Report No. 35626-ZR Democratic Republic of Congo Health, Nutrition and Population Country Status Report May 2005 Africa Region Human Development & The Ministry of Health, Democratic Republic Of Congo Document of the World Bank Acknowledgements This Health, Nutrition and Population(HNP)Country Status Report (CSR) for the Democratic Republic of Congo (DRC) was producedintwo phases by a World Bank team ledby Eva Jarawan (Lead Health Specialist), incollaboration with a Congolese team. The first phase benefitedfrom participatory work of the national "Health and Poverty" team with the assistance of Koffi Ekanmian, World Bank Consultant, and Souleymane Sow (Senior Operations Officer). The national team assembledrepresentatives from a range of partners inthe sector, inparticular from the Ministry o f Health and the National Institute of Statistics, universities and non- governmental organizations (NGOs). The team formed working groups with the following participants: Group I(Analysis of health indicators and householdbehaviors): Messrs. Kayembe, Kuvula, Matangwa and Manunga; Group I1(Analysis o f health systemperformance): Messrs. Wangata, Kalonji, Kabanga, Komba Djeko and Kipulu; Group I11(Analysis o f Public Health Spending): Messrs: Munyanga, Makengo Maswa, KanguMuya, Kosi and Kalambay. This first phaseproduceda preliminary version of the report which was distributed and presentedby Mrs. Jarawan duringthe Round Table on HealthheldinKinshasa on May 11-12,2004. This first version was also subject of discussion duringa dissemination and validation workshop. Duringthe secondphase, in-depthanalyseswere undertakenbythe World Bankteam, onthe basis of studies, action plans, documents from the Ministryof Health, as well as reports from the National HealthInformation System. The report benefits from data from Multiple Indicator Cluster Surveys (MICS) done by the government, with the support of UNICEF, in 1995 and 2001. The analysis also relied onnumerous surveys, some on a national scale, implementedby NGOs and measuringmortality levels, trends, and determinants, as well as other healthissues. Finally, the report was enrichedby the fieldwork of Dr.Martin RCvillion (ConsultantICOWI), a large number of small-scale studies andreports by NGOs working inDRC, and the 2002 Public Expenditure Review (PER) done by the Government incollaboration with the World Bank. This document was written by Mr.PatrickMullen, World BankConsultant. Mr.Fabrice Houdart, World Bank Consultant, wrote the chapter on health sector financing, and Mr.Marc DonaldNtnC(ConsultantICOWI) wrote the chapter on organization of the health system. Mr. Krishna Rao (ConsultantlCOWI) undertook econometric analyseso f data on utilization of health services. Special thanks are addressedto Mrs.Nathalie Lopez-Diouf who followed up on the productionprocess of this report. Finally, the authors would like recognize the generous contribution o f the IDA and Danish Consultant Trust Funds for supporting consultants, andpublication and disseminationof this report. Table of Contents Summary and Conclusion 1. ............................................................................................................. ................................ 1 2. Health situation and the MDGs ........................................................... Households and communities............................................................................................. 1 3 4. 3. Health service utilization .................................................................................................... 4 5. Health system...................................................................................................................... 7 6. Public financing of health services ..................................................................................... 9 Governmenthealth sector strategy ................................................................................... 10 Introduction 1. .................................................................................................................................. ....................................................................................................................... 15 2. Background ............................................................................... 15 3. Data used and limits o f the analysis.................................................................................. Objectives and analytical framework 16 17 Chapter 1: HealthSituation andDeterminants 1. ........................................................................ 18 2. Millennium Development Goals....................................................................................... 18 3. Childmortality.................................................................................................................. 20 4. Childillness...................................................................................................................... 29 5. Reproductiveand maternal health .................................................................................... 34 Childnutrition................................................................................................................... 31 6. HIV/AIDS......................................................................................................................... ........................................................ ..................................................................... 36 8. 7. Malaria ', 37 9. Tuberculosis and others .................................................................................................... Overall mortality............................................................................................................... 38 38 Chapter 2: HealthService Utilization ........................................................................................ 1. Overall service utilization................................................................................................. 41 41 2. Hospital service utilization ............................................................................................... 43 4. 3. 44 Reproductive, maternal, and neonatal health service utilization ...................................... Childhealthandnutition service utilization.................................................................... 46 6. 5. Utilization by type ofprovider.......................................................................................... 49 7. Determinants of utilization ............................................................................................... Trends ............................................................................................................................... 50 53 Chapter 3: The HealthSystem 1. Organizationof the health system .................................................................................... .................................................................................................. 57 2. Network of health services ............................................................................................... 57 58 4. 3. Private sector .................................................................................................................... 59 61 Humanresources .............................................................................................................. Community participation .................................................................................................. Services and quality .......................................................................................................... 6. 5. 63 7. Pharmaceutical sector ....................................................................................................... 63 67 9. 8. Health information system................................................................................................ 68 10. Government strategy......................................................................................................... Important programs .......................................................................................................... 69 74 Chapter 4: Financingthe HealthSector ................................................................................... 1. 75 Financingby public andprivate enterprises ..................................................................... Public health expenditures ................................................................................................ 75 2. 79 4. 3. Financingby households .................................................................................................. External aid to the health sector........................................................................................ 79 81 References..................................................................................................................................... 87 Figures Figure 1 Socio-economic inequalities inmortality . (540) Figure 2 Utilization indicators by socio-economic status quintile. urban andrural. DRC. 2001..................25 . children. DRC..................................................................................................................... and chronic malnutritionamong under-five Figure 3. Doctors and nurses per 100.000 population. DRC 1998................................................................. -8 Figure 4. Domestic public health spending and GDP per capita (countries with GDP per capita under US$ ................................................................................................................................ Figure 5 Analytical framework reflecting the situation inthe DRC............................................................ . 1.000) 10 16 Figure 6. Indirect estimates o f under-fivemortality. DRC............................................................................ 20 Figure 7 Indirect estimates o f under-fivemortality. urban andrural areas. DRC 21 Figure 8 Indirect estimates o funder-five mortality. by regions. DRC 22 Figure 9 Indirect estimates o f under-five mortality. lowest andhighest SES quintiles. DRC ... ......................................................... ........................................ ...................... 24 Figure 10. Concentration curves for child mortality. DRC. 1995 and 2001.................................................. 26 Figure 11 ................................................................. 29 Figure 12 Trends inestimated prevalence o f child malnutrition. DRC........................................................ Figure 13. Concentration curves for under-fivechronic malnutrition(stunting). DRC. 1995 and 2001.......31 ..Reported causes o funder-five deaths. DRC. 2003-04 32 Figure 14 . "North" family model life tables impliedby under-five and crude mortality rate estimates from 39 Figure 15 Annual per capita rate o f curative consultations intwo Health Zones inProvince Orientale . different sources. DRC. 1984-2004 .................................................................................. supported by the EU. 2000-2004 ...................................................................................... 42 Figure 17. Utilization indicators by socio-economic status quintile. urbanand rural. DRC. 2001 ..............48 Figure 16. Utilization indicators by mother's educationlevel. DRC. 2001 ................................................. 50 Figure 18 Measles immunization. DRC. 2001 ("ho f children 12-23 months) 52 Figure 19 Regional differences inhealth service utilization. DRC. 2001 .................................................... ............................................ Figure 20 Trends invaccination coverage. DRC (% children 12-23 months) ............................................. 53 54 Figure 21 Concentration curves for measlesvaccination and treatment o frespiratory infection. DRC. .... 1995-2001 54 Figure 22 Physicians and nurses per 100.000population. DRC. 1998 ........................................................ 64 Figure 23 Physicians and nurses per 100.000 population. DRC. 1998 ......................................................... ........................................................ 65 Figure 24 Share o fthe healthbudget inthe total governmentbudget 76 Figure 25 Domestic public expenditure for health and GDP per capita (countries with GDP/capita < .... ......................................................................................................................... US$l.000) Figure 26 Rate o-utilization o f curative services as a hnctiono f average cost per episode. DRC. 2005 (n . ........................................................................................................................ -77 f 26) ................................................................................................................................. 83 Tables Table 1 Nutrition and health indicators and estimated numbers o fpeople affected annually. DRC Table 2 The report's discussion o f elements o f the analytical framework 17 Table 3 Health and nutrition-related MDGindicators. DRC. most recent estimates ... .................................................. ..............1 18 Table 4 Selected health-related MDGindicators. DRC and comparator countries 19 Table 5..Under-fivemortality ...................................... ................................... estimated from population-representative retrospective mortality surveys. DRC Table 6 Crude mortality and implied under-five mortality rates Table 7 Impliedunder-five mortality rates 23 Table 8 Random-effects poisson regression models o f the determinants o f mothers' reported number o f ... ................................................................................................................................. -21 (540). specific locations. DRC ..................23 (540). specific locations. DRC.................................................. Table 9 Pooledrandom-effects poisson regression model o f the determinants o f mothers' reportednumber . children dead, DRC, 2001 ................................................................................................ 26 o f children dead, DRC, 1995 and 2001 (mothers 15-34 years) ........................................ 27 Table 10. Random-effects logistic regression models o f the determinants o freported fever, respiratory infection, and diarrhea inthe previous two weeks among under-five children, DRC, 2001 Table 11 Random-effects logistic models o f the determinants o f under-fivemalnutrition, DRC, 2001 .....30 . (n= 10,254) ....................................................................................................................... Table 12. Annual rate o fnew curative consultations per capita, 2001......................................................... 33 Table 13 Annual rates o f hospital inpatients per 1,000 population and hospital bedoccupancy, 2001 . ......41 44 Table 14. Child health service utilization indicators. DRC. 2001 (%) ......................................................... 45 Table 15 Reproductive and maternal health service indicators. DRC. 2001 ("?women 15-49) ................. . 47 Table 16. Delivery attendant (% o fbirths inprevious year). DRC. 2001 Table 17 Treatment o f child with ARI symptoms. DRC. 2001 (% o f under-5 children with ARI symptoms . .................................................... 47 Table 19. Logistic regression models o fthe determinants o f curative service utilization. DRC. 2001........51 Table 18 Logistic regression models o fthe determinants o f preventive service utilization. DRC. 2001 . inprevious 2 weeks) ......................................................................................................... ....48 51 Table 20. Trends inhealth service utilization by region. DRC. 1995-2001 (%) 55 Table 21 Pooledlogistic regression model o f the determinants o f measlesvaccination. children 12-23 . .......................................... months. DRC. 1995 (n= 1.035) and 2001 (n= 2.231) 55 Table 23 Number o f HealthZones and population per Zone. DRC. 1986 and 2004 59 Table 22 Number o f inhabitants per health care facility. DRC 1998 .. .................................................... .................................. ........................................................... 59 Table 24. Availability o fhumanresources inthe health care sector. DRC.1998......................................... 64 Table 25 Physicians per 100.000 population. DRC. 1998-2003 ................................................................. Table 26 Projectedgovernment budget allocations to the health sector. DRC ........................................... Table 27 Healthsector budget byprovince. DRC. 2002 (US$ '000. unless otherwise indicated.) .............76 78 Table 29 Proportion o f cases using self-medication andproportionthat didnot receive care. DRC..........81 Table 28 Proportion o f cases not receiving care. total and for financial reasons. DRC .............................. 82 Table 30 Examples o f fees observed for health services. DRC................................................................... ...... 66 84 Summary and Conclusion SummaryandConclusion 1, The objective ofthis reportis to describeand analyzethe health, nutrition,and population situationinDemocraticRepublic of Congo (DRC) inorder to informthe Government's strategy developmentinthe sector, particularlyinthe context of itsPoverty ReductionStrategy Paper (PRSP). Thereport analyzeshealth, nutrition, andpopulation outcomes and determinants, focusing on the MillenniumDevelopment Goals (MDGs) and the health situationof the poor. Health service utilization and its determinants are assessed, and the main features o f the health system described. The policies and strategies of Government and external partners are discussed, with particular attention to the health care financing situation and its impact on the poor. 1. Healthsituationandthe MDGs 2. Health, nutrition,andpopulationoutcomes,includingthe mainsector-relatedMDG indicators, are extremely poor inDRC and havedeterioratedover the past decade. DRC is emerging from a long and destructive conflict, which followed years of economic crisis, so that it i s among the poorest countries inthe world. Over one third of under-five children are chronically malnourished(stunting), and 16% suffer from acute malnutrition (wasting), reflectingwide vulnerability to short-term crises. Retrospective mortality surveys have revealedextreme levels o f mortality among conflict-affected populations, so that it i s estimated that 3.8 million deaths can be attributedto the war since 1997. Under-fivemortality, estimated from the 2001Multiple Indicator Cluster Survey (MICS2), i s inthe range of 220 per 1,000 or greater, one o f the highest inthe world. Maternalmortality is similarly among the highestanywhere, estimated at 1,289 per 100,000 live births. The total fertility rate remains very highat 7.1. Table 1. Nutritionand health indicatorsand estimatednumbersof people affected annually, DRC ~ ~~ estimated indicator number of estimates people affected annually population2004 58,318,000 gross nationalincome (GNI) per capita 2003 (US$)' 100 under-5 malnutrition(stunting) (%) 38 4,210,560 infant mortality(,so) (per 1,000) 128 362,038 under-5mortality (sqo)(per 1,000) 220 565,101 maternalmortality (per 100,000 live births) 1,289 36,458 adult HIV prevalence(%) 4.5 1,167,818 Sources: 2004 MICS2, UNAIDS (2004),World Bank (2004) 3. Becauseof itspopulationsize andthe severity ofthe healthsituation,DRC represents an enormousconcentrationof morbidityand mortalityinthe center ofAfrica. With an estimated 58.3 million inhabitants in2004, DRC i s the thirdmost populous country in Sub- SaharanAfrica (after Nigeria and Ethiopia). It i s estimated that 4.2 millionunder-fivechildren are malnourishedinDRC, 362,000 infants die before their first birthday, over half a million under-fivechildrendie annually, 36,000 mothers die inchildbirth annually, and almost 1.2 million adults are infectedwith HIV. 1 Summary and Conclusion 4. Malaria i s the number one killer of childreninDRC. Malaria i s highly endemic inDRC. Surveys have shown that fever i s associated with 40% o f child deaths and a significant proportion o f mortality at all ages. This implies annual deaths o f 150-250,000 under-five children due to the disease. Coverage o f insecticide-treated bednets i s minimal, and parasite resistance to standard treatments i s growing. 5. HIV/AIDS andtuberculosisare majorproblems. HIV prevalence i s estimated at 4 to 5% among the general population and at least 30% among high-riskgroups. Tuberculosis incidence i s high, at 384 cases per 100,000 annually according to accepted estimates. 6. The war hasaccentuated disparities, althoughmostof the population is affectedby the poor healthsituation. Household survey data on childmortality and malnutrition show that the western part o f the country, not directly affected by the war, generally has better outcomes than the rest o f the country. Similarly health indicators are better inurban areas than inrural areas. Nevertheless, even these better-off areas experienced declines since the early 1990s and it should be notedthat their health and nutrition situation i s poor compared to overall averages inother countries. For example, the estimatedunder-five mortality rate in 1997 inurban areas was 158 per 1,000, which i s comparable to estimates for Tanzania or Ethiopia as a whole, and exceeds the overall rate for Kenya. Figure 1. Socio-economicinequalities in mortality (&) and chronic malnutritionamong under-fivechildren, DRC 300 250T 1- mortality(5qO) chronic malnutritionI 160% 50% 8 200 40% ,E ' 9 r L '$-2 f0E150 30% 5e 100 20% 50 10% 0 0% 1 2 3 4 5 quintile Authors' estimatesfrom data from 2001 MICS2. 7. The poor experiencehigher malnutritionandmortality. Fromhouseholdsurvey data, it i s estimated that under-five mortality among the poorest quintile o f households was 256 per 1,000 in 1997-98, comparedto 128per 1,000 among the highest quintile. (Figure 1) Similarly, in2001 chronic malnutrition among under-fives was 43% inthe poorest households and 19% among the better-off. However, among the lower four quintiles, disparities inthese outcomes are not so clear, suggesting a situation o f mass vulnerability. At the same time, it should be recognized that although some groups inthe population are doing better than others, the health situation o f even the better-off groups i s far from optimal. Estimatedunder-five mortality among the most well-off socio-economic quintile inDRC i s estimated for 1997 at 128 per 1,000, which, for example, exceeds the estimatedrate inKenya as a whole. 8. In this situation, achievingprogresstowardsthe MDGswill requiresignificant effort and resources. The worldwide MDGtargets are expressed as reductions inmalnutrition and 2 Summary and Conclusion mortality as a proportion of 1990levels. DRC has not only lost the decade o f the 199Os, but has gone backwards towards, for example, mortality and life expectancy levels last experienced inthe 1950s and 60s. Although there is evidence that mortality inparticular may be improvingas peace i s consolidated, reversingthis situation will depend on, first of all, political and economic stability, but also significant focus and investment 2. Householdsandcommunities 9. Important household-level determinants of health and nutrition outcomes are mothers' education, and behaviors such as breastfeeding, sexual practices, and contraceptive use. Except for fever incidence (which largely depends on the epidemiological patternof malaria), most of the various multivariate models of the determinants o f a number of healthoutcomes (childmortality, malnutrition, diarrhea, andrespiratoryinfection) show that children ofmothers with any education are at lower risk-even after controlling for socio-economic status. This is consistent with findings inmany other countries, and can be explained by better-educated mothers havingbetter knowledge o fpreventivehealthpractices and beingmore likely to take a sick child to a trained healthprovider. InDRC, a majority of mothers (72%) have received at least some education, but the proportion i s considerably lower inrural areas (62%) than inurban areas (91%). These somewhat encouraging statistics are tempered by the estimate that current gross enrolment rates inprimary school are around 65%, consistent with other poor countries in Sub-SaharanAfrica. 10. Exclusivebreastfeeding is a crucial determinant o f infant and childhealth andnutritionas well as child development. While almost all children arebreastfedto an extent, only around a quarter are exclusively breastfed duringtheir first six months of life, and this rate has been decreasing over time. Among other practices with a important impact on healthare modem contraceptive use, which i s low at 4.4%, andrisky sexual behavior. 11. Poverty, affecting the mass of the population, clearly undermineshealth and nutrition status. For all the health andnutrition outcomes analyzed (except fever incidence), there are clear and large differences between the poorest and the most well-off. The various regression models show socio-economic status as a consistent determinant of health outcomes. For example, controlling for a variety of other factors, children from households inthe highest quintile are around 0.7 times less likely to have respiratory infections or diarrhea. However, such associations are not as evident over the lower ranges of household economic status, indicating that the mass of the population i s at a similar level of poverty and suffers similarly from poor health and nutrition. However, it i s evident that increasing inequality i s a large risk as the country's economy grows inthe coming years. 12. Very important among community-level - contextual-factors, the conflict since 1997 has caused severe increases inmortality and deterioration inother health and nutrition outcomes. Extreme levels of mortality have been measured among conflict-affected populations, while mortality was also observed to increase inother parts of the country not directly affectedby fighting. Data show that most deaths were not directly due to violence butrelatedto the disruption of the economy and society and deterioration of household coping mechanisms. The direct and indirect effects of the conflict on health and nutrition worked through many mechanisms, includingits impact on household resources, on the health system, on other sectors, and on Government action and finances -includingthe health system 13. Empiricalevidence for the effects of the conflict on nutrition and health outcomes can be readily seen in time trends and geographic patterns at both national and regional levels. A regression model found that, controlling for avariety of other factors includingsocio-economic status, children inthe Center and East of the country were far more likely to be chronically 3 Summary and Conclusion malnourishedthan children inthe western Provinces.' Surveys among particular war-affected populations revealed sometimes extreme levels o f mortality, while a regression model indicates that, other important factors held equal, the risko f child mortality in2001 was significantly greater inthe Center and East than inthe West. Withregardto trends, household survey data indicate that chronic childmalnutrition increasedbetween 1995 and 2001inthe East o f the country while remaining stable or declining elsewhere. Retrospective mortality surveys showed increased mortality coinciding with the most intense periods o f the conflict, with the largest increases concentrated inthe Center and Eastern parts o f the country, most directly-affectedby the war. 14. There is evidence that the conflict decreased the importance to health of socio-economic factors such as education and household economic status, but increased the importance of access to healthservices. Regression models o f child mortality data from household surveys in 1995 and 2001 indicate that the protective effects o f mother's education and householdeconomic status lessened over time, suggesting that the conflict affected wide swathes o f the population regardless o ftheir socio-economic status. However, the analyses suggest that the positive effects o f access to health services may been accentuated over time, particularly inthe regons most affected by the war. This i s encouraging evidence that health services make a difference insuch situations. 3. Health service utilization 15. At the householdlevel, utilization of basic child health services is low overall. Ingeneral, utilization o f preventive health interventionsfor children i s low. In2001, only 50% o f one-year- olds were vaccinated against measles and BCG, only 11.5% o f under-fivesrecently received vitamin A supplementation, and only 0.7% o f under-fives slept under an insecticide-impregnated bednet. Similarly, utilization o f primary curative interventions is low. Various sources o f information indicate that the per capita rate o f curative consultations inmany areas i s 0.20 or less, compared to around 0.60 observed inthe 1980s. In2001, only a third of children with respiratory infections and half o f children with fever receivedtreatment by a health provider. 16. With the exception of antenatal care, reproductiveand maternal health service utilization is low. Utilization o f family planning services i s very low, with modem contraceptive prevalence at 4.4%. Although utilization o f antenatal care from medical personnel i s relatively highat 65.7%. Delivery care bya medicalprovider is muchlower, at 32.0% inurbanareas, 20.2% inrural areas and 23.7% overall in2001. Although information i s not available on utilization o f emergency obstetric care -the main determinant o f maternal mortality - it i s known that geographic and financial accessibility and quality are significant problems inDRC. For example, a study o f data from two rural hospitals concluded that only 3% o f potential complicated births arrived at the referral facilities. 17. Nevertheless, many people do not access services, particularly the poorest. Inboth urban and rural areas, the 2001MICS2 found that 40-45% o f children with respiratory infections do not receive treatment, and about 25% seek medication from drug sellers or others. A number o f more recent smaller studies have found that 50-60% o fpeople who are illdo not go to a formal health provider; they prefer to either not seek treatment or to self-medicate. Ingeneral ,up to two- thirdso f cases do not go to the formal health system for care. 1For the purposes o f this report Provinces are grouped as follows: West (Bas-Congo, Kinshasa, and Bandundu), Center (Equateur, Kasai-Oriental, Kasai-Occidental, and Katanga), and East (Province- Orientale, Maniema, Nord-Kim, and Sud-Kivu). 4 Summary and Conclusion 18. The poorestare significantlyless likely to use basic health services. Inboth urban and rural areas o f DRC, utilization o f basic health services steadily decreases with lower socio- economic status. (Figure 2) For example, inbothurban and rural areas, around 15% o f mothers from the poorest quintile received delivery care from medical staff, compared to around45% in the highest quintile. Similarly, inurban areas, 34% o f febrile children from households inthe poorest quintile are likely to be treated, compared to 66% among the highest quintile. The proportions inrural areas are 29% and 37% respectively. Regression models show that . comparing each quintile to the next higher one, children inthe higher quintile are 1.2 to 1.4 times more likely to be vaccinated against measles and to receive medical care incases o f fever or respiratory infection. 19. Financialbarriers are one of the main reasonsfor low utilizationof services amongthe poor. L o w coverage and insufficient inputsand quality have reducedoverall service utilization, butthe poor are more affecteddue to the financial barriersrelatedto the lack o fpublic funding for the system. Unlike with health outcomes, elasticity of service utilization i s evident over the entire socio-economic scale, suggesting that demand i s dependent to a considerable extent on financial factors. A number o f smaller surveys have found that 10-20% o f people requiring care do not receive treatment due to financial reasons. Similarly, trend data inspecific Health Zones show that utilization can increase significantly when consultation fees and drug prices are reduced (and quality increased) under external assistance programs. Figure 2. Utilizationindicators by socio-economic status quintile, urbanand rural, DRC, 2001 measles 80% , urban vaccination 80% rural measles vaccination i 70% 4 70% $1 60% icaI 60% treatment /imedical ,*.c of fever 50% delivery care 10% 10% 0% 1 0% 1 2 3 4 5 1 2 3 4 5 quintile quintile Authors' estimates with data from 2001 MICS2. 20. The cost of health services can have impoverishingeffects. Inthe absence o f Government and external funding, the main burden of financing health services has been left to households. Given the level o f poverty inthe country, this burden cannot be sustained by many households, so they choose to either not seek care, to obtain cheaper treatments fromnon-formal providers, or to further impoverishthemselves. For example, a 2003 study inNord-Kivu found that inorder to pay medical bills, 24% o f patients sold assets and 18% went into debt. 21. Mothers' educationis an important determinant of health service utilization, particularly in urban areasand particularly preventivecare. Inurban areas, utilization o f health services, particularly preventive interventions, increases with each year o f mothers' schooling, but the association i s not as clear inrural areas- suggesting that lack o f service accessibility inrural areas (both geographic and financial) may affect both the educated and non- educated. Regression models indicate that mothers with any amount o f education are more likely 5 Summary and Conclusion to have receivedmedical delivery care and to have children who are vaccinated against measles. However, after controlling for socio-economic status inparticular, such an advantage i s not evident withregardto basic curative care for children - again suggesting that service availability may be the issue. 22. Residentsof ruralareas are less likely to utilize health services, both becausethey are poorer and because of less service availability. In2001, measles immunization coverage o f one-year-old children was 65% inurban areas, but only 40% inrural areas. Similarly, delivery care by a medical professional was 32% inurban areas and only 20% inrural areas. Regression models controlling for socio-economic status show that service utilization i s considerably more likely inurban areas, probably reflecting greater availability o f services. For example, a child with fever is 1.4times more likely to receivemedicaltreatment inan urbanarea. 