Economics Answers 2011


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Economics Answers 2011

  1. 1. DEMOCRATIC REPUBLIC OF THE CONGO Last update: 27 July 2004 The Present Context • The installation of the transitional national government in July 2003, following the peace agreement of December 2002, formally ended 7 years of civil conflict. • In September a brigade-strength UN (“MONUC”) contingent for Ituri armed with a new Chapter VII mandate replaced the EU- led Artemis force. • The international community is cautiously optimistic, and has recently launched major reconstruction programmes. • There are concerns that the peace in the east of the country is not stable and there is expectation for further consolidation of the peace process and the holding of elections. • Humanitarian needs are likely to continue to exist while the capacity of agencies to deliver humanitarian services is often inadequate to meet all the needs, mostly due to the size and inaccessibility of many parts of the country, aggravated by continuing insecurity and instability in the east of the country. • In addition, natural disasters—including volcano eruptions in the East, droughts in the South, and flooding of the Congo River—further add to the vulnerability of the population.Main Public Health Issues and ConcernsHealth status • Mortality rates found in mostly eastern DRC continue to be above emergency thresholds. It is estimated that millions of people have died in excess to normal baseline mortality rates for sub-Saharan countries. Childhood mortality is at least double the normal rate, indicating that the severity of the crisis is still in emergency conditions. Most of these excess deaths are attributable to malaria and other common diseases, rather then directly due to violence. • Maternal mortality rates in the east of the country are estimated to be above 1,800 per 100,000 live births. • The principal public health concerns in the DRC are communicable diseases such as malaria, tuberculosis, and diarrhoeal diseases (including cholera). Malaria accounts for 45% of childhood death. Acute respiratory infections (ARI), diarrhoea and measles are other important causes of morbidity and mortality among children • Control of epidemics is one of the highest priorities in DRC, as the country faces almost every possible outbreak. Most important are cholera and measles, but include pertussis and (re)emerging pathogens such as Marburg, Ebola, Trypanosomiasis and plague.
  2. 2. • The EPI program has low coverage, with for example only 40% of children vaccinated against measles. Environmental health conditions—such as lack of sanitation, indoor air pollution, inadequate hygiene and insufficient water supplies—increase the potential for ill health. High levels of malnutrition heighten susceptibility to disease, particularly aggravating the health predicament of children under five. • Conflict-related injuries are on the increase, particularly after recent surge in violence. Gender-based violence in conflict areas, , although mostly undocumented, remains the greatest threat to womens reproductive/sexual health and their emotional well- being. • The poor health status can further be attributed to high levels of poverty, displacement and limited access to adequate health services.The Health System • Conflict and collapsed infrastructure have resulted in a severely weakened health system with insufficient capacity to meet the needs of the population. In many areas, the health system functions as if it were private and patients can not afford to seek assistance. • Most people buy drugs of dubious quality in the many private pharmacies. In areas supported by international NGOs, acceptable consultation rates of between 0.5-1 consultations per person per year are reached.. Different forms of user fees and cost recovery schemes are being introduced ranging from symbolic flat fees of 0,125 US$ to 50% of costs recovered, sometimes risking to decrease access to services for the indigents. • In most cases, health workers have not received salaries from the MoH for decades. In particular doctors left the periphery and went to the cities, or were employed by international agencies. Many nurses stayed and started working for themselves. The health worker education system does not function well anymore, with concerns about the qualifications of staff. • Access to secondary level of care is still a serious unresolved problem. This level receives the least international support compared to the first line health centers. Capacity for emergency surgical procedures or treatment of severe illnesses is very limited, or patients have no access due to the high costs as procedures are often not subsidised. Emergency obstetric procedures like caesarean section can induce or further increase poverty of families.Main Sector Priorities• Detection and control of epidemics in the entire country• Emergency assistance to IDPs and returnees• To ensure equitable access to basic health services in targeted health zones mostaffected by the conflict and/or with proven mortality rates above the emergency threshold − Scaling up the minimum package of services including expanding immunization coverage. − Access to secondary level care for severely ill patients and acute surgical procedures. − Search an adequate solution to remove the barrier of user fee issues with the MoH, NGOs and donors• Increased efforts to control malaria; increased access to effective curative treatment andprevention through insecticide treated bednets, targeting conflict areas with the longesttransmission season.