SUPPORTING LOCAL HEALTH CARE IN A CHRONIC CRISIS

MANAGEMENT AND FINANCING APPROACHES IN THE EASTERN DEMOCRATIC REPUBLIC OF THE CONGO

Dennis Dijkzeul and

Caroline Lynch

Roundtable on the Demography of Forced Migration

Committee on Population

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES and

Program on Forced Migration and Health

Mailman School of Public Health

Columbia University

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo SUPPORTING LOCAL HEALTH CARE IN A CHRONIC CRISIS MANAGEMENT AND FINANCING APPROACHES IN THE EASTERN DEMOCRATIC REPUBLIC OF THE CONGO Dennis Dijkzeul and Caroline Lynch Roundtable on the Demography of Forced Migration Committee on Population NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES and Program on Forced Migration and Health Mailman School of Public Health Columbia University THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by a grant to the National Academy of Sciences and the Joseph L. Mailman School of Public Health of Columbia University by the Andrew W. Mellon Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-10038-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Research Council. (2006). Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo. Dennis Dijkzeul and Caroline Lynch. Roundtable on the Demography of Forced Migration, Committee on Population, Division of Behavioral and Social Sciences and Education and Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University. Washington, DC: The National Academies Press.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo ROUNDTABLE ON THE DEMOGRAPHY OF FORCED MIGRATION 2004-2005 CHARLES B. KEELY (Chair), Walsh School of Foreign Service, Georgetown University LINDA BARTLETT, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta RICHARD BLACK, Center for Development and Environment, University of Sussex STEPHEN CASTLES, Refugee Studies Centre, University of Oxford WILLIAM GARVELINK, Bureau of Humanitarian Response, U.S. Agency for International Development, Washington, DC ANDRE GRIEKSPOOR, Emergency and Humanitarian Action Department, World Health Organization, Geneva JOHN HAMMOCK, Feinstein International Famine Center, Tufts University BELA HOVY, Program Coordination Section, United Nations High Commissioner for Refugees, Geneva JENNIFER LEANING, School of Public Health, Harvard University NANCY LINDBORG, Mercy Corps, Washington, DC CAROLYN MAKINSON, Andrew W. Mellon Foundation, New York SUSAN F. MARTIN, Institute for the Study of International Migration, Georgetown University W. COURTLAND ROBINSON, Center for Refugee and Disaster Studies, Johns Hopkins University SHARON STANTON RUSSELL, Center for International Studies, Massachusetts Institute of Technology WILLIAM SELTZER, Department of Sociology and Anthropology, Fordham University PAUL SPIEGEL, Global Coordinator on HIV/AIDS, United Nations High Commissioner for Refugees, Geneva RONALD WALDMAN, Joseph L. Mailman School of Public Health, Columbia University ANTHONY ZWI, School of Public Health and Community Medicine, University of New South Wales BARNEY COHEN, Director, Committee on Population ANA MARIA-IGNAT, Senior Program Assistant* ANTHONY MANN, Senior Program Assistant** *   Until November 2004 **   Since November 2004

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo COMMITTEE ON POPULATION 2004-2005 KENNETH W. WACHTER (Chair), Department of Demography, University of California, Berkeley ELLEN BRENNAN-GALVIN, School of Forestry and Environmental Studies, Yale University ANNE C. CASE, Woodrow Wilson School of Public and International Affairs, Princeton University JOHN N. HOBCRAFT, Population Investigation Committee, London School of Economics CHARLES B. KEELY, Walsh School of Foreign Service, Georgetown University DAVID I. KERTZER, Department of Anthropology, Brown University BARTHELEMY KUATE-DEFO, Department of Demography, University of Montreal CYNTHIA LLOYD, Population Council, New York DOUGLAS S. MASSEY, Department of Sociology, University of Pennsylvania THOMAS W. MERRICK, Population and Reproductive Health, World Bank RUBEN G. RUMBAUT, Center for Research on Immigration, Population, and Public Policy, Department of Sociology, University of California, Irvine JAMES W. VAUPEL, Max Planck Institute for Demographic Research, Rostock, Germany ROBERT J. WILLIS, Institute for Social Research, University of Michigan, Ann Arbor BARNEY COHEN, Director

