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Introduction

Providing medical support to the local population during a chronic crisis is difficult. The crisis in the Democratic Republic of the Congo (DRC), which is characterized by high excess mortality, ongoing armed violence, mass forced displacement, interference by neighboring countries, resource exploitation, asset stripping, and the virtual absence of the state, has led to great poverty and a dearth of funds for the support of the health system.

International nongovernmental organizations (NGOs) have stepped in to address the dire humanitarian situation. This study looks at four organizations that support local health care in the eastern DRC: the International Rescue Committee (IRC), Malteser, Medical Emergency Relief International (Merlin), and the Association Régionale d’Approvisionnement en Médicaments Essentiels (ASRAMES). The study makes a comparison of the management and financing approaches of these four organizations by collecting and comparing qualitative and quantitative data on their interaction with the (remaining) local health providers and the local population.

In a chronic crisis, knowledge or documentation of management and financing approaches to health care system support is limited. In particular, the topic of cost recovery, or more modestly, cost sharing, in these crises has rarely been studied, and there are no standard responses for simultaneously recovering costs and increasing a population’s access to health care in war zones. Higher quality data on the management of cost recovery can lead to a better understanding of the interaction of price, quality, access, and



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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo 1 Introduction Providing medical support to the local population during a chronic crisis is difficult. The crisis in the Democratic Republic of the Congo (DRC), which is characterized by high excess mortality, ongoing armed violence, mass forced displacement, interference by neighboring countries, resource exploitation, asset stripping, and the virtual absence of the state, has led to great poverty and a dearth of funds for the support of the health system. International nongovernmental organizations (NGOs) have stepped in to address the dire humanitarian situation. This study looks at four organizations that support local health care in the eastern DRC: the International Rescue Committee (IRC), Malteser, Medical Emergency Relief International (Merlin), and the Association Régionale d’Approvisionnement en Médicaments Essentiels (ASRAMES). The study makes a comparison of the management and financing approaches of these four organizations by collecting and comparing qualitative and quantitative data on their interaction with the (remaining) local health providers and the local population. In a chronic crisis, knowledge or documentation of management and financing approaches to health care system support is limited. In particular, the topic of cost recovery, or more modestly, cost sharing, in these crises has rarely been studied, and there are no standard responses for simultaneously recovering costs and increasing a population’s access to health care in war zones. Higher quality data on the management of cost recovery can lead to a better understanding of the interaction of price, quality, access, and