• Improved access to reproductive health programmes, including emergency ObstetricCare.• To address Gender Based Violence and provide curative treatment and counselling tovictims of rape. 3
  3. 3. • HIV/AIDS prevention program to control the epidemic in its early phase• Reduce malnutrition in areas with high acute malnutrition rates. Integrate nutritionalservices in the PHC system in areas where acute malnutrition rates have decreased belowemergency thresholds• Advocacy to gain access to isolated areas, rapid assessments and emergency supportbased on findings to newly accessible areas remains a top priority.• The humanitarian approach is to support the existing health structures. Particularly inareas where there is no longer active conflict, strategies need to be adopted that makecommunities less dependent on external aid and that allow transition and handover todevelopment partners, and further strengthen the capacities of the national health authoritiesin management and supervision: • Support to the Bureaux Inspection Provinciale (BIPs), Bureaux Centrales des Zones de Sante (BCZS) and the Committees de Santes (CoSas) using perfomance based contracts • Increase the percentage of costs for the population only if signs of improved purchase power through socio economic surveys, to guaranteeing equitable access for the poorest, acknowledging that many parts of the country will continue to face an economic crisis. • Maintaining accomplishments achieved through the humanitarian programs• More funds are being pledged from development donors, but implementation is likely tobe delayed, awaiting further consolidation of the peace process and the elections next year.Other priority Humanitarian NeedsAlleviate or prevent human suffering while helping vulnerable communities in the DRCto live a life with dignity.This overarching goal is translated into three axes: • Preserve lives through life saving interventions; • Reduce vulnerabilities within affected communities; • Maximise coordination mechanisms and facilitate the transition from relief to development.Sector ActorsPlease see Annex 3DisclaimerThe emergency country profiles are not a formal publication of WHO and do not necessarily representthe decisions or the stated policy of the Organization. The presentation of maps contained herein doesnot imply the expression of any opinion whatsoever on the part of WHO concerning the legal status ofany country, territory, city or areas or its authorities, or concerning the delineation of its frontiers orboundaries.Contact Details (Country code 243)Minister of HealthDr Y. SitoloMonsieur le Ministre de la Santé publiqueMinistère de la Santé publique4310, boulevard du 30 juin 4
  4. 4. 3088 Kin 1Kinshasa GombéRépublique démocratique du CongoTel. 243 12 33216; 243 12 33213; 243 12 33214WHO RepresentativeDr Leonard TapsobaT: +243 88 40789E-mail: tapsobal@cd.afro.who.intUN Resident CoordinatorMr. Herbert M CleodUN Resident & Humanitarian CoordinatorUNDP Resident RepresentativeKinshasa+243 12 33 424 / 81 880 4637 / 880 4603 (T)+243 884 36 75 (Fax) 5
  5. 5. Annex 1: Health Profile - DRC1General IndicatorsPopulation (2004) 58 millionRefugees2 415,000 3Internally Displaced Persons 3.4 millionHealthy life expectancy at birth m/f (years) 41/46 4GNI (Gross National Income) per capita (US $, 2002) 90Infant Mortality rate (deaths/1000 live births) 127Under-five mortality rate (deaths/1000 live births) 212Total adult literacy m/f % (2000) 76/55Population using improved drinking water sources 45%Population using adequate sanitation facilities 21% 5UNDPs Human Development Index ranking 168/177Health Systems ProfileTotal expenditure on health as % of GDP 3.5Total per capita health expenditure (US $) 5Nurses rate per 100,000 population 44.2Physicians rate per 100,000 population 6.9Hospital Beds per 1000 population 1.4TuberculosisPrevalence per 100,000 511Mortality rate per 100,000 57HIV/AIDSAdult prevalence of HIV/AIDS (15-49 years) 4.9%Estimated number of adults living with HIV/AIDS (2001) 1.3 millionReported number of people receiving antiretroviral therapy 2500Orphans due to AIDS 800,000MalariaMortality rate per 100,000 452Immunization (2002)6BCG 48%DPT3 40%Measles 40%Polio 40%Pregnant women receiving tetanus vaccine 35%Womens HealthTotal fertility rate 6.7% of antenatal care coverage 30-80%of skilled attendant at delivery 20-60Maternal mortality ratio 18371 WHO/CDS baseline statistics unless indicated otherwise2 The World Bank Annual Report, 20035 UNDP World Report 20046 6