23. Regionaldifferencesin service utilization are not as evident as with healthoutcomes. There are clear regional differences inmeasles immunization coverage betweenregions, particularly inrural areas, with children inthe western Provinces more likely to be vaccinated. However, disparities inutilization o f other types o f services are not as evident. Except for measles immunization, the various regressionmodels o f determinants o futilization indicators do not show significant effects associated with region. 24. The limited availabletrend data indicatethat between1995 and 2001, utilization of basic curativeservices declinedoverall,while coverage of some preventiveinterventions remainedstable or slightly improved. Trend data on curative care services is limited; however, it i s estimated that in 1995, around55% o f children with respiratory infections receivedmedical care, and this declined to an estimate o f 48% in2001. Evidence on trends incoverage o f basic preventive services i s more positive, as measles immunization coverage increased from 32% to 48%, and antenatal care coverage remained stable at around 63%. 25. I t seems that declines in utilization of curativecare occurred in all regions, but improvementsinchild immunizationinparticular were concentratedinthe Center and East of the country. For example, the proportion o fchildren with respiratory infections who receivedtreatment decreased fiom 58% to 50% inthe West, from 52% to 42% inthe Center, and from 60% to 52% inthe East. However, while measles immunization coverage remained stable inthe West at around 55%, itincreasedsignificantly inthe Center andEast, from around25% to 40-50%. The reasons for these patterns are unlaown. Perhaps the humanitarianresponse to the conflict inthe Center and East was successful inraising immunization rates through mass campaigns, but had less effect on curative services. 26. Nevertheless,data on utilization and patient perceptionsindicatethat the demandfor formal sector healthservices runby Government, churches and NGOsis important, providing a goodbasis for developmentof the system. Household survey data indicate that 40% o f children with respiratory infections inurban areas and 30% inrural areas receive care from public or confessional health services. The proportion treated inhospitals (15% inurban areas and 2% inrural areas) i s relatively low, indicatingthat contrary to what can be observed in other countries, the referral system i s not bypassed (although this may be due to a lack or deficiencies inhospital services). These data indicate that the public primary health care system can attract a significant proportion o f the demand for care. At the same time, data on user opinions about service quality, particularly inurban areas, suggest relatively good perceptions (except with regardto the cost o f services). A 2004 survey innine provinces found that 80% o f patients who went to a hospital were satisfied or very satisfied with their treatment. 27. The patternsin utilization discussedabove reflect not only demandbut also supply factors, particularly service coverage, quality, and cost. Higher utilization inurbanareas reflects better service coverage and perhaps also better quality. Regional differences inservice 6 Summary and Conclusion utilization are not as evident, although the western Provinces seem to be better-off than the rest o f the country. Socio-economic differences inservice utilization are clear, and certainly reflect financial barriers to care, but also likely differences inservice availability betweenpoorer and better-offpopulations. 4. Health system 28. The organizationof the health systemis decentralized,with primary and first-referral services integratedin Health Zones. Inthe 1980s, the country was a leader inreforms which focused on integratedprimary with first-referral services on the Health Zone model. Much o fthe thrust o f development o f the system was on improving the functionality o f the Health Zones. Each Health Zone i s responsible for primary and referral care among a catchment population o f on average 110,000. The number o f Zones was increased by the Government in2001 from 306 to 5 15. Above the Health Zone inthe administrative hierarchy are Districts, Provinces, and the Ministryo fHealthheadquartersinKinshasa. Exceptfor their responsibilities for provincial and tertiary hospitals, the roles o f these levels are not operational but focused on overall policy- setting, supervision, and regulation. 29. Health Zones and individualfacilities operatewith considerableautonomy, although Ministry structures have retained a certain administrativecontrol, particularly over personnel. Lack o f Government fundingover the past decade has leadto significant autonomy for Health Zones and individual facilities. Inthe absence o f external support, many facilities became defacto privatized, relying exclusively on receipts from patients inorder to pay staff and operating costs. Hospitals inthe major cities operate with almost complete autonomy. Inmany cases, the oversight function o f Ministryo f Health structures became only exercises inextraction o frevenue from health facilities. Recently, with improvements inthe Government's administrationand funding, intermediate and central levels exercise more influence, particularly over personnel issues. 30. The Health Zone structureprovidesa goodbasis for recoveryand development of the system. Economic and social crisis and subsequent conflict inthe 1990s severely undermined service delivery, but inmany cases Health Zone structures showed remarkableresilience. In many areas, these structures -physical infrastructure and staff -remain inplace even though at very low levels o f functionality. Recognizing this, external humanitarianand development assistance has been anchored inthe existing service-delivery system. 31. The Governmenthaslongexperiencewith public-privatepartnerships,particularly with churchgroups and NGOs, while the for-profit sector is limited. It is estimated that a thirdo fthe healthfacilities inthe country are operatedby church groups who havetraditionally worked inpartnership with Ministry o f Health structures. For example, the reference hospital o f many Health Zones i s a church-run facility. This experience has facilitated more recently- established partnerships with internationalnon-governmental organizations (NGOs) which are implementingassistance programs, particularly at the Health Zone level. Along with the decentralized Health Zone model, this experience with integratingnon-governmentalactors provides a good foundation for reconstructiono fthe service delivery system. 32. Inthe past, parastatal companies, such as transport and miningconcerns, operated significant health services, but little remains o f this system. Formal for-profit private providers are limitedto small clinics and maternities inthe major cities. Informal providers, inparticular drug sellers, are common inmany urban and rural areas. 33. Although administrativedata is out-of-date, it is clear that geographiccoverage is insufficientand deterioratedover the past decade. The Government's recent creation o f over 7 200 a ~ ~ ~HealthoZones \bas prrmarily a strategy to increase ~ e o ~ a coveragecof refenat ~ i n p ~ ~ sermces, since each EfeatthZone is to have a referral ~ospital,This is unders~~~i~ab~ethe -grJ*cn ~eograph~candpo~u~at~onofm size of the Zones, a largeproportionof thc p o ~ ~ I ~ ~ ~ ~ n areas do not live within reach of a h facility, Xn ~ q u a ~ efor~example, physical acces ~ r , rvices varies widely; reccnt surveys found that in ~ a s ~ n42,7?4of h o ~ s ~ l i o~iecdto k ~ s ~ l d ~ tvak over eight hours to reacha healthfacility, nhile inBefale and ~ o l o thc ~ ~ m propo~~o~is are 21.2% and J.b%,respectively. 34. The availableinventoryof facilities dates from 1998,so docs nor reflect d c ~ e ~ ~ ~ofr thet ~ o ~ a system since then, p a ~ i ~ ~ linathe~~y~ ~ a r ~ a fparts~ofthe country, where a s i ~ i f ~ c a ~ t r f e ~ e d p r ~ } p # ~ofohealth servrce i ~ f r a s ~ ~is~no~longeref~nc~yonal~ ~ n c ~ r IIealthserviceswereoften targets of .vroIcnccand looting. Even in 1998, population-ro-~~~iIityratios were high. There 'it'ss one reference h o s p ~ ~for~~ ~ 0 , people inurbanareas and for 1~ a 0 0 ~ 0peopleInrural areas. ~ , ~ ~ The officiai noms are ~ 5 ~ , arid ~ 0 0 1~~~~~~in urban andrural areas res~ecti~~el~.Sintitarly, in 1998 there was reportedto he one healthcenter per I~ ~ ~p,~0p u# ~~~ ~urban~areas and ~ in i o i ~ , ~ 0 ~ inrural areas, compared IO noms ~ f and 15,000 respectxvely. ~These ratios are ~ ~ ~ 0 ~ ~ ~ ~ ~higher than othern~ ot ~l nin~S~b~Sahar~n ~ ~ a ~ ~ e s Africa. Doctas Nurses JS. ~ ~ ~ ~health personnelare lacking~in numbersand quality, p a r ~ ~in~ u ~ ~ r ~ ~ e ~ - ~ ~ I I ~ ~ ruralareas. Data onhealthpersonnel are Incomplete,but indicatelaw numbers of' highcrcadres of healthpersonnel. In 1998, there \vere around 2,000 doctorsreported to be worktng in the country, for a ratio of p h ~ ~ sper~~0~,000~ j ~ ~ npopul~~i~na r ~3,6,naniongshe lo\best inrhe o ~ ~ d world. Nurses are incompara~jbelygre r supply, as there u'crc 27,000 in 1998, for a ratio of around 50 per ~~~,~~~ pop~lat~on. This is low, even thoug ot the very lo\vest inthe world. The official nornzsinDRCare I O phy~~ciansand 20 nurse r 1 ~ 0 , po~ula~~on, ~ 0 ~ 36. Training i n f r a s ~ ~ c tis~ tiieplace; there arc scvcral mcdicalschoolsand dozcns of tee r training schools for nursesandother ~ e ~ h nspdff.a ~However,likethe rest ofthe.systcm, lack of ~ c ~ u n dandnsupport has severely c o ~ ~ p r o ~thesquality o ~ ~ a Data~ the skills and ~ ~ i ~ d ~ on ~ n ~ . Summary and Conclusion quality o f healthpersonnel are not available, although anecdotal evidence suggests that the need for in-service training i s significant. 37. Humanresourcesare concentratedinKinshasa,butinfrastructurehas not keptpace with populationgrowthinthe city. For example, the data from 1998indicatethat the ratio of physicians to 100,000 populationinKinshasa i s over 10, but less than 2 inthe rest o f the country. However, it seems that infrastructure has not kept pace with population growth inthe capital city, as population to facility ratios inKinshasa are worse than inother Provinces. 38. Drugsupply is fragmentedand inefficientalthoughthere are recent efforts to develop regionaldistributioncenters. Like other aspectsofthe system, the withdrawal of Government support inthe 1990sleft Health Zones and individual facilities with independent responsibility for drugprocurement. This resultedinconsiderable inefficiencies of scale and lack o f quality control, as service providers purchased drugs from a wide range o f private sellers. Inmany parts of the country, suppliers are few and costly. At present, a network o fregional procurement and distribution centers i s being developed, although inmany cases service providers continue to purchase from private sources which have lower prices due to an absence of quality control. 39. Other sectors-particularlyeducation,water, sanitation,food security, andtransport- have an importantimpacton healthand nutrition. This report focuses onthe healthsector, butit isrecognizedthat other sectors canhave a considerable impact onhealthandnutrition outcomes. The clear protective effects of mother's education are discussedabove. Regression models of the determinants of mortality, morbidity andmalnutrition didnotreveal clear effects o f safe water and adequate sanitation, but it i s well-known that such access i s essential for good hygiene and health. Malnutrition is largely determinedby factors outside the health sector affectinghousehold food security, including economic and agricultural conditions and social protectionmechanisms. Another important sector i s transport. The lack ofroads and means o f transportation inmany parts of the country exacerbatethe poor geographic coverage o f the health system, particularly referralservices. This has an impact, inparticular, on maternal andneonatal mortality, the prevention of whichrequires accessible and timely delivery and emergency obstetric care. A study o ftwo hospitals inNord-Kivu found that women living more than 90 minuteswalk away were at increasedriskofobstetric complicationsandneonatalmortality. Although health services provide an important lever for working to improve the health-related MDGs, improvement will also dependonprogress inthese sectors, as well as overall economic and political development. 5. Publicfinancingof healthservices 40. Insufficientpublicfunding over the pastdecadeledto deteriorationof the healthsystem andleftto householdsalmostthe entire burdenof financinghealthservices. Inthe 1980s, the country was an innovator inhealth sector reforms, focusing onprimary healthcare (PHC), integration of referral systems, and decentralization. The development of HealthZones, which integrate PHC and first-referral services under a decentralized administrative structure, represented a partnership between the Government (which was to finance recurrent costs, particularly salaries), the population (which was to largely finance drugs, throughrevolving drug funds), and external donors (who were to finance investment). Thispartnership broke down in the early 1990swith severe cuts inGovernment fundingand withdrawal o fexternal aid, leaving households with the mainburdenof financing services. Health facility staffraiseduser fees and drugprices inorder to finance their remuneration. Financialbarriers to care (along with deteriorating quality) caused service utilizationto plunge, particularly by the poorest. 41. Government healthbudgetshaveincreased,but actual executionlags behind. The Government's 2002 IPRSP contains a commitment to allocate at least 15%of the national budget 9 Summary and Conclusion to the health sector. The proportion allocated to health inthe Governmentbudget has indeed dramatically risen from less than 2% in2002 to over 7% in2004. However, only a portion o f these budgets have been executed; in2004, estimated spending was aroundU S 2 5 million, compared to the over US$SO millionbudgeted. Equivalent to aroundUS$0.40 per capita, this level o f domestic public spending on health i s among the lowest inthe world. (Figure 4) Figure 4. Domesticpublic health spending and GDP per capita (countrieswith GDP per capita under US$ 1,000) 45 1 a # 5 c3 .-0 25 I 1 E 20 2 il5 n Bm 0 0 100 200 300 400 500 600 700 800 900 1000 per capita GDP2000 ($US) Authors' estimatesfrom WHO and World Bank data. 42. Nevertheless, increased external support in the coming years, combined with better Government financing, should go some way towards meeting the requirements for achieving progress on the MDGs. It i s anticipated the external assistance to the health sector could exceed U S 2 0 0 million annually inthe coming years. Combined with increased Government spending, total public spending on health could reach US$4 per capita annually. Although this i s some distance from estimates o fU S 1 6 per capita neededto reachthe MDGs in other countries inthe region, itprovides a good start, particularly since the bulkofresources are focused on basic services which address the most important causes o f morbidity and mortality. Nevertheless, it i s clear that even with highrates o f economic growth, significant donor assistance will be requiredto sustain progress over the longterm. 6. Government health sector strategy 43. The Government's overall objectives inthe sector are to increase access to primary health care services and control priority diseases. The Government's strategy inthe health sector i s outlined inits 2002 Interim Poverty Reduction Strategy Paper (IPRSP), which sets the overall objective o f increasing access by the poor to primary health care. To achieve this goal, the IPRSP emphasizes development o f Health Zones, particularly inrural areas, and supporting disease-specific interventions. Programs to address HIV/AIDS,tuberculosis, malaria, reproductive health, and vaccination, are outlined. 44. External partners support the Government's sector strategy. Much external assistance to the sector, even under humanitarianprograms, i s inthe form o f support to basic service delivery 10 Summary and Conclusion through the existingstructures of the Health Zones. At the same time, a considerable proportion of anticipated external assistancewill focus on priority diseases. These are two mainpillars of the Government's strategy inthe sector. 45. The focus of Governmentand externalpartners on basic healthcare services responds to the enormous health needsofthe population. Analysis ofthe health situationmakes clear that the DRC population suffers from an enormous burdeno f morbidity and mortality from causes which can be preventedand treated at the primary and first-referral levels. The focus of the Government and external donors on basic health services i s entirely appropriate, given that, for example, most childmortality i s relatedto malaria, respiratory infection, diarrhea, and malnutrition-all of which can be addressedat the community and primary service levels. 46. Overall, Government strategy and policyprovide a good foundationfor further developmentof the system. The Government's emphasis on decentralized service delivery through the Health Zones and its embrace of partnerships with church groups and NGOs are important advantagesfor reconstructionand development. Inparticular, these elements are entry- points for external assistanceto the sector, with the Health Zone structure andnon-governmental actors well-adapted to channeling resourcesto improve basic service delivery. 47. Functions o fthe different structures of the HealthZone are well-defined, and essential packageso fprimary and first-referral services reflect the epidemiological situation and follow internationalbest practice. The health information systemhas also beenwell-designed, focusing on a limitedset o f basic data, althoughthere are significant gaps inimplementation. 48. Large gaps remain, with Governmentand donor support unevenly coveringthe population. Upto a third of the populationlives inHealthZones that receive little or no external support, either from the central Government (except for wages insome cases) or from internationaldonors. Health service quality and utilization therefore remain very low, and the serious health situation unchanged. At the same time, support provided to HealthZones varies widely, with donor assistanceranging from $US0.70 to $US5.00 per capita. Although these disparities inmany cases respond to differing needs, particularly with regardto humanitarian programs, they more often than not reflect the fundinglevels, priorities, and modalities of individual donors. As the Ministryo f Health's policy and coordination capacity develops, with the cooperation of donors it needs to take more o f a lead inimproving the coherence o f external assistance. 49. As needs are increasinglymet among the rural poor, attention shouldbe turnedto urban areas. First,although better than inrural areas, the health situation inurban areas of DRC i s poor by any standard. For example, the estimated under-five mortality rate in 1997 inurbanareas was 158 per 1,000, which i s comparable to estimates for Tanzania or Ethiopia as a whole, and exceeds the estimated rate for Kenya. Second, the size ofthe poor populationinurbanareas is large and expanding. Kinshasa, where urbanpoverty is significant, represents at least 12% o f the country's population. Consistent with this, current support to the sector includesassistanceto urban Health Zones. 50. Current support to basic services largelyfocuses on primary healthcare facilities, often neglectingdemandfactors, community-basedapproaches, and ruralreference hospitals. First, primary among the demand factors affecting utilization are financial barriers to care. Although for the most part humanitarianprograms address this by reducing user fees and highly- subsidizing drugs, most development programs have not grappled directly with the problem, which i s o f course closely tiedto their levels of funding. Uniform strategy and policy may not be possible, nor even desirable given the vastly different contexts inthe country, but further study, coordination, and discussion are clearly needed. 11 Summay and Conclusion 5 1. Second, althoughpolicy on community health workers i s inplace, this service delivery strategy needs to be better understood and then reinforcedinorder to reachpopulations who have poor geographic access to health facilities. Experience inother countries indicates that strengthening o f community health interventions should go hand-in-hand with overall support to the primary health care system. Strategies for bringingcurative care closer to the population- treatment o frespiratory infectionsmay be an example - should be tested. 52. Third, the rural reference hospital i s the anchor for the HealthZone, providing referral services as well as supervisory and technical support to the network o f PHC facilities. This i s the key strength o fthe integrated Health Zone system. However, current assistance to Health Zones usually includes only limited support to first-referral services, often relating to obstetrics and blood transfusion. First,the cost o f providing more extensive recurrent and investment support to existing structures i s daunting. Second, the recent expansion o f the number o f Health Zones implies a significant and costly expansion inthe hospital network, since each Health Zone i s to have a referral facility. Nevertheless, as primary health care i s improved inthe coming years, work should started on addressingthe needs o f these front-line rural hospitals. 53. A large proportion of increasedexternalsupportwill take the form of disease-specific programs, raisingthe riskof further verticalizationof the system. Inthe past, a plethora o f disease and issue-specific departments and programs have developed within the Ministryo f Health, often with the impetus o f external financing. Inthe coming years, a thirdor more o f annual external assistance to the sector could be tied to programs addressing specific diseases, HIV/AIDS and malaria inparticular. There i s a need to forestall fragmentation at boththe central and service delivery levels. Rationalization o f the Ministrystructure as well as effective coordination among the Ministry and external partners are required. Duplicate management, procurement, and information and reporting mechanisms shouldbe forestalled at the central level, while material and staff resource imbalances and inefficiencies at the service delivery level need to be avoided. This requires both leadership from the Ministry and flexibility on the part o f external donors. Ideally, the role of disease-specific programs shouldbe as sources o fnecessary inputsandtechnical guidance, leavingthe details o f implementationto the HealthZones. 54. At the same time as supportingbasic health servicesto address the urgent needsof the population, progressivelymore attention and resources should be devotedto developingthe capacities of the system. At present, external support to HealthZones provides resources through NGOs inorder to revive basic health services so that the urgent needs o fthe population are addressed. However, as progress i s made, progressively more attention to improving the longer-term capacity o f the health system i s needed. Health Zone and District authorities need to be more fully involved inallocation and management decisions inorder to improve their ownership as well as develop their capacity inthese areas. Budgeting, financial management, and personnel management, are particular areas inneed o f capacity building. At the same time, more focus on developingthe technical skills o f front-line staff i s neededthrough increased training and technical assistance. Inrecent years, some donors have supported capacity-building at the central level, but this similarly needs increased attention, particularly to improve the Ministry's leadership and coordinationroles. 55. Knowledgeand strategy developmenton health human resources is needed. Policy and strategy inthe pharmaceutical area i s advancing - and drug supply i s mentioned several times in the IPRSP -but little attention has been given to the other key input, healthhuman resources. It i s increasingly recognizedthe humanresources are a key constraint to improving and scaling up basic health services inorder to achieve progress towards the MDGs inSub-Saharan Africa. A variety o f issues are involved, including civil service and salary reform, public-private partnership, training resources, quality and production, the skill-mix o f the health workforce, and 12 Summary and Conclusion the health labor market and incentives. Better understanding o f such issues i s a prerequisite to effective strategy development inthe area. 56. Wage levels are a crucial issue relatedto humanresource strategy as well as the Government's overall civil service reform and fiscal decentralization plans. Most domestic public health spending i s for wages, and the Government seems to have made progress recently in improving their regular payment. However, the level o f health sector wages i s universally recognizedas too low, so that many health staff are more dependent on supplements provided through external assistance programs than on their official salaries. Developing strategy on wage levels inthe sector needs to be part o f work on overall human resource strategy, part o f the medium-term strategy and costing for the sector as a whole, as well as linked to Government- wide efforts on civil service reform and fiscal decentralization. Reanimating the centralized healthpersonnel system from the past may be an option, but Government should also consider innovative strategic options, for example buildingon the current autonomy o f Health Zones and facilities and on public-private partnerships. 57. Learning and policywork is needed on the healthsector's placeinthe Government's decentralizationstrategy. This question concerns the place ofthe health sector inthe Government's current plans for fiscal decentralization, which envision a large centralrole in personnel issues and salary payment, combined with block transfers to decentralized administrations to meet their social service delivery responsibilities. Strategic decisions for the health sector include the extent to which the center should retaincontrol over day-to-day personnel management and salary issues, as well as the extent to which the central level should have control and be directive on the transfers to decentralized structures. A first useful step could be to learn about the decentralization experiences o f other countries. 58. There are requirementsfor developingknowledge,policy, and capacityin a number of other areas related to healthcarefinancing. Numerous issues relatedto healthcare financing require attention: i)Betterunderstandingofpublicfinancingflowsandmechanismsisrequiredinorderto understand and address the current bottlenecks. A related issue i s the development o f strategic and operational coordination between the Ministryo f Health and the Public Service and Finance Ministries. ii)Capacityatalllevelsrelatingtofinancingshouldbedeveloped: atthecentraland intermediate levels, this relates to overall budgeting and management o fpublic resources, while at the service delivery level, basic budgeting and accounting capacity i s required. iii)Exemptionschemesforthepoor mentionedasapriorityinthePRSP-areaparticular - area that requires attention. iv) Analytical work on community financing schemes is currently being done by an external partner and results should inform Government strategy and policy. v) Better data on household out-of-pocket payments is necessary inorder to address this key barrier to service utilization. 59. Finally, inter-sectoralcoordinationi s essentialto achievingsignificantprogresstowards the MDGs. The need for coordinationbetween sectors i s often recognizedbutrarely achieved. InDRC, three sectors inparticularare keyto improving the healthsituation -education, water, and transport. The importance o f mother's education has been repeatedly shown inthe analysis, and this points to not only the role o f primary education but also to the necessity o f improving health education at the community level. Inaddition, the technical and university education sector i s crucial to healthhumanresource strategy and longer-termdevelopment o f the system. 13 Summary and Conclusion Safe water supply, lacking inmany urban and rural areas, i s essential to child health inparticular. Lack o f roads and transport exacerbates the already poor geographical coverage of the health system, having a severe impact on maternalmortality inparticular, where delay inreaching emergency obstetric care i s fatal. Boththe Government and external partners have a role in improving inter-sectoral coordination. A good example inthis area i s the World Bank's Emergency Multisector Rehabilitation and Reconstruction Project which centers support to education, health and other sectors along the reconstruction o fRoute Nationale 1. The benefits o f coordinated geographic targeting shouldbe hlly exploited at the same time as improving strategic coordination at the policy level. 14 Introduction Introduction 1. Background 1. After a decade of armed conflict and political instability inthe Democratic Republic o f Congo (DRC), a peace and reconstructionprocess hasbeen underway since 2002. However, the precedingwar and decades ofpoor management have contributedto the impoverishment o f one o f Africa's potentially richest countries. Eightypercent of its population lives on only US$0.50 per day and the Gross Domestic Product (GDP), at less than US$lOO, is among the lowest inthe world. With a populationof nearly 60 million, the DRC represents an enormous concentration o f extreme poverty inthe middle o f the African continent. The scope of the need, as well as the devastation throughout the DRC, therefore present areal challenge for the Government and the international community, which have triedto mount a responseover the past few years. 2. The economic fallout of the conflict, the instability o f the macroeconomic framework, and the decline innational production, have affected householdpurchasing power. Per capita GDP fell from US$307 in 1970 to US$167 in 1992, and then to US$96 in2002, one of the lowest levels in the world. 3. The effects ofthe recent conflict onthe Congolese populationwere extreme, and included excessmortality estimated at over 3.8 million lives and the displacement of 2.7 millionpeople over the 1997-2004 period. 4. The low level of social indicators, particularly for health, i s indicative of the conflict's catastrophic impact on the living conditions o f the population, and particularly on those o f the poor and vulnerable. Life expectancy, which stood at 52.4 years in 1994, had fallen to 45 years or less by 2004. Infant, child, and maternal mortality rates rose duringthe 199Os, and are well above the averages for Sub-SaharanAfrica. Diseases, including inparticular malaria, malnutrition, and the HIV/AIDS epidemic, further compromise the health status o f households. 5. Government services, and particularly social services andbasic social infrastructures, gradually collapsed as the Statebudget inthese sectors reached its lowest level inthe country's history. 6. Livingconditions inthe country vary widely depending on the province andplace of residence. Ofthe 11provinces, those located along the former combat front (i.e., Orientale, Kasai' Occidental, Kasai' Orientale, Katanga) have suffered greatly, while some easternparts o f the country, e.g., NordKivu, SudKivuand Maniema, are still very unsafe and inthe throes o f a humanitarian crisis. The provinces of Bandundu and Equateur have specific problems associated with their remoteness. Kinshasa, the administrativeand political capital, and Bas-Congo, are somewhat less poor but have large populationsthat are vulnerable to economic instability. 7. Inaddition, wide disparities exist within these provinces between rural areas and the more privilegedurbanmilieu. Conditions are particularly dire inconflict-ridden or inaccessible areas, where the interventions of the State and external partners have not yet penetrated. 8. Since 2002, the political situationhas improved significantly due to: i)the establishment o f a government of national union; ii)the reunification of the national territory; and iii)a plan for making the transition to democratic elections. Progressinimplementingeconomic programs supported by the BrettonWoods institutions also boosted economic growth in2004. The DRC i s eligible for debt relief within the framework o f the HighlyIndebtedPoor Countries (HIPC) Initiative, and i s preparinga Poverty Reduction Strategy Paper (PRSP). The Government, with 15 Introduction donor assistance, has establishedreform and investment programs aimed at improving living conditions both inKinshasa and inthe provinces, including the most remote. 9. Finally, the Government, inits MinimumPartnership Program for Transition andRecovery [ProgrammeMinimum dePartenariatpour la Transition et la Relance, PMPTR] o fNovember 2004, which has been presented to donors, has developed a clear strategy framework setting out priority interventions inall areas inorder to rebuild and stabilize the country. Objectives inthe health sector, which coincide with the Millennium Development Goals (MDGs) for 2015, focus on: i)revitalization o f the 515 Health Districts; and ii)capacity-building at all levels o f the health system. Figure5. Analyticalframework reflectingthe situation in the DRC - I_-- ~ , ~ - - ~ ~ 3. Healthsystem and related 4. Government policy sectors and actions Alarminghealth and Appropriate nutritionalsituation Deterioration in coverage strategies but chronic malnutrition of basic health andqualityof health limitedcapacity 38% of under-5s services Decentralization severe malnutrition strategy, 16% of under-5s integrating * under-5 mortality primary and first- 220/1,000 (around referralservices 600,000 deaths Insufficientfinancingof at the same annually) healthservicw time, vertical * maternalmortality 3 * Poor remunerationof 1 approach 1,289/100,000 births healthworkers insufficient (about 35,000 maternal lack of medications and planning and deaths annually) other inputs management capacities 0HIV 4.5% of adults * totalfertilityrate 7.1 * malariathe most Relatedsectors inwortantcauseof * precariousfood security mortality (around situation Lowfinancial government 350,000 deaths annually) - * poor educationsystem resources lack of roads and 0 low Government I transportation spending lack of water and growth in MassPoverty I` j sanitation infrastructure externalaid Y _"._ -_-_- ._- -.."".