2
The Organizations

All four organizations, except the Association Régionale d’Approvisionnement en Médicaments Essentiels (ASRAMES), established themselves in the eastern Democratic Republic of the Congo (DRC) during the Rwandan refugee crisis, but they increasingly paid attention to the needs of the local Congolese population. Following up on a drug supply program of Médecins Sans Frontières–Hollande (MSF-H), ASRAMES began drug distribution in support of the Congolese population of North Kivu in 1995. Currently, all organizations provide medications as well as other forms of support to the local health institutions (see Table 2-1). This chapter explains briefly the organizations’ history and basic activities.

INTERNATIONAL RESCUE COMMITTEE

The International Rescue Committee (IRC) began to support the population of South Kivu by way of structured health zone programs (instead of Rwandan refugee camps) in 1996 (Table 2-2). The IRC regional office is located in Bukavu. The organization runs health interventions in two zones: Katana and Kabare in South Kivu. In 2002, it also carried out water and sanitation activities in Kalemie and provided emergency aid in Goma after the Nyiragongo eruption.



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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo 2 The Organizations All four organizations, except the Association Régionale d’Approvisionnement en Médicaments Essentiels (ASRAMES), established themselves in the eastern Democratic Republic of the Congo (DRC) during the Rwandan refugee crisis, but they increasingly paid attention to the needs of the local Congolese population. Following up on a drug supply program of Médecins Sans Frontières–Hollande (MSF-H), ASRAMES began drug distribution in support of the Congolese population of North Kivu in 1995. Currently, all organizations provide medications as well as other forms of support to the local health institutions (see Table 2-1). This chapter explains briefly the organizations’ history and basic activities. INTERNATIONAL RESCUE COMMITTEE The International Rescue Committee (IRC) began to support the population of South Kivu by way of structured health zone programs (instead of Rwandan refugee camps) in 1996 (Table 2-2). The IRC regional office is located in Bukavu. The organization runs health interventions in two zones: Katana and Kabare in South Kivu. In 2002, it also carried out water and sanitation activities in Kalemie and provided emergency aid in Goma after the Nyiragongo eruption.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo TABLE 2-1 Population Covered and Health Facilities Supported NGO Total Health Facilities Estimated Population of Health Zones Hospital Reference Health Center Health Center Total IRC support 489,000 3 6 43 52 Merlin support 800,000 4 4 132 140 Malteser support 646,000 2 0 55 57 ASRAMES support 3,859,381 22 28 343 393 TOTAL 5,794,381 31 38 573 642 TABLE 2-2 IRC Health Zone Summary, 2001-2002 Health Zone Estimated Population Total Health Facilities Hospital Reference Health Center Health Center Total Katana 347,000 2 4 28 34 Kabare 142,000 1 2 15a 18 TOTAL 489,000 3 6 43 52 aFive of these health centers are actually health posts, which is a smaller type of health center, more like a dispensary that does only outpatient care. A health center also has the facility to do minor inpatient care for 24 or 48 hours. IRC Activities The IRC strove to strengthen the functioning of the health centers and simultaneously improve access to care. In 2001-2002, its ultimate sector objective was to reduce mortality for the population served by 32 percent by September 30, 2004, in a manner that strengthens local capacity to sustain these results. Intervention in the Katana health zone began in 1996. The IRC esti-

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Health Facilities Supported Hospital Health Center Reference Health Center Total % Original Government Health Facilities (PHC) Supported by NGOs 1 6 43 50 100 5 4 85 94 64 2 0 42 44 76 20 23 272 315 79 28 33 442 503 77 Health Facilities Supported Hospital Reference Health Center Health Center Total 0 4 28 32 1 2 15 18 1 6 43 50 mated in August 2002 that about 45 percent of the zone’s population was indigent according to its criteria. In the west of this zone, rebels—mainly Interahamwe—regularly committed violence. A Belgian nongovernmental organization (NGO) called Fondation Médicale de l’Université de Louvain en Afrique Centrale (FOMULAC) was also active in Katana. Because the Katana bureau was never fully part of the national health system, this organization had been integrated into the local zone bureau, playing a leading