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo sustainability in local health systems. In essence, one central question needs to be answered: What management and financing approaches are used by NGOs to raise access to health care, while strengthening the capacity and quality of the local health care system in a situation of chronic crisis in the eastern DRC? Specific objectives of the study are To identify which management and financing approaches, including the setting of fees, are used by the four NGOs supporting health care in the eastern DRC. To determine how these financing approaches affect utilization rates in the health zones supported by the four NGOs. To assess how these utilization rates compare with donor and humanitarian standards. To determine at what level fees must be set to allow for cost recovery or cost sharing in health facilities. To identify the managerial problems confronting the four NGOs. Many epidemiological and public health studies focus on the interaction between health providers and target groups. This study concentrates more on how the relationship between the supporting NGOs and the local health system actually develops. In addition, a common aspect of many of the epidemiological and public health studies is the search for an optimal, or at least appropriate, management and financing approach. This comparative organizational analysis shows that these organizations would like to realize such an approach, but that the daily pressures of ongoing insecurity, uncertain financing, lack of scientific data, and a focus on implementation—saving lives takes priority—prevent this to a large extent. The organizations instead attempt to improve their operations gradually over time. As a result, actual implementation of health care support may differ considerably from the recommended approach as detailed in the guidelines of the Sphere Project1 or standard epidemiological research. This study shows that three complementary approaches are followed 1   The Sphere Project is an international program launched in 1997 to develop a set of universal minimum standards in core areas of humanitarian assistance. The standards are contained in a handbook, Humanitarian Charter and Minimum Standards in Disaster Response (Sphere Project, 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 to ensure maintenance of the local health system in the eastern DRC: (1) bringing in outside (international) funding, (2) using local resources (either financial ones, such as cost sharing, or contributions in kind, such as cooperation from health committees), and (3) lowering or at least controlling costs, while improving the allocation of revenues. Typically, the organizations combine all three approaches. Consequently, no complete cost-recovery system is currently possible; the organizations use different forms of cost sharing. The key to health care financing is to establish a health management system that provides the right incentives for the staff and organizations involved to improve the quality of health care and keep it cost-efficient. Health facility utilization shows the current level of the population using the health facility, as well as the difference in health facility usage with different payment schemes by different organizations. However, utilization varies with each agency and also depends on factors other than fees and proximity. The actual management of the health system also influences attendance and sustainability. Generally, additional measures, such as free drugs and direct subsidies, are necessary to ensure that revenues are high enough to pay for staff incentives and running costs. This study found that the management approaches of the four different organizations vary considerably, in particular with regard to indigent treatment and the supervision of the health system. In principle, there are two poles on a continuum of approaches: the “intense supervision” approach, with continuous attention to capacity building and management control with many health supervisors, frequent field visits, and an elaborate system for indigent care, and the “hands-off contract approach,” with a contract document that spells out the amount funded by the international organization, the expected results, and the times and methods of evaluation. In the latter approach, the international organization does not interfere in the day-to-day management of the local health system. The first approach may receive the criticism that it leads to a parallel health (control) system. The second may receive criticism for not ensuring sufficient capacity before its hands-off methodology can be successful. Our research did not find any organization that used a complete hands-off contract approach. To differing degrees, they all carry out capacity building and supervisory control. They all rely on cost sharing and the provision of free drugs and other medical supplies. The organizations have improved access with lowered fees and, in two cases, coupons for the indigent. The IRC works with an intense supervision model and a coupon system for the indigent.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo ASRAMES has also increased supervision. Merlin has pioneered the contract approach, but in a hands-on manner that emphasizes intense supervision. Malteser works mostly through local health structures but increasingly emphasizes supervision. Intensive international support will remain necessary as long as there is no well-functioning government that can take over from the international donors. The four organizations work to improve the population’s access to health care, while building the capacity of health personnel. Cost sharing creates revenues for health centers, but sometimes to the detriment of population access to health care. Intensive support to health systems is costly, but it results in higher utilization of health facilities. In this way, the organizations can contribute to building capacity and facilitate the transition to a more sustainable system once the war ends. Only then can a higher degree of cost recovery be reintroduced. BACKGROUND For more than 30 years, the people of the DRC suffered under President Mobutu’s unchecked corruption and mismanagement, which “left public services in disrepair, creating desperate poverty, chronic poor health,” and ethnic conflicts (see Van Herp, Parque, Rackley, and Ford, 2003:141; Wrong, 2001). In 1996, a civil war ensued in which neighboring countries interfered. In May 1997, Laurent Kabila’s forces overthrew Mobutu with strong support from the Rwandan and Ugandan armies. A year and a half later, the Rassemblement Congolais pour la Démocratie (RCD) started another war to displace Kabila’s regime with support from the Rwandan, Ugandan, and Burundian armies. This “second” war soon reached a stalemate. Kabila received support from Angola, Zimbabwe, Chad, and Namibia, while Uganda and Rwanda grew apart over their differing economic interests and supported different rebel groups. As a result, the country was divided into roughly three parts. The Front de Libération du Congo (FLC), supported by the Ugandans, occupied the northern part of the DRC. The RCD, supported by the Rwandans, maintained control over the eastern part, and the government forces controlled the western and southern parts. In the meantime, the Interahamwe rebels continued to destabilize parts of eastern DRC and various Mai-Mai factions—originally local self-defense groups that fought against foreign occupation, increasingly turned into armed bandits that also raped and looted the local population—were also active in RCD- and FLC-held territory.