--.A -__- ~-x "_ _I__--"" "I__c1 Adapted from Wagstaff and Claeson (2004) _ x _ I 2. Objectives and analytical framework 10. Within this context, the objective o f the present document i s to describe, analyze, and evaluate the health status o f the population and the health system. Its goal i s to provide a basis for decision-making concerningthe development and implementation o f the Government's sector strategy and policies.. Inparticular, the aim i s to highlightthe contribution o f health interventions to poverty reduction and to focus on the health status o f the poorest. 11, The document's secondary objective is to serve as an inputto the process o f drawing up the PRSP and allocatingresources freed up by the HIPC Initiative to the health sector. It i s an integralpart o f efforts by the Government and its partners to achieve the MDGs. 12. This analysis, conducted by the Ministryo f Health incollaborationwith the WorldBank, benefitedfrom the participatory work o f the national "Health and Poverty" team composed o f representativeso fthe Ministry,universities, non-governmental organizations (NGOs), and other partners inthe sector. A first draft o f the document was discussed inMay 2004 at the time o f the 16 Introduction Health Roundtables. Ithas also beenthe subject of a dissemination workshop and a validation workshop. 13. The analytical framework focuses on the status of, and trends in,health and poverty indicators associatedwith objectives that the Government set within the framework o f the MDGs, whichare described and analyzed inChapter 1ofthis report. (See Figure5 andTable 2). Table 2. The report's discussionof elements of the analyticalframework Elementof analytical framework Chapter and topic of analysis 1 MillenniumDevelopmentGoals 1 Healthstatus, nutrition and population 4 Householdhealth care expenditures 2 Householdsand communities 1 Factorsdetermining health status 2 Factorsdetermining utilizationof services 4 Householdhealth care expenditures 3 HealthCare System 3 Organizationand componentsof the health system 2 Utilizationof the healthsystem 4 Financingof the healthsystem 4 Governmentpolicies and interventions 3 Organizationand componentsof the health system 4 Financingof the healthsystem 14. The analysis thentracks the causal chain of measures and interventionsthat help improve health and poverty indicators. These are thenanalyzed taking into account the often complex interactions among households' behaviors and resources, socio-economic and demographic characteristics, and the community environment. Utilizationo f health care services, and the determinants o f suchuse on the part of households and communities, are discussed inChapter 2. 15. InChapter 3, the analysis turns to factors associatedwith the heath systemand government policies: i.e., organization, standards, role, strengths, and weaknesses o f the health systemthat support households. Chapter 4 analyzes the financing of the sector, including household contributions. Finally, the mainconclusions of the analysis are presented, along with the implications for sectoral strategy. 3. Data used and limits of the analysis 16. This report i s basedprimarily on the studies, action plans and documents o f the Ministryof Health and on reports generatedby the National Health Information System [SystBmenational d'informations sanitaires, SNIS]. It was enhancedby data from the national surveys on women and children (Multiple Indicator Cluster Surveys, MICS) conducedby the Government in 1995 and 2001 with the assistanceo f UNICEF. The analysis draws from numerous studies, some o f them national inscope, conducted bynon-governmental organizations (NGOs) on mortality levels, trends, and contributing factors. Finally, the report incorporates the results of a large number o f ad hoc and local studies, NGO reports presented inthe DRC, and a public expenditure review carried out in2002 by the Government incollaborationwith the World Bank. 17. However, the unavailability o f some information and the quality o f the data presented inthe existing documentationimpose a limitation on this study, especially where the resources and operation of the health system are concerned. Informationon public expenditures i s therefore incomplete, and a national household expenditure survey has not yet been carried out inthe DRC. The lack of up-to-date basic administrative data onhealthcare facilities, their staff, operations, and performance also imposes limits on the analysis. 17 Chapter I: Health Situation and Determinants Chapter 1: HealthSituation andDeterminants 1. MillenniumDevelopmentGoals 1. The Millennium Development Goals (MDGs)were agreed to by world leaders at the UN Millennium Summit in2000 and reflect the multi-dimensional nature o f development. Quantitative indicators and targets have been adopted inorder to guide policy and assess progress. Five o f the eight MDGs are directly relatedto nutrition and health, and their indicators DRC. and targets provide useful tools for assessing the health, nutrition, and population situationin Table 3. Health and nutrition-relatedMDG indicators, DRC, most recentestimates urban Sub- DRC DRC rural DRC Saharan Afrim MDG 1: Poverty and Hunger prevalencechild malnutrition(underweight)(% under 5) 22 36 31 30 prevalenceof child malnutrition (stunting)(% under 5) 29 43 38 41 prevalencechild malnutrition(wasting)(% under 5) 12 18 . 16 10 MDG4: Child Mortality under-5 mortalityrate (per 1,000 live births) 158 243 220 174 infant mortalityrate (per 1,000 live births) 95 144 128 103 measles immunization(% of children 12-23months) 65 40 48 58 MDG 5: Maternal Mortality maternal mortalityratio (per 100,000 live births) .. 1,289 917 births attended by skilled healthstaff (%) 32 20 24 39 MDG 6: HIWAIDS, Malaria, and Other Diseases prevalenceof HIV (% adults aged 15-24) .. 4 to 5 7.5 contraceptiveprevalence rate (% of women ages 15-49) 31 23 number of children orphaned by HIV/AIDS ..770,000 12.1M proportionsleeping under insecticide-treatedbednets (% children underd) .. 0.7 2 proportionof childrenwith fever treated with antimalarials (% children under-5with fever) 63 47 52 42 incidenceof tuberculosis(per 100,000 per year) .. 384 358 tuberculosiscases detected under DOTS (%) 52 MDG 7: Environment access to an improvedwater source (% of population) 84 29 46 58 access to improved sanitation (% of population) 61 39 46 54 General Indicators population ..58.3 M 689 M total fertility rate (births per woman ages 15-49) 6.3 7.4 7.1 5.1 life expectancyat birth (years) .. 45.3 45.8 Sourcesare 2001 MlCS2 in DRC, UNAIDS (2004),World Bank (2004a),World Bank (2004b). 2. Most health-relatedMDGindicatorsinDRCare worse than Sub-SaharanAfrica averages, with levels of child and maternal mortalityamong the highestinthe world. Table 3 presents estimates for the various MDGindicators for the country, for rural and urban areas, as well as comparisons with regional averages for Sub-Saharan Africa. Ingeneral, DRC performs 18 Chapter I: Health Situation and Determinants quite poorly, and ofparticular concern are the levels ofchild andmaternalmortality. Estimates for DRC are lower than the regional average on many of the other MDGindicators such as measlesimmunization, skilled delivery care, and access to safe drinkingwater and adequate sanitation. 3. Chronic childmalnutrition i s comparable to the average level in Sub-SaharanAfrica, but acute malnutrition i s muchhigher, reflecting the impact of the conflict. Estimatedaccess to anti- malarial medication i s higherthan the Sub-Saharan Africa average; and the prevalence o f adult HIVis also lower than the estimated average for Sub-SaharanAfrica. The latterisperhapsrelated to the isolation of the largeruralpopulations inDRC, but could also be due to the range of uncertainty around such estimates. Table 4. Selectedhealth-relatedMDG indicators, DRC and comparatorcountries DRC Ethiopia Kenya Nigeria Tanzania population2004 (million) 58.3 71.3 33.0 125.8 36.1 gross nationalincome (GNI) per capita 2003 ($US)' 100 90 390 320 290 under-5 malnutrition(stunting) (%) 38 52 30 38 44 under-5 mortality(per 1,000)'" 216 166 115 201 147 measles immunization(% 12-23 months) 48 52 78 40 89 maternalmortality(per 100,000 live births)"' 1,289 871 414 800 1,500 skilled birth attendance (% deliveries) 24 6 42 36 adult HIV prevalence(%) 4.2 4.4 6.7 5.4 8.8 ***Atlas method The estimatefor DRC is from an indirectmethod (Brass)while estimatesfor comparatorcountries are from direct methods (birth histories). *** The estimatefor DRC is from an indirect method (Sisterhood)while those for Ethiopia and Kenya are direct estimates and the those for Nigeriaand Tanzania are from a model. Sourcesare 2001 MlCS2 in DRC, AbouZahr and Wardlaw (2001), Measure DHS (2004), UNAIDS (2004), US Census Bureau(2004),World Bank (2004a),World Bank (2004b). 4. In general, MDGindicator levelsinDRC are worse than the very poor situation observed inother large and poor countriesin Sub-SaharanAfrica. Table 4 compares selectedMDGindicator estimates inDRC with other countries inSub-SaharanAfrica with large populations. It shouldbe noted, however, that only Ethiopia i s as poor as DRC, since Kenya, Nigeria, and Tanzania are estimated to have average per capita incomes three times larger or more. Indicators inthe comparator countries that are worse than the DRC estimates are given in boldtext inthe table. The maternal and childhealth situation inDRC i s generally worse than the other countries, as DRC has the highest estimated rate of under-fivemortality, the second-lowest rate o f measles immunization, the second highest estimated maternalmortality, and the second lowest rate of skilled delivery care.3 Note that giventhe uncertaintyintervals aroundestimates of maternalmortality ratios, all of these countries (except perhapsKenya) suffer from very high levels of maternal mortality. Infact, most o f the indicator levels inthese countries are inthe same order of magnitude-very poor. * The estimates for chronic malnutritionand access to anti-malarials seem to be contradictory with the very highrate o f child mortality. Possible explanations are discussed elsewhere inthe report, and inall cases may include possible problems with the data. With regardto chronic malnutrition, explanations may include regional patterns o f malnutritionand mortality as well as survivor bias, both associated withthe conflict. With regardto access to antimalarials, an explanation may involve increasingparasite resistance to the most commonly-used drugs. The DRC under-5 mortality estimate is from the indirect method and the others derived from the direct method, so they cannot be considered comparable. However, other evidence, discussed below, indicates that child mortality inDRC i s indeedextremely high. 19 Chapter I: Health Situation and Determinants 5. Due to the crisis experienced by DRC over the past decade, the country has seen little or no progresstowards the 2015 MDGtargets. Monitoringthe performance o f DRC on the MDG indicatorsover time i s limited due to the paucity o f data. Unsurprisingly,given the crisis experienced by the country inrecent years, the available information suggests that DRChas made little or no progress towards the MDGtargets. Trends inhealth outcomes are discussed further below. Like many other countries inSub-Saharan Africa, achieving the MDGsby 2015 is unlikely inDRC, althoughprogress towards them i s o f course possible with considerable effort and investment. Figure 6. Indirect estimates of under-five mortality, DRC 230 , MDG Target `0 1980 1985 1990 1995 2000 2005 2010 2015 2020 Authors' estimatesfrom 2001 MlCSPdata. 2. Childmortality 6. Overall, DRC experiencesone of the highest child mortality rates inthe world, with at least one infive children dyingbeforethe age of five years. The 2001 MICS2 household survey collected data (on each sampled woman's number o f children ever born and number still alive) which can be usedto derive indirect estimates (usingthe Brass method) o f child mortality. Figure 6 shows the under-five mortality estimates from this survey with the time periods to which they refer. It i s estimated that under-five mortality inthe 1997-98 period was 220 per l,000.4 Such a mortality rate translates into the deaths o f 450,000 to 500,000 children per year. Estimatedinfant mortality (children under one year old) i s 128 per 1,000, indicating that over one inteninfantsdie beforetheir firstbirthday. 7. Non-governmental organizations (NGOs) have conducted a number o fretrospective mortality surveys which provide direct estimates o f child mortality based on the recall o f family members. Table 5 provides estimates from population-representative retrospective mortality surveys conducted between 2002 and 2003. Crude mortality rates are measured, but to ease The estimate is from sample-weighted data, usingthe North family o f model life tables, and based o n the mortality experience of women aged 25-29, consideredmost reliable. (The child mortality experience o f younger women i s usually higher than average due to confoundingby the lower than average economic status o f women who have children at younger ages). 20 Chapter 1: Health Situation and Determinants comparability, these have been translated into impliedunder-five mortality rates, or the risk of death betweenthe exact ages of 0 and 5 years ( ~ q ~ ) . ~ Table 5. Under-fivemortalityestimatedfrom population-representativeretrospectivemortalitysurveys, DRC crude implied recall period location NGO mortality rate mortality rate mortality rate crude under-5 (per 10,000 (per 1,000 Per day) Per year) (per(go) 1,ooo)* Jan. 02 Oct. 02 - non-conflict-affectedareas IRC 1.4 53 228 Jan. 02 - Oct. 02 conflict-affectedareas IRC 3.0 108 408 Jan. 02 Oct. 02 - overall** IRC 1.7 64 267 Jan. 03 - Apr. 04 non-conflict-affectedareas IRC 1.3 48 210 Jan. 03 Apr. 04 conflict-affectedareas IRC 1.9 70 288 Jan. 03 Apr. 04 -- overall** IRC 1.7 61 259 * The mortalitythat would be experienced by a birth cohort during itsfirst five years if the measuredcrude mortality rate were to prevailover the five years. ** not reported, but estimated by the authors on the basis of informationin the IRC report 8. The most recent estimate for the country as a whole refers to 2003 andpart o f 2004 and implies an under-five mortality rate o f 259 per 1,000. Figure7. Indirectestimatesof under-fivemortality, urban and ruralareas, DRC p $ 150- E 0 1986 1988 1990 1992 1994 1996 1998 Authors' estimatesfrom 2001 MlCS2 data. A crude mortality rate is the measured mortality during a definedrecall period. The impliedunder-five mortality rate tSqO)is the mortality that would be experienced by a birthcohort over five years ifthe measured crude mortality rate were to prevail for the five years. The translation i s done with the formula nm 5 4 0= l+(n-a)m where n = the number o f years inthe interval (5 years ), m = the observed crude mortality rate for one year, and a = the average number o f years livedby those who died during the interval (assumed to be 2). (Preston, Heuveline, and Guillot, 2001) 21 Chapter 1: Health Situation and Determinants 9. Infant mortality estimates from the 2004 retrospective mortality survey are 150per 1,000 live birthsinthe conflict-affectedhalfo fthe country and97 per 1,000 inthe partnot affected by conflict, for an overall average o f around 115 per 1,000. 10. Child mortalityhas risen dramaticallyinthe past decade. The target for the fourth MDG i s to reduce child mortality by two-thirds between 1990 and 2015. However, child mortality increased duringthe 1990s inDRC, implyingthat that the country has lost a decade inthe effort to achieve progress towards this goal. The indirect estimates fiom the MICS2 survey described in Figure 6 show an increasing trend inunder-five mortality since the mid-1980s. The MICS2 estimate o f 220 per 1,000 for 1997-98 can be compared to the indirect estimate fiom the 1995 MICS1o f 192 per 1,000, referring to the period 1991-92. 11. The estimates from retrospective mortality surveys indicate continuingdeteriorationduring the years o f intense conflict, starting in 1997, with overall estimates for the country inthe range o f 250-270 per 1,000, (Table 5). Figure 8. Indirectestimates of under-five mortality, by regions, DRC 250 East 230 A I 1986 1988 1990 1992 1994 1996 1998 2000 Authors' estimatesfrom 2001 MICS2 data. 12. Childmortalityis higher and hasincreasedfaster inruralareas. Figure 7 shows indirect estimates o f under-five mortality inurban andrural areas from the 2001 MICS2. Estimated mortality for the period around 1997 i s significantly higher inrural areas (243 per 1,000 in 1997) than inurban areas (158 per 1,000). Mortality has also increased significantly inrural areas since the early 1990s, while there has been a slight increasing trend inurban areas. 13. The rise inchildmortality inDRC was concentrated inconflict-affectedregions. The rise inchildmortality inrural areas was driven by large increases inparts o f the country affected bythe conflict. Figure 8 shows indirect under-five mortality estimates for different regions o f the country: East (Province-Orientale, Maniema, Nord-Kivu, and Sud-Kivu), Center (Equateur, Kasai-Oriental, Kasai-Occidental, andKatanga), and West (Kinshasa, Bas-Congo, and Bandundu).6 Duringthe war, the West group o f Provinces was not directly affected, the front line went through the Center, and the East was the scene o f much fighting. Figure 8 shows that the western Provinces have consistently experienced lower levels o f mortality, although there was a These regions are defined for the purpose o f the analysis and do not reflect any administrative divisions. 22 Chapter I: Health Situation and Determinants steady increase duringthe 199Os, with an estimate of 163 per 1,000 for 1997. Child mortality in the rest o fthe country increasedmore dramatically inthe 1990sto estimates for 1997 of 231per 1,000 inthe central Provinces and 240 per 1,000 inthe East. This indicates that the regional trends inmortality were evident beforethe war startedin 1998. Table 6. Crude mortality and implied under-fivemortality rates (GO),specific locations, DRC crude implied recall period location NGO mortality rate mortality rate mortality rate crude under-5 (per 10,000 (per 1,000 Per day) Per year) (per(GO) 1,oooy Jan. 98 Feb. 99 - Katana (Sud-Kivu) IRC 3.3 121 444 Jan. 99 Apr. 00 Katana (Sud-Kivu) IRC 2.3 83 332 Jan. 99 Apr. 00 Kabare (Sud-Kivu) IRC 1.9 70 288 Jan. 99 May 00 --- Moba (Katanga) IRC 8.1 294 781 Jan. 99 - Apr. 00 Kisangani(Province-Orientale) IRC 1.6 58 246 Jan. 00 Mar. 01 Kalemie (Katanga) IRC 3.6 130 467 Jan. 00 Mar. 01 -- Kalima (Maniema) IRC 2.5 90 354 Jan. 00 - Feb. 03 Katana (Sud-Kivu) IRC 4.2 155 529 Jan. 00 Apr. 01 Lubunga (Province-Orientale) IRC 2.3 83 332 Jan. 00 Mar. 01 -- Lusarnbo(Kasai-Oriental) IRC 3.3 120 441 Jan. 00 - Mar. 01 Kabare(Sud-Kivu) IRC 1.8 67 280 Jan. 01 - Oct. 01 Kimpangu (Bas-Congo) MSF 2.0 73 299 Jan. 01 Oct. 01 - lnongo (Bandundu) MSF 37 164 Jan. 01 - Aug. 01 1.o Basankusu(Equateur) MSF 6.6 241 699 Jan. 01 Sep. 01 Lisala (Equateur) MSF 1.8 66 274 Jan. 01 Oct. 01 -- Kilwa (Katanga) MSF 3.1 113 422 May 01 - Jul. 01 Malemba-Nkulu(Katanga) ACF 10.4 380 887 Mar. 02 Jun. 03 - Bosobolo (Equateur) Epicentre 3.9 142 499 Mar. 02 - Jun. 03 Zongo/Libenge (Equateur) Epicentre 5.5 201 626 Oct. 03 Dec. 03 - Bolomba (Equateur) ACF 4.9 178 581 Nov. 03 -Jan. 04 Befale (Equateur) ACF 2.5 89 353 Dec. 03 - Feb. 04 Basankusu(Equateur) ACF 3.2 117 432 * The mortality that would be experiencedby a birth cohort during its first five years if the measuredcrude mortality rate were to prevail over the five years. Table 7. Implied under-fivemortality rates (GO), specific locations, DRC 1998-99 1999-2000 2000-01 2002 2003-04 Katana (Sud-Kivu) 201 162 250 107 127 Kabare (Sud-Kivu) Kalemie (Katanga) 467 219 191 Kalima (Maniema) 354 162 196 Moba (Katanga) 506 177 Kisangani(Province-Orientale) 158 304 75 Basankusu(Equateur) 699 432 Authors' estimates based on NGO reports. 23 Chapter 1: Health Situation and Determinants 14. The effects o fthe war on mortality since that time are clear from the findings o fretrospective mortality surveys presentedinTable 5. Separate samples were taken from areas directly affected by the war (the eastern Provinces andparts o fthe central Provinces) andthose not directly affected (the western Provinces and parts o f the central Provinces). The impliedunder-5 mortality rate inthe conflict-affectedhalf o f DRC in2002 was 408 per 1,000, compared to 228 in the rest o f the country. Figure 9. Indirect estimates of under-five mortality,lowestand highest SES quintiles, DRC 300 250 lowest quintile 8 0- 200 r .- k 0 150 E 100 1986 1988 1990 1992 1994 1996 1998 2000 Authors' estimatesfrom 2001 MICSP data. 15. Extremelyhighrates of childmortalityhavebeenexperiencedby many conflict-affected andother populations. The impliedunder-five mortalityrate o f408 per 1,000 observed inthe eastern half o fthe country in2002 (Table 5) i s exceptionally high. Itmeans that ifthe observed crude mortality rates during2002 prevailed duringthe first five years o f life o f a birthcohort, 40% o fthem would die before reachingtheir fifthbirthday. 16. Table 6 presents crude mortality estimates from retrospective mortality surveys in specific locations duringthe war. Such estimates are often presented inhumanitariansituations as rates per 10,000 per day to enable comparison with a standard o f 2 under-five deaths per 10,000 per day which i s taken as the threshold for an emergency situation. Many o f the situations presented inTable 6 experienced crude under-five mortality rates well abovethat. For example, inparts of Sud-Kivu, western Katanga, and parts of Equateur, crude mortality was such that 15 to 30% o f under-five children could have been expected to die injust one year. Some recent surveys in Equateur Province show continuinghighcrude mortality, equivalent to under-five mortality rates (5qo)o f 300-500 per 1,000. 17. There are signs of improvementinmanylocationsinthe past few years, but mortality remainshigh. The recentpopulation-representativeretrospective mortality surveys described in Table 5 indicate that the overall child mortality situation i s starting to improve since the beginning of the peace process. Under-five mortality has significantly decreased inthe war- affected areas (from an impliedrate o f 408 per 1,000 in2002 to 288 in2003-04), with a smaller decline inthe rest o f the country (from an impliedrate o f 228 per 1,000 in2002 to 210 in2003- 04). Nevertheless, suchrates are still highby any standard. Table 7 presents impliedunder-five mortality rates from retrospective mortality surveys done at different times inthe same locations, also indicating that the situation i s improving. For example, the Katana Health Zone inSud-Kivu has been surveyed four times since 1999, showing an increase inchildmortality until2001, after which a significant improvement i s evident. 24 Chapter 1: Health Situation and Determinants 18. There are large and increasing disparities inthe child mortality experiences of the poorest and the most well-off. Box 1provides details on the methodologies for measuring socio-economic inequalities inhealth appliedhere to the available household survey data. Figure 9 compares indirect under-fivemortality estimates for the lowest and highestsocio-economic status (SES) quintiles from the 2001 MICS2 data. It suggests that untilthe mid-l990s, child mortality was decreasing among boththe poorest and the better-off, and even that disparities were narrowing. However, since then, it seems that childmortality increased among boththe poorest and better-off, rising at a muchfaster rate among the poorest.' In 1997-98, the estimated under- five mortalityrate experiencedbythe poorest quintilewas 256 per 1,000, compared to 128 among the highest quintile. 19. Although the most well-off experience less child mortality, butthere is little difference over the rest of the socio-economic scale, suggesting a situation of mass poverty and widespread vulnerability. Figure 10 shows the concentration curves for child mortality in 1995 and 2001, The curves are relatively flat, indicatingthat the child mortality experience o f most households i s similarly high- suggesting a situation of masspoverty and vulnerability. Despite the increasing disparity between the lowest andhighest quintilesshowninFigure9, basedonthe 2001 MICSl data, Figure 10, which draws onboththe 1995 and 2001 surveys, indicates virtually no change inthe socio-economic distribution of childmortality between 1995 and 2001. This may indicate that over most o f the socio-economic scale, there was little change inconditions duringthat period. The estimated concentration index for 1995 is -0.09 and-0.10 for 2001. 20. Regression models confirm the importance of the maindeterminants of child mortality, but present a complex picture of change over time intheir strength. Table 8 reports estimates from Poisson regression models of the determinants o fmothers' reportednumber o f children deadbased on data from the 2001 MICS2. These models control for the reported number ofchildrenborn (the exposure variable). Becausemortality canbe highlyclustered, the models are estimated ina way which accounts for the variation (random effects) between sample clusters that i s not explainedby the variables includedinthe models. The first model examines 'Such conclusions about trends require the assumption that socio-economic status measured in2001 was similar inthe past for the households inthe sample (ie. that there was little upward or downward mobility). 25 Chapter 1: Health Situation and Determinants the determinants o freportedmortality among children born inthe five years prior to the survey, while the second model refers to children bornbefore five years prior to the survey. These models allow both an overall assessment of the importance o f different determinants o f mortality as well as provide indications about how this may have changed over timem8 Figure 10.Concentrationcurvesfor child mortality,DRC, 1995and 2001 0% 20% 40% 60% 80% 100% Curnul% births, ranked by SES Authors' estimates from 1995 MlCSl and 2001 MlCS2 data. Table 8. Random-effectsPoissonregressionmodels of the determinantsof mothers' reported number of childrendead, DRC, 2001 number dead among children numberdc?adarnona " born in previous 5 years children born (n = 6,781 mothers) before 5 years previously (n = 4,692 mothers) incidencerate p-value incidence rate p-value ratio ratio mother'sage (years)* 1.oo 0.44 0.99 0.00 mother'sage' 1.oo 0.80 1.oo 0.02 householdsize' 0.91 0.00 0.92 0.00 householdsize' 1.01 0.00 1.01 0.00 1 = mother has any education 0.96 0.54 0.85 0.00 1 = highestSES quintile 0.82 0.12 0.79 0.00 cluster proportionBCG vaccination 0.56 0.30 0.32 0.00 1 = improved water supply 1.02 0.79 0.98 0.67 1 = adequate sanitation 0.83 0.01 0.96 0.27 1 = urban 0.77 0.03 0.84 0.00 Center 1.38 0.01 0.98 0.68 East 1.60 0.00 0.96 0.44 * centered at the mean Center = Equateur, Kasai-Occidental,Kasai-Oriental,and Katanga. East = Province-Orientale,Maniema, Nord-Kivu,and Sud-Kivu. Referenceregion is West = Bas-Congo, Kinshasa,and Bandundu. Authors' estimates from 2001 MlCS2 data. Coefficients measure the ratio of incidence o f mortality associated with each determinant to the incidence associated with the reference group (inthe case o f dichotomous variables, the reference group i s the absence of the determinant; inthe case o f continuous variables, the reference is one unit decrease inthe . variable). 26 Chapter 1: Health Situation and Determinants 21. Table 9 provides another way of lookingat these questions, modeling pooled data from the 1995 and 2001 MICS on childmortality reportedby women aged under 35. The coefficient on the Timevariable measuresthe ratio of the incidence o f mortality in2001 over the incidence in 1995, after controlling for change inthe various determinants. The coefficients on the variables without interactions measure the riskof mortality associatedwith the differentdeterminants in 1995. The coefficients on the variables with interactions (with the Timevariable) estimate the change over time (from 1995 to 2001) inthe risk associatedwiththese determinants inquestion. The analysis is stratifiedbyregion. Statistically-significant estimates (p<0.1) are inboldtext. 22. Although safe water and adequate sanitation are known to be beneficialto child health and nutrition, protectiveeffects are overall not evident inthe models. The modelsmeasure the association between childmortality and accessto an improved water source (for example covered well or spring) and adequate sanitation (for example covered latrine). However, such correlations are not evident inthe models, except inrelation to recent mortality (the first model of Table 8). This may suggestthat access to adequate sanitation may have become more important inrecentyears, butsucheffects arenot statistically significant inthe modelspooling 1995 and 2001 data for the different regions. (Table 9). Table 9. Pooled random-effectsPoissonregressionmodel of the determinantsof mothers' reported number of children dead, DRC, 1995 and 2001 (mothers 15-34years) West Center East (n = 2,492 mothers) (n = 3,507 mothers) (n = 2,324 mothers) incidence p-value incidence p-value incidence p-value rate ratio rate ratio rate ratio Time: 0 = 1995,1 = 2001 1.07 0.79 1.11 0.46 1.02 0.90 mother'sage (years)' 1.02 0.03 1.03 0.00 1.01 0.04 mother'sage' 1.oo 0.82 1.oo 0.11 1.oo 0.32 householdsize* 0.94 0.00 0.95 0.00 0.93 0.00 householdsize' 1.oo 0.00 1.oo 0.00 1.01 0.00 1 = mother has education 0.92 0.53 0.80 0.01 0.88 0.19 mother`seducationinteractionwith Time 0.73 0.06 1.11 0.30 1.07 0.58 1= highestSES quintile 0.63 0.10 0.94 0.74 0.63 0.10 quintile interactionwith Time 1.53 0.18 0.51 0.02 1.oo 0.99 cluster proportionBCG vaccination ' 1.11 0.75 0.52 0.00 0.68 0.08 cluster proportionBCG interactionwith Time 0.56 0.43 0.31 0.03 0.25 0.01 1 = improvedwater source 0.84 0.26 1.18 0.14 0.86 0.36 improvedwater source interactionwith Time 1.27 0.21 0.85 0.22 1.16 0.42 1 = adequatesanitation 0.82 0.38 0.88 0.38 1.09 0.61 adequate sanitation interactionwith Time 1.11 0.67 1.14 0.39 0.80 0.24 1 = urban 0.73 0.13 0.96 0.77 1.06 0.75 urban interactionwith Time 1.10 0.68 0.81 0.19 0.75 0.22 centeredat the mean Authors' estimatesfrom 1995 MlCSl and 2001 MlCS2 data. 23. Ingeneral, even after controllingfor economic status, mother's educationis associated with decreasedriskof child mortality, but this protectiveeffect seems to have declinedin war-affected areas. Inmany contexts, mother's education has consistently been shown to be beneficial for childhealth, even after consideringhousehold economic status. Overall, these models also measure this relationship inDRC, but indicate that mother's education became less important as a protective factor duringthe war. The risk of mortality among children bornbefore 1996 i s 0.85 times lower when the mother has any education, butthis effect i s not evident among children born more recently. (Table 8) This suggests that the war reducedthe protective effect of mother's education; that is, the benefits accordedby mother's education couldnot operate in 27 Chapter I: Health Situation and Determinants conditions of conflict. Such an interpretationi s supported by the pooled models (Table 9), where the protective effect o f mother's education increased inthe West, but decreased (or didnot significantly change) inthe Center, and was not evident inthe East. 24. In general, death of a child i s less likely to occur inurbanareas. Differences inhealth outcomes between urban and rural areas are related to differences inwater and sanitation conditions, service availability, poverty levels, and other factors. However, even after holding such determinants constant, analyses inmany contexts usually show a benefit associated with urbanresidence. This i s the case with both models o f the 2001MICS2 data (Table 8), where urbanresidence i s associated with decreased risk o f mortality among children bornduringeither o f the two time periods. This confirms the urban-rural differences inestimated under-five mortality shown inFigure 7 above. However, the effect i s not as clear inthe regionally-stratified analyses pooling 1995 and 2001 data. The coefficients associated with urban residence are not statistically significant, althoughtheir directions suggest that the protective effect diminished in the West, but increased inthe Center and East. (These effects have greater statistical significance when the water and sanitation variables are not includedinthe models). 25. In general, the poor experience greater risk of child mortality, while change over time in the protective effect of socio-economic status shows complex regional patterns. The models o f the 2001 MICS2 data (Table 8) show that children inthe highest SES quintile born before 1996 had 0.79 times the risk o f mortality as other children. A similar protective effect may be seen among children bornmore recently, althoughit i s not quite statistically significant. These findings are consistent with the comparisono funder-five mortality estimates for the lowest and highest quintiles presented inFigure 9. Other models (not shown) indicate that the relationship between socio-economic status and child mortality i s not as evident among the lower four quintiles, also consistent with the previous discussion. 26. The pooled models o fthe 1995 and 2001 data (Table 9) indicate that higher socio-economic status was similarly protective in 1995, particularly inthe West and East. However, the models suggest that this protective effect may have diminished inthe West (although the change i s not statistically significant), but remained stable inthe East and was accentuated inthe Center. This may suggest that the indirect economic and social effects o f the war undermined the advantages o f higher socio-economic status inthe West, but the direct effects o f the war may have accentuated them, particularly inthe central Provinces. 27. An indicator of access to health services i s associated with decreased risk of child mortality, and this effect increased over time inwar-affected regions. Absent direct data on availability o f health services, the proportion o f children vaccinated with BCGineach sample cluster is used as an indicator o f access to health services. This indicator i s associated with significantly decreased risk inmortality among children born before 1996. Among children born more recently, the direction o f the coefficient i s consistent with a protective effect, but it not statistically significant. (Table 8) The pooled analysis o f 1995 and 2001 data (Table 9) indicate that the protective effect associated with this indicator o f access to health services was significant in 1995 inthe Center andEast ofthe country, andincreasedover time inthese regions. Coefficients inthe model for the West were not statistically significant. This suggests that the effects o fhealth services became more important amongpopulations affectedby the war. 28. The models confirm that increased child mortality in recent years was concentrated in the Center and East of the country, regions most directly-affected by the war. The 2001 MICS2 data show that the risk o f mortality among children born since 1996 was 1.60 times higher inthe East than inthe West o f the country and 1.38 times higher inthe Center than inthe West, holding a range o f other determinants constant. (Table 8) This effect i s not evident among 28 Chapter I: Health Situation and Determinants children born earlier, perhaps becauseregional differences were more due to factors includedin the model, such as differences insocio-economic status or access to health services. 