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo role. For example, FOMULAC used to sell drugs to the local health centers, but this arrangement was superseded by the IRC’s free drug distribution. As a consequence, cooperation between FOMULAC and the IRC was sometimes tense. The IRC was active in Kabare from October 1999 to April 2000 but had to suspend its activities because the Department for International Development (DFID) refused refunding. The DFID preferred free health care, but the IRC and the local health inspection did not. In July 2001, the IRC restarted its activities in Kabare with support from the Office of U.S. Foreign Disaster Assistance (OFDA) and was fully operational again by the end of August 2001. In addition to health center support, the IRC also supports seven nutrition centers. It estimated that the indigent constitute about 90 percent of the population according to IRC criteria.1 In 2002, the IRC was the only international organization active in the Kabare zone. Both zones had a sizeable population of displaced people coming from the Bunyakiri health zone. As a humanitarian organization committed to primary health care and funded by OFDA, the IRC mainly supports health centers and reference health centers (i.e., those to which more serious cases are referred). OFDA usually prefers not to support hospitals, but it is flexible in emergency situations.2 The IRC has consciously decided to provide assistance to all health centers in its zones, because with partial coverage, unsupported health centers would not be able to compete and would ultimately have to close, further weakening the battered health care system. The main IRC activities in its two zones are The provision of essential drugs and supplies to allow health centers to provide comprehensive services to the population. The provision of such necessary equipment as cold chain equipment (which protects heat-labile vaccines, sera, and other medicines against high environmental temperatures). The development of revenue generation mechanisms for the local 1   The word “indigent” is commonly used in the eastern DRC to denote extremely poor people. 2   Since August 2001, the IRC has provided support to the indigent who get referred to the hospital in the Kabare region with funding from OFDA. In Katana, such support started after the signing of a new, delayed memorandum of understanding in August 2002.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo health centers. Revenues from patients are used to pay incentives, buy additional drugs, facility maintenance, etc. The modification of the fee system to ensure access of the population through lower rates, exemptions (e.g., consultations for children under age 5, tuberculosis), and waivers for the indigent. The fee modifications especially aim to ensure that the most vulnerable population has access to health care. The establishment of training through official programs as well as on-the-job training with mobilizers and health supervisors. The provision of technical training and logistical support (fuel, office supplies, etc.) to the zone bureau. The supervision and monitoring of the health centers and the health care system with its health supervisors. The mobilization of communities, in particular of local health committees, in order to promote good health behaviors in the population. The promotion of preventive activities, such as a malaria program with bed nets and community education. The formation of a community health worker program to improve local health care (community health workers are involved in active case-finding and referral of those cases), to educate and mobilize the community, and to increase the quantity and quality of the epidemiological data collected. The IRC also carries out a series of monitoring and evaluation surveys, such as malaria prevalence, nutrition, and notably mortality, throughout the DRC. Organizational Setup A memorandum of understanding between the IRC and the zone bureau sets out the basic forms of cooperation between them and the health facilities. In order to ensure a high level of contact regarding IRC activities in health facilities, the IRC employs one health supervisor3 per four health centers. IRC supervisors visit each health center in their charge at least once 3   The IRC actually prefers the term “monitor” for supervisor to distinguish the position from health zone office supervisors. These IRC supervisors are skilled medical professionals themselves, who generally have several years of experience in the health system.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo a week and work closely with the health staff and the zone bureau. Joint supervisory visits are made with staff from the zone bureau every month. An IRC health supervisor carries out on-the-job training of health facility staff; verifies drug use and stocks; verifies that treatments are in accordance with national guidelines, for example, with routine immunizations; checks the accuracy of health records; conducts home visits to verify indigent status; trains and supports health committees; and collects epidemiological, financial and management data each week. In sum, the IRC uses a rather intensive supervision approach. MEDICAL EMERGENCY RELIEF INTERNATIONAL The main DRC office of Medical Emergency Relief International (Merlin) is located in Goma, from where it has been directing its programs for the Maniema province since March 1997. This province has eight health zones: Kindu, Kalima, Punia, Kampene, Lubutu, Lusangi, Kibombo, and Kasongo. Merlin originally operated health programs in the first three zones. In March 2001, it also started health activities in North and South Lodja in eastern Kasai (Table 2-3). Access to the Punia health zone was irregular due to fighting between TABLE 2-3 Merlin Health Zone Summary, 2002 Health Zone Estimated Populationa Total Health Facilities Hospital Reference Health Center Health Center Total Kindu 180,000 1 1 21 23 Kalima 170,000 1 2 23 26 Puniab 100,000 1 1 21 24 Lodja North 200,000 1c n/a 32 n/a Lodja South 150,000 c n/a 35 n/a TOTAL 800,000 4 n/a 132 n/a aPopulation figures are estimates based on the 1984 population census. For example, for Kindu, one can only assume that the population number will be between 150,000 and 220,000.