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Preface In response to the need for more research on displaced persons, the Committee on Population developed the Roundtable on the Demography of Forced Migration in 1999. This activity, which is supported by the Andrew W. Mellon Foundation, provides a forum in which a diverse group of experts can discuss the state of knowledge about demographic structures and processes among people who are displaced by war and political violence, famine, natural disasters, or government projects or programs that destroy their homes and communities. The roundtable includes representatives from operational agencies, with long-standing field and administrative experience. It includes researchers and scientists with both applied and scholarly expertise in medicine, demography, and epidemiology. The group also includes representatives from government, international organizations, donors, universities, and nongovernmental organizations. The roundtable is organized to be as inclusive as possible of relevant expertise and to provide occasions for substantive sharing to increase knowledge for all participants, with a view toward developing cumulative facts to inform policy and programs in complex humanitarian emergencies. To this aim, the roundtable has held annual workshops on a variety of topics, including mortality patterns in complex emergencies, demographic assessment techniques in emergency settings, and research ethics among conflict-affected and displaced populations. Another role for the roundtable is to serve as a promoter of the best research in the field. The field is rich in practitioners but is lacking a coher-

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo ent body of research. Therefore, the roundtable and the Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University have established a monograph series to promote research on various aspects of the demography of forced migration. These occasional monographs are individually authored documents presented to the roundtable and any recommendations or conclusions are solely attributable to the authors. It is hoped these monographs will result in the formulation of newer and more scientifically sound public health practices and policies and will identify areas in which new research is needed to guide the development of forced migration policy. This monograph has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published monograph as accurate and as sound as possible. The review comments and draft manuscript remain confidential. Ronald J. Waldman of Columbia University served as review coordinator for this report. We wish to thank the following individuals for their participation in the review of this report: Christopher Schwabe, health and public finance economist at Medical Care Development International, and Steven Hansch of the Institute for the Study of International Migration, Georgetown University. Although the individuals listed above provided constructive comments and suggestions, it must be emphasized that responsibility for this monograph rests entirely with the authors. This series of monographs is being made possible by a special collaboration between the Roundtable on the Demography of Forced Migration of the National Academies and the Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University. We thank the Andrew W. Mellon Foundation for its continued support of the work of the roundtable and the program at Columbia. A special thanks is due Carolyn Makinson of the Mellon Foundation for her enthusiasm and significant expertise in the field of forced migration, which she has shared with the roundtable, and for her help in facilitating partnerships such as this.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Most of all, we are grateful to the authors of this monograph. We hope that this publication contributes to both better policy and better practice in the field. Charles B. Keely, Chair Roundtable on the Demography of Forced Migration Ronald J. Waldman, Member Roundtable on the Demography of Forced Migration Director, Program on Forced Migration at the Mailman School of Public Health of Columbia University

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Contents 1   Introduction   1      Background,   4      The Health System in the DRC,   6      The Problem,   7      Methodology,   10 2   The Organizations   13      International Rescue Committee,   13      IRC Activities,   14      Organizational Setup,   17      Medical Emergency Relief International,   18      Merlin Activities,   20      Organizational Setup,   21      Changes in Merlin’s Approach,   21      Malteser Bukavu,   24      Malteser Activities,   25      Organizational Setup,   26      Association Régionale d’Approvisionnement en Médicaments Essentiels,   26      ASRAMES Activities,   28      Organizational Setup,   31      Comparison of Organizational Approaches,   31      Organizational Setup,   31      Organizational Strategies,   34

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo 3   Main Findings   36      Different Approaches Concerning Indigent Care,   36      Supply,   50      Supervision: Capacity Building, Monitoring, and Evaluation,   52      Revenues,   61      IRC-Supported Health Facilities,   61      ASRAMES-Supported Health Facilities,   62      Merlin-Supported Health Facilities,   63      Malteser-Supported Health Facilities,   63      Revenues and Their Contribution to the Health System,   64      Economic and Security Situation,   64      Role of the Donors,   65      Local Management.   66 4   Discussion   67      Implications and Practical Considerations,   71      Further Research,   74     Bibliography   76     Appendix: Merlin Standard Health Contract Agreement (Memorandum of Understanding)   81     About the Authors   89