29. Insum, the models suggest that inthe West, the economic and social crisis of recent years diminished the importance of household socio-economic status to child health, but increased the protective effects of mothers' education. In the Center and East, directly- affected by the war, the protective effect of higher socio-economic status did not change while the importance of mothers' education diminished, and the beneficialeffect of access to health services was accentuated. 3. Childillness 30. Malaria, diarrhea, respiratory infections, malnutrition, and measles are the maincauses of child mortality in DRC. Figure 11presents reportedcauses o f death among under-five children from a retrospective mortality survey done inthe western and easternhalves o fthe country in2004. It shows that the patternof causes of child mortality inDRC i s similar to other poor countries in Sub-SaharanAfrica, with most child deaths causedby malaria, respiratory infections, diarrhea, andmeasles, often associatedwith malnutrition. Although fever could accompany differenttypes of infection, the fact that it i s reportedto have beenpresent in40% of child deaths testifies to the heavy burdenof malaria inthe country. Figure 11. Reportedcauses of under-fivedeaths, DRC, 2003-04 non-conflict-affectedregion (western DRC) conflict-affectedregion(eastern DRC) accident meningitis measles accident meningitis tuberculosis / 3% measles tuberculosis anemia 0% \('% f 4% fever- fever 39% 40% neonatal 9% diarrhoea Q% diarrhoea otherlunknown 15% 12% 11% Source is IRC (2004). 31. The conflict has increased mortality by accentuating children's vulnerability to malnutrition and disease. As discussed above, these retrospective mortality surveys found significantly higherchildmortality inthe easternhalf of the country, directly affectedby the conflict. The fact that the patterno f morbidity suggestedby Figure 11is very similar to the western half o f the country indicates that the conflict didnot cause child deaths directly through violence butby undermininghousehold socio-Fconomic status and coping mechanisms, as well as affecting social conditions, including accessto health services. 29 Chapter I: Health Situation and Determinants 32. Models of the determinants of child morbidity confirm that the epidemiological pattern of disease and other environmental factors are important. Table 10presents estimates from logistic regression models o f data from the 2001MICS on the determinants o freported fever, respiratoryinfection, and diarrhea among under-five children. Because morbidity i s clustered, random-effects models account for variation between sample clusters not explainedby the variables included inthe models. Indeed, quite highproportions o f the variation inthe outcomes (10% to 30%) can be attributed to between-cluster variation not explainedby the observed variables. This i s consistent with the fact that disease patterns have important environmental causes. Table 10. Random-effectslogistic regressionmodels of the determinantsof reportedfever, respiratoryinfection,and diarrhea in the previoustwo weeks among under-fivechildren, DRC, 2001 (n = 10,254) fever respiratoryinfection diarrhea odds ratio p-value odds ratio p-value odds ratio p-value child's age (months)' 1.oo 0.00 0.99 0.00 0.97 0.00 child's age' 1.oo 0.00 1.oo 0.00 1.oo 0.00 1 = male 1.02 0.65 1.09 0.25 1.15 0.01 householdsize' 1.01 0.25 0.99 0.59 1.01 0.35 mother`s age (years)' 1.oo 0.16 1.oo 0.98 0.99 0.01 1 = mother has education 1.18 0.00 0.98 0.79 1.oo 0.98 1 = highest SES quintile 0.97 0.77 0.62 0.00 0.70 0.00 cluster proportionBCG vacciriation 0.35 0.08 1.61 0.64 0.91 0.87 1 = improvedwater supply 0.94 0.41 0.98 0.88 1.01 0.87 1 = adequatesanitation 1.02 0.77 1.29 0.01 1.01 0.92 1 = urban 0.80 0.07 0.73 0.18 1.01 0.96 Center 1.11 0.42 1.94 0.01 1.28 0.03 East 1.07 0.61 3.75 0.00 1.07 0.57 % variation associatedwith cluster 14% 31% 9% centered at the mean Referenceregion is West. Estimationof significanceaccounts for survey design. Authors' estimatesfrom 2001 MlCS2 data. 33. Riskof fever seems to be largely independent of socio-economic factors, likely varying according to the epidemiological pattern of malaria, although there is evidence that access to health services makes a difference. The 2001MICS found that 41.9% o f under-five children had fever inthe previous two weeks, and Figure 11 shows that fever i s by far the most commonly reported cause o f child deaths. Because most fevers are associated with malaria, the incidence o f fever depends greatly on the epidemiological pattern o f the disease. The risk o f fever i s lower in urban areas, suggesting that malaria i s less present. The model shows that the main socio- economic factors do not have an impact on the risk o f fever. Infact, mother's education is unexpectedly associated with an increase inthe risko f fever. On the other hand, the indicator o f access to health services shows a statistically significant protective effect, associated with a lower risko ffever. 34. Respiratory infectionshows more sensitivity to socio-economic factors, with children from poor families experiencing higher risk of disease. The 2001MICS2 found that 10.3% o f under-five children had a respiratoryinfection inthe previous two weeks. The model o f the determinants o frespiratory infection indicates that under-five children inthe highest SES quintile are at considerably reduced risk. However, other models (not shown) indicate that differences among the lower four quintiles are not evident, consistent with the patterns seen with child 30 Chapter I: Health Situation and Determinants mortality, and indicative o f socio-economic homogeneity among the mass o f the population. The model also indicates that children inthe central and eastern Provinces are two to four times more likely to have respiratory infections than children inthe West. (The increased riskassociated with access to adequate sanitation is unexpected). 35. The risk of diarrhea seems to be similar inurban and rural areas, but i s lower among childrenfromthe most well-off households. The 2001 MICS2 estimatedprevalence o f diarrhea among under-fives to be 19.5%. Interestingly, the model o fthe determinants o f diarrhea does not show a statistically significant result for urbanresidence, perhaps indicating that environmental conditions and hygienic practices inurban areas are similar to rural areas. Access to safe water and adequate sanitation do not show significant effects, perhaps suggesting that hygienic practices (which are not measured and included inthe model) may be important. Like respiratory infection, children inthe highest SES quintile are at reducedrisk,but differences are not seen among the lower four quintiles, again pointing to a situation o f mass poverty. Risko f diarrhea i s 1.28 times higher inthe central Provinces compared to the West, but the difference East and West i s not statistically-significant. 4. Childnutrition 36. The prevalenceof child malnutrition in DRC is high, comparableto the average in Sub- SaharanAfrica with regard to chronic malnutrition (stunting), but muchgreater than the averagewith regard to acute malnutrition (wasting), reflectingeconomic and social crisis. Table 3 above presents estimates for malnutrition prevalence from the 2001 MICS2. Chronic malnutrition affects 38% o f under-five children, which i s comparable to the estimated average for Sub-Saharan Africa of around40%. However, acute malnutrition, reflective of shortfalls in nutritional intake inthe immediate term, i s 16%, higher than the average o f 10% seen inother countries on the continentogMalnutrition increases the risk o f death inyoung children and ina synergetic combination with illness can be particularly deadly. For survivors of childhood malnutrition its effects are lifelong -they are less physically and intellectually productive and suffer from more chronic illness and disability. Figure 12.Trends in estimated prevalenceof child malnutrition,DRC 50% , 40% - \ chronic malnutrition 30% - '*, MDGTarget . '* 20% - acute malnutrition 10% ---... - - - - - - 0 MDG Target 1995 2001 2015 Sources are 1995 MlCSl and 2001 MICS2. A height-for-age ratio under -2 standard deviations (Z-scores) fromthe median of a reference population i s the indicator for chronic malnutrition(stunting), while a weight-for-height ratio under -2 standard deviations from the reference median andor presence o f oedema is the indicator for acute malnutrition. 31 Chapter I: Health Situation and Determinants 37. Trends inchronic malnutrition are complex but overall improvements in the non-war- affected parts of the country have been offset by deterioration in conflict-affected areas. The first MDGi s to eradicate extreme poverty and hunger which translates into a specific target of halving between 1990 and 2015 the proportion o fpeople suffering from hunger. The 1995 MICS1estimated prevalence o f chronic malnutrition among under-5 children to be 45.2% while the 2001 M I C S l estimated 38.2%. This may represent an improvement inthe overall average for the country, but it hides widening regional disparities relatedto the conflict and associated socio- economic disruption. The data indicate that chronic malnutrition decreased somewhat inboth urban and rural areas o f the western Provinces (Kinshasa, Bas-Congo, and Bandundu), and also decreased inurban areas o fthe central Provinces (Equateur, Kasai-Oriental, Kasai-Occidental, and Katanga). However, chronic child malnutrition increased substantially inthe eastern Provinces (Province-Orientale, Maniema, Nord-Kivu, and Sud-Kivu), inboth urban andrural areas. For example, in 1995, prevalence o f stuntingwas substantially higher inrural areas o f the western Provinces than inrural areas o f the eastern Provinces, but the situation reversed by 2001. 38. Acute malnutrition has increased, indicatinggreater vulnerability to short-term crises. Incontrast to chronic malnutrition, estimatedprevalenceofacute malnutrition amongunder-fives increased from around 12% in 1995 to 16%in2001. Prevalence o f acute malnutrition i s considered sensitive to short-term fluctuations innutritional intake. The increase inprevalence indicates both increased crises affecting household food security and an erosion intheir ability to cope. The data show increases inprevalence across the country inboth urban andrural areas, indicatingthat children are increasingly vulnerable to short-term shocks to household economies, related to the conflict inthe eastern part of the country, but also evident inthe West. Figure 12 draws the trends inestimated prevalence o f child malnutrition comparedto the MDGtargets, showing the contradictionbetween trends inchronic and acute malnutrition, illustrating how overall averages can mask the complexity of such a large country.'o Figure 13. Concentrationcurves for under-fivechronicmalnutrition(stunting), DRC, 1995 and 2001 100% 80% .o J 22e,60% 0 E E 40% 05a 20% 0% 0% 20% 40% 60% 80% 100% Cumul % children,rankedby wealth Authors' estimatesfrom 1995 MlCSl and 2001 MICS2 data. 39. The nutritional situation in rural areas in 2001 was at crisis -2vels and also very serious inurbanareas. In2001, chronic malnutrition affected 43% ofunder-five childreninrural areas 10The increase inacute malnutritionmay also suggest that the measured decrease inchronic malnutrition may be partly attributable to survivor bias. That is, highrates o f acute malnutritioncause highmortality and it may be that large numbers o f children didnot survive to be measured in2001. This i s consistent with the increase inchild mortality during the period. 32 Chapter 1: Health Situation and Determinants and 29% inurban areas. Acute malnutrition prevalence was 18% inrural areas and 12% inurban areas. (Table 3) All of these prevalence estimates are very high; the rate o f acute malnutrition in particular suggests a crisis situation inrural areas (particularly for acute malnutrition) and a serious situation inurban areas. 40. More recent studies in specific locations present a varying picture but show generally highrates of malnutrition. A nutritionstudy inKinshasa in2004 found 8.1% acute malnutrition and 22.4% chronic malnutrition among under-fives. Studies inthree locations in Equateur in2004 found rates of acute malnutrition ranging from 3.5% to 12.7%." 41. There are large disparities in child malnutrition betweenthe poorest and the most well- off, but smaller differences betweenmost of the population. Prevalence of chronic malnutrition among the poorest quintile i s 43%, compared to 19% among the highest quintile. Similarly prevalence of acute malnutrition i s 20% among the poorest quintile and (a still high) 8% among children inthe highest quintile. However, Figure 10 draws concentration curves which are quite flat, indicating little difference inchronic malnutrition prevalence inthe general population-a signal o f mass deprivation. The graph also indicates that inequality changed little between 1995 and 2001. The concentration indices for chronic malnutrition inboth 1995 and 2001 were -0.10. Table 11. Random-effectslogistic modelsof the determinantsof under-fivemalnutrition,DRC,2001 chronic (n = 11,371) (n =acute 11,446) odds ratio p-value odds ratio p-value child's age (months)* 1.06 0.00 0.99 0.00 child's age' 1.oo 0.00 1.oo 0.00 1 = male 1.29 0.00 I.20 0.00 household size" 1.oo 0.81 1.01 0.16 mother's age (years)* 1.oo 0.29 1.01 0.09 1 = mother has education 0.85 0.01 0.73 0.00 1 = urban 0.63 0.00 0.88 0.37 socio-economicquintile" 0.88 0.00 0.91 0.01 cluster proportion BCG vaccination 1.60 0.45 1.32 0.70 Center 1.44 0.00 1.07 0.62 East 1.82 0.00 0.75 0.08 % variation associatedwith cluster 17% 20% ***centered at the mean incidence rate ratiosare associatedwith an increasefrom a quintile to the next higher quintile Authors' estimatesfrom 2001 MlCS2 data. 42. Multivariatemodels confirm that mother's education, urbanresidence, and higher socio-economic status are associated with lower riskof child malnutrition. Table 11reports estimates from regression models o f the determinants of chronic (stunting) and acute (wasting) malnutrition among under-five children as measuredby the 2001 MICS2. The highproportion of variation associatedwith differences between sample clusters andnot explained by variables in the model (16% for stuntingand 20% for wasting) indicates that other contextual factors are important (ie. climate, agricultural and economic conditions, and conflict and insecurity). Children whose mother received any education are estimated to be 0.85 times less likely to be l1 The low 3.5% estimate is clearly due to survivor bias inthis particular location, since the same survey found extremely high crude mortalityrates among under-fivechildren. 33 Chapter I: Health Situation and Determinants stunted and 0.73 times less likely to be wasted. Better educated mothers are more likely to offer better caring and feeding practices for their children and would also be more likely to ensure that their children receive skilled health care. Residents o f urban areas are significantly at lower risk o f chronic malnutrition (although this i s not statistically significant for acute malnutrition). For each increase in SES quintile, the risko f stuntingdecreases by 0.88 times and the risko f wasting by 0.91 times. 43. Regional patterns are also evident, as the risk o f stunting i s 1.4 to 1.8 times greater inthe central and eastern Provinces than inthe West o f the country. Unexpectedly, a lower risk o f acute malnutrition inthe East i s marginally statistically-significant." 44. Rates of exclusive breastfeedingare low and decliningin DRC,increasingthe vulnerability of infantsto malnutrition and disease. Becausebreastfeeding significantly reduces infant morbidity and mortality in developingcountries, it i s recommendedthat infants be exclusively breastfed for the first 4 to 6 months o f their lives. Data from the MICS2 survey show that although 95% o f children are breastfed at some point, only 29% o f children under two years o f age are exclusively breastfed for their first four months and 24% for their first six months. 45. The prevalence o fbreastfeeding does not appear to be affected by urbadruralresidence, socioeconomic group, or the education level o f the mother. However, there are some significant regional differences. Exclusive breastfeeding i s more common inEquateur, Province-Orientale, Nord-Kim, and Maniema (45-60% o f children under four months), and less common inBas- Congo, Katanga, and Kasai-Occidental (under 20%), with Kinshasa and Kasai-Oriental inthe middle (around 30%). 46. Exclusive breastfeeding appears to be on the decline inDRC.According to the MICS1, in 1995, 34% o fthe infants were exclusively breastfed for the first four months, comparedto 29% in 2001. 5. Reproductiveand maternalhealth 47. The populationof DRC is large, growingfast, and very young. With an estimated 58.3 million people in2004, the population o f DRC i s the third largest in Sub-Saharan Africa (after Nigeria and Ethiopia). Estimatedannual populationgrowth i s 2.9%. (US Census Bureau, 2004) With its highfertility andmortality, almost halfthe population(48%) i s under 15 years old and only 3.5% i s over 60. 48. Fertility is amongthe highest in the world, inbothurban and rural areas, and is not decreasing. The total fertility rate (TFR) is very highat 7.1, indicatingthat women inDRChave on average more than seven children. This i s considerably higher than the estimated average o f 5.1 in Sub-Saharan Africa and among the highest inthe world. It i s estimated to be 7.4 inrural areas and a still high6.3 inurban areas. This i s consistent with the level o fpoverty, lack of access to family planning, and highchild mortality inDRC. (Given the child mortality rates discussed previously, o f these seven children, one or two can be expected to die before the age o f five, providing a motivation to have many children). The estimated annual crude birthrate i s 48.5 per 1,000 population, indicating about 2.8 million birthsannually. There are no indications that fertility i s declining-the estimated total fertility rate in 1995 was 7.2. An increasing trend in fertility has been evident since the 1950s, when total fertility was estimated to be around 5.9, risingto 6.3 inthe 1980s. (Schneidman, 1990) '*This i s due to very low measuredprevalence inurban areas of the eastern Provinces, which i s unexpected and may be a result of error. 34 Chapter I: Health Situation and Determinants 49. Adolescent fertility i s particularly high. The 2001 MICS2 found that 20% o f girls aged 15- 19 were mothers. Adolescent motherhoodi s more common among the poorest (26% inthe lowest quintile, compared to 13% inthe highest). Although the 2001 MICS2 found that adolescent girls were slightlyless likely to be mothers inurban areas (17% compared to 22% in rural areas) a small survey of girls 12-19 inKinshasa found that 30% had had a sexual experience, and that one third of these hadbeenpregnant. (Casey, 2002) 50. Mothers suffer from a very high risk of mortality which has increasedduring the 1990s and is apparent all parts of the country. The maternalmortality ratio inDRC is estimated from the 2001 MICS2 data at 1,289 per 100,000 live births. This impliesover 36,000 maternal deaths annually. This estimate i s derivedfrom indirect methods andrefers to the time period about 12years before the survey -the late 1980s. Giventhe crisis experiencedby the country duringthe 1990s, current maternal mortality is likely higher. For example, a direct estimate from a survey in 1998 (n= 8,613 households) was 1,837 per 100,000, (Ministbre de la SantC, 1999a) Giventhe range of uncertainty around any particular maternalmortality ratio estimate, what i s important i s the order of magnitude, and it i s clear that the level o f maternalmortality inDRC i s among the highest inthe world. The target for the fifth MDGi s to reduce maternalmortality by three-quarters between 1990 and 2015, implyinga ratio by 2015 inDRC o f around 320 per 100,000 live births. This i s certainly unattainable by that time, although significant progress i s possible with sufficient effort and investment. 51. A 2001 survey (n= 3,049 households) inKinshasa estimated a maternal mortality ratio of 1,393 per 100,000 live births usingthe directmethod, which refers to mortality duringthe previous year. Likewith other health outcomes, urban areas and the west of the country wouldbe expected to have lower maternalmortality. However, the level o f mortality observed inKinshasa i s still extremely high(even thoughperhaps lower than elsewhere), indicating that the risk of maternal mortality is elevated across the country. Indirect estimates from this survey indicate that maternalmortality inKinshasa inthe late 1980sand early 1990swas considerably lower, at around 500-600 per 100,000 live births.(OCHA, 2001) 52. It i s also important to note that the highfertility significantly increases each individual woman's lifetimerisko f maternal death. Inaddition, the highrate o f adolescent fertility increasesmortality, as young mothers are at increasedrisk. 53. Mothers die in childbirth due to lack of access to emergency obstetric care, delays in seeking and obtainingsuch care, and oftenpoor quality. A health facility survey inKinshasa in2001foundthat the mainimmediatecauses ofmaternaldeathinfacilities were hemorrhage (31%), sepsis (lo%), eclampsia (9%), and severe malaria (5%). (OCHA, 2001) These conditions are all preventable or treatable ifappropriate quality care i s receivedintime. However, in situations such as DRC, delay indeciding to seek care, delay inreaching a facility where care i s offered, and delay inreceiving appropriate care at the facility, all contribute to a lack o f effective care for delivery complications. Unsafe abortion seems to be an important cause of maternal death. A survey inKinshasa, for example, found that 30% of pregnant adolescent girls had attempted unsafe abortion. (Casey, 2002) 54. A sixth of mothersare malnourished. The 2001 MICS2 measured the body-mass index of non-pregnant mothers, estimating that 17.3% are malnourished. Inrural areas 19.2% are malnourished, while inurban areas the proportioni s 13.2%. Among the poorest quintile, 21% of mothers are malnourished, compared to 12% among the most well-off. Children of under- nourishedwomen are also significantly more likely to be acutely malnourished(wasted). For example, 21% of the under-five children of mothers considered malnourishedwere also acutely malnourished, while the proportion for other mothers was (a still high) 12%. 35 Chapter 1: Health Situation and Determinants 55. Poor maternal healthand care leadto poor pregnancyoutcomes. A significant proportion of pregnancies end inwhat can be consideredpoor outcomes. A study of 10,528 deliveries between 1993 and 2001 inone reference hospital inthe Ituridistrict Province-Orientale found that 15.3% hadpoor outcomes, including 10.5% premature births, 3.8% stillbirths, and 3.3% abortions. The study also found an increasing trendinthese outcomes associatedwith the conflict. For example, premature deliveries were 6.3% o f the total in 1993, but exceeded 11% duringpeakperiods of the conflict. (Mugisho et al., 2003) Similarly, a 2004 retrospective mortality survey inall parts o f the country found that around 11%ofpregnancies ended in spontaneous abortion or stillbirth. (IRC, 2004) 56. Poor maternalhealth andinadequatedelivery care leads to high neonatalmortality. Good care at delivery i s essentialto newborn health. Neonatal mortality (under one montho f age) inDRC i s not known. Inother countries o f Sub-SaharanAfrica it can account for halfor more o f infant mortality (under one year of age), which i s estimated at a very high 128 per 1,000 inDRC. Assuminganeonatalmortalityrate of65 per 1,000 suggeststhat 200,000 ofthe 2.8 millionnewborns annually inDRC will die soon after birth. 57. Over one inten newbornshaslow birthweight. Low birthweighti s an indicator of poor maternalhealth and nutrition, and i s a determinant o f the child's longer-tem survival and development. The 2001 MICS2 found that only half o f birthsinthe previous year were weighed. Of these, 11% hadlow birthweight. A similar proportion of all birthswere considered underweightaccording to the perception andreport o ftheir mothers. This proportion is consistent with estimates from other very poor countries. 58. Many girls andwomen are victimsof sexual violence associatedwith the conflict, particularly inEasternDRC. Thousands of women and girls (and someboys andmen), particularly inEastern DRC, were victims of sexual violence committed by members o f the different amed groups involvedinthe conflict. An assessment inSud-Kivuin2001 estimated that 2,000 women had experienced sexual violence duringrecent conflict there. (Casey, 2002) Over a six-month period during the last halfof 2003, 550 victims of sexual violence, including some boys and men, were treated at one NGO-supportedhospital in Sud-Kivu.(MSF, 2004) Medical consequencesinclude HIV/AIDStransmission andreproductive healthproblems, particularly fistulae. There are also serious psychological and social effects, particularly ostracism bywomen's family and community. Along with continuing insecurity inparts of the country, sexual violence continues; for example, in2004 an NGO documented 130rapes committed during several weeks of conflict inBukavu, Sud-Kivu. (IRIN,2004) 6. HIVIAIDS 59. Adult prevalenceof HIV is estimatedat 4-5%, which indicatesan epidemicwhich has spreadfromhigh-risk groups to the generalpopulation. The economic disruption and isolation due to the war may have kept the epidemic from increasing at a faster rate inrecent years, although large groups, such as displacedpersons, have likely become more vulnerable to the disease. Itis estimatedthat about 1.1millionpeople are livingwith the disease, among whom almost 60% are women, and that 100,000 deaths annually are causedby AIDS. An estimated 770,000 children are orphans becauseof the disease.13(UNAIDS, 2004) Because a nationally- representative prevalence survey has not beendone, these estimates are derivedfrom models. Sentinel surveillance among pregnant women attending antenatal care i s not complete or systematic. The available data measureprevalence amongpregnant women inthe range o f 4-8%, l3Note that these are UNAIDS estimates for end 2003. U N A I D S estimates adult prevalence at 4.2% while the DRC National HIV/AIDS program estimate is over 5%. 36 Chapter I: Health Situation and Determinants and suggest that prevalence has remainedrelatively stable inurban areas since 1990 butthere are signs of an increasing trendinrural areas. (UNAIDS, 2004) 60. The availableinformation indicateshighprevalenceamonghigh-risk groups. Studies in Kinshasa through the 1990shave consistently shown HIVprevalence o f over 30% among commercial sex workers. Studies inthe late 1990sina hospital inGoma (Nord-Kim) found that 50-99% o f sexually-transmitted infection (STI) patients were infectedwith HIV. Prevalence among tuberculosis patients inhospitals inKinshasa, Bwamanda (Equateur), and Mbuji-Mayi (Kasai-Oriental) in 1997 was found to be over 30%. (UNAIDS, 2004) 61. General awareness of HIV/AIDSi s high, but more specific knowledgeof preventive measuresis limited. The 2001MICS2 found that 92% o f adult women knewo fHIV/AIDSand that 87% knew of at least one preventive measure. However, only 40% knew of three methods o f prevention (faithfulness to a un-infected partner, condom use, and use o f sterilizedneedles). While 80% reported that faithfulness can preventthe disease, only 48% knew that condom use could do so. Inaddition, only 20% knewthat all three erroneous statements given about HIV transmission were false; for example, only 35% knewthat the diseasecannot be transmittedby mosquitoes. Taken together, only 10% o f women bothknew o f the three preventivemethods and knewthat the three erroneous statementsabout transmission were false. 62. Specificknowledgeis lower inrural areas and amongthe poor. Although awarenessof the disease i s highinbothruraland urban areas, specific knowledge is more limitedinrural areas. Inrural areas, 35% of women knewo f the three preventivemethods, compared to 50% in urban areas, and 43% knew of condoms as a preventivemeasure compared to 57% inurban areas. Inruralareas, 18% knewthatthethreeerroneousstatementswerefalse, comparedto24% in urban areas. Similarly, although general awarenesso f the disease i s almost 90% among the poorest quintile, only 32% know o f all three preventive measures, compared to 54% inthe highest quintile. With regardto false statements about transmission, 18% inthe lowest quintile could identify all three, compared to 25% inthe highestquintile. 63. Risky behaviorscontributeto HIV transmission, with women inrural areasparticularly vulnerable. The 2001 MICS2 found that about 11% o fwomen hada sexual partner other than theirregularpartner duringthe previousyear, andthat only 13% oftheseusedcondoms. Almost 50% of those reportingnon-regular sexual relationshad two or more non-regular partners. Inall relationships, condom use i s very low -in2001, only 2.3% of women inpartnerships reported usingthem. 64. Inrural areas, non-regular sexual relations are more common (12%) compared to urbanareas (9%), use of condoms inthese relationships muchless frequent, and several partners more common. Socio-economic differences inrisky sexual behavior are also evident, as lower quintiles are more likely to have non-regular partners, less likely to use a condom, and more likely to have severalpartners. These patterns indicatethat risky sexual behavior is associated with economic vulnerability (as opposed to beingsolely an issueof choice or morality). 7. Malaria 65. All of the populationof DRCis vulnerableto malaria, which is the single most riskofendemic malaria, whilethe remaining3% - mostly livinginhighlands inthe east ofthe important causeof morbidity inthe country. It is estimated that 97% of the population i s at country -are vulnerable to epidemic malaria. As discussed above, the 2001MICS2 showed that 42% of under-fivechildren had fever inthe previous two weeks, and that this varied little geographically or by socio-economic status. This level o fprevalence i s consistent with 6 to 10 episodeso f malaria experiencedby under-fivechildren annually -for an impliedtotal o f 60-100 37 Chapter 1: Health Situation and Determinants million cases. Not surprisingly, malaria i s estimated to account for at least one third of outpatient consultations at health facilities. 66. Malariai s the number one killer of under-fivechildreninDRC and a significantcause of mortalityamongolder childrenand adults. Recent retrospective mortality surveys show that fever i s associatedwith 40% of deaths of under-fivechildren inall parts o f the country. Assumingthat 80% ofthese fevers are dueto malariaimplies over 180,000 annual deaths of under-fivechildrencausedby the disease. The data also indicatethat fever i s also the most commonreportedcause o f death for older children and adults -around 20%. (IRC, 2004) 67. Malaria i s an important contributor to poor maternal health and nutrition, directly and indirectlycontributingto maternalmortality. The data from one hospitaldiscussedabove indicatedthat 5% of maternal deaths could be directly attributedto malaria. Inaddition, having malaria duringpregnancy can result ina variety of adverse outcomes such as spontaneous abortion, low birthweight,and neonatal death. 8. Tuberculosisandothers 68. Tuberculosis(TB) incidenceis high, seems to beincreasing, causes a significant proportionof mortality,and is associatedwith HIVinfection. The NationalTuberculosis Control Programestimates annual TB incidence inDRC at 384 per 100,000 population. Incidence may be increasing, as the number of notified cases has increased steadily since the early 1990s. It i s thought that 25-30% of TB cases are also infectedwith HIV.(WHO, 2004) Data from recent retrospective mortality surveys suggestthat 10-20% o f mortality among older children and adults i s associatedwith TB. A recent study inKinshasa found that 5.4% of new and previously-treated cases were multi-drugresistant. Country-wide, resistance i s estimated at 1.5% of cases. Social stigma adds to the burden of those suffering from the disease and hampers control efforts. 69. A number of other infectiousdiseases are endemic andepidemic. Along with the infectious diseases which cause most morbidity and mortality among children (malaria, measles, respiratory infections, and diarrhea) a number o f other diseases are endemic among some populations or erupt inperiodic epidemics. These include meningitis,trypanosomiasis, onchocerciasis, leprosy, schistosomiasis, plague, ebola virus, and others. 9. Overallmortality 70. An estimated3.8 million "excess" deathshavebeenassociatedwith the conflictinDRC since 1998. Any descriptionofthe health situation inDRC requiresa discussion of overall mortality, particularly relatedto the conflict. The NGOretrospective mortality surveys discussed above inrelation to under-five mortality were primarily concerned with estimating crude mortality rates for all ages. In 1998-2001, a series o fretrospective mortality surveys were done by IRC inEasternDRC. Crude mortality rates (all ages) ofbetween2.7 and 12.1per 1,000 per month were estimated from households' reports of members dying during a recall period. In terms of daily rates, these were equivalent to 0.9 to 4.0 per 10,000 per day. Observed crude mortality i s often presented this way inorder to allow comparison with a threshold o f 1 deathper 10,000 per day, acceptedas the signal for a humanitarian emergency. 71. In2001, MSF studied mortality infive locations across the country, finding crude mortality rates of 0.6 to 2.7 per 10,000 per day. In2002, IRC conducted a set o f surveys which were more representative than previous exercises, covering areas inbotheast and west and contacting 4,500 households in20 HealthZones. Inthe easternhalf of the country, monthly crude mortality was estimated at 3.5 per 1,000, while inthe West it was estimated at 2.0 per 1,000, for an overall 38 Chapter 1: Health Situation and Determinants average o f 2.2 (equivalent to 1.2 per 10,000 per day inthe East and 0.7 per 10,000 per day inthe West). IRC conducted a similar and expanded set of retrospective mortality surveys in2004, questioning 19,500 households in25 Health Zones. Fromthis, it was estimated that crude mortality was 2.3 per 1,000 per month inthe easternhalf of the country, 1.7 inthe West, and 2.0 overall (equivalent to 0.7 per 10,000 per day). 