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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 Rassemblement Congolais pour la Démocratie (RCD) and the Mai-Mai. By August 2001, insecurity had become so severe that Merlin had to end its activities in Punia. In summer 2002, it once again started up its operations in this zone. The Kindu health zone covers both urban and rural areas, but the rural areas have become inaccessible due to the Mai-Mai, who often blocked roads. The Kalima health zone is predominantly rural. Different armed troops were active in its eastern part bordering Pangi (where the Mai-Mai regularly kidnapped women and girls for forced prostitution), as well as in the part close to Shabunda in the South Kivu province. An IRC mortality survey in April 2001 indicated a mortality rate for children under age 5 in Kalima of 17.1/1,000/month and a crude mortality rate of 7.5/1,000/month. In May 2001, the under-5 mortality rate was at a disaster level of 3.6/10,000/day with measles as the leading cause (Merlin, May 2002:6). In both Kalima and Kindu, Merlin has had to evacuate its expatriate staff for several months due to insecurity, while local staff continued its activities. The accessibility of North and South Lodja was better as the Kasai Oriental enjoyed a relative calm. No Mai-Mai and Interahamwe were active in these zones and the government and RCD forces had withdrawn from the front lines. As a consequence of the insecurity and the long distances involved, Health Facilities Supported Hospital Reference Health Center Health Center Total 1 1 19 21 1 2 21 24 1 1 13 15 1c n/a 17 n/a c n/a 15 n/a 4 n/a 85 n/a bIn September 2002, Merlin expanded its activities in Punia to 14 health areas and also began to support the local hospital. cNorth Lodja and South Lodja share one hospital.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Merlin could reach its health zones from Goma only by plane, which was costly. It opened small support offices in each of its zones. By strategic choice, Merlin intervened only in isolated health zones, where no other international NGOs were active. The organization made one exception to its strategy, when it began operating a safe motherhood program at 21 health centers in Goma. After the Nyiragongo eruption, it perceived a need for such a program. In addition, it wanted to strengthen its presence in Goma. Merlin Activities The overall goal of Merlin in the DRC is to reduce mortality and morbidity rates in its health zones. The Merlin activities in these zones are To distribute free essential drugs and renewable medical supplies, so the local population can obtain these at an affordable price and on a regular basis. This also includes the provision of such equipment as delivery kits and weighing scales. To provide technical support to the zone bureau, especially in their supervision activities. This supervision includes monitoring and on-the-job training of the Congolese health staff. To repair and maintain health centers to defined minimum standards, including minor rehabilitation of water and sanitation facilities at all supported health centers. This rehabilitation involves health committee and other community participation. To help reestablish routine immunization services through the provision of vaccines and vaccination supplies (for example, syringes, refrigerators, and cool boxes) from Goma to supported facilities. To promote quality care by training staff at both the zone bureau and the health centers. Training already done by Merlin includes usage of treatment guidelines, vaccination training for the vaccinators, management of the cold chain, laboratory training, safe motherhood initiative activities, including refreshment training and training for the health committees. To treat the indigent for free. To support disease surveillance and data management systems through critical review, training of health staff, and epidemiological assessment of recent disease outbreaks to maintain an emergency response for epidemic outbreaks in all supported facilities. To actively encourage community participation and awareness of