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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 different warring factions and their international supporters are generally more interested in economic exploitation—for example of diamonds and coltan (a metallic ore used in cell phone circuitry)—than in ending the war, so it has become a chronic conflict in which it is often unclear who is fighting whom (see United Nations, 2001). As a result, these Congolese wars have broken down into “dozens of overlapping micro-wars … in which almost all the victims are civilians” (The Economist, July 4, 2002). Economic activity has deteriorated rapidly and extreme poverty has increased sharply. The United Nations (UN) estimates that, of an estimated population of 60 million, approximately 3.4 million people have become internally displaced (United Nations Office for the Coordination of Humanitarian Affairs, 2003, 2004) and 31 million people suffer from food insecurity (United Nations Office for the Coordination of Humanitarian Affairs, 2003). The eastern DRC has become an “unchecked incubation zone for diseases,” with the highest rates of excess mortality known to have occurred in the world (Roberts, 2000:3). IRC surveys in eastern DRC in 2000, 2001, and 2002 estimated that between August 1998 and November 2002, 3.3 million excess deaths2 (of a population of approximately 20 million) occurred. The mortality resulted from three related root causes: The violence leads directly to a higher death rate. In addition, gender-based violence is also appallingly common (Human Rights Watch, 2002). People flee their villages when they are attacked or they hide, often in the forest, at night. As a result, their access to health care is hampered, they are exposed to the elements and parasites, they have little food and no clean water, and they suffer from exhaustion and malnutrition. Consequently, epidemics of diseases such as tuberculosis, cholera, meningitis, and malaria exact a heavy toll. 2   The IRC aimed “to provide a profile of mortality to guide political or humanitarian responses” and to make public “the level of suffering and death” among civilians. It used retrospective, verbal autopsy, household-based two-stage cluster sample surveys. Estimates could vary from 3.0 to 4.7 million depending on assumptions about the population excluded from the survey (Roberts et al., 2003:i). A recent IRC survey estimated that by April 2004 the total excess mortality for the whole country was 3.8 million (with a minimum of 3.5 and a maximum of 4.4 million depending on assumptions about the population excluded from the survey) (Coghan et al., 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 The health care system has collapsed, and people increasingly lack the economic means to buy its remaining services. Simultaneously, the fees obtained cannot adequately cover all operating costs of the health centers. At the national political level, the death of President Laurent Kabila in January 2001 and subsequent replacement by his son, Joseph Kabila, led to renewed diplomatic interventions to achieve peace. A UN observer force was placed close to the front line, and the warring factions have withdrawn. The forces from other African countries also started their withdrawal and an often haphazard process of national reunification with a transitional national government was established. Nevertheless, local armed conflicts flare up regularly, and the country may still slide back into full-scale war. THE HEALTH SYSTEM IN THE DRC Under pressure from the World Bank and the International Monetary Fund (IMF), the national health budget was cut during the 1980s. As a consequence, the health system increasingly had to become self-reliant and the DRC became a natural experiment in cost recovery. Put differently, health care is based on an “auto-finance system,” with each health facility generating its own revenues by charging fees for medical consultations and drugs. These consultation fees are a legal requirement under Congolese law, and their eradication is not accepted by the local health authorities. The health facilities use the revenues to pay staff incentives (instead of salaries officially due by the government, which have not been paid in more than a decade), buy drugs, and pay for maintenance and building repairs. Despite years of neglect and violence, a decentralized structure of health zones (districts) has been preserved to a large extent. In each province, the provincial health inspection office (Bureau de l’Inspection Provinciale de la Santé) officially supervises its health zones and determines the fee structure. This office is led by a provincial health inspector (médicin inspecteur provincial), who is responsible for the overall health policy in the province. Each health zone is managed and supervised by a chief medical officer (médicin chef de zone, or CMO), who is responsible for monitoring the daily activities of all health centers in the health zone and ensuring the quality of services provided to patients. Chief medical officers and their support staff are located at the health zone bureau (bureau central de zone). Since several provinces are not effectively governed by Kinshasa, the national health care system has increasingly become a patchwork of local initiatives, sometimes with international support, and national and provincial policies.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo In addition, each health center has, ideally, its own health committee (comité de santé), which consists of members elected by their community. These members often hold positions of respect in their community: church leaders, schoolteachers, retired civil servants, village chiefs, leaders of women’s groups, and so on. In a well-functioning health committee, the representatives participate fully in health center management, ensuring financial and material accountability, representing community health needs, and encouraging service uptake by community members, in particular the poorest of the poor. Its members are charged with the responsibility to spread health education messages and other important health information, such as dates for upcoming vaccination campaigns. They are often also responsible for gathering such health statistics from the community as births and deaths that did not occur at the health center or the hospital. THE PROBLEM The topic of cost recovery or cost sharing in today’s chronic crises has rarely been studied, and cost sharing has become a contentious issue inside and outside war zones and can be a key barrier to overcoming health inequities. In addition, there are no commonly acknowledged standard responses for simultaneously recovering costs and increasing attendance in war zones (Poletti, 2003, 2004). Cost sharing through raising fees from the local population can limit access, especially for the poor, further aggravating the effects of insecurity. For some poor people, who can barely afford health care, a fee may constitute a so-called catastrophic expenditure, which puts them in debt or makes them cut back on such basic necessities as food. The poor who need care but cannot pay may be sent away at the door of the health facility, because they take up time and do not bring any revenues to the health facility or its staff. If their health problems are not treated, they may need more expensive care later on. If the disease is contagious, they may infect other members of their community. In other cases, they may require care from family members who do not have the resources available to provide it. However, at the same time, free health care may cause unnecessary use and thereby unsustainable demand.3 The general rationale for cost recovery in health has frequently been 3   Arhin-Tenkorang (2000:8) disputes this frivolous use argument. “Where cost of travel, waiting, and income loss is high as in the case of most low-income countries, it can be argued that most or all excess utilization will already have been eliminated.”