72. The various IRC studies compared their mortality estimates to an assumedbaseline for Sub- SaharanAfrica of 1.5 deaths per 1,000 per month inorder to estimate "excess" mortality due to the war. By the time of the 2004 study, this estimate hadreached 3.8 million. 73. Life expectancy i s low, at an estimated 45 years or under, and has been decreasing. Estimates of life expectancy are derivedfrom models and can vary depending on the baseline data and assumptions. The most recent census inDRC was in 1984 but demographers are still dependent on it to make projections, particularly on overall population size. The 1995 MICS1 and 2001 MICS2 provide more recent data on some parameters, inparticular age and sex distributions, fertility, and childmortality. However, overall mortality was not measuredbythese surveys, so that estimates for life expectancy at birthcan vary significantly. For example, the U S Census Bureauestimatesthat life expectancy inDRC was 48.3 years in2000, the World Bank indicates that it was 45 years in2004, and the UNPopulationDivision estimates that it will be 43.8 years duringthe period 2005-10. Figure 14."North" family model life tables implied by under-fiveand crude mortality rate estimatesfrom differentsources, DRC, 1984-2004 -under-5mortality(5qO) e--- mortality (5qO) 200/1,000(1984census) .....annual under-5 220/1,000(2001 MICS2) crude mortality24/1,000(2004 IRC study) 0.0104 I I I I I I , I I , , , I I I I , 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 age Authors' estimates using US Census Bureau(2003)and data from Schneidman(1990), 2001 MICS2, and IRC (2004). 74. The estimates for under-fivemortality from the 2001 MICS2 data, discussedabove, were derivedusingan indirectmethodwhichmakes use ofmodel life tables (representations of the mortality o f all ages ina model population). These tables can be used to characterize the overall population mortality patternimpliedby observed mortality among one or more age groups, such as estimated under-five mortality rates.14(Figure 14) Usingthis method, the under-fivemortality estimate from the 2001 MICS2 data of 220 per 1,000 implieslife expectancy at birthof 47.6 years. l4The "North" family ofthe Coale-Demenymodellife tables is used. 39 Chapter I: Health Situation and Determinants 75. The 2004 IRC retrospective mortality survey provides mortality estimates derived ina different manner; that is, direct estimation from reportednumbers o f deaths duringa 16-month recall period. The survey estimated crude mortality among the entire population-2.0 deaths per 1,000 per month. Linkingthis to an impliedlife expectancy on a model life table results ina considerably lower figure o f 39.2 years.I5 Insofar as this set o fretrospective mortality surveys was valid - and there i s no obvious reason to question this -this estimate i s the more likely because it comes from data on the mortality experience o f the entire population. Ifthis i s the case, it would further indicate that the mortality experienced by the population o f DRC inrecent years has beentruly catastrophic. 76. One basis for comparison may be estimated life expectancy in 1984 (47.2 years) and 1990 (52 years). Even the higher range o f current estimates would meanthat decades o f progress have been erased. 77. The increased mortality associated with the conflict was not due to direct violence, but due to deterioration of socio-economic, nutrition, and health conditions. Data on the causes associated with reported deaths from the 2004 retrospective mortality survey make clear that most mortality i s due to increasedmalnutrition and disease caused by displacement and socio- economic disruption associated with the conflict. Cause-specific mortality among under-fives i s detailed above inFigure 11. Among older children and adults, about a third o f deaths had unknown or unreported causes. The mainreportedcauses o f death were fever (around 20% o f the total which includes the unknowdunreported category), diarrhea (8-12%), tuberculosis (7-12%). Respiratory infection and malnutrition were reportedto each cause around 510% o f deaths. Measles, meningitis, and accidents were reportedto be associated with around 4-5% o f mortality. HIV/AIDSwas reportedinabout 1.5% o fcases, andmaternal mortality was reportedto account for 254.0%. Violence was one o f the least common reportedcauses, althoughmuch higher in the eastern part o fthe country (around 3%) than inthe West (less than 0.5%). l5Like other life expectancy estimates, this is the expected years o f life for a birthcohort ifit were to experience the mortality conditions measured for a particular period- inthis case, the survey recall period from January 2003 to April 2004. 40 Chapter 2: Health Service Utilization Chapter 2: Health Service Utilization 1. Overallservice utilization 1. Utilization indicatorsare analyzedas reflectionsofthe performanceof the health system, but dependon a rangeof factors. Becausethe effectiveness ofthe health systemcan only be felt through the use o f its services, health service utilization indicators are analyzed as reflections of health systemperformance. Utilization i s affectedby a range o f factors, bothinside and outside the health system. Supply-side factors, relating to policy andprograms, organization, human resources, drug supply, and service quality, are discussed inChapter 3. In this chapter, levels, trends, and disparities inhealthservice utilization are described as reflections o fpatterns inperformance o f the system, recognizing that a number o f demand-side factors, in particular household education and socio-economic status, are important. Table 12. Annual rate of new curative consultationsper capita, 2001 % population province average rate range covered by reoorts Bandundu 0.16 0.00-0.25 65% Bas-Congo 0.07 0.01-0.21 72% Equateur 0.40 0.04-0.78 19% Kasai-Occidental 0.06 0.02-0.36 87% Kasai-Oriental 0.09 0.03-0.62 60% Katanga 0.16 0.02-0.64 64% Kinshasa 0.15 0.05-0.45 100% Maniema 0% Nord-Kivu 0.42 0.05-1.99 100% Province-Orientale 0% Sud-Kivu 0% overall estimate 0.15 0.00-1.99 54% Source is Service Nationaldes InformationsSanitaires(SNIS) (2003). 2. Health information system indicatorsshow overall service utilization i s very low, both in comparisonto needand in comparisonto past decades. Inaddition to indicators derivedfrom household surveys, healthinformation systems can provide measuresof service utilization. An indicator usedwidely inDRC i s the ratio ofnew consultations for curative care to catchment area population. This is often measured on the scale o f the Health Zone and can vary widely. Small- scale surveys and NGOreports suggest that deterioration of health services over the past decades has ledto very low utilization inthe absence of external assistance-inthe range of 0.10 to 0.20 curative consultations per capita. Table 12provides 2001 data on this rate from the national healthinformation system.16 With Health Zones covering about 54% o f the populationreporting, the averagerate ofnew curative consultations per capita was 0.15. Bycomparison, ratesof 0.60 were observed inthe country duringthe 1980s. The rate o f 0.60 i s also a goal for current humanitarianprograms, while an often-citedideal target for health services inDRC i s 1.O. However, the real need for health services inthis malaria-endemic country i s more likely at least 2.0 consultations per capita annually. l6Reported estimates do not reflect utilization o fprivate for-profit services, which may be important in particular inKinshasa. Data from private non-profit (confessional) providers inrural areas are more likely to have been collected by the health information system, but this i s not clear from the documentation. 41 Chapter 2: Health Service Utilization 3. There is wide variation inutilization, with higher levelsof utilization concentratedina limited number of facilitiesin a minority of Health Zones. Table 12shows that, except for Equateur and Nord-Kivu, province average curative service consultation rates are fairly similar, inthe range of0.06-0.16per capita. Reportingis very incompleteinEquateur, so that the real figure i s likely inthis low range. However, within provinces, there i s wide variation, with many Health Zones reporting curative consultation rates o f less than 0.10, and only a few with utilization rates anywhere close to 1.O. This suggests a situation in2001where adequately functioning public health services were concentrated inlimitednumber o f facilities in a minority o f Health Zones. Figure 15. Annual per capita rate of curativeconsultationsin two HealthZones in ProvinceOrientalesupported by the EU,2000-2004 1.00 Zone de Sante d'ku _I 0,QO 0,60 0,70 influxdes d@la&deBufla 0,60 0.50 0,40 0,30 rentr8e scblaire 0,20 deplanter saison deplantec 0.10 :1: ,Zone de Sante de Logo 0 3 Source is Maltheser (2004). 4. External support to HealthZones, improving service quality and reducinguser fees, can raiseutilization rates. The 2001 utilization rate o f 0.42 shown inTable 12 for Nord-Kivu, where all Health Zones reported, i s somewhat higher than what i s observed elsewhere, perhaps reflectingpatterns o f external assistance at this time. At the Health Zone and facility levels, NGO reports indicate that external assistance can indeed increase utilization. For example, the NGO 42 Chapter 2: Health Service Utilization COOP1reports that the curative consultationrate intwo Health Zones it supported under a humanitarianprograminEquateur increased from 0.18 inmid-2000 to 0.65 by end-2002. The NGO ECC/IMA reports that under a World Bank-supported project, average utilization rates ina numberofHealthZones increasedwithinayear from 0.06 to 0.21 inKasai-Occidentaland from 0.10 to 0.27 inKatanga. 5. External support is not the only factor affecting utilization as servicesare affected by a variety of contextual forces. A variety o f factors can be at work preventing significant improvement, from the scale and quality o f the external assistanceitself, to contextual forces such and economic and seasonalevents and political instability and conflict. 6. Figure 15 provides interestingillustrations of some o f the factors which affect health system performance and utilization. The graphs show the evolution inthe annual rate of curative consultations per capita intwo Health Zones inProvince-Orientale supported by the European Union through the NGO Maltheserbetween2000 and 2003. InbothZones, baseline utilization rates were under 0.20. Factors related to the health systemitself are associatedwith changes in utilization. InAru, the start of assistancein2000 i s associatedwith increasesinutilization, followed by ups and downs, but a general increasing trend to rates o f around 0.40-0.50 by the end of 2003. InLogo, an initialincrease after the start of assistancei s followed by stagnation, so that by the end of 2003, the ratewas around0.30. Short-term variation is associatedwithdiscrete events, but the overall trendinLogo is explained by the fact that a number o fprivate non-profit providers are present and extensively used by the population. This illustrates anumber of issues: i)theimportantroleoftheprivatenon-profitsector; ii)theneedforassistanceprogramstotake inaccount privateproviders; andiii)the weaknessofhealthinformationstatistics which do not include data from private services. Other health systemfactors are at work. InAru, inclusion of additional facilities "which didnot take off well" inthe assistanceprogram i s associatedwith a decrease inutilization. NationalImmunizationDays (JNV)are associatedwith decreases in utilization, perhaps due to diversion of health staff. 7. Seasonal factors, inparticular the planting season, are also correlated with decreases in utilization. Conflict and displacement are also important. InLogo drops inutilization are correlated with fightingin2002, while general insecurity in2003 i s associatedwith a declining trend inutilization. InbothZones, utilizationjumps with influxes of displaced persons. 8. Data from RutshuruinNord-Kiw also illustrate how contextual factors can affect health services, at the same time as showing that Health Zones can be quite resilient insituations of crisis. Porignon et al. (1998) found that the annual per capita rate of curative consultations increased from 0.10 in 1985 to 0.39 in 1995, despite drastic cuts ingovernment and external fundingat the start ofthe 1990s. An influx ofRwandanrefugees in 1994dramatically increased the demand, whichthe HealthZone was largely able to meet with some externalassistance. The authors conclude that the resilience o f the health systeminthese circumstances can be attributed to the zonal organizationof services, integratingprimary and first-referral services, decentralization of decision-makingto the zonal level, the long-term development o f health humanresources inthe zone, and the limitedbut steady external support. 2. Hospital service utilization 9. Hospitalinpatient admission rates are very low. Inline with overall service utilization rates, inpatient admissions to first-referral hospital services are very low, estimated inmany areas to be around 10-15 new admissions per 1,000 population. This can compare to rates around 35 observed inthe country duringthe 1980s and an average rate of 45 observed inseveral Sub- SaharanAfrican countries duringthe same period. Table 13 provides 2001 healthinformation systemestimates, averaging around 15 inpatients per 1,000 population. A 2005 study o f data 43 Chapter 2: Health Service Utilization from 78 hospitals found similar rates, with on average 18.9 hospital admissions per 1,000 population. (RCvillion, 2005) Table 13. Annual rates of hospital inpatientsper 1,000 populationand hospital bed occupancy,2001 inpatients bed % population province per 1,000 occupancy covered by population rate reports Bandundu 21 49% 58% Bas-Congo 12 10% 85% Equateur 15 47% 29% Kasai-Occidental 0% Kasai-Oriental 14 60% 53% Katanga 10 16% 56% Kinshasa 0% Maniema 0% Nord-Kivu 17 38% 90% Province-Orientale 0% Sud-Kivu 0% overallestimate 15 37% 37% Source is Systeme Nationaldes InformationsSanitaires (SNIS) (2003). 10. Bed occupancy rates are similarly low, reflectingboth low utilization and a legacy of poorly-functionalinfrastructure. The overall average bedoccupancy rate in2001from reported data i s 37% (Table 13). Inprovinceswith relatively highreporting completeness, the rate i s 10% inBas-Congo and 38% inNord-Kivu. The 2005 study o f 78 hospitals found an averagebed-occupancy rate o f 37.7%. (RCvillion, 2005) These figures suggest a situation of low utilizationcombined with a legacy of infrastructure which i s no longer functional after years of deterioration. 3. Childhealthandnutritionservice utilization 11. Indicators from household survey data similarly show low utilization of basic child healthand nutrition services. Indicators of service utilizationmeasured by household surveys do not have some o f the limitations of health information systemdata, inparticular relating to reporting completeness anduncertainties about the denominator. Some o f the health-related MDGindicators described inTable 3 inChapter 1are suchmeasures. Table 14provides estimates from the 2001 MICS o f anumber of indicators relatingto childhealth services. 12. Coverageof routine immunization and other basic preventivechild healthservices is low, especially inrural areas. Coverage ofbasic preventive services i s low, particularly inrural areas, where less than halfof one-year old children hadmeaslesor BCG vaccination. Coverage of at least one polio vaccination i s better, at over 70% inbothurban andrural areas. These patterns suggest that while polio vaccination campaigns may be achieving some success, routine immunization inrural areas i s performing very poorly. A survey o f five provinces (n= 613) found measlesvaccination coverage o f 70.9%. (ESP, 2003) A small survey inNord-Kivu in2003 (n=292) foundthat 53% were fully vaccinated. Ofthe 22% who hadnovaccinations, reported reasonswere mostly related to supply factors -lack of vaccines and services at the health centers. (Soeters, 2003) Problems experienced on the ground by an NGO operatinginProvince-Orientale include poorly trained andmotivatedpersonnel (since they cannot charge fees for vaccinations, butdo notreceive adequatesalaries), problems with the cold chain, andunreliablevaccine supply.(Maltheser, 2004) 44 Chapter 2: Health Service Utilization 13. Coverageof regular vitamin A supplementationi s low. The 2001 MICS found that overage o f Vitamin A supplementation i s low, with 11.5% of one-year children havingreceived it duringthe previous six months. However, althoughnot administered as often asrecommended, this interventionseems to besomewhat available inthat an additional 51.6% ofchildrenwere reportedto have received supplementation at some point. A survey infive provinces (n= 880) found a lower rate of 22.5% who hadreceivedvitaminA supplementation at some point. (ESP, 2003) Table 14. Child healthservice utilization indicators,DRC, 2001 (%) urban rural overall primary preventive polio-I vaccination (12-23 mos) 79.4 69.0 72.4 measles vaccination (12-23 mos) 67.2 36.5 46.4 BCG vaccination (12-23 mos) 73.6 43.3 53.1 vitamin A supplementation (6-59 mos)' 13.7 10.4 11.5 insecticide-treatedbednet (under 5) 2.1 0.1 0.7 primary curative ARI treatment by health provider (under-5)'* 46.3 32.3 35.8 treatmentwith anti-malarials (under-5)** 63.0 47.4 52.0 **inchildren with ARI or fever in previous 2 weeks previous 6 months Source is 2001 MICS2. 14. A service packagedesignedto providebasic child healthand nutrition interventions seems to be available to an extent, but regular utilization is low. The main strategy for providing basic preventivechildhealthand nutrition services, particularly immunization, vitamin A supplementation, and growth monitoring, is through "consultations prC-scolaires" at primary health care facilities. The 2001 MICS measured several indicators for utilization of these services. Inurban areas, 64.7% of under-five children are reportedto have a growth chart, compared to 42.9% inruralareas. The overall average i s 50.0%. This indicates fairly high coverage inurban areas inparticular, but there i s evidence that these services are used infrequently, particularly as the child gets older and vaccinations are no longer provided. The survey found that only 28.2% o funder-fivechildren inurban areas and 21.9% inrural areas had beenweighedduringthe previous three months. The overall averagei s 24.0%. 15. Continuity of child health services is poor. Vaccination coverage data can provide indicators for continuity o f services. Three doses o f DTP are necessaryfor effective protection and the 2001 MICS found that overall coverage o f DTPl among one-year-olds was 51.2%, but this declinedto 29.9% for DTP3. Thismeansthat 41% ofthe childrenwho receivedthe first does didnot continue onto the third dose. Inurban areas, this proportionwas 32%, while inrural areas it was 50%. 16. Use of insecticide-treatedbednets is extremely uncommon, relatedto lack of awareness, availability, and cost. The 2001 MICS indicates that only 0.7% ofunder-5 children were sleeping under one. Infact, utilization of any bednet (treated or untreated) i s low, at 11.8%. This low utilization i s likely relatedto both awarenessand cost. A study inNord-Kivu found that only 39% of respondents had even heard ofbednets, and only 5.6% of households use one (n= 352). The average price o f abednet was found to be over $US6, and 49% of o frespondents indicated they do not use anet becauseo f the cost. (Soeters, 2003) InKasai-Oriental, a survey (n=470) 45 Chapter 2: Health Service Utilization found that only 12% of households useda bednet. O f those not usingbednets, 47% reportedit was due to financial reasons and 24% reportedit was due to lack o f availability. (PSF, 2003) 17. The evidence on household child healthknowledgeandbehavior indicatesconsiderable requirementsfor healtheducation. The 2001MICS assessedcaregivers' knowledge of signs which should spur themto seek care for their child: not able to drink or breastfeed (2 1.7%), becomes sicker (32%), develops a fever (47.5%), has fast or difficult breathing (22.8%), has blood instools (18.9%), or i s drinkingpoorly (13.5%). A survey infive provinces (n=4,658) found that 72% o f caregivers recognized highfever as a sign that treatment shouldbe sought, 43% would seek treatment ifthe child seems be sufferingor does not play, and 29% indicated that at childnot eating or drinkingwould be cause for concern. (ESP, 2003) These figures indicate substantial gaps inknowledge of childhealth danger signs. 18. Indicators also suggest that utilization of basic curativechild healthinterventionsi s low. The 2001 survey found that less than a thirdofunder-5 children with ARI symptoms were treated by a health service provider inrural areas, andless than halfinurbanareas, with anoverall average of 35.8%. (Table 14) Although treatment with anti-malarials for febrile children inurban areas i s higher, at around two-thirds, it i s less than 50% inrural areas, with an overall average o f 52.0%. 19. Only a minority o f febrile children receive treatment. The 2001 MICS2 found that 31% o f children sufferingfrom fever were brought to a clinic and only 53% o f these received treatment. 20. Data on home treatment of diarrhea reflects lack of knowledge. The 2001 MICS found that only around 10% inbothurban and rural areas reported increasing fluids and continuing feeding for a child with diarrhea inthe previous two weeks. A 2003 survey infive provinces found that 25.5% of children with diarrhea inthe previous two weeks were not treated inany particular way, while 58.4% received anti-diarrheal, antibiotic, or other types of drugs -which are in inappropriate inmost cases. Only 23.8% were treated with a packet of oral rehydration salts (ORS) or homemade solution. (ESP, 2003) This survey also found that of childrenwho were ill inthe previous two weeks (n= 1,955), 22.2% were givenless breastmilk than usual, 26.3% receivedless liquidsthan usual, and 52.2% consumed less solid food than usual. (ESP, 2003) 4. Reproductive, maternal, and neonatalhealth service utilization 21. Although higher in urban areas, utilization of modern contraceptives is not suficient to meet demand. Modem contraceptive prevalence of 9.0% inurban areas i s higher than observed in other very poor Sub-SaharanAfrican countries, but still i s unlikelyto meet demand. The rate o f 2.5% inrural areas i s very low. (Table 15) A qualitative study inNord-Kivu andManiema in 2002 found that family planning services are not offered inan effective way through health services, partially becausemen, who often have the decision-making authority inthe family, are not targeted. (Casey, 2002) There i s evidence that the unmetdemand i s considerable; for example, an NGO assessment intwo HealthZones inManiema in2002 found that o f 600 women interviewed,two-thirds were interested inusingmodern contraceptives, butnone were available to them. (Traore and Grant, 2002) A study inNord-Kivuin2003 found that 58% o f 462 surveyed women would like to use a family planning method, but only 3% were usinga modem method of contraception. (Soeters, 2003) A small survey inKasai-Oriental (n= 508) found that 58% of women use a traditional method of contraception, while only 13% use a modem method. (PSF, 2003) A survey infive provinces (n= 5,519) found that 8.6% of women were usinga modern method, compared to 55.5% usinga traditional method. Among the 45.9% not usinga method, around half said the reason i s that they do not know of any. (ESP, 2003) 46 Chapter 2: Health Service Utilization 22. Antenatal care coverage fairly high inurban areas, but overall only half or pregnant women receive care. The 2001 MICS found that 58.9% o f women inurban areas with abirthin the previousyear received antenatal care from a qualified person. Inrural areas, utilization i s lower, at 40.6%. The overall average is 46.1%. Followingstandard practice, these figures do not include traditionalbirthattendants, trained or untrained." Table 15. Reproductiveand maternal health service indicators, DRC, 2001 (%women 15-49) urban rural overall moderncontraceptiveprevalence* 9.0 2.5 4.4 antenatal care from medical provider** 58.9 40.6 46.1 delivery care by medical provider** 32.0 20.2 23.7 * women married or in union '* women with a birth in the previous year Source is 2001 MICS. 23. Three quarters of mothers do not receive delivery care by medical personnel. The 2001 MICS shows 32.0% of deliveries inurban areas are attendedby qualified personnel, the proportion inrural areas i s 20.2%, and the overall average i s 23.7%. Table 16provides 2001 MICS data on the distribution of delivery care by type o f provider, showing that traditional birth attendantsare the most common caregiver inbothurban and rural areas. These findings suggest that efforts to train village midwiveshave shown some success inDRC. Table 16. Deliveryattendant (% of births in previousyear), DRC, 2001 urban rural overaII doctor 7.5 1.7 3.4 nursehidwife 26.2 19.2 21.3 trained traditional birth attendant 59.1 34.5 41.9 traditionalbirth attendant 6.6 28.0 21.6 relative/friend 6.4 16.1 13.2 other 1.9 3.5 3.0 no assistance 4.6 7.2 6.4 Source is 2001 MICS. 24. A range of factors may be working to limit utiliz.ation of medical delivery care inrural areas, including cultural barriers and financial and opportunity costs. For example, an NGO working in Province-Orientale has found that, compared to public providers whose attitudes may be less than welcoming, many women preferprivate and traditional delivery attendants with whom they feel more comfortable. Private and traditional attendantsalso accept more flexible payment terms. Women are also reluctant to leave their homes becausethey needto ensure the care o f other children and also feel they need to buyclothing for themselves and for the newborn ifthey delivery ina healthfacility. (Maltheser, 2004) These factors certainly vary byregion. For example a small study inNord-Kivu found that women prefer to deliver with a trained attendant rather than traditional providers, who have a poor reputation for quality. O f 148 deliveries, 81% were at a health facility and only 19% at home with arelative or traditional birthattendant. (Soeters, 2003) 25. The limited information on emergency obstetric care (EOC),one of the main determinants of maternal mortality, suggeststhat services are available at referralhospitals Estimatesprovidedby the survey reportare higherbecausethis categoryis included. Estimatesof skilled delivery care differ for the same reason. 47 Chapter 2: Health Service Utilization but quality is an issue, and there are significantfinancial and geographicalbarriers to access. A study ofhospitaldata from RutshuruZone inKivu-Nord for the period 1985-95 found a consistent and large differencebetween the number of Caesareansections for patients living under 5 kmfrom the hospital compared to those living over 5 kmaway. (Porignon et al., 1998) A retrospective cohort study of 1,162 women admitted to two rural referral hospitals inNord-Kivu in 1995-96 foundthat women who lived90 minuteswalk or more fromthe hospitalhadgreater risks of obstetric complications andneonatal mortality. The authors estimated that, considering the expected number of complicatedbirths inthe catchment areapopulation, less than 3% of potential cases arrived at the hospitals. (Mugisho et al., 2003) Figure 16. Utilizationindicatorsby mother`s educationlevel, DRC. 2001 90% urban measles vaccination 80% 80% - 70% - measles 60% - vaccination 40% { P 30% * 20% - ...I.- ....mdical -*.. ,: 7nv0 I .---,, ,,,,,. .-....-. delivery care 10% - lo% i4 0% 0 1 2 3 4 5 6 t years of schooling Table 17. Treatmentof childwith ARI symptoms, DRC, 2001 (% of under-5childrenwith ARI symptoms in previous2 weeks) urban rural lowest highest Overall lowest highest Overall quintile quintile quintile quintile hospital 7 25 15 4 3 2 PHC facility 56 43 40 31 37 32 mobileclinic 0 13 0 0 0 0 CHW 0 0 0 0 0 0 company clinic 0 0 0 0 0 0 privatedoctor 6 0 3 3 6 6 pharmacy/drugseller 27 0 13 6 14 13 relative/friend/other 26 0 13 19 4 13 none 39 19 41 45 48 45 Source is 2001 MICS2. 26. Along with lack of accessibility relatedto distance, financial barriers are often high. The cost of a Caesareansection can range from US$20 to over US$lOO ina country with estimated per capita annual income o f under US$lOO. There are anecdotal reports o f the practice o f health facilities detainingwomen untiltheir families come up with the fees for the procedure. Criel, Van der Stuyft, and Van Lerberghe (1999) provide empirical evidence on the effects of both distance and cost, examining data on insurance coverage andthe distance of village o f origin for 48 Chapter 2: Health Service Utilization 322 Caesareansections at Bwamandahospital inEquateur Province. They found that those not covered by a community insurance scheme were bothless likely to have the procedure and more likely to be affected by distance. 27. A study inNord-Kim indicates other kindsof issuesrelatedmaternalcare and financing. There, it was found that 7.5% o f medically-assisted deliveries involved Caesareansections and that 39% o f deliveries inhospitals were Caesareans. The authors suggestthat these rates, high compared to other parts of the country, are relatedto the financial incentives for healthproviders. (Soeters, 2003) 5. Utilizationby type of provider 28. The 2001MICS2 collecteddata on the treatment o f childrenwith ARI symptoms inthe two weeks previous to the survey (n= 1,025). Table 17provides estimates for urban andruralareas, comparing the lowest quintilewith the highestquintile of an index o f socio-economic status. A number ofpatterns are evident: I n both urban and rural areas, over two thirds of cases either do not receive care or turn to drug sellers orfriendsfamily. I n both urban and rural areas, over 40% of cases do not receive treatment. Inurban areas, the poor are much less likely to receive treatment, while inruralareas, socio-economic differences are not as apparent. An additional one-quarter of cases self-treat. Together, private pharmacies and drug sellers, and treatment by family, friends, or others (both implyingunsupervised or self-medication), account for a total o f 26% of cases inbothurban andrural areas. Inurban areas, the poor are clearly more likely to turn to these types o fproviders. Inrural areas, the better-off are more likely to turnto drugsellers, while the poor are more likely to go to family, fiiends, or others. Among those who receive treatmentfrom aformal provider, PHCfacilities (bothpublic and confessional) are the most commonly used type ofprovider. This is the case inbothurban and rural areas, accounting for 40% and 32% o f cases respectively. Inurban areas, the poorest are more likely to attend a PHC facility, while inrural areas the better-off may be more likely. Non-facility types of PHCproviders, particularly community health workers (CHWs), are not used at all, indicating that they are not available for this type of curative care. Hospitals are more likely to be usedfor this kind ofprimary care in urban areas (15% of cases), especially by the better-ofl Inrural areas, hospitals are rarely utilized for this type of treatment, accounting for 2% o f cases). Even in urban areas,few go toprivate doctors (3% o f cases inurban areas and 6% inrural areas). Inurban areas, these tend to be the poorest, while inruralareas, they tend to bethe better-off. 29. These patterns are seen insmaller-scale studies, whichinaddition indicate: i)that traditional healers represent a small proportion o f utilization; and ii)utilization of privatepharmacies as opposed to PHC facilities seems to vary geographically. A survey inKasai-Oriental (n= 853) found that among those illinthe previous 30 days, 50% went to a health center, 17%went to a privatepharmacy or drugseller, around 4% went to a traditional healer, and 17% receivedno treatment. (PSF, 2003) A study infive provinces (n=4,050) found that among household membersillinthe previous 15 days, 30% turned to publicor confessional healthfacilities, 40% relied on self-medication, 9% went to traditional healers, and 21% receivedno treatment. (ESP, 49 Chapter 2: Health Service Utilization 2003) A study inKivu-Nord (n= 501) similarly found that a total o f 33% o f illness cases went to a public or confessional health facility, 38% turned to a private pharmacy or drug seller, 11% went to a for-profit private healthprovider, 2% went to a traditional healer, and 15% receivedno treatment. The study found that the poor were more likely to not receive treatment and to go to a public or confessional facility, while the better-off were more likely to go to a private for-profit pharmacy or healthprovider. (Soeters, 2003) Figure 17. Utilizationindicatorsby socio-economicstatus quintile, urbanand rural, DRC, 2001 80% 70% 70% - 60% - 60% - 50% - 50% - 40% - 40% - 30% - ;`medical I . I . 30% 1 .-' deliverycare 20% - I. ...,. * . * 10% 0% 1 10% 0% 1 1 2 3 4 5 1 2 3 4 5 quintile quintile Authors'estimateswith data from 2001 MICSP. 6. Determinants of utilization 30. Utilization of health services can be affected by a range o f supply and demand factors. Many of the supply-side factors, .suchas availability, quality, and price o f services are discussed inother chapters. Demand-side factors, such as household socio-economic status and education, are also important. Regression analysis can help assess the influence o f some o f these different factors. Usingdata from the 2001 MICS2, models o fthe determinants o f important utilization indicators are presented inTable 18 and Table 19. (Statistically significant results o f p < 0.10 are inbold). 31. Direct information on health service availability is not availableto beincludedin the models, but there are indicationsthat it is an important factor determiningutilization. The statistical method applied takes inaccount the variation (random effects) between sample clusters which i s not associated with the variables inthe model. This proportion is large, between 20 and 40% o f the total variation depending on the model. This indicates that contextual factors -for example, availability and accessibility o fhealth services - are very important to utilization. 