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo disease control and maternal/child health in the supported health zones through appropriate training of identified health providers. Organizational Setup Merlin has employed a relatively small number of staff. It has a total of 25 supervisors for a program that is covering 5 zones. These are located in the different health zones as long as the security situation permits this. They usually visit the health centers by motorcycle, although sometimes they need to travel by plane and then by motorcycle or car. On average, they visit each supported health center twice a month. Merlin consciously decided not to support all health centers in its zone. Its management assumed that the actual number and spread of facilities in the zones was not necessarily optimal. It thus selected a number of facilities in each health zone.4 In this way, the organization attempted to optimize its expenditures. Merlin supported, or given the insecurity attempted to support, 23 of 25 centers in Kalima, 20 of 22 centers in Kindu, and 14 of 22 centers in Punia.5 In North Lodja, Merlin supported 17 of 32 centers, in South Lodja 15 of 35 health centers. Changes in Merlin’s Approach In 2001, a Memorandum of the Cost Sharing Support Mission indicated that the management of the health programs suffered from four prob- 4   World Health Organization standards indicate that one health center should serve between 5,000 and 10,000 people after adjusting for geographical spread of the population (Merlin, May 2002:15). Merlin employs six criteria to choose facilities to support: (1) capacity of the health centers to provide basic curative care, immunization, and maternal health services both from the static facility and as an outreach service; (2) presence of an adequate cadre of staff able to provide standard and quality care to the population; (3) evaluated efficiency of functional processes, including transparency of financial management and record-keeping; (4) community acceptance and support of the facility; (5) presence of a vulnerable/displaced population, including geographical location, will also weigh significantly in the choice of a particular facility for support; and (6) the risk of looting by warring groups. It is possible that some of the health facilities serving the most vulnerable may be in this category. Merlin will therefore propose an emergency approach for support to these areas if the current service delivery configuration is unable to provide it. 5   In summer 2002, Merlin could reach only 20 health centers in Kalima and 18 in Kindu. In Punia, 22 health centers should serve the local health needs; however, only 12 of these health facilities were accessible due to the insecurity.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo lems. First, staff motivation remained low. Many health staff members were not able to make a living under war duress despite Merlin support. Zone bureau staff was also unable to make ends meet. Some donors also pressured Merlin to rely on its Congolese staff instead of zone bureau staff, which caused expensive duplication; as a result, the Merlin and zone bureau supervisory teams tended to operate in competition with each other. Second, Merlin operated a community fund that was not working well. In practice, the community fund was labor intensive for Merlin staff, war-induced hyperinflation caused financial risks, and health committee representatives of different health centers could not agree on the allocation of the money. Third, the memorandum authors doubted whether the 25 percent of cost-sharing revenues for the zone bureau was either fair or efficient. It seemed to promote underreporting of revenues. Fourth, Merlin drug prices were judged to be low compared with private pharmacy prices. Some of the drugs were later sold by either patients or health staff to the pharmacies, which created a black market for Merlin drugs. As a result, patients needed to buy more expensive drugs at the pharmacies or drugs were sometimes unnecessarily out of stock. In addition, private pharmacies rarely employed professionals able to prescribe rationally. In response to these problems, the authors of the memorandum proposed a new cost-sharing system: To start new incentive payments to motivate health staff. Approximately 50 percent of these incentives should be generated from cost-sharing revenues, while the remaining 50 percent should be generated from subsidies by Merlin. The organization would sign performance-based contracts (elaborated MOUs) with the management of the health zones. Merlin would not enter into the internal running of the health facilities, and in particular not in human resource management. It would allow Merlin to make the subsidy dependent on the performance of each health facility. Output measures could include National Health Information System (SNIS) data entry and analysis, regular supervision of health facilities, achievement of immunization standards, transparent management of funds, and so on. More work done would mean a higher subsidy, irrespective of the number of staff, and would create a strong incentive for managers to improve health facility efficiency. In sum, Merlin should institute contract management and leave the essential internal management decisions to health management and staff. To cancel the community fund and replace it by a 20 percent run-

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo ning cost/community fund run by the health facility management and health committee. User fees could then be spent on the site of collection. To lower the health zone bureau’s part of cost-sharing revenues from the health facilities from 25 percent to 10 percent. To fix the price of Merlin drugs at 60 percent of private sector prices to reduce the incentive to sell them to the private pharmacies and to increase cost-sharing revenues. To counterbalance the higher drug prices, Merlin should reduce the fixed prices for consultations, and reduce or waive prices for under-5 consultations, immunization cards and antenatal cards. It also suggested an equity fund to reimburse for bills made by the indigent, both the local poor and internally displaced persons. In addition, the memorandum proposed several measures to improve statistics collection and analysis, the Health Management Information System, and hospital care. Together, the proposals opened the door for some wide-reaching managerial changes, and Merlin and its operations changed considerably in the course of a year. Merlin support is now based on revocable contractual agreements with zone bureaus, hospitals, and health centers. Merlin established its contracts in a participatory process with the local health facilities and staff members (see the Appendix). It canceled the labor-intensive community fund and created a 15 percent running cost/community fund managed by the health committee. The money earned will now be spent at the health center or on health-related work in the local community. In comparison to its old system of revenue allocation, it increased the percentage for incentives to 65 percent and reduced the percentage to the zone bureau to 20 percent. The pricing policy for its drugs, as well as the treatments, changed considerably. The proposed equity fund was intended as an external subsidy mechanism to stimulate activities with a public benefit, such as family planning and immunizations (Extended Program on Immunization, EPI), and to pay for the costs of indigent care. However, it was not implemented because it would be too complicated to manage for the health committees. Merlin staff felt that the current system of social control functioned generally better than a complex system with funds that could be mismanaged or

