alisei, Solidarité, CARITAS, MSF-E, IRC, MDM-F
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Annex 4: Context
• Since 1998 the Democratic Republic of the Congo (DRC) has been rent by ethnic strife and civil war. Troops from several countries have intervened in the conflict.
• A cease-fire was signed in 1999, but skirmishing has continued. In January 2001 President Laurent Kabila was assassinated; he was replaced by his son Joseph who has since moved to implement the stalled Lusaka Peace Agreement, allowing the deployment of UN troops, and adopting economic policies in line with WB and IMF prescriptions.
• United Nations Military Observer Mission to Congo (MONUC) established in November 1999 to monitor the implementation of the Lusaka peace deal signed earlier the same year. Presently, in phase III of their intervention and dealing with the program for Disarmament, Demobilisation, Repatriation, Reintegration and Resettlement (DDRRR).
• The economic and political crises in DRC as well as natural disasters, such as recent volcano eruption, have increased public health risks for the population.
• Civil Conflicts have displaced over a 2 M persons in North and South Kivu. More than 330,000 people are refugees in DRC due to civil conflicts in neighbour countries (Sudan, Rwanda, Republic of Congo, Burundi and Angola).
• DRC is one of the poorest countries of the world (GDP per capita of USD 97) and has a Human Development Index of 0.43 (ranking it 152nd out of 175 countries). The economy has been declining for years, as well as overseas development assistance has been reduced from USD 476 M to USD 168 M between 1991-97.
• Languages spoken are: French (official), Lingala, Kingwana , Kikongo, Tshiluba
• Main religious groups: Roman Catholic 50%; Protestant 20%; Kimbaguist10%; Muslim 10%; others sects and indigenous beliefs 10%.
• Main ethnic groups: over 200 African ethnic groups of which the majority are Bantu; in the North and South Kivu are the Banyarwanda, divided in Hutus (Bantu) and Tutsis (Hamitic)
• Each province is sub-divided in districts and each district in administrative areas (zones).
Affected Population
• Total country population: 58, 317,9307
• Internally Displaced Persons: 3.4 million as of August 20038
• Despite continued efforts by humanitarian actors to reach the victims, it is estimated that out of the 4 million inhabitants of Ituri, 500,000 to 1 million were displaced, and out of this million displaced, only 110,000 of them who reached Oicha and Beni towns in North Kivu received assistance.2
7 http://www.cia.gov/cia/publications/factbook/geos/cg.html 8 UN OCHA 18 Nov 03
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Distribution of IDPs by province (July 99-end 2003) • Great increase of IDPs in Orientale due to crisis in Ituri (mid-2003) • The majority of displaced persons were found in the eastern provinces of North Kivu, Katanga, Orientale and South Kivu, (Aug 2002)The majority of displaced persons were found in the eastern provinces of North Kivu, Katanga, Orientale and South Kivu, (Aug 2002) • about 1 million IDPs in the Kivus as of Aug 2002 • The number of IDPs in Equateur decreased greatly from Dec 2000 to Sept 2001 • The number of IDPs in Orientale increased greatly from Dec 2000 to Sept 2001 and then increased again in Feb 2002 • The number of IDPs in Katanga increased by 100,000 between Dec 00 and Sept 01
November 2003
ORIGIN FIGURES
Equateur DRC 168,000
Katanga DRC 412,000
Maniema DRC 234,000
North Kivu DRC 1,209,000
Orientale DRC 791,000
South Kivu DRC 413,700
East and West Kasai DRC 145,000
Kinshasa DRC 41,000
TOTAL IDPs 3.4 million
(Based on numbers provided by UN OCHA, 18 Nov 03, p19)
Source: UN OCHA 15 July 1999, 11 July 2000, 31 December 2000 (p.11), 30 September 2001; 28 February 2002, p.13; August 2002; 31 July 2002
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Accessibility and Essentials for Logistics
• Rainy season: north of Equator: April to October, south of Equator: November to March
• Routes of access. Transport infrastructure has largely collapsed, and insecurity is widespread. Transport cost for humanitarian assistance goods is extremely high.
• Transport by rail/road: out of the 145,000 km of roads, no more than 2,500 are asphalt.