32. Educationsignificantlyincreaseshealthservice utilization, especially inurban areas. Figure 16 shows the unadjusted relationships between indicators o f utilization and education level. It shows that inurban areas, measles immunization, medical treatment o f febrile children, and delivery care by medical personnel increase with education. It seems that just one year o f education has an important effect, with the slopes less steep over higher levels o f education. In rural areas, differences inutilization by education level are less evident, althoughutilization among those with no education at all tends to be lower. The overall lack o f differentiation may indicate that poor service accessibility inrural areas affects most groups, educated or not educated. 50 Chapter 2: Health Service Utilization 33. The multivariate models described inTable 18 andTable 19 suggest further than mother's education i s important with regardto immunization and delivery carebuteffects are not evident for basic curative childhealth services. A mother who has any education (after controlling for socio-economic status) has 2.0 times the odds that her child i s vaccinated against measles and 1.6 times the odds o f having qualified assistanceat delivery. However, mother's education i s not a statistically significant factor with regardto medical treatment of child fever or respiratory infection. Table 18. Logistic regressionmodels of the determinantsof preventiveservice utilization, DRC, 2001 measles vaccination medicaldelivery care (n=2,224) (n=2,614) odds ratio p-value odds ratio p-value age (months)* 0.56 0.00 age2 0.97 0.00 1=male 1.03 0.78 householdsize* 1.02 0.34 0.97 0.05 mother's age (years)* 1.oo 0.18 1.oo 0.95 l=mother has some education 1.99 0.00 1.62 0.00 socio-economicquintile 1.37 0.00 1.30 0.00 1=urban 3.13 0.00 1.47 0.12 Center 0.38 0.00 1.oo 1.oo East 0.49 0.02 1.23 0.45 % variation associatedwith cluster 41% 34% * centered at the mean ** odds ratios are associatedwith an increasefrom a quintile to the next higher quintile Reference region is West. Estimationof significanceaccountsfor survey design. Authors' estimateswith data from 2001 MICS2. Table 19. Logisticregressionmodels of the determinantsof curative service utilization, DRC, 2001 medical treatmentof medicaltreatment of fever respiratoryinfection (n=4,143) (n=l,O25) odds ratio p-value odds ratio p-value age (months)* 0.99 0.00 0.99 0.06 age2 1.oo 0.13 1.oo 0.79 1=male 1.09 0.24 0.94 0.66 householdsize* 1.00 0.76 0.98 0.45 mother's age (years)* 1.oo 0.20 1.oo 0.55 1=mother has some education 1.09 0.37 0.94 0.71 socio-economicquintile 1.22 0.00 1.16 0.06 1=urban I.40 0.08 1.33 0.32 Center 0.94 0.74 0.84 0.56 East 1.25 0.26 0.90 0.72 % variation associatedwith cluster 23% 22% * entered at the mean ** odds ratios are associatedwith an increasefrom a quintileto the next higher quintile Reference region is West. Estimationof significance accounts for survey design. Authors' estimateswith data from 2001 MICS2. 51 types of services are 52 Chapter 2: Health Service Utilization Figure 19. Regionaldifferences in health service utilization, DRC, 2001 1 urban rural 80% 80% 1 IlWest 70% (1 rn Center 70% rnCenter 60% 50% 50% 4 40% 40% 4 30% 30% 20% 20% 10% 10% 0% 0% fever treated at measles medicaldelivery fever treated at measles medicaldelivery clinic vaccinator attendant clinic vaccinatior attendant Authors' estimateswith data from 2001 MICS2. 37. This i s contradictory with the regional differences inmortality and malnutrition discussed in Chapter 1, and can perhapsbe explained bythe importance o f other contextualfactors affecting health status- especially the economic and security situation. As well, it seems that deterioration of the health systemoccurredthroughout the country, notjust inthe regionsmost affected by the conflict. 7. Trends 38. Overall, utilizationof basic curative services declined inthe 1990s, while coverageof preventiveinterventions was more stable. As discussedelsewhere inthisreport, the Congolese health systemhas beenunder severe stress for years. However, the systemalso seems to have surprisingresilienceinmany cases. Utilization data can provide indicators about overalltrends; based on the limited available data, it seems that coverage o f preventive interventionsmay have heldsteady while utilization of curative care decreasedinrecent years. 39. Although antenatal care coverage seems to have remained stable, utilizationof skilled delivery care has declined inrecent years. Comparingthe 2001 MICS2 estimates with a 1998 household survey by the Ministry of Health suggests that antenatal care coverage has remained stable, but utilization o f trained delivery care has declined inrecent years, bothinurban and rural areas. 40. Vaccination coverage seemsto be starting to recover from declines during the 1990s, with improvements concentrated inrural areas and inthe Center and East ofthe country. Figure20 shows estimated trends invaccinationcoveragebetween 1991, 1995, and 2001. It shows that coverage declined duringthe first part of the decade, but seems to have improved to a small extent between 1995 and 2001 -despite the insecurity and conflict duringthose years. These trends reflect cuts ininternational assistanceto the nationalprograminthe early 199Os, with resumptionofassistance-often under humanitarianprograms -later inthe decade. These increases appear to be driven by trends inrural areas, where between 1995 and 2001 measles immunization rates increased from 28% to 37%, while urban areas experienced a slight decline from 72% to 67% inthe same period. Inaddition, Table 20 shows that measlesimmunization coverage clearly increased inthe Center and East regions, but hardly changed inthe western 53 Chapter 2: Health Service Utilization Provinces. This regional pattern can likely be attributed to vaccination campaigns under humanitarianprograms. Figure20. Trends in vaccinationcoverage, DRC (% children 12-23months) 8o 1 i *O 10 0 4 1991 1995 2001 Sourcesare 1991 Enquete Nationale de CouvertureVaccinale, 1995 MICSI, and 2001 MICS2. Figure21. Concentrationcurves for measlesvaccinationand treatmentof respiratoryinfection, DRC, 1995-2001 100% 100% .o cough treated .E 80% p 80% ` .E z 8 3 60% 60% E Y) c' EP, 40% z.c 40% ll#l-ll#*.)1995 0 ae -ap za 20% 20% a -2001 0% 0% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% curnul% children, ranked by wealth Cumul % children, ranked by wealth Note that treatment for cough is from any "modern" source, includingdrug sellers. Authors' estimateswith data from 1995 MlCSl and 2001 MICS2. 41 Utilization of basic curative child health services seems to have declined inthe latter - part of the 1990severywhere inthe country. Table 20 compares data from 1995 and 2001 on treatment o f children with respiratory infection. For the purpose o f comparability with the 1995 data, unlike estimates presentedpreviously, these figures refer to any "modern" treatment, including from drug sellers. Nevertheless they indicatethat access to basic curative treatment declined everywhere inthe country. 42. Socio-economic disparities inimmunization coverage decreased inthe late 1990s,but change i s less evident with regard to basic curative services. As discussed above, data from 2001clearly shows that the poor are less likely to have access to bothpreventive and curative services. When comparing to 1995 data, socio-economic disparities inmeasles immunization remained large, but decreased over time. InFigure 21, the concentration curve moved closer to the diagonal, indicating greater equality inthe distribution o fmeasles immunization. Trends are less evident with regard to treatment o f respiratory infection. (The fact that the estimates include drug sellers may obscure the relationship). 54 Chapter 2: Health Service Utilization Table 20. Trends in health service utilization by region, DRC, 1995-2001 (%) measles immunization receivedtreatmentfor respiratory infection* (children 12-23 months) (under-5 1995 2001 1995 2001 West 55.6 54.2 57.6 49.6 Center 23.7 50.5 51.6 41.8 East 26.1 39.1 59.6 52.2 overaII 32.0 48.0 55.4 47.9 * includesdrug sellers Table 21. Pooled logistic regressionmodel of the determinantsof measlesvaccination, children 12-23 months, DRC, 1995 (n = 1,035) and 2001 (n = 2,231) measles immunization treatment for respiratory (children 12-23 months) (under-5 children) infection (n 3,266) (n = 875) odds ratio p-value odds ratio p-value Time: 0 = 1995,l = 2001 2.17 0.11 1.39 0.48 age (months)' 0.67 0.00 0.99 0.02 age2 0.97 0.00 1.oo 0.66 1 =male 1.04 0.66 0.92 0.44 householdsize* 0.99 0.60 0.99 0.36 mother's age (years)' 0.99 0.20 1.oo 0.89 1 = mother has some education 1.96 0.00 1.76 0.01 mother's educationinteractionwith Time 1.03 0.92 0.53 0.02 socio-economic quintile** 1.46 0.00 1.16 0.12 quintile interactionwith Time 0.87 0.22 0.97 0.80 1 = urban 3.82 0.00 1.54 0.17 urban interactionwith Time 0.57 0.16 0.68 0.35 Center 0.33 0.00 0.78 0.45 Center interactionwith Time 1.03 0.94 0.92 0.86 East 0.47 0.05 0.82 0.59 East interactionwith Time 0.71 0.49 1.26 0.63 % variationassociatedwith cluster 36% 20% * centeredat the mean ** odds ratiosare associatedwith an increasefrom a quintile to the next higher quintile West is referenceregion. Authors' estimateswith data from 1995 MlCSl and 2001 MICS2. 43, Table 21 presents findings from an analysis of change inthe determinants of measles immunization between 1995 and 2001, usinga logistic regressionmodel ofpooled data from the 1995 MICSl and 2001 MICS2. The findings seemto be consistent with the concentration curves inFigure21. Themodel suggeststhat the oddsofmeaslesimmunizationwere significantly greater among highereconomic status quintilesin 1995,butthis effect may have decreasedby 2001 (although the interaction term i s not statistically significant). With regardto treatment of respiratory infection, higher socio-economic status seems to be associatedwith increased utilization in 1995 (although the effect i s not quite statistically significant), and there is no significant change inthe effect in2001. 55 Chapter 2: Health Service Utilization 44. The effects of mother's education on service utilization may have decreased over time. The model presented inTable 21 shows that in 1995 a mother with any education was much more likely to get treatment for her child with respiratoryinfection (odds ratio o f 1.76). However, the interactionterm (with the "Time" variable) indicates that this protective effect was significantly reducedby 2001. This suggests that the conflict may have undermined the advantages educated mothers have -possibly by making curative services less accessible to everyone. 56 Chapter 3: TheHealth System Chapter 3: The HealthSystem 1. Organizationofthe healthsystem 1. With its healthsector reformsof the 1980s, DRCwas one ofthe first countriesto emphasize primary care, an integratedreferralsystem, and decentralization. The adoption o f a newhealthpolicy in 1981, the main theme of which was primary health care, was the point of departure for an in-depthrestructuring o f the health sector, andresultedinthe emergence of the first decentralized entities, i.e., the HealthZones. InDRC, the concept ofprimary healthcare actually predatesthe Alma Ata Declaration. Indeed, the national colloquium in 1975 on community healthcare, chairedby the Ministryo f Health and gathering together church-affiliated medical directors at the national and regional levels, adoptedthe principles of integratedcare and proposed the creation of geographically-definedhealth zones and the decentralized management o f health care services. In 1986, the national territory was subdivided into 306 Health Zones that serve as operational units for the provision o f primary care. In2001, DRCpromulgated a new healthpolicy that increasedthe number of HealthZones to 515 and aligned their boundaries with those o f administrative districts. 2. The supply of health servicesis decentralized,but the Ministry of Health also has a clear hierarchicalstructure. The HealthZones have considerable operational autonomy, but they are far from constituting a federated system, since they are part of a hierarchical organization answerable to the Ministryo f Health. The intermediate levels (District and Province) have considerable administrative power over the Health Zones, particularlywhere staffing i s 57 Chapter 3: TheHealth System concerned. The central level o f the Ministry o f Healthprimarily defines standards and policy, but also has considerable administrative authority interms o f oversight and management o f personnel issues. However, given the Ministry'slow budgets, the powers o fthe central and intermediate levels remain limitedinpractice, with the Health Zones and provincial and tertiary hospitals acting with a relatively large amount o f operational autonomy. The Government has indicated its intention to move inthe direction o f financial decentralization, making the provinces directly responsible for social services and allocatingto them an overall budget for this purpose. Nevertheless, under current proposals, some responsibilities associated with personnel, and particularly salaries, would be retainedat the central level. 3. The centrallevelof the MinistryofHealthi s responsiblefor generalsector policy and systemregulation,nationalprograms, andtertiaryhospitals. The national level o f the MinistryofHealthconsistso fthe Minister, who exercises political authority; the General Secretariat o f Health, which has administrative authority; the thirteen central directorates, including the 4th Directorate, responsible for the major endemic diseases and preventive measures, and the 5th Directorate, responsible for primary health care; and, finally, the specialized programs (52 innumber) responsible for efforts to combat specific diseases, including malaria, HIV/AIDS, tuberculosis, etc. This i s the level at which the design, coordination and organization o f healthpolicy, as well as interventions o f national scope, are handled. The teaching hospitals, national hospitals, specialized hospitals, and national laboratories, are also located at the central level. 4. The Districts andProvinces are responsiblefor technicalsupport and supervision of the HealthZones. The intermediate levelis representedbythe Provincial Health Directorateand its divisions, which organize and provide technical support to the Health Zones. All directorates o f the Ministry o f Health are represented at this level, as i s the coordination o f the various specialized programs. Provinces are subdivided into Health Districts, which are supposed to serve as an interface betweenthe Provincial Directorate and the Health Zone, but are not completely functional. As o f 2005, there were 65 District-level Health Inspectorates and 11 Provincial Health Inspectorates. Inaddition, there are 11so-called Provincial Level Hospitals under the responsibility o f the Provincial Directorates. Each Provincial Directorate i s managed by a Provincial InspectorPhysician. 5. The HealthZone is the operationalunitthat integratesprimaryhealth care services and the first-referrallevel. A HealthZone covers an average populationof 110,000 and consists o f a Central Health Zone Office, an array o f health posts and centers that provide the population with the MinimumPackage o f Activities definedbythe Ministryo fHealth, a General Referral Hospital, offering a Complementary Package o f Activities. EachHealth Center serves an average o f 5,000-10,000 people. The Health Zone i s managed by the Chief Physician o f the Zone, the General Referral Hospital by the Managing Physician (who is often the zone's ChiefPhysician as well), and Health Centers by Designated Nurses. 2. Network of health services 6. Data are poor onthe supply of healthservices inthe country, but it is generally deemed insufficientto meetthe needsofthe population. Geographic accessibility is a major obstacle to the use o f health care facilities, especially inrural areas and on the outskirts o f large cities. The increase inthe number o f Health Zones in2001 was largely intendedas an administrative framework for expansion o f the health service network. Each Health Zone, for example, i s slated to have a general referral hospital, which means that the country would have a deficit o f about 60 hospitals (RCvillion, 2005). However, such expansion will require substantial long-term investment. Table 22 shows the average number o f inhabitants per Health Zone ineach province. 58 Chapter 3: TheHealth System Table 22. Numberof HealthZones and populationper Zone, DRC, 1986and 2004 No. of Health No. of Health Population Province Zones in Zones in per zone 1986 2004 2004 Kinshasa 22 35 140 038 Bas-Congo 27 31 80 982 Bandundu 38 52 144 515 Equateur 33 69 109 150 Kasa'iOriental 27 49 168 875 Kasa'iOccidental 31 43 142223 Katanga 40 67 128 692 Province Orientale 47 83 98 052 Nord-Kivu 19 34 142 020 Sud-Kivu 14 34 133 226 Manierna 8 18 95 295 Total 306 515 111006 Source : Ministryof Health 7. Information on the number o f functioning health care facilities i s not up-to-date. Table 23 shows the ratio o f inhabitants to health care facilities as of 1998, i.e., before the war. The ratios are not only higher than those inother Sub-Saharan African countries, buthave also worsened since 1998 due to the destruction and pillaging o f infrastructure duringthe war and the deteriorationo f the healthcare network. Table 23. Number of inhabitantsper healthcare facility, DRC 1998 Urbanareas Rural areas Standard inhabitants Standard inhabitants per facility per facility General Referral Hospital 150 000 293 598 100 000 163 794 Referral Health Center 20 000 100 924 15 000 62 676 Health Center 10 000 18 144 5 000 9 165 Source : Ministryof Health(1999a) 3. Private sector 8. DRC has a true culture of publidprivate partnership in the managementof healthcare facilities and inthe provisionof care, and a very large non-profit private sector. The network o f hospitals and health centers consists o f facilities belonging to the State, religious denominations, enterprises and private parties. There are a number o f faith-based organizations and NGOswith a significant presence inoperating an array o f health centers and hospitals at all levels o f the health care pyramid. Inmany cases, the health care facilities o fNGOs and faith- based organizations are well-integrated into the structures o f the Health Zones, and often serve as general referral hospitals. This sector i s believedto account for 50% o f all in-and out-patient care. The network of religiously-affiliatedhealth care facilities covers cities as well as rural areas, but the interventions o f these organizations do not extend to all of the country's Health Zones. Due to inadequate Government financing for public health facilities, NGOs have acquired a reputation for delivering care o f better quality. 9. The for-profit private sector has expanded considerablyin cities, but remainsvery small overall. Since the late 1980s, the private sector has developed significantly, mainly inthe capital, 59 Chapter 3: TheHealth System Kinshasa, and inother urban centers. Initially consisting o f establishments offering nursing care, it quickly broadened its scope to include all levels o fmedical care. It i s also involved at all levels o f the health care pyramid and includes healthposts, health centers, maternity clinics, specialized hospitals with more or less sophisticated and differentiatedservices, medical testing laboratories, and diagnostic imaging centers. It is not known how many o f these facilities exist, or what their service capacity is, but it i s believedthat the private for-profit sector ingeneral i s still relatively small. 10. Regardingtheir geographic distribution, private healthcare facilities are mostly concentrated inKinshasa, butthey are also found to some extent inthe other large cities. They are essentially implantedinplaces where the population can afford their services. Although dispensaries and healthposts are found more or less throughout rural areas, the same i s not true o f medical clinics, which prefer to concentrate on specialized services that are more profitable, more costly, and out o f the reach o frural populations. The fees are generally higher than those applied by public establishments or private non-profit facilities, but information on this subject, as well as on the quality o f the services they offer, i s generally lacking. 11. There are reports of the existence of informalhealers and medicinesellers who provide services of questionable quality, but little information i s available about them. Inaddition to 60 Chapter 3: TheHealth System traditional healers, there are informal unqualified providers who offer health services inmany regions. Drugsellers are particularly active to the extent that their drugs and advice are generally less costly than the treatments offered informal public or private establishments. The quality o f these services i s doubtful, but there i s little information on them. 4. Services and quality 12. DRC has a clearly-definedMinimumPackage of Activities(MPA) offeredinhealth centers and healthposts, and ComplementaryPackageof Activities(CPA) providedby first-referral hospitals. However,few healthcare facilitiesprovideall ofthe services includedinthe standardpackages. The services contained inthe MPA, offered at health centers and health posts, are divided into promotional, preventive, and curative healthcare activities. They essentially include neonatal and maternalpreventive care (e.g., tetanus shots, provision o f iron and folic acid supplements, etc.), pediatric preventive care (e.g., immunization, vitamin A supplementation, promotion o fbreastfeeding, etc.), and the management o f maternal, neonatal and childhood diseases (mainly those targeted by the specialized programs o f the MinistryofHealth). Inadditionto these services, testing andtreatment for certaincommunicable or chronic diseases, such as HIV/AIDS, tuberculosis, leprosy, highblood pressure, etc., are also includedinthe MPA. The general referral hospitals are responsible for supplyingthe services includedinthe CPA, including pediatric, internal medicine, gynecological and obstetrical services, as well as general surgery, as well as medical analysis and diagnostic imaging facilities and a bloodbank. Inaddition to an array o f preventive services, they are mainly incharge o f handling cases referredby the lower-level structures. 13. Within the context o f DRC, it i s difficult to gauge the extent o f the services actually provided inthe various healthcare facilities, althoughstudies inspecific districtsandprovincesmay provide an idea o f the situation. Due to the chronic shortage o f financial, material and human resources, the available information suggests that a large proportion o f health centers and health posts do not offer all, or even most, o f the services included inthe minimumpackage. A survey o f 56 health posts selected throughout the country (NGO- and State-run) reveals that 32% are not providing child health care services, 50% are not offering obstetrical services, and 91% are not prepared to handle or counsel HIV/AIDSpatients (BERCI, 2004). Some activities, including mobile service strategies, are not being implementeddue to the lack o f material resources and inputs. 14. Familyplanning services are often unavailable inhealth care facilities, even thoughthey are includedinthe MPA. Of 191persons queried ina survey inNord-Kivu province, 63% stated that condoms were available inprivate pharmacies, while only 9% said that they could be obtained from health centers (Soeters, 2003). In a survey conducted inKasaY-Oriental (n= 356), 37% o f those queried indicated that condoms were available inhealth centers. (PSF, 2003). 15. At the higher levels o f the health care pyramid, the CPA services are also sometimes unavailable at the general referral hospitals and provincial hospitals. The same study (BERCI, 2004) reports that, o f a total o f 56 hospitals surveyed, about two-thirds have no X-ray equipment, over a third lack a gynecological examinationtable, and over 20% are operating without a centrifuge. 16. The healthsystem's responseto sexualviolence is limitedto small-scale NGO programs. A small qualitative study conducted inEasternDRCin2002 indicatedthat healthcare services provided to the victims o f sexual violence are generally o f poor quality. Victims are not provided with emergency contraception, to say nothing o femergency anti-retroviral drugs (ARVs); they are often denied treatment, with the result that their stigmatization i s exacerbated (Casey, 2002). Some NGOprograms have attempted to address this problem inthe most affected regions. 61 Chapter 3: TheHealth System 17. The technical quality of services deteriorated significantly duringthe 1990s' butthe situation seems to have improved perceptiblywith the resumption of development cooperation andthe process of revitalization of health services. DRClacks a quality control, accreditation, or certification agency; there i s therefore no information on service quality at the national level. However, a number o f surveys o f health facilities, conducted by NGOs in several districts and provinces, provide a picture o f the situation. 18. A study carried out inthe Ituriand Haut UClC districts inthe Orientale province evaluated, in a set o f Health Zones, the extent to which diagnoses and treatments prescribed inhealth centers and general referral hospitals conformed to medical standards. (Maltheser, 2004) Prior to the NGO's intervention in2002, the proportiono f diagnoses conforming to disease symptoms varied greatly from one Health Zone to another, butrarely exceeded 50%, suggesting that nearly half o f diagnoses were erroneous. Drugprescriptions conforming to the stated diagnosis accounted for, at best, 45% o f all prescriptions. The same study noted overuse o f antibiotics and o f injectable forms of drugs. Another study conducted inNord-Kivu (Soeters, 2003) presents a similar situation: overuse o f injectables, use o f non-sterile surgical materials, transfusions o f untested blood, and use o f treatments or interventions without therapeutic indication, such as appendectomies, Caesarian sections, and intravenous drips. A survey o f 35 hospital facilities in the city o f Kinshasa (Kahindo, 2002) indicatedthat only one had undergone a medical audit duringthe six monthspreceding the survey. Onlyone o fthe 35 facilities visitedhadregularly gathered and analyzed data on hospital-acquired infections. Over one establishment infive failed to carry out routine cleaning o f the operating room betweenprocedures, and o f those that did so, only 15% followed a protocol. 19. With the resumption o f development cooperation and the process o frevitalizing health services, an improvement inthe technical quality o f services i s expected. Staff retraining and the provision o f equipment and consumables to heath facilities have brought perceptible improvement to some regions. For example, NGO support inthe Orientale province improved the percentage o f correct diagnoses and prescriptions and, therefore, patient care. (Maltheser, 2004) 20. Despite technical deficiencies, users' perception of service quality i s generally positive, except with regard to cost of care. Church-affiliated establishments seem to be rated higher than State-run structures. Satisfaction surveys indicatethat the users o fhealthfacilities are generally satisfied with the quality o f care received, whether inurban or inrural areas, and this applies to all provinces. A survey o f hospital users inall provinces (except for Kasai' Occidental and Orientale) (BERCI, 2004) indicatedthat over 80% (n= 3,304) deemed intake procedures to be satisfactory or very satisfactory; 47% felt that they were always treated respectfully and courteously by the care personnel, while 35% indicatedthat respect and courtesy were `sometimes' inevidence (n= 3,016). Only 6% o f users claimed that they were always treated disrespectfully, as against 60% who said that they were never treated disrespectfully. The rate o f satisfaction interms o f positive outcome o f treatment was also high,with over 80% o f users satisfied or very satisfied with their treatment (n= 3,002). Regardingwaiting times, over half o f the users inthis study felt that they were long or too long, while 34% found them acceptable. Rather surprisingly, only 2% o f users who were dissatisfied with the treatment received mentioned the problem o f a shortage o f drugs. The lack o f other materials is, however, mentionedby 25% o fthose questioned. Most patients deploredthe highcost o f consultations and treatments, which they wished to see reduced. 21. The study inNord-Kivu (Soerters, 2003) corroborates the preceding conclusions, with nearly 90% o f users satisfied, 88% finding care personnel courteous, and 77% satisfied with waiting times inhealth care facilities, The rate o f satisfaction with treatment outcome was about 66%. This study also pointed out users' preference for church-affiliated facilities (50%) over community-run structures (32%) andprivate dispensaries (8%). The mainreasons invoked for 62 Chapter 3: TheHealth System thispreference were goodquality ofcareandcourteous reception. Usersofprivate dispensaries emphasized the speedof intake procedures, butnot the quality o f care. 22. Another survey of 510 households conducted by the NGOPSF inKasay-Oriental indicated lower rates of user satisfaction, with nearly 60% indicating that care was of good quality, 64% that drugavailability was good, 67% that the staff was courteous andrespectful, 56% that waiting times were reasonable, and49% that they were cured by the treatment received. A slight preference for private (i.e., not community-run) facilities was noted. 23. The relatively highpatient satisfaction rates are at odds with the poor technical quality o f care, butmay be explained inseveral ways. First, it shouldbe notedthat those queriedabout quality were those who hadactually receivedcare, as opposed to the large proportion of the populationthat lacks access to care. The results o f the aforementioned studies are probably not representative of the general perceptiono f quality. For example, the BERCIstudy was conducted inthe largest healthcarefacilities inthe selectedhealthzones, where services aregenerally reputed to be of better quality than inrural areas. The observations of the Nord-Kivu study may be linkedto the highlevel of external assistanceto the health sector inthis province. The survey inKasaYOriental, where external assistanceis less extensive, revealslower levels ofsatisfaction. Inaddition, satisfaction surveys conductedinother Afr-ican countriesproducesimilar results under conditions where quality i s poor, suggesting that most users have low expectations. Indeed, somepoor quality care practices, such as the systematic use o f injectable forms o f drugs and antibiotics, are partly the result ofpatients' demands. 24. However, these results on patientperception, along with the observation on the use o f health centers (30-40% of cases o f children's illnesses are handled ina healthcare facility) (Table 17), suggestthat the demandfor services at facilities runbythe Government, NGOs, and religiousorganizationsis potentially large,andrepresentsa solidbasis for the reconstruction and development o f the healthcare system. 5. Communityparticipation 25. Mechanismsexistfor involvingthe community inhealthsystemmanagement,butthey are non-functionalinmany cases. The model adoptedbythe DRC inthe mid-1980s for decentralizing healthcare requires the strengthening of community participationinthe management of health care services, with a view to improving the responsivenesso f the system. There are currently management committees -that include community representatives -for many health care facilities, butthey are not always operational. Although these management communities do meet occasionally, inmany cases they do not have influence over the management of staff, equipment, finances, or purchasesof medical supplies. There i s no formal framework that clearly sets out the prerogatives of these entities. A 2001 study inKinshasa indicatedthat only 29% o f facilities had amanagement committee. (OCHA, 2001) Conversely, a study of 59 healthcenters (some of which were urban) throughout the country found that 85% of health care facilities had a `health committee' whose statedrole was to serve as a liaison between thepopulationandthe healthcare establishment, to educatethe population, andto ensureproper management of the facility (BERCI, 2004). 6. Humanresources 26. The number ofphysiciansinthe DRCi s low by any standard, whereas the number of nursesis larger than inother very poor countries. At thenationallevel, available data indicated, as of 1998, arelatively highnumber o fnurses, compared to an alarmingly low number o f medical doctors (Table 24). The ratio of 1,700 inhabitants per nurse meets the standard set out 63 Chapter 3: TheHealth System bythe MinistryofHealth. However, the physicianshortage is very severe, with over 22,000 inhabitants per physician, compared to the standard o f 10,000. These figures can also be presentedinthe form o fratios of staffper 100,000 inhabitants, for the purpose of facilitating internationalcomparisons. In 1998, the DRChad about 4.4 physicians per 100,000 inhabitants, a figure that is among the world's lowest, althoughinkeepingwith the country's poverty level (Figure22). The country also had, as of 1998, about 58 nurses per 100,000 inhabitants, a figure higher than that observed inother very poor countries, but still low by international standards. Table 24. Availabilityof human resourcesin the health care sector, DRC,1998 Professionalcategory No' in No. in rural Total in Ratio of population/personnel areas urban areas DRC standard urban rural DRC Medicaldoctors 1406 650 2056 10 000 6891 56698 22 637 Dentists 89 11 100 30 000 99 884 3 071 146 426 995 Pharmacists 85 36 121 50 000 113 985 1023 715 384 649 Administrators/Managers 295 227 522 50 000 32 843 162 351 89 162 Nurses 9800 17362 27162 5 000 989 2 123 1714 Lab technicians 188 62 250 5 000 51 536 594415 186 170 Radiologytechnicians 134 44 178 15 000 72304 837595 261 471 Nutritionists 85 91 176 113 985 404 986 264 446 Physicaltherapists 101 38 139 15 000 95928 962836 334 838 Anesthesiologists 80 19 99 15 000 121 109 1939671 470 126 Pharmacy assistants 90 43 133 107 653 857 064 349 944 Hygienetechnicians 52 64 116 15 000 186322 575840 401 228 Source : Ministryof Health(1999a) Estimatesof the authors basedon WHO and World Bank data. Figure 22. Physiciansand nurses per 100,000 population,DRC, 1998 1000 physicians/100,000 population -6 "'m 100 n a E!? 8, 8 8 5 f 10 E 1 0 500 1000 1500 0 500 1000 1500 percapitaGDP (US$) per capita GDP (US$) 27. Qualifiedhealthcare personnelare concentratedinthe city of Kinshasa. Figure23 shows clearly that the great majority ofphysicians and nurses are basedinKinshasa, where there were 24 medical doctors and 120nursesper 100,000 inhabitants in 1998. The province with the second-highestnumber of qualified healthpersonnel i s Bas-Congo, with about 7 physicians and 64 wer than 3 physxciansand 60 declinedsteeply ~ ~ ~ ~ ce 1998. Table 25 compares hinto acc~unt,it is estimated that the ratio of by 30-50940inmostpravinces, andby 75% lit Figure 23 Physiciansand nursesper 100,000 P~Pulati~n, DRC, I998 65 Chapter 3: TheHealth System scrutiny withinthe framework o f an institutional audit o f the Ministry o f Health and in connection with broader efforts to reform the civil service. Table 25. Physiciansper 100,000 population,DRC, 1998-2003 Physicians Physicians physicians No. of physicians No. of Province Change (%) per 100,000 per 100,000 Change (%) inhabitants inhabitants 1998 2003 1998 2003 Kinshasa 950 699 -26% 23.6 14.8 -37% Bas-Congo 159 101 -36% 6.7 3.6 -46% Bandundu 100 89 -11% 1.9 1.4 -24% KasaiOccidental 71 56 -21% 1.7 1.1 -33% KasaiOriental 105 58 -45% 2.6 1.2 -53% Equateur 80 64 -20% 1.4 0.9 -32% ProvinceOrientale 119 64 -46% 1.9 0.9 -54% Maniema 22 1.6 Nord-Kivu 89 2.5 Sud-Kivu 80 2.6 Katanga 281 87 -69% 4.5 1.2 -74% DRC 2,056 4.4 Estimatesof the authors basedon data from the Ministry of Health. 