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo office managed health and nutrition activities in the Walungu and Nyangezi health zones (Table 2-4). The Malteser approach was in many ways a follow-up of its earlier rehabilitation work. It consciously worked through the local health system. Its main objective was to improve the level of health of the populations in these two zones. Malteser Activities As a large zone, Walungu was often difficult to travel, which severely hampered operations. The degree of insecurity in the Walungu health zone was high, in particular in the areas bordering Shabunda. From December 2001 to May 2002, Malteser had to cease operating in this zone. Surprisingly, security improved considerably during summer 2002, because the local population did not want to lose its health care support again. If, for example, a Malteser vehicle had been halted by the Mai-Mai, the local population would ask the local Mai-Mai commander to stop such obstruction. Security in Nyangezi, a much smaller zone, was better. In addition to Malteser, there were two other organizations active in the Walungu and Nyangezi zones, namely Louvain Développement and Fondation Sud Kivu. Both came from Belgium. Louvain Développement focused on supporting hospitals with medicine, improving the functioning of the health committees (including treatment of the indigent), and rehabilitation. Malteser focused on support of the health centers. The cooperation between Malteser and Louvain Développement was quite positive; Health Facilities Supported Hospital Reference Health Center Health Center Total 1 0 25a 26 1 0 17 18 2 0 42 44

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo they regularly exchanged information to harmonize their activities. The relationship between Fondation Sud Kivu and Malteser, however, was more restrained. Fondation Sud Kivu worked with the hospital, but it was not clear to Malteser what this organization supported in the hospital. Nor was it clear how much funding they provided to the zone bureau. Organizational Setup Malteser Bukavu operated with a small number of staff. The 2002 office director also carried out the administrative position. For its two health zones, Malteser worked with two supervisors and the medical and nutritional coordinators, who ideally visited each health center once a month. The medical coordinator had three local supervisors, who visited the field four days a week. The zone bureau and Malteser operated under a memorandum of understanding, and Malteser health supervisors generally visited the field together with zone bureau officials. The health supervisors also provided on-the-job training to the health staff. Formal training took place approximately 10 times a year, with four sessions of 2 or 3 days. The zone bureau and its chief medical officer developed and organized the training. They officially arranged the room and training modules and also made sure that the health center staff attended. Malteser provided only the funding and did not control the substance of the training. In addition, Malteser supported the UNICEF National Immunization Days, which took place in July, August, and September. They provided staff time (supervisors) and free use of Malteser’s cars for these days. ASSOCIATION REGIONALE D’APPROVISIONNEMENT EN MEDICAMENTS ESSENTIELS In contrast to the other three organizations, the Association Régionale d’Approvisionnement en Médicaments Essentiels (ASRAMES) is a local NGO based in Goma, under the leadership of former MSF-H staff. It was founded in September 1993 as an association with eight members: the Association des Donneurs de Sang de Goma, Appui Médical Intégral au Kivu, Bureau Diocésain des Oeuvres Médicales, Diocèse de Goma,