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo macroeconomic balance as promoted by the World Bank and the IMF. “In situations of chronic and growing trade and domestic budget deficits, cost-recovery for publicly financed goods and services offers one route to deficit reduction” (Creese and Kutzin, 1995:3). More specifically, the “most compelling case for user charges … has been their capacity to provide an emergency boost for the recurrent (usually non-salary) costs of health care provision, which have been most depleted by declining real expenditure” (p. 4). If fees are used to improve service quality close to where people live, they can also increase equity. Furthermore, “there may be potential benefits from user charges in both mobilizing additional resources and in setting price signals to encourage more efficient behaviors by purchasers and providers” (p. 4).4 In sum, raising revenue and increasing efficiency and equity constitute the main arguments in favor of introducing fees.5 The assumptions behind the rationale for cost recovery center on the role of the state and its accountability to its population, in particular on the idea that a willing and able government takes the interests of its population seriously, and that despite economic problems sound macroeconomic policy will help improve the lives of its citizens. These assumptions also imply that health care staff will be motivated by the interests of their patients and that these interests dovetail with their own interests. These assumptions, however, do not apply in cases of chronic civil conflict. In many civil conflicts the state oppresses or marginalizes parts of its population. Often the official government becomes one of the warring factions, refusing or unable to pay for social services, so that access and quality deteriorate further. The economy is generally in steep decline and official macroeconomic policy does not reflect the underlying corruption 4   Ironically, the traditional arguments against cost recovery/cost sharing thus mirror the arguments in favor of it. They have a possible negative impact on equity (with fees the poor get priced out of the market) and efficiency (preventive and curative care that has wider public health benefits than just individual health care will not be provided because the fees obstruct demand. Alternatively, there can also be supply-induced demand of unnecessary treatment), while not raising enough revenues to improve health care. Hence, the similarity in arguments for and against cost recovery/cost sharing highlights the need for empirical research. 5   In addition to user fees, insurance schemes, either private (risk-based insurance) or social health insurance, tax-based systems, and foreign aid may provide other resources for improvements in health care (see Arhin-Tenkorang, 2000; Poletti, 2003). Except for foreign aid and fees, these financing methods have broken down in the eastern DRC.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo of patronage politics and clientele socioeconomic systems. Insurance schemes increasingly break down, and development-oriented work often comes to a standstill. In many cases, a warlord economy develops, in which a tiny elite uses violence as a way to enrich itself at the expense of the great majority of the population (Reno, 1998). In such a situation, the population is increasingly marginalized, while it still needs to find ways to survive. The health staff often do not earn enough money, and their immediate day-to-day survival needs may take priority over patient interests. Paradoxically, cost recovery itself will become more important to health facilities and their staff in order to cover recurrent costs, including salary and other financial incentives, while the capacity to pay for these services will be diminishing. A vicious cycle of inability to pay, worsening access, lower quality, and destruction of capacity is thus set into motion. Support by international organizations may then, in principle, help address the suffering by bringing in new resources to break the cycle. For this reason, the interaction between the local population, the local health system, and the international organizations becomes a crucial topic for further study. Since there are no commonly accepted approaches to health financing in chronic crises in general or to cost recovery in particular, many international organizations—and their donors—promote their own approaches to support health care, and concomitantly, cost recovery. Sometimes, the difference is mainly semantic when a related concept like cost sharing is used. At other times, these approaches imply rather different philosophies about local participation, indigent access, and the sustainability of health systems. Some NGOs and donors do not require the health centers to implement cost-recovery schemes while the war is ongoing. UNICEF and Médecins Sans Frontières (MSF), for example, promote free health care. However, this approach does not ensure sustainability of the local health system once the international organization leaves. Other NGOs require some degree of cost recovery—in other words, cost sharing—partly out of concern for financial sustainability of the local health system and partly to prevent misuse of health care. Some also argue that paying for services, even if it is only a nominal amount, preserves the dignity of the patients. In addition, the NGOs differ in their approaches to such managerial issues as health zone coverage, monitoring, staff training, and indigent support. In general, the appropriate size of the fee, including exemptions and waivers, such as coupons for the indigent, has been difficult to determine. The different approaches by the donors and the NGOs can lead to fragmented and perhaps unsustainable health care systems in different parts of the country, which