31. DRC hasseveraltrainingestablishmentsthat constitutea basisfor humanresource development inthe sector, butthey are currently under-funded. Inthe area o ftraining, the DRChas an important asset interms o f capacity to produce qualifiedhealthpersonnel. The country has three State-run medical schools and about twenty more or less viable ones runon community initiative, a national school o f public health with a 12-monthtraining cycle leading to a master's degree, and about two hundrednurses' training institutes scattered throughout the country. 32. It would appear that the programs are not always a good fit with the country's socio- economic realities. The production o fpublic healthprofessionals capable o fpracticing their profession in a way that i s inkeeping with the country's environment and mainly rural population i s de-emphasized in favor o f the teaching o f modem, sophisticated medicine. The result i s that few physicians accept assignments inpoor regions and rural areas, which are deemed hardship postings due to the lack o f modem conveniences (runningwater, electricity, schools, etc.), and because o fthe severely deteriorated condition o f health care infrastructure. Less demanding paramedical personnel seems better adapted to the rural milieu and are better distributed throughout the country. This state o f affairs i s aggravatedby the lack o f incentives insupport o f a strategy for redeploying personnel to the disadvantaged zones. Inthe absence o f in-service training, the qualifications o f staff inpost also present a problem. 33. Emigrationofhealth care professionalsnegatesthe Government's investmentintheir training. Emigrationo fmedical doctors ingeneral and o f specialists inparticularis a significant factor inthe observed staff shortage. The appeal o f the international market has been enhanced bythe crisis experienced by the country. Manyhealthcare professionals, andparticularly highly skilled physicians and specialists, have gone abroad in search o fbetter salaries and living conditions. Indeed, it i s estimated that over 1,000 Congolese physicians are practicing inthe countries o f southern Africa. 66 Chapter 3: TheHealth System 34. Salaries are so low that performancebonuseshave becomeimportant sources of income. Not only are payments and salaries inthe civil service deemed low (US$15-20 per month for the chief physicianof a zone and less than US$50 per month for a provincial medical inspector), but the State i s often several months behind insalary payments. The staff of health services supported or managed byNGOs or religious associations are generally more motivated and more efficient than inthe public sector. Indeed, bonuses are often higher than State salaries. These bonuses are highlyvariable. A study conducted in2005 found, for example, that staff incentives paidto Health Centers rangedfrom US$40 to US$200 per month, and those for general hospitals were betweenUS$200 andUS$2,400 per month, whereas the central bureaus ofhealth zones receivedbetween US$350 andUS$l,OOO per month. (RCvillion, 2005). 35. The concentration o fprivate for-profit facilities inKinshasa and inlarge urban centers also provides some explanation for the distribution of staff inthe various provinces o f the DRC. Cities offer much more opportunity for double duty. Inaddition to a guaranteedjob inthe civil service, many physicians, nurses, and midwives work additional hours inprivate establishments inorder to supplementtheir incomes. 7. Pharmaceuticalsector 36. Followingthe withdrawal of Governmentsupportto the health sector over the past decades, most health care facilitiesuse their own resourcesto obtain drugs and consumables. The national system of drug supply and distribution largely ceasedto operate in the 1990sdue to the cessation ofgovernment financing andoutside support. Supplythenbecame highlyfragmented, inefficient, and costly, with healthfacilities and healthzones obtaining drugs from the available private suppliers. A 2003 study of those supplyinghealth facilities inthree different regions found that 29% of facilities were gettingtheir supplies from private suppliers, 52% from external support, and 19% from regional distribution centers. 37. Church-affiliated associations and externalpartners, as well as NGOs and some specializedprograms, provide drugs and supplies for many health services. Some special programs responsible for combatingendemic diseases have developed supply systems for their specific needs, and resort either to church-based networks or to their own supply sources. This i s the case, inparticular, withthe ExpandedProgramon Immunization (EPI), whichhas its own relatively efficient supply chain. Church-affiliated networks and internationalNGOsplay important roles insupplyingthe health facilities that they support. Inseveral cases, the supplies they provide to health facilities take the form of standardized kits. 38. The private for-profit pharmaceuticalsector has expanded, but it i s still largely unsupervisedand concentratedinlarge urban centers, and particularly inthe city of Kinshasa. Itincludes wholesale importers, private pharmacies, and several illegal points of sale. Itis the main source of supply for healthfacilities andHealthZones that have no support from local or internationalpartners. There are currently nearly 65 wholesale importers; they are distributedover the country inaccordancewiththe laws o fthe market, andare thus highly skewedtowards urbanareas. In1998, there were about 121registered pharmacists throughout the country. A 2004 survey o f 39 private pharmacies distributedamong the country's maincities found that 82% o fthemgot their supplies from local suppliers and 8% had international sources of supply. (BERCI, 2004). This same study found mixedresults interms o f quality: 42% of these pharmacies hadno pharmacist on staff and 38% kept no records of prescriptions. 39. The internal production capacities of the DRC have mirrored the country's economic deterioration. The pharmaceutical industryi s inits infancy and the country essentially gets its supplies on the international market. 67 Chapter 3: TheHealth System 40. The scope o f the informal sector i s currently unknown, butit i s an important source o f supply for the population despite the questionable quality o f its products. There i s limitedinformation available on this topic, except for household surveys indicating that nearly a thirdo f sick people turnto sellers o fmedicines rather than to formal sector practitioners. 41. The cost of medicines is largelyborneby households. Inhealth facilities, the price often includes large margins intended to pay the salaries o fhealth care personnel. At the level o f the Health Zones, the sale o f medicines inaccordance with the recommendations contained inthe Bamako Initiative disappeared with the stoppage o f external aid. However, stocks are rotateddue to the sale o f medicines by personnel to users, with highmargins intendedto cover their pay. In zones supported byNGOs, and particularly by the humanitarianprograms, medicines are often subsidized by external aid. The level o f subsidy needed in order to improve utilization o f health care services and, ultimately, the country's health outcomes, i s still a major concern for the Government and donors. 42. A national pharmaceuticalpolicyhas beenadopted and efforts are underwayto improvethe distributionsystem. The DRC has had since 1987 a list o f essential drugs, revised in 1991andagain in2001after the adoptionin 1999o fthe nationalpharmaceuticalpolicy. A study conducted in2002 pointedout the fragmented and inefficient nature o fthe drugdistribution system, and ledto the development o f a strategy for improved coordination o fpurchasing and distribution; it i s being implementedprogressively. The reorganizationo f the sector, characterized by a commitment to the decentralization o f supply, has ledto the development o f about 10 Regional Distribution Centers financed by external partners. Experiments underway involve three centers financedby the European Union, five financed by the World Bank, one financed by the Belgian Cooperation, and the 10-year-old ASRAMES purchasing center inNord- Kim,whichhasjustbeenintegratedinto the system. The desireto centralize purchasing has led to the creation o f the regional distribution agency FEDECAME[Fdddration des centrales de distribution rdgionales], the main function o f which i s to centralize purchases. 43. University-levelpharmacyprogramsare operationalbut are short on resources. There are two pharmacy faculties inthe country, inKinshasa and inLubumbashi; they had 651students , as o f the 2004 academic year. Due to the lack o f Government funding, these institutions are financed by fees paidby students. The study conducted by BERCI in2004 noted a lack o f basic equipment and consumables. 8. Healthinformationsystem 44. A system of health surveillanceand information is in place,with standardizedreporting forms, but problemswith duplicationand underreporting are still apparent. The National Heath Information System [SystBme national d 'informations sanitaires, SNIS] i s designed to collect and share data between the various layers o f the healthcare system, from the community level up to the Ministryo f Health. The detection and reporting o f cases i s done by the staff o f the Health Centers or referral hospitals. Data collection i s done at the peripherallevel by the Central Bureau o f Health Zones; it conveys the data to the Provincial Health Inspectorate, which inturn transmits it to the Ministry o f Health. Standardized and simplified data collection forms have been developed. 45. Alongside this data collection system, there are other systems with different criteria for the production o f figures. For example, surveillance data on priority diseases i s gatheredby the 4th Directorate, polio surveillance i s performed within the framework o f the polio eradication program, and the EPI also collects vaccination data. 68 Chapter 3: TheHealth System 46. Several shortcomings impair the credibility o f all of the data thus collected. Given the low level of utilization of health facilities, one i sjustified infearing a great deal of underreporting. In addition, it i s estimated that about 40% of HealthZones submit incomplete activity reports that fail to cover all of their facilities. Private facilities, even ifthey belong to the formal sector, are generally not part o f the data-gathering process. The denominators -usually the size of the target population of the various interventions- are poorlyknown, and this situation has worsened due to the populationmovements that the country has experienced. 9. Important programs 47. A number of specialized programs are responsiblefor combatingprioritydiseasesand supplementthe services put inplace inthe HealthZones. The DRC has established several programs to combat certainpriority communicablediseases that impose a heavy burdeno f morbidity and mortality on the population as a whole and particularly on the most vulnerable groups, women, and children. The Ministry o f Health oversees these various programs, which include the EPI and the national programs to combat malaria, tuberculosis, HIV/AIDS, leprosy, sleepingsickness, river blindness, and iodine deficiency disorders. They are managedby Directors responsible for the coordination o f all of the programs' administrative, financial, and technical activities. At the intermediate level, linkages are providedby the ProvincialMedical Inspectors [Mddecins Inspecteurs Provinciausc] who are assistedby the District Physicians [me`decinsde district] and provide technical and material support to the HealthZones. The Central Bureauo f a HealthZone represents the various programs at the peripheral level and, at this level, the ChiefPhysicianofthe Zone hasthe task ofintegratingthe disease-prevention activities into primary health care activities. Anti-malarial efforts 48. The DRC is followingthe international"RollBackMalaria" strategy, emphasizingthe distributionof bednetsand effective treatment. The five-year planfor combatingmalaria (2002-2006) follows this global framework, and its basic strategy has four mainthemes: treatment of cases, prevention, epidemiological surveillance, and institutional capacity-building, 49. The treatment of uncomplicatedcases involves households, community-level health personnel andthe health centers. The strategy adopted recommends the administration o f first- line anti-malarial medication inthe event of any isolated instance of fever. Serious cases o f malaria are referredto the general referral hospital or to the relevant facilities for appropriate treatment. Preventiondepends on informingthe population about the use of insecticide- impregnated nets, intermittentpresumptivetreatment for pregnant women, and to a lesser extent, on environmentalmeasures. 50. The treatment protocolhasbeenreviseddueto the parasite's growingresistanceto current drugs. Followingstudies in2000-2001assessingthe resistanceofthe Plasmodium falciparum to anti-malarial drugs, which found a 2940% rate ofresistance to chloroquine, the recommended first-line treatment was changed to the sulfadoxine-pyrimethamine(S-P) combination. However, the parasite's growing resistance to S-P (ranging from 2 to 61% infive locations from 2002 to 2004) has promptedthe Ministryof Health to change the national anti- malariapolicy to make therapeutic combinations basedon artemisinine the first-line treatment in regions where resistance i s particularly high. Some internationalNGOs have begunto implement this therapy, but on a limitedscale. 5 1. Thus far, the coverage effective preventive and curative interventions are stilllimited. The populationgenerally lacks informationabout proper treatment ofcases ofmalaria and when 69 Chapter 3: TheHealth System to seek care. It i s also under-informed about preventive activities, especially inrural areas. The health systemrelies upon community-level healthpersonnel to relay information to communities and households, but their effectiveness i s limited. Inthe absence o f health information and education, and given the inadequacies o fthe system generally, households are still relyingto a great extent to itinerant sellers o f medicines. Inhealth centers, some staff administer quinine as a first-line treatment ifthe patient can afford it. Intermittent chemical prophylaxis inpregnant women i s still very uncommon (5%). As part o f its effort to provide the population with the means to prevent and combat malaria, the Government initiatedthe distributiono fnets in some Health Zones in2000, with the assistance o finternational partners. In2001, less than 1%o f children under the age o f five were sleeping under mosquito nets impregnatedwith insecticide. By2004, only 24,000 mosquito nets hadbeendistributed, as against a goal o f 500,000 for the 2003-2004 period. 52. The availability of additionalfinancing should improvethe situation, but the programs, as planned,can only cover part of the population. In2004, the Global Fundapproved a five- year US$54 millionprogramto combat malaria (US$25 millionover the first two years), thereby supporting the main components of the national strategy (i.e., distribution o f insecticide-treated nets, treatment o f cases, and intermittent presumptive treatment for pregnant women). Acknowledging that these resources are inadequate to cover the entire population, the program involves 120 Health Zones and aims for a coverage rate o f about 50% within each zone. A new World Bank health project includes a malaria "booster" component which allocates US$ 30 million to malaria interventionsin 150 Health Zones. HIVIAIDSprevention 53. The DRC has a national HIV/AIDSpreventionprogramwith a multisectoralstrategy. In1987, the DRCimplementedanationalAIDS preventionprogram. At the policy and organizational level, the Multisectoral AIDS/STD Prevention Committee has the task o f defining national policy inthe fight against the pandemic, validating the national action plan, and assessing the effectiveness o f the program's efforts and activities. The National Program to Prevent HIV/AIDS, Sexually Transmitted Diseases and Opportunistic Infections (French acronym :PNLSAST) i s the framework withinwhich the various preventive efforts are coordinated. The program's objectives are to mobilize civil society, to improve access to preventive services, to diagnose and treat, and to strengthen the capacities o f the institutions and actors involved inthe effort. Inits activities, it i s supported by linkages at the provincial level and at the level o f the Health Zones. The involvement o f the various actors inthe sector - including NGOs, private enterprises, and church-affiliatedassociations -has created several coordination mechanisms aimed at obtaining a certain synergy o f action. 54. HIV/AIDSpreventionactivities, suspended during the 1990s due to the crisis, have thus far had a limited impact. To date, the results o fvarious interventions carried out inthe fight against AIDS have been relatively disappointing. This situation was aggravated by the withdrawal o f the various donors in 1993, and the crisis made it impossible to effectively coordinate prevention activities. 55. The population'slevelof knowledgeand educationneedsto be improved. Educational activities and advocacy towards safe sexual behaviors are being conducted, mainly by non-profit associations. They are being carried out inhealth care facilities and schools, and through the mass media. Unfortunately, they do not seem to be very effective with the population, judgingby the level o fknowledge o fAIDS andways to avoid it onthe part o fwomen ofchildbearingage (in 70 Chapter 3: TheHealth System 2001, only 10% of such women had accurate information on the disease).I8 Moreover, the promotion of condom use i s not beingaccompanied by efforts to disseminate themor to make themavailable to populations already reluctantto use them, particularly inrural areas where points of sale are scarce. 56. Activities aimed at preventingmother-to-childtransmissionare still at the pilot project stage, with interventionsat about thirty sites inthe three provinces o fKinshasa, Bas-Congo and Sud-Kivu. These activities consist oftesting, with informed consent, followed by free provision of the antiretroviral (ARV)Nevirapine to AIDS-infected women, or nutritional counseling about breastfeeding for the others. 57. Voluntary testing and advisory services are stillvery limited. The three maincomponents of the treatment of persons living with AIDS, i.e., diagnosis, treatment o f opportunistic infections, and access to ARVs, scarcely have enough resources for their effective and efficient implementation. The country has only ten centers for voluntary and anonymous testing. 58. Effectivetreatment of opportunisticinfectionsi s hamperedby the inaccessibilityand poor quality of hospitalservices. The poor quality o ftreatment givento opportunistic infections inthe internal medicine departments o f hospitals, where highmortality rates (estimated at 70%) are observed, spurred the PNLS in2002 to publisha guide on the treatment o f these infections, with a minimumpackage o f activities to be included inhospital services. However, the weak purchasingpower ofthe populationand the general scarcity ofdrugs facing most of the country's healthcare facilities are underminingthe effectiveness o f this initiative. 59. Access to antiretroviral therapiesis stillvery limited. Access to ARVs i s still as problematic inthe DRC as it i s inthe other countries of the region. Highcost remains a major obstacle to the treatment o fpatients. Inaddition to this factor, there i s a shortage o f trained personnel, especially at the lower levels o f the health care pyramid. 60. Improving the safety of bloodtransfusionsis still a major challenge, despite significant progress. The State still has little control over the bloodchain. It is reported that about 60% of hospitals lackbloodbanks. Apart from the General Hospital of Kinshasa, which i s thought to have about 10,000 voluntary blood donors, many private facilities collect and utilize bloodunder totally uncontrolled and non-transparent circumstances. It was estimated in2001 that 85% of the bloodusedfor transfusions inthe capital hadnot beentested. The National BloodTransfusion Policy aims to remedy this situation, and has met with some success, particularly ininput coverage, which hasrisen from 13 to 40%. 61. Significant financing is inthe offingfor the DRC's HIV/AIDS program. In2004, the Global Fundapproved a grant for US$114 million over a five-year period (US$35 million over the first two years). The WorldBank also agreedto provide US$102 millionto finance, over five years, the Multisectoral AIDS Program(MAP). The Global Fundgrant will support an array o f activities includinghealthinformation and education, prevention (particularly for high-risk groups), assistanceto infectedpersons, treatment of opportunistic infections and, on a more limitedscale, antiretroviral treatments. The multisectoral interventionsincludedinthe MAP will beimplementedby the Government, the private sector, NGOs and communities. About one fifth of this project's resources will be directly allocated to medical activities, includingtransfusion safety, diagnosis, and treatment o f sexually transmitted diseases and opportunistic infections, voluntary testingand assistance, and the promotion and distribution of condoms. 18A woman i s deemedto have goodknowledgeabout HIV/AIDS ifshe knows the three mainmeans of prevention and can identify three erroneous notions about HIV/AIDS. 71 Chapter 3: TheHealth System Tuberculosis control 62. A national tuberculosis control programexists, buti s hampered by the inadequate coverageof primary health services. Likethe vast majority of programs o f the Ministryof Health, tuberculosis activities have been decentralized down to the peripheral (local) level. However, the weaknesses of the health care system interms of primary service coverage are an important obstacle to progress inthe fight against this disease. The NationalTuberculosis Control Program [Programmenational de lutte contre la tuberculose, PNLT] i s now inthe implementationphase of its 2001-2005 strategic plan, which aims to increase DOTS program coverage to 90%, detection rate o f contagious casesto 70T, and the cure rate for smear-positive newcases to 85%. In2002, the case detection rate was estimated at 52%, and the proportion of the populationwithimmediateaccess to antitubercular drugs at about 70%. Theseratherhigh figures, providedbythe PNLT, are quite surprisinggiventhe population's low level o f contact withthe healthcare system. 63. Drug shortages and inadequatehuman resourcesare major challenges. Despite the central authorities' avowedcommitment to tuberculosis control, the PNLT labors under two major handicaps: the absence o f an effective national systemfor the supply and distribution o f drugs and consumables, and a lack of qualified healthpersonnel -laboratory specialists inthis instance. The expertise of laboratory technicians intuberculosis microscopy i s deemed insufficient and this shortcoming i s made worse by the lack of in-service training and by the poor morale causedby low salaries. Inaddition, equipment (e.g., microscopes, slides, etc.) i s either in short supply or absent inthe vast majority of the country's laboratories. 64. It i s common for health care facilities to runout of antitubercular drugs, and the quality of ' coverage achievedunder the DOTS strategy i s questionable due to the lack o f continuity inthe treatment of many patients o f whom the system loses track. The risko f the emergence of multipleresistant strains is particularly highunder suchcircumstances. The most recent study of resistance dates back to 1999, at which time a 5.8% rate ofresistance to the usual antitubercular drugs was observed inall new and longstandingpatients inthe province ofKinshasa. The lack o f linkages between public and private structures has diminishedthe effectiveness of treatment. 65. Informationcampaigns about this disease are conducted through the media and are aimed at spurring social mobilization and at inducing tuberculosis sufferers to enter into contact with the health systemas soon as the first symptoms appear. 66. Studies conducted inKinshasa have found that 30% of those with tuberculosis are co-infected with HIV. The integrationo f anti-tuberculosis andHIV/AIDSpreventionactivities i s still at the pilot stage inthe province of Kinshasa. Entitiesresponsible for coordination of tuberculosis and HIV/AIDSpreventionexist at the national andprovincial levels. 67. Insupport o fthe national tuberculosis prevention strategy, the Global Fundapproved in2003 a financing programtotaling US$8 million over three years. Prevention of childhood diseases 68. As was mentioned inthe preceding chapters, vaccination coveragei s still low inthe DRC,andthis is true for all EPIantigens: 53% for BCG; 48% for measlesvaccine; 42% for Polio 3 vaccine, despite the great efforts put forth by the WHO; and 30% for DTC3. In2001, barely 23% of children had the full series of vaccinations. (MICS2,2001). 69. The Expanded Programon Immunization (EPI) is relatively effective, but suffers from a lack of resources, particularly at the primary care level. EPI activities are carriedout using facility-basedand outreach strategies. Alongside these routine activities, mass vaccination 72 Chapter 3: TheHealth System campaigns are also conducted on the occasion of local or national `vaccination days'. The EPIhas developed a relatively efficient supply system, but the cold chain, travel problems affecting the outreach strategies, andthe weak supervisory capacity o f the provincial offices are among the factors citedinorder to explain the disappointingperformance interms o f vaccination coverage. Theprogress made is mainly attributable to stepped-upinterventionsbyNGOsincertainHealth Zones, and to improvementsinthe cold chain due to the expanded polio eradication program. The shortage of inputsrequiredfor vaccination activities seems to be causedmore by a lackof fundingthan by inadequacies inthe logistical supply chain of the healthcenters. Vaccination booklets, fuel for refrigerators, and vehicles are among the items that cannot be counted upon to be constantly available inthe health centers and within the units charged with implementingthe outreach strategy. 70. EPI objectives for the 2003-2007 period include the achievement o f an 80% coverage rate (whichi s probablyunrealistic) for all antigens, reductiono fvaccine waste/loss from 35 to IO%, improvement of the safety of injections, the introduction of new antigens, improved surveillance and information systems, and the integration of other infadchildhealth activities (such as vitamin A supplementation and distribution of insecticide-treated mosquito nets, inparticular). 71. International support for the vaccinationprogram hasbeenconsiderableover the past few years, but the needfor stable and adequatefunding is still great. In2003, the Global Alliance for Vaccines and Immunization (GAVI) approved a grant o f US$49 million over a five- year period to support the vaccination o f children. Since this financing i s due to stop in2007, the Government i s still faced with aneed for stable and adequate funding from local and international sources. 72. The riskof breaksinthe cold chain i s high. The supply chain operates as follows: the vaccines are removedby the Central Bureauof a Health Zone from provincial warehouses and stored inarefrigerator at the Bureau. Insome HealthZones, one to three intermediate warehouseshave been established inhealth centers. They are suppliedby the Central Bureau. The other centers, which do not haverefrigerators, sendsomeone on a bicycle,with a cooler, to get the supplies over a round-trip distance that can exceed 100km(a 2-day trip.) Vaccination sessions are then organized as soon as the vaccines arrive (under the facility-based or outreach strategies), with a systemto proactively track down children who have been missed. This set-up makes it difficult to have vaccination available on an ongoingbasis, especially since, insome HealthZone bureaus andrelay centers, the refrigerators are only turnedon 15 days per month due to a lack of fuel. Iti s therefore difficult to organize more than one fixed-location vaccination day per month, andto cover the entire healthcare zone under the outreach strategy (RCvillion, 2005). 73. DRC adopted in 2001 the strategy of Integrated Management of ChildhoodIllness (IMCI) and is now inthe initial implementationphase. An array of interventionsat the level of health care facilities, communities, and households is carried out inthis connection using facility-based and outreach strategies-preventiono f malaria, diarrhea, malnutrition, and acute respiratory infections (AN). The national nutrition program i s part o f this framework. The success of this strategy is compromised by the system's lack of humanresources and low quality care, andthe failure to promote healthy behaviors within households. A survey conducted in Health Zones receiving support under a World Bank project revealed that although over 70% of mothers recognize a highfever as ared flag, barely 2% o f themreact to convulsions, severe diarrhea, or coughing intheir children. Maternal health 74. A reproductivehealth programis in placebut lacksthe funds neededto operate properly. DRC established in 1998 aNational Reproductive HealthProgram [Programme 73 Chapter 3: TheHealth System national de la sante` de la reproduction, PNSR] which attaches top priority to the prevention o f maternalmortality. Its main objectives are to improve access to good quality health care and to improve the status o fwomen inDRC. The PNSR defines a minimumpackage o f activities for each category o f health care establishment, as well as procedures to be followed inproviding care at the various levels inthe health care pyramid. Unfortunately, and as i s the case with most specialized programs o fthe Ministryo f Health, the PNSR lacks the financial and material resourcesneeded for its implementation. As was noted ina previous chapter, maternal mortality i s excessive inthe DRC althoughthe prenatal consultationrate i s relatively high. Access to good quality reproductive care and services, and particularly emergency obstetrical care, i s generally inadequate. Family planning services are not widely available (in2001, only 4.4% o f women aged 15 to 49 were usinga modem method o f contraception). 10. Government strategy 75. Since 2001, the Government hasmade a considerableeffort to develop policies and strategies inthe sector, emphasizingprimary healthcare and specializedprograms. As was mentioned previously, the Government's strategy inthe sector has focused essentially on the development o f Health Zones. The national healthpolicy adopted in2001 reaffirms the strategy of providing an array o f essentialhealth services through the Health Zones. The number o f HealthZones has been increased inorder to create the administrative framework for expansion o f the care network to improve the geographic accessibility o f services. In2002, operating standards for the Health Zones and the content o f the activity packages were defined. The policy of 2001 also affirms the decentralization o f the system, and particularly the autonomy o f the Health Zones. This new policy has been accompanied by a Government commitment to dealing with issues relatedto human, financial, andmaterialresources. More specifically, the document sets out the Government's pledge to allocate 1520% o f the total budget to the health sector. 76. As a reflection o f the vertical structure o fthe Ministryo f Health, the new policy sets out the general objectives o f a large number o f specialized programs. Also in2001, new strategies emerged from the main specialized programs, and particularly EPI, and the malaria and tuberculosis control programs. 77. Recentpolicy developmenthas continuedto emphasize two main objectives - Le., the developmentof the Health Zones and the controlof priority diseases -while at the same time reflectinga better understandingof the demandfactors, and particularly financial barriers, that affect service utilization. The Government's draft Poverty Reduction Strategy Paper (PRSP) for 2002 conforms to the preceding policy orientations, as it stresses the development o f basic health services by means o f the Health Zones and support for specialized programs, and especially those dealing with HIV/AIDS, malaria, and tuberculosis. This strategy also includes a Government pledge to increase the sector's budget to 15% o f the total budget. The health component of the Government's 2004 MinimumPartnership Program for Transition and Recovery [Programme minimum departenariat pour la transition et la relance, PMPTR] likewise has as its general goal the revitalization o f the health care system inorder to improve progress towards the MDGs, and as its specific goals the development o f the Health Zones and strengthening o f institutional capacities at all levels. 78. A new financing strategy for the health sector, drawn up in2004, reflects inparticular the Government's willingness to address the major problem of financial barriers to service utilization, as well as its intention to decentralize and improve financial management. 74 Chapter 4: Financing the Health Sector Chapter 4: Financing the Health Sector 1. The DRChealth system derives its fimdingfromvarious sources, includingprivate enterprises, the State budget, donors, and householdcontributions. The State budget steadily declined prior to 2002 andnow scarcely suffices to cover the low salaries o f healthcare personnel. As a result, the health care costs for households have steadily increased inorder to offset the State's disengagement. Investmentinthe sector, which was particularly l o w duringthe decade o f conflict, i s essentially coveredby external aid. The immediate impact o f this imbalance in sector funding sources i s the creation o f financial barriers limitingaccess to care for much o f the population. 