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Bureau Diocésain des Oeuvres Médicales Diocèse de Butembo et Beni, Centre Scientifique et Médical de l’Université Libre de Bruxelles, the Eglise du Christ au Congo, Fondation Damien and Médicins Sans Frontières–Hollande. The office of provincial health inspection of North Kivu is its direct counterpart. Until fall 2002, its main funding organizations were the Humanitarian Aid Office of the European Union and the Dutch government.6 ASRAMES played an active part in the relief operations for the Rwandan refugees in 1994-1996. In contrast to the other three organizations that support a limited number of health zones, under its 2002 memorandum of understanding, ASRAMES was active in all 19 health zones in North Kivu, thus covering a whole province (Table 2-5). The insecurity greatly impacted its operations. Several health zones, including Pinga, Mweso, Birambizo, Manguredjipa, Rwanguba, Walikale, and Masisi, have been hard, and sometimes dangerous, to access. By the end of 2000, ASRAMES could reach only 249 health facilities. In May 2002, it was already able to supply 315 facilities, and it hoped to reach 350 health facilities by the end of February 2003. All in all, the security situation has slowly been improving. Pinga remains difficult, but a chief medical officer has recently been installed. Walikale can be reached only by air. Due to the war, ASRAMES also had to operate two separately located facilities: a head office and distribution center in Goma, which was in the Rwandan-dominated part of the province (the so-called Petit Nord), and a branch office in Musienene in the Ugandan-dominated part (the so-called Grand Nord). Originally, ASRAMES attempted to distribute its supplies from Goma only, but as the war progressed this became almost impossible. The new structure with two locations had the added advantage that the organization could never be fully looted, as once happened in 1996. Nor could it fully be destroyed by the Nyiragongo eruption. 6   Novib, a Dutch NGO that is part of the Oxfam family, is the counterpart for this funding since February 2000. It functions as a conduit for providing funding and helps with management and evaluation. UNICEF had played that role since September 1999. The Dutch government covers the operational costs of ASRAMES, which include supervision, training, distribution, and research costs.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo TABLE 2-5 ASRAMES Health Zone Summary, 2002 Health Zone Estimated Populationa Total Health Facilities Hospital Reference Health Center Health Center Total Beni 234,060 1 2 24 27 Birambizo 299,853 1 1 20 22 Butembo 198,616 1 5 18 24 Goma 218,534 2 2 21 25 Katwa 263,585 2 3 22 27 Kayna 201,086 1 4 12 17 Kirotshe 346,665 1 2 23 26 Kyondo 194,929 1 1 19 21 Lubero 208,930 1 1 16 18 Manguredjipa 111,394 1 2 8 11 Masisi 289,477 1 0 23 24 Musienene 155,698 1 1 17 19 Mutwanga 163,113 1 0 14 15 Mweso 158,874 1 0 12 13 Oicha 154,785 1 0 20 21 Pinga 125,325 1 0 23 24 Rutshuru 276,703 2 3 15 20 Rwanguba 166,699 1 1 14 16 Walikale 91,055 1 0 22 23 TOTAL 3,859,381 22 28 343 393 aExtrapolation of 1984 population census data. In other words, these numbers are estimates. ASRAMES Activities Since ASRAMES is responsible for an entire province, it cooperates with many international organizations, either with specific functional tasks or in health zones: UNICEF for the protection of mother and child (immunization program). International Committee of the Red Cross, which supports rehabilitation of health structures destroyed by war.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Health Facilities Supported Hospital Reference Health Center Health Center Total 1 0 20 21 1 1 16 18 1 5 18 24 2 0 15 17 0 2 20 22 1 3 12 16 1 2 20 23 1 1 18 20 1 1 16 18 1 1 5 7 1 0 19 20 1 1 16 18 1 2 7 10 1 0 7 8 1 0 18 19 1 0 3 4 2 3 13 18 1 1 13 15 1 0 16 17 20 23 272 315 Save the Children Fund UK, which provides nutrition and logistical support for several health facilities. Centre Scientifique et Médical de l’Université Libre de Bruxelles pour ses Activités de Coopération, which carries out institutional support in three health zones (Rutshuru, Kirotshe, and Masisi), as well as to the provincial health inspection. OXFAM UK for water and sanitation. Projet de Développement de la Santé Rurale, a program for institutional support and drugs supply in five health zones (Goma, Rwanguba, Katwa, Oicha, and Musienene).