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo can obstruct national rebuilding and perhaps even hamper the postwar viability of the Congolese state. METHODOLOGY This research studies the different approaches to health management and cost recovery used by four organizations active in the eastern DRC: the IRC, Merlin, Malteser, and ASRAMES. These NGOs aim to improve the collapsed health care system in the eastern DRC. They also responded to the eruption of the Nyiragongo volcano on January 17, 2002, which destroyed parts of Goma in North Kivu. Except for ensuring the provision of essential drugs, it was initially not clear whether and how much the approaches of the four organizations to care differ. Field research took place with participant observation during two summer periods, August 4-19, 2001, and July 3-August 16, 2002. Additional quantitative data were collected in 2004 and 2005. Data resources included (1) internal documents of the four organizations with quantitative data on attendance and management of the health care system; (2) a literature study on cost recovery/cost sharing; and (3) open and semistructured interviews and email exchanges with staff members of the four organizations, patients and nonpatients, local health staff, and other local and international organizations. The field visits were followed up with telephone interviews. Finally, staff members of the four organizations double-checked and commented on the drafts of this document. One of the main problems of this research was that it was complicated to get access to high-quality quantitative material, which was difficult to collect on the organizations, due to insecurity, staff rotation, and sometimes loss of data. In addition, population data are generally extrapolated from the 1984 population census. Given the long time frame, high mortality rates, and internal displacement, such extrapolations can provide only a rough indication of the actual population numbers. Box 1-1 is a list of acronyms relevant to this paper.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo BOX 1-1 Acronyms ADOSAGO Association des Donneurs de Sang de Goma AFDL Alliance des Forces Démocratiques pour la Libération du Congo AMI-KIVU Appui Médical Intégral au Kivu ASRAMES Association Régionale d’Approvisionnement en Médicaments Essentiels BCG Bacille Calment et Guerrin (Tuberculosis vaccination) BDOM Bureau Diocésain des Oeuvres Médicales CHW community health worker CMO chief medical officer CMR crude mortality rate CEMUBAC Centre Scientifique et Médical de l’Université Libre de Bruxelles pour ses Activités de Coopération DFID Department for International Development DRC Democratic Republic of the Congo DTP3 Diphtheria, Tetanus and Pertussis (vaccination in three doses) ECC Église du Christ au Congo ECHO Humanitarian Aid Office of the European Union EPI Extended Program on Immunization EU European Union FrC Franc Congolais FLC Front de Libération du Congo FOMULAC Fondation Médicale de l’Université de Louvain en Afrique Centrale FSKI Fondation Sud Kivu HC health center HMIS health management information system ID internal document

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo IDA International Dispensary Association IDP internally displaced person IMF International Monetary Fund IRC International Rescue Committee KAP knowledge, attitudes, and practices MDM Médicins du Monde Merlin Medical Emergency Relief International MONUC Mission Observatrice des Nations Unies pour le Congo MOU memorandum of understanding MRND Mouvement Républicain Nationale Démocratique MSF Médecins Sans Frontières MSF-H Médecins Sans Frontières–Hollande NGO nongovernmental organization OCHA United Nations Office for the Coordination of Humanitarian Affairs OFDA Office of U.S. Foreign Disaster Assistance ORS oral rehydration salt PATS Programme d’Appui Transitoire au Secteur de la Santé PHC primary health care RCD Rassemblement Congolais pour la Démocratie RHC reference health center SANRU Projet de Développement de la Santé Rurale SNIS Système National d’Information Sanitaire UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WHO World Health Organization