2. A partnershipbetweenthe Government, donors, andusersof healthcare, inorderto ensurethe sector's financing,was an essentialingredientinthe HealthZone reformofthe 1980s. After some pilot studies, Za'ire beganin 1982 to develop the HealthZone system. The financing strategy for the Zones was based on partnership: donor assistance for investment costs, payment o f health worker salaries and operating costs o f central and intermediate structures by the Government, and eventual self-financing for operating expenses at the peripheral level. The needto cover operating costs - apart from drugs - forced the Zones to establish cost-recovery mechanisms. Positive results were obtained and by 1987,220 o f the 306 Zones were deemed to be operational. However, most Zones indicated that they had trouble covering all operating costs. 3. This partnershipcollapsedinthe 1990sfollowingthe cessationof development cooperationandthe Government'sconsiderablereductioninhealthexpenditures,leaving householdswith the entireburdenof financingthe sector. Inthe early 1990s, external aid for the health sector, which hadbeen covering the system's investment costs and helping Health Zones with their self-financing difficulties, diminished sharply due to international sanctions against Zalre. Only a few donors continued to provide sporadic aid through NGOs and churches inorder to maintainaminimallevel ofactivity inthe sector. At the sametime, the healthsystem saw its State support dwindle over the years. 1. Publichealthexpenditures 4. As of 2004, the totalStatebudgetwas smallbut growing. The public finance crisis existing since the early 1980s was characterized by: i)a drop in State revenues, to only 5% o f GDP; ii)a growing budget deficit; and iii)an increaseinsalary-related operatingcosts, to the detriment o fnon-salary operating costs and investment. Since 2001, however, State expenditures have been growing at a faster pace than GDP growth, reaching 19% o f GDP by 2003. In addition, the DRC became eligible for the HIPC Initiative inJuly 2003." The funds thus freed up are intended to finance "pro-poor" expenditures, of which the health sector i s one o f the most important." 19 Underthe HIPC Initiative, the DRC obtains debt relief estimated at US$76 million in2004, ofwhich 20% was allocated to the health sector (although the execution rate was low, with most funds budgeted for the rehabilitationofthe large nationalhospitals.). The same percentageis anticipated for the 2005 budget. The 2004 remainder will be carried over into the 2005 budget, which suggests that as o f2005 the budget allocation for the health sector could increase considerably, raising the issues o f equity and efficiency o f allocation. 2o After 2007, if the DRC reaches the completion point, the proceeds from debt relief will no longer be reserved for the social sectors. 75 Chapter 4: Financing the Health Sector Figure 24. Share of the health budget in the total governmentbudget 1960 1964 1972 1985 1998 2002 2003 2004 Sources : Ministryof Health and Health Roundtables, Kinshasa,May 2004. 5. Budget allocationsto the health sector haveincreasedconsiderablyover the past few years. The budget allocation ofthe Ministryo fHealth, whichwas US$3 millionin2001 (or US$0.05 per capita), was about US$13.5 million in2002,21or about 1.5% o f the total State budget. By2003, this share (under a budgetdrawn up inNovember 2003) was 5.3%, corresponding to 17billionCongolese francs or US$44 million and 0.8% of GDP. This amount doubled in2004, reaching 35.2 billion Congolese francs (of which 8.8 billion Congolese francs were freed up under the HIPC Initiative), or US$87 million-US$l.40/capita. This allocation representsan increase relative to the 1990s(see Figure24), but i s still far from the goal of 15% set out by the Government inthe interimPovertyReduction Strategy Paper (PRSP-I). Table 26. Projectedgovernment budget allocationsto the healthsector, DRC 2003 2004 2005 2006 2007 GDP (in US$ millions) 5 580.6 5 932.2 6 347.5 6 791.8 7 267.2 Real GDP growth (%) 5.6 6.3 7.0 7.0 7.0 Total governmentbudget (as YOof GDP) 13.6 19.3 25.3 21.6 21.4 Total governmentbudget (in US$ millions) 759.0 1 144.9 1 605.9 1467.0 1 555.2 YOof budgetallocatedto health 5.3 7.1 8.0 9.0 10.0 Healthbudget (in US$ millions) 40.2 81.3 128.5 132.0 155.5 Source :Authors, based on IMF projections (2004). 6. The government healthbudget couldtheoretically reachUS$l55 million, or US$2.7O/capita/year, by 2007. The macroeconomic objective for the 2004-2007 period is GDP growth of 6.8% per year (IMF, 2004). The Government i s committedto increasing the health sector's share o f the total budget to 15%. Assuming that the share o f expenditures allocated to the sector increasesgradually, reaching 10%bythe end of the period, the sector allocation could reachUS$l55 millionby 2007 (Table 26). These projectionsmustbe tempered, however, given the government's recordwithregardto budgetexecution, particularly inthe healthsector. 7. Dueto the low budget executionrate, government expendituresinthe sector diverge widely fromthe allocatedbudget; actualper capita expenditurein 2004 was thus only US$ 0.40. Allocations are executed partially and sporadically, and are not always accounted for. In 2002,55% o f the sector budget (US$8 million) was executed. By the midpoint of 2004, less than 30% of the 2004 budgethadbeen executed. In2004, the Government o fthe DRC actually spent less than US$0.40 per capita, Le., less than 0.5% of its GDP. Figure 25 shows that the level of ''4.6billionCongolesefrancsin 2002. 76 Chapter 4: Financing the Health Sector domestic public expenditures onhealth i s one of the lowest inthe world, consistent with the fact that DRC has one of the world's lowest per capita incomes. Achievingthe goal of US$2.50 per capita, as estimated inTable 26, would put the DRC at a level comparable to that o f countries with averageper capita incomes at least twice as large. Figure 25. Domestic public expenditure for health and GDP per capita (countries with GDP/capita US$l,OOO) 45 1 e a c 9 40- .E e ? 35 - e B a 30- 5 1 a s 25- .Y E a 20- 48 6 15- -0 .-a1 0 -DRC I m 0 ba 5 - a 0 4 I 0 100 200 300 400 500 600 700 800 900 1000 per capita GDP($US) Source: Authors, based on WHO and World Bank data. 8. Available data onpublic expenditures in2002 indicate the scope o f the budgetary pressure at that time. According to information onnon-salary operating expenditures providedby the MinistryofHealth, only US$0.50 per capita hadbeenbudgeted andUS$0.25 executed. Itwould seem logical that this level of expenditure would have a devastating impact on the functioning o f services and on institutional capacity. The situationhas apparently improved since then, butthere are no data available to confirm this. Whatever the case may be, this corroborates the beliefthat the projections set out inTable 26 should be considered a desirable goal, butone that can only be achieved if significant progress i s made inbudget execution, financial management, and absorptive capacity. 9. Unitswithin the Ministry of Health are uninterestedinthe budgetaryprocess, preferring to focus on externalaid. The departments do not know how much fundingi s allocated to them, do not try to pursue budget execution, and are not interestedinthe preparation of budgets from one year to the next. This situationleads to a fragmentation o f effort inthe sector, and encourages non-execution, as was observed with H P C funds allocated to the sector in 2004. 10. Although salariesare the largestcomponent of the government budget inthe sector and have the highestexecutionrate, averagesalaries of health personnelare very low in absoluteterms. In2002, the government healthbudget was distributedas follows among the expenditure categories: 62% for salaries, 14% for non-salary operating costs, 13% for investment expenditures, and 10% for ancillary budgets. A budget for the purchase of drugs has beennon- existent since 1980. It i s notpossible to obtainreliable figures on budget execution by expenditure category. It would appear, however, that execution rates are about 70% for salaries and about 40% for non-personnel current expenditures. No information i s available on budget 77 Chapter 4: Financing the Health Sector execution for joint expenditures and ancillary budgets; in2001, no investment credits appear to have been executed inthe health sector. 11. Average salaries inthe health sector have steadily deteriorated over time. Indeed, the `salaries' budget item accounted for only US$9 million in2002 and US$6 millionin2003.22 This amount, which represents an average monthly salary o f US$14, makes it impossible to pay sector employees an appropriate salary or to promote employees. The inadequacy o f the amount i s also causing arrears to accumulate. The Ministry o f Health indicates that monthly salaries paidby the State are about US$15 to US$20 for a ChiefPhysician ina Heath Zone and less than US$50 for a Provincial Medical Inspector, while a nurse ina health center i s paidUS$10 to US$.23 Table 27. Healthsector budget by province, DRC, 2002 (US$ `000, unlessotherwiseindicated.) Ancillary Ancillary Total Total budget Province Main budget budgets budgets budget per capita (salaries) (salaries) (ooeratina) (operating) (US$) Bas-Congo 295 3 44 342 0.09 Equateur 553 23 44 620 0.10 Bandundu 552 0 4 556 0.08 Kinshasa 5 172 401 989 6 562 0.89 KasaiOccidental 346 54 44 446 0.10 KasaiOriental 621 0 4 625 0.11 Katanga 589 0 151 740 0.17 Total 8 128 482 1282 9 893 0.26 No figures are availablefor the provincesof Nord-Kivu,Sud-Kivu, Maniema, and Orientale. Source: Ministryof Finance (2002). 12. The geographic distribution of the budget clearly favors Kinshasa. Data regarding the health sector budget for 2002 indicate that US$O.lO-0.20 per capita are allocated to the provinces, compared to US$ 1per capita for the city o f Kinshasa (Table 27). As for actual expenditures, 60% o f the salary amount (executed budget) i s spent inKinshasa (main towns and city), while 35% i s spent on provincial personnel and 5% on personnel included under the Ancillary Budgets. This is explained to a great extent bythe unevendistribution o fphysicians withinthe country. Another explanatory factor may be a certain amount o f growth within the central Ministry,where the number o f directorates went from 6 to 11between 1998 and 2004, and the number o f specialized programs rose from 8 to 52. 13. Budget allocation clearly favors the central level of the Ministry. It i s difficult to determine, on the basis o f available information, the distribution by administrative entity. It seems clear, however, that the intermediate level i s not formally represented inrecurrent expenditures, and that 44% o f this budget was allocated in2002 to the central Ministry and to its subordinated administrative units. 14. The Ministry's intermediate levelsreceive no operating allowancesfrom the Government, with the result that there are `negative transfers' from health care facilities and their users. Indeed, the absence o f operating allocations inthe budget for provincial departments makes it impossible to finance the decentralized administrationo f the sector. Thus, the burden o f financing the operations o f Provincial Health Inspectorates, provincial antennae of 22No explanation is readily available for this decrease. 23Soeters (2003) puts a desirable monthly salary for a Chief Physician ina Health Zone at US$lOO -200, and that o f a nurse at US$SO - 60. 78 Chapter 4: Financing the Health Sector programs and directorates, and District Inspectorates, is borne through the taxation of health services by these levels. 2. Financing by public and private enterprises 15. The financingof health servicesby enterprises,and particularly by public and parastatal enterprises,was widespreadinthe 1980s. A 1986 study indicatedthat, for the 7.2 million inhabitants that they were covering, enterprises had spent U S 1 4 4 million for healthcare, or U S 2 0 per person. In1989, the contributionof enterprises to the financing o f the sector was estimated at U S 1 4 2 million, covering about 27% of the population (Ministkre de la SantC, 1999b). The role o f enterprises inthe miningsector, most of which are public, was crucial (they accounted for 25% o f GDP, 25% of government revenues, 75% o f the country's exports, and 7% o f formal-sector jobs.) The roughly one hundredpublic enterprise^^^ often had their own medical facilities, and sometimes even large hospitals. Private enterprises more often entered into service contracts withmedical facilities and paiddirectly for care providedto their employees and their families. 16. This contribution from publicand private enterprises disappearedover the last decade and may resumewith some difficulty. The bankruptcy o f the public enterprises, which experienced production drops o f 50-80%, causedtheir contribution to sector financing to disappear. The tax authorities estimated in2003 that only 600 enterprises had a turnover exceeding US$lOO,OOO. A 2004 survey found that only 2.6% o frespondents seeking care had their medicalexpensespaidbytheir employers (Ministry ofHealth, 2004). Another recent study putthe figure at 4.1% (BERCI, 2004). 3. External aid to the health sector 17. External aid to the healthsector is growing and accounts for more sector financingthan the government. This aid, estimated at U S 9 5 million in 1989, hadbecome marginal inthe 1990s due to donor withdrawal. With the resumption of the peace process since 2001, external aid to DRC -bothhumanitarian and development aid-has steadily increased. This support to the health sector, which was estimated in2001 at US137 million andin2004 and 2005 at US$l50 million, could reach US$210 million per year (US$3.6O/capita) over the next few years.25 18. A large share of externalaid is inthe form of integratedassistanceto the Health Zones, and is oftenimplementedby NGOs. According to the Ministryo f Health, about 60% of aid i s inthe formof"global support" for implementationofthe MinimumPackageofActivities (MPA) through intermediate financing entities, most of which are NGOs. In2004, this support covered 60% of the 515 Health Zones and emphasized expansion o fthe supply of primary health care services.26The annual amount o fthis support per Health Zone i s highlyvariable, ranging fiom US$70,000 to 500,000. Moreover, some donors provide direct support to the Ministry'scentral and intermediate levels, and particularly to vertical programs. 24Including, for example, GCcamines, Petrocongo (Cohydro), Onatra and SNCC. 25This combinedhumanitarian anddevelopment aid amount calculated bythe authors assumesan annual contribution o f about US$45 million fromthree World Bank-financed projects; US$33 million from the Global Fund; US$20 million from the European Union; US$20 million from USAID; US$10 million from the Belgian Cooperation; US$8 million from the African Development Bank (AfDB); US$37 million from UnitedNations agencies; US$25 million from ECHO; and about US$12millionfrom other donors. 26This figure couldreach72% in2005 withupcoming World Bank- and European Union-financed projects. 79 Chapter 4: Financing the Health Sector 19. Humanitarianaidto the sector consistsmainly of direct support to HealthZones in regionsaffectedbythe conflict, and emphasizes an improvementof the quality of supply, alongwith a reductionof financial barriers. Humanitarianaidis channeled through internationalNGOs and United Nations agencies. Inorder to improve quality o f services and their affordability, humanitarianprograms direct their support to the provision o f essential drugs, payment o f healthcare personnel, and the regulation o f consultation fees. 20. Developmentaid is dividedbetweensupport to HealthZones andto the various levels of the Ministry,andprimarilytargets improvementsinservice supply. A substantial portion o f development aid (about 50%) consists o f investment ininfrastructure, equipment, and materiel. It also supports administrative structures (e.g., Central Bureaus o fHealth Zones, Provincial Medical Inspectors, etc.), technical and medical training institutes, and Regional Distribution Centers (RDCs). This aid often includes incentives for personnel and subsidies for essential drugs. 21. Withinthis context,the Ministryof Healthconfinesitselfto a strategic, normative,and coordinatingrole, and does not directly implementdonor-financedprojects. Inits declaration following the May 2004 Health Roundtable, the Ministryexpressed its desire to "harmonize [donor support], particularly interms o f the policy on personnel payment, performance contracts, drug supply, and the subsidization o f short-term care." An assumption of these responsibilities by the Ministry,particularly inthe areas o f cost recovery, pharmaceuticals, and the coordination o f a variety o f intermediate implementing agencies, i s crucial inthis context. 80 Chapter 4: Financing the Health Sector 22. The questionof the sustainabilityof donor interventionsis not raised, due to the common understanding that the State and households will be unable, for the foreseeable future, to shoulder the burdenof financing adequate health services inDRC. 4. Financingby households 23. Partialcost recoverythrough user fees haslongbeena source of financingof health care services inthe DRC. Inthe 1980s, the sale of drugs and a systemo f consultationfees, based on the Bamako Initiative, were introducedat the same time that the country was organized into HealthZones. These changes were accompanied by donor-financedinvestments in infrastructure and inimproved quality o f care. It was an era of structuraladjustment programs involvingbudgetary restrictionsand a quest for stable and sustainable financing on the part of donors. The strategy at that time, which was promoted inparticular by the World Bank, consisted of encouraging an increase inconsultationfees inorder to support quality improvements, while at the same time developing exemption schemes to preventthe poorest from reducing their utilization of services. InSub-SaharanAfrica, despite the existence of a few documented experiments inwhich higher consultationfees, offset by improved quality, have ledto increased utilization of services, the cost-recovery experience usually resultedinrecovery on a low proportion of costs, dysfunctional exemption systems, and low utilization of services. 24. In the DRCinthe 1990s, householdsbecamepracticallythe only source of financing for health care services, due to the nearly total cessation of all international aid and the reduction o f public expenditure inthe sector. The lack of a government budget for personnel payments and the absence of international support for investment ledinevitably to a considerable drop inservice utilization. Per capita utilization rates for curative care observed after donors' withdrawal were about 0.15 or less, compared to rates of about 0.6 observed inthe 1980s. Health care services deteriorated, butthe meager financing derivedfrom users' payments and sporadic donor assistanceenabled the system to continue hnctioning at a low level. Table 28. Proportionof cases not receiving care, total and for financial reasons, DRC (% of cases) Did not receive Did notseek/ receive care carereasons for financial Source Basankusu(Equateur) 36 29 MSF(2001) Lisala (Equateur) 24 19 Kilwa (Katanga) 28 23 Kimpangu(Bas-Congo) 20 10 lnongo (Bandundu) 22 18 Nord-Kivu 19 15 Soeters (2003) Kasai-Oriental 16 7 PSF (2003) 9 provinces 23 19 BERCl (2004)* Refersto prenatalconsultations;the sample was drawn from target populationsof health care facilities. 25. The financial barrier excludes a large proportion of the population. Various studies have shown that the proportion of sick people who either do not seek or do not receive care varies considerably, but may be as highas 50% (Table 28 and Table 29). For example, the 2001 MICS2 indicated that 40% o f children with symptoms of acute respiratory infection hadnot beenseen by a medical provider. Inall studies inwhichthis was measured, inability to pay was the major reason, with the percentage o f cases excludedby financial barriers ranging from 7 to 30% (Table 81 Chapter 4: Financing the Health Sector 28). For example, ina sample ofpopulations livingclose to health facilities innine provinces in 2004, 19% of households indicatedthat pregnant women lacked access to prenatal care due to its prohibitive cost (BERCI, 2004). 26. In addition, a large proportion of the sick resortto self-medication. The proportion of the populationresorting to self-medication, i.e., who use private pharmacies and medicines obtained `on the street', i s estimated by various surveys at 20-40% (Table 29). Thus, the MICS2 showed that about 14% of children with symptoms of acute respiratory infection hadreceivedmedication from privatepharmacy or medicine seller, while 10% hadbeen treated only by relatives or friends. A study inNord-Kim likewisedetermined that 38% o findividuals illduringthe precedingmonthhad consulted privatepharmacies andmedicine sellers. This study also estimated that the poorest halfof the populationwas more likely to use this type of treatment (Soeters, 2003). These surveys indicate that inthe event of illness, the proportion of the population lacking contact with a formal-sector healthprofessionali s around 50%. 27. Some studies have also demonstrated the financial constraints facing those who do contact health care facilities. One study inManiema indicatedthat 6% o f cases that receivedtreatment were obligedto abandon the course of treatment due to its cost (Poletti, 2003). The survey in Nord-Kivu(Soeters, 2003) determined that 25% o fpatients who had consulted a formal-sector healthprofessional hadnot continuedthe treatment (although the reasonswere not investigated). Table 29. Proportionof cases using self-medicationand proportionthat did not receive care, DRC (% of cases) Did not Self-medication* seekheceive Source care Nord-Kivu 38 19 Soeters (2003) Kasai-Oriental 25 16 PSF (2003) 5 provinces 40 21 ESP (2003) 9 provinces 38 BERCI (2004) Bandundu 19 40 MlCS2 (2001) Bas-Congo 21 50 Equateur 29 45 Kasai-Occidental 18 44 Kasai-Oriental 26 50 Katanga 24 47 Kinshasa 6 38 Manierna 28 21 Nord-Kivu 38 27 Province-Orientale 25 42 Sud-Kivu 19 53 Country as a whole 24 44 * Care sought from pharmacy,medicineseller, family, neighbor,or other. 28. The price elasticityof healthcare demand, althoughrarely measured, appearsto be significant and greater for the poorest. There are anumber o f documented cases inthe DRC inwhich itwas determined that areductioninconsultation fees ledto anincreaseinservice utilization, or that increased fees had anegative impact on frequency o f consultation. A substantial drop inservice utilization was seen particularly clearly when consultation fees increased suddenly inthe 1980s(Bethune et al., 1989). A prospective study from 1987 to 1991 in 82 Chapter 4: Financing the Health Sector a Health Zone inthe province o f Bandundu observed a drop inservice utilization of up to 40% when consultation fees were introduced, with an improvement inquality that didnot offset the impact o f the introduction of fees (Haddad and Fournier, 1995). A programimplementedby an NGO in2002 began with a per capita service utilization rate as low as 0.18 for curative care; this rate rose to 0.44 and thento 0.65 as consultation fees decreased(Poletti, 2003). 29. A 2005 study comparing data obtained from 26 Health Zones receivingNGO support clearly demonstrated the relationshipbetween the cost of care and the rate of service utilization. Indeed, itwould appearthat the cost ofaconsultationmustdropbelow US$1inorder to obtain service utilization rates exceeding 0.5 consultations per capita per year (Figure26). The improvement in quality due to external intervention must, o f course, also be taken into account as another factor in increasedutilization. 30. There are no reliabledata inthe DRCon householdhealthexpendituresor ontotal healthcare expenditures.27 The World Bank estimated in 1980that annual per capita health care expenditures were about US$5.60. The 2003 study inNord-Kivu estimated per capital healthexpenditures at US$6.50 (Soeters, 2003). These estimates, as well as the prices for various health care services (Table 30) may be compared to per capita GDP, which is estimated at less than US$lOO. Figure26. Rateof utilizationof curative services as a function of average cost per episode, DRC, 2005 (n 26) 0 0.2 0.4 0.6 0.8 1 consultationsper year per person Source : Rbvillion(2005). 31. However, it seems obviousthat healthcare expendituresweigh heavily on household budgets,particularlyfor the poorest. Giventhe level ofpoverty inthe DRC, one can deduce that health care costs represent a considerable burden for households. A study conducted by an NGOinManiemain2001 determinedthat 30% o fpatients hadbeenobligedto sell some belongingsto cover their medical costs, whereas 15% had hadto borrow money (Poletti, 2003). As for the Nord-Kivu study, it determined that 24% ofpatients hadbeen forced to sell some possessions to pay their medical bills, whereas 12% hadgone into debt, and 6% hadborrowed money from their families (Soeters, 2003). The recent study of populations livingnear health facilities determined that 35% of patients who hadreceivedcare hadbeenunableto pay their entire bill (BERCI, 2004). The impoverishing effect on households o f out-of-pocket payments " numberofadhocstudieshave,however,estimatedthecostperincidentofillnessatUS$1to5.50,and A the average number of episodes o f illness per person at 3. Assumingthat 60% o f illness episodes are treated and that the average cost per episode i s US$3, annual per capita expenditure would be US$5.40. 83 Chapter 4: Financing the Health Sector may manifest itself ina reduction o f capital, an accumulation o f debt, and a diversion o f resources away from productive activities. Table 30. Examples of fees observedfor healthservices, DRC Amounts noted IUS$\ Episodeof malaria 3.8 (of which medicine = 0.53) Episodeof diarrhea 4.7 (of which medicine = 0.6) Birth at a HealthCenter 3 - 10 Birth at General Referral Hospital 5 - 15 Surgicalintervention 5 45 Caesariansection 10 125 -- Source: Fees recorded in various studies cited. 32. On the other hand,revenuesderivedfrom users' paymentshavemadeit possibleto maintain a minimumlevelof healthcare. Experience inSub-Saharan Africa has shown that the cost recovery system covers between 5 and 10%o f the total cost o fprimary care, but might manage to cover the cost of drugs. A study inZaYre inthe 1980s determined that users' payments covered 97% of non-salary operating costs (most o fwhich were drug costs) (Poletti, 2003). However, salaries inthe DRChave not been highenough or paid consistently enough over the last decade, with the result that healthpersonnel remunerationhas to be coveredby fees for care and inthe resale cost o f drugs. Eventhough these payments have helped maintain the health care system at a minimal level, it seems that only an improvement inpublic financing (out o f internal and external resources), covering at least adequate salaries for health care personnel, can improve quality and boost utilization rates. 33. There are numerousfee-setting systems.Inthe Health Zones supported by NGOs, the fee scale i s either set by health committees, generally on a per-interventionbasis (a profit margin on the sale o f drugs i s set inthat case by the NGO), or fees are set by the NGOunder its project and imposedby it. Inthe area o f fee-setting, there are two options: i)one fee per episode, which covers all interventions and drugs prescribed for the same consultation; and ii)fee for service, by which all interventions and prescriptions are billed separately. Fees per episode have the advantage o f streamliningprescriptions and billing, while creating a sort o fpooling o frisk. The disadvantages have to do with financial risks associated with over-prescription or, conversely, o f rationing o fprescriptions inorder to boost profit margins. This system also requires constant availability o f drugs and rigorous monitoring o f their consumption. Fees for each service ensure financial viability, essentially with regardto drugs. However, this method may also foster over- prescription, since revenues are no longer proportional to the number o fpatients seen, but instead to the number o f interventionsperformed and prescriptions issued per patient. Moreover, it does not encourage continuity o f care, since patients cannot always pay for the entire course o f their prescriptions. 34. Financialmanagementi s at bestinformal,exemptionschemesfunction poorly,andthe collectionof consultationfees hasledto abuses. Indeed, budgetsand financial management seem to be nonexistent at the level o f health facilities. A recent study o f 56 healthcenters showed that none o fthe facilities surveyed had an official budget (BERCI, 2004). 35. The exemptionpolicies inplace are supposed to ensure access for those who are designated as indigent by the local administration. However, only an infinitesimal portion o f the population seems to be benefiting from these exemptions. A survey o f target populations o f health care facilities innine provinces (n= 2 880) indicates that only 1.4% o fpatients possess a "benefit entitlement" or "indigence" card enabling their bills to be covered by the State (BERCI, 2004). The local administration i s supposed to reimburse the Health Zones directly for care provided to 84 Chapter 4: Financing the Health Sector indigents, but this rarely happens. Infact, the exemptions enjoyed by civil servants and military personnel represent a greater proportion than those benefiting the indigent. Inaddition, the administration's failure to reimburse for the cost o f care for civil servants and soldiers weighs more heavily nthe revenues o f health facilities and Health Zones (Maltheser, 2004). This forces health care facilities to further increase fees, a strategy that makes these exemptions an indirect and regressive tax. 36. One example o f the perverse effect of this situation, inwhich the poorest bear most o f the financial burden o f financing health care services, i s the practice o f obliging patients who have received care to remain inthe facility untiltheir families have paidthe bills. This practice seems to be particularly common inthe area o f emergency obstetrical care, since the highprice o f a Caesarian section i s unaffordable for most people. Empirical evidence i s supplied by the study o f target populations o f health care facilities innine provinces, inwhich 28% o f respondents said that health care facilities imprisonedpatients ifthe family didnot pay the fees (BERCI, 2004). 37. The numerousexperimentswith community-basedhealthinsuranceschemesthat protecthouseholdsfrompotentiallycatastrophic healthcare expendituresshouldbe explored. The most extensive andmost thoroughly studied is the mutual o fBwamanda (province of Equateur), which insures its 114,000 members for hospital care. There are also many different arrangements involving small groups that protect themselves against the risk o f catastrophic expenditure. These arrangements are small-scale; a 2004 study o fnine provinces found that 2.4% o fhouseholds had their health care costs coveredby a mutual (BERCI, 2004). It shouldbe noted that such programs are not easily reproduced and do not necessarily benefit the poorest. In Bwamanda, for example, although hospitalizationi s greater among the insuredthan inthe rest o f the population, the poorest remain the least likely to be insured (Criel et al., 1999). The failure o f at least one pilot community insurance scheme, which was supported by external aid, has been studied inMasisi, Nord-Kivu. The reasons for its failure included weak design (leading to overconsumptiono f services), and the lack o f a feeling o f ownership on the part o f those who were insured (Noterman et al., 1995). Insurance mutuals- and any other form o f community- based insurance - cannot improve the overall situation unless public expenditure inthe sector increases, butthey are a potential way o f reducingrisks and o f improving equity at the household level. 38. Economicbarriersto access, andthe burdenon households,canbe reducedby a considerableincreaseinpublic expenditureandexternalaidto the sector. The populationo f DRC is too poor to be able to finance the sector alone. Reducingthe financial barriers to care and the impoverishing effects o f health care expenditures on households will require a higher level o f public expenditure. Although the government budget has grown over the past few years, the increase remains illusory to the extent that only a small part o f it i s executed: an estimated U S 2 4 million in2004, or US$0.40 per capita. External aid has increased considerably, and projections for the coming years are for about US$l50 millionor US$3.60 per capita per year. 39. Additionalsupport to the sector shouldbeaccompaniedby specificmeasuresaimed at reducingdirectpaymentsby users. Inany scenario, it is certainthat a portion o fthe financing requirementwill continue to be covered by user fees. The increase inpublic expenditure and external aid mustbe accompanied by measures aimed at improving exemption systems inorder to protect the poorest households inparticular from the impoverishingeffects o f health care costs. On the supply side, at the level o fthe healthcare facilities and HealthZones, these initiatives may include better management and accounting, financial transparency, proper allocation o f user fees inorder to enhance quality, andmore efficient exemptionsystems. Suchmeasures couldonly have an impact ifpublic expenditure i s increased, particularly interms o f salaries and the reimbursement of costs generatedby fee-exempt patients. 85 Chapter 4: Financing the Health Sector 40. Achievement of the MDGswill requirea muchgreater effort,butthe financing gap is notinsurmountableinthe short term. Estimates ofthe cost ofachievingthe MDGsby2015 in other Sub-SaharanAfrican countries vary considerably. The UnitedNations MillenniumProject estimates the annual requirement for Ghana, Tanzania, and Uganda at US$16 to US$23, reaching US$30 to US$44by 2015. A joint estimate by the Government of Ethiopia and the World Bank puts the annual marginal cost (ie. Additional to what is currently spent) at around US$6, risingto US$15 by 2015. 41. Inthe absence o f data specific to DRC, and assuming that the country's additional requirements couldbe equivalent to those estimated for Ethiopia, the annual public financing requirement over the next few years wouldbe about US$6per capita. 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