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo World Vision International for rehabilitation of nutrition centers. Bureau Diocésain des Oeuvres Médicales, which provides institutional support to two health zones (Birambizo and Mweso). Église du Christ au Congo, an organization for institutional support to Protestant health facilities. Fondation Damien with institutional support to two health zones (Lubero and Kayna). In addition to its regular supply and other activities in its health zones, ASRAMES also delivered drugs to many international organizations active in the eastern DRC. In August 2001 and May 2002, it was invited by the health minister in Kinshasa, who wanted to use the activities of ASRAMES as an example for the DRC (or at least the parts of the country under Kinshasa’s control). The overall goal of ASRAMES is to make essential drugs available to the population of North Kivu in line with the principles of the Bamako initiative.7 The main objectives of ASRAMES are To make drugs and essential medical material available and accessible to organizations integrated in the primary health care system and humanitarian actors. To promote the rational use of essential drugs. To promote coherent management of the available resources to make essential drugs accessible. To stimulate the local production of several essential drugs. 7   In 1978, the Alma Ata Declaration set forth the goal of achieving primary health care for all. During the 1980s, the World Bank began pushing for the inclusion of national cost-sharing mechanisms, often as part of Structural Adjustment Programs. The 1987 Bamako initiative elaborated on the Alma Ata Declaration by asserting that primary health care for all would not be achieved sustainably without some form of cost recovery. The initiative encouraged donors, United Nations agencies, and NGOs to adopt a strategy of sharing recurrent costs through community financing, to generate sufficient income to cover some local operating costs, such as the essential drug supply, the salaries of some support staff, incentives for health workers, and investment of health staff and investment of community health activities. Bamako suggested that community financing should be creative and open to being based on user fees, prepayment for services, local taxes, or various income-generating activities. In addition, communities can help pay health care costs by contributing labor or making direct and in-kind contributions.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Consequently, its main activities are The provision of essential drugs and medical equipment to health organizations in North Kivu. The organization and execution of training for health professionals in North Kivu. The publication of a quarterly review of information, called ASRAMESSAGE, for the general public and health professionals, which covers rational prescription, as well as prevention and treatment of illnesses. The installation and rehabilitation of solar energy equipment for electricity generation in health structures. ASRAMES also carried out studies on the local health situation. Since it is a local NGO, it did not operate emergency programs; instead, its ongoing activities were a humanitarian adaptation of its original, more development-oriented work. Likewise, it will not withdraw after the war has ended. In addition to its local long-term presence, its contacts with all warring parties may make ASRAMES an example, perhaps even a player, for a long-term strategy for Congolese health care. Organizational Setup ASRAMES works with its own health supervisors, who are generally recruited when they already have several years of experience in supervising health care at NGOs and the zone bureau. When they go into the field, they always go together with the zone bureau supervisors for the specific health center. In 2001, these ASRAMES supervisors made 70 field visits. Of the 309 health structures that were then included in the program, 236 were visited at least once. In cooperation with zone bureau staff, the supervisors provide on-the-job training as well as supervisory control. In particular, they train the zone bureau staff. The role of the supervisors in monitoring is so strong that they are sometimes nicknamed the supersuiveurs (suivi is a French term for evaluation/follow-up). In general, ASRAMES works in close consultation with the zone bureaus and organizes quarterly meetings with the chief medical officers to discuss program developments. Box 2-1 describes a development involving changes in the fee structure used by ASRAMES, which had implications for its operations.

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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 2-1 Changes in Fee Structure The support of the Humanitarian Aid Office of the European Union (ECHO) was intended as emergency funding, until more development-oriented funding could commence again (before ASRAMES instituted its humanitarian policy with funding from ECHO, it had already received funding from the Programme d’Appui Transitoire au Secteur de la Santé, PATS). In November 2001, a consultant from the European Union (EU) suggested restarting a development-oriented approach, because of the stabilizing macroeconomy (albeit at a very low level) and improving security situation. Organizationally, this would mean working with PATS, a different, more developmental EU funding organization, and a higher level of fees in order to gradually go back to the old cost-recovery system. The association would go from Don des Médicaments to the new Bons Médicaments (good drugs), which would include a 10 FrC raise in fees. This meant that consultation fees rose from $0.50 to $0.55. This raise was meant to sensitize people to the real costs of health care and would also allow health staff to build capacity to manage increased resources from cost recovery. The ASRAMES management was apprehensive about instituting this new policy. While the macroeconomic situation might have been improving, paying bills was still a problem at the household level. Recent socioeconomic surveys by ASRAMES actually COMPARISON OF ORGANIZATIONAL APPROACHES Organizational Setup In their setup and supply of drugs and other supplies, the organizations reflect the fact that they partially take over or support the traditional role of the state health institutions in supervision and training. All organizations work with health supervisors, yet the number of visits and the size of the region they cover differ considerably. For example, the IRC has gone furthest with its supervision. Its health supervisors visit “their” health facilities at least once a week. And at least once a month, IRC supervisors visit their health centers together with the zone bureau supervisors, while Malteser operates with only two supervisors for each health

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo showed a declining ability to pay. Also, it was not clear whether the price increase would lead to more revenues, because attendance could also drop (negative price elasticity). Nor was it clear whether the new system would be efficient in terms of hidden costs for such additional tasks as reporting, administration, and handling cash (transaction costs). The small raise could also open up opportunities for corruption. The biggest risk was a decline in attendance, with its concomitant impact on morbidity and mortality. In the end, most chief medical officers actually wanted the raise in fees. They argued that any increase in resources would be useful for their functioning. At the same time, some funding organizations that prefer free health care during emergency situations, such as UNICEF, judged the price increase negatively. ASRAMES management went along with the preference of its donor and chief medical officers. It decided to initiate a pilot project with six health centers that would last eight months. If the cost recovery approach would be instituted further and if there would be funding for improving the functioning of the zone bureau, then ASRAMES would be able to transform itself to a real procurement and distribution agency. The provincial health inspection would then take over the supervisory tasks, training, health information analysis/management, transport of drugs, support to the health facilities and itself, as well as specific studies, such as socioeconomic surveys. However, PATS funding to ASRAMES is only one step in such a direction. zone. As a result, the control and on-the-job training opportunities also differ. In general, close supervision seems to be necessary to build skills and prevent corruption, but it is also cost-intensive. The health committees are a crucial participatory mechanism for improving health care. The organizations think that more care should be spent on involving them from the early stages, as well as in ongoing training. In principle, there are two poles along a continuum of management approaches toward supervision and capacity building: the intense supervision pole, which more closely resembles the IRC program, and the hands-off contract pole, which comes close to the initial 2001 Merlin proposals. The actual operations of Malteser and ASRAMES, as well as the accepted changes by Merlin, fall in between these approaches.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Organizational Strategies Although the organizations differ in the set-up of their day-to-day work, their background in health care, the conditions of war, and their dependence on donors for funding lead to important strategic similarities. They do not have elaborate strategy formulation processes at the field level; their focus on medical humanitarian tasks is strongly ingrained and does not seem to require more strategic elaboration. Moreover, the daily practice of addressing the needs of the local population and the fact that donors generally provide funding for only six months to a year tend to drive out long-range planning. All four organizations have as their central goal to save lives and relieve suffering, and they do so in quite a dynamic, entrepreneurial fashion. All four NGOs are continually seeking to expand their activities. They all responded to the Rwandan refugee crisis and increasingly started to support the local population. They also moved into more development-oriented activities. Their main strategies are Geographic expansion, as Merlin did with its operations in Lodja North and South and ASRAMES with reaching more health facilities in North Kivu. When a zone becomes more secure, it is highly likely that a humanitarian organization will move in. Diversification. While all organizations focus on health and to a lesser extent nutrition, Merlin also looks at reproductive health and the IRC at water and sanitation. Umbrella projects, such as the IRC’s Ushirika project for capacity building with local NGOs, good governance and decentralization, and micro-credit are all examples of further diversification. Deepening the scope of existing programs. Preventive programs, for example malaria projects with community education and bed nets, are a good example of this. The organizations are flexible. Due to their work in the chronic emergency of the eastern DRC, the organizations were well placed to react to the sudden, natural emergency of the volcanic eruption that destroyed parts of Goma. In essence, they extended their programs and adapted parts of their regular activities. In general, the organizations can establish themselves fast, grow rapidly and, if necessary, leave quickly. They also change their management, in terms of personnel and methods, continuously. Merlin in 2002 operated differently from Merlin in 2001.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo All the organizations are on a slow track toward a higher degree of professionalization and accountability. But none of them has an explicit organizational methodology to get there. Elements of such a methodology include Merlin’s contract approach with its local counterparts, the IRC’s quantitative goal setting, and ASRAMES’s local capacity building. Participatory programming can also be an element of such an approach. Interestingly, this professionalization coincides with the integration of more development-oriented activities into their daily work. All organizations guard their autonomy. Although they cooperate with other organizations in UN and NGO coordination meetings, they often prefer to work alone—or at least without interference of other organizations—in their health zones. Merlin does this explicitly. But the IRC has a tense relationship with FOMULAC and the same holds true for Malteser and Fondation Sud Kivu. These four complementary strategies are key aspects of organizational survival. They help the organizations adapt to the difficult operational conditions of humanitarian crises. At the same time, they provide opportunities to obtain new donor funding.