  6. 6. Annex 2: Health SectorHealth system descriptionThe country is divided in 11 provinces, with each a Bureau Inspection de Province, lead by aMedecin Inspecteur de Province. The structure of this bureau resembles that of the ministryof healths 9 Directions. The provinces are divided in Zones de Sante with each a Bureaucentral de Zone de Sante, headed by a Medecin Chef du Zone. The health zones correspondwith what is often referred to as districts, with a general referral hospital and 20-30 healthcenters. Some have health posts in addition. In total, there are 400 hospitals (1 generalhospital per 180,397 inhabitants), 5078 health centres (1 HC per 10,218 inhabitants). Averagepopulation per health zone used to be 200.000, but recently the number of zones has beenincreased from 308 to 515. Most of the new zones are virtual as there are no funds toconstruct the required infrastructures or pay for the staff. A national health policy and actionplan exists. In Mai 2004, a roundtable was organised by the MoH bringing all healthstakeholders together to plan for implementation and scaling up of the health system.The administrative structures (BCZdS and BIP) continued to exist though, even if they were notfunctioning as they should. In areas supported by international agencies, the BCZdS often getdirect financial budget support and/or a percentage of the revenues of the health centres is to begiven to them. In return, performance based contracts are often introduced, for examplespecifying supervisory responsibilities and the delivery of health surveillance reports. Themedecin chef du Zone is often also working as a doctor in the referral hospital.The Health Centres (HC) are to provide a prioritised Minimum Package of Activities (PMA)including basic curative treatment for both out and inpatients and preventive programsincluding Antenatal Care and the Expanded Program on Immunisations; HCs are staffed bynurses, reference hospitals ideally with a doctor. Health centres are to have community basedCommittees de Sante, often consisting of up to 30 people who are to be involved incommunity mobilisation and other preventive programs.Churches traditionally have been providing up to half of the health services in the DRC. With zerostate investment and minimal or no state contribution to running cost (see below), Churchesrelied on their external partners for investment and on the patients to cover the cost of treatmentand other running cost. In addition to the public and church run health facilities, there is aflourishing market of unregulated private pharmacies and traditional healers.The role of the private for-profit sector with regard to drug supply is overwhelming: it supplies atpresent 80% of the drug market. With the help of external aid (FEDECAM) however, 30 RegionalDistribution Centres (CDR) are planned throughout the country to be operational by the end of2004, covering the needs for essential drugs for 38% of the Congolese population. Crucial factorsfor their success include adequate supervision and training of BCZSs in management, improvingthe rational drug use at health facility and community level, subsidised purchases and thecommitment of NGO working in these areas to purchase via the CDR.The Ministry of health has not been able to financially support most of the provinces over the lastdecades. Since the independence in 1960, hardly any investments were made in theinfrastructure. Staff has received no salaries from the MoH. Health services, if not run by aChurch-based organisation, became the responsibility of the community and/or were self-managed. This system, which had become a de facto private system with full cost-recovery tofinance the income of the health staff and medicines, had already produced a high rate ofeconomic exclusion before the war, resulting in very low consultation rates (less than 0,1consultation per person per year). During the war, health structures suffered from looting, lack ofmaterial and drainage of human resources. Many doctors went to the larger cities or wererecruited by international agencies. Many nurses stayed in their areas and started working forthemselves, sometimes using the existing health facility. The health workers education systemdoes not function well and there are concerns about the qualifications of staff. Some are selftrained, and/or receive training from NGOs. 7
  7. 7. Health sector objectives to address concerns:• Strengthen capacity of the health system to prevent, detect and control epidemics• To expand access to the minimum package of activities in health centres• To bring more coherence in user fees mechanisms, retaining equitable access• Increase access to effective malaria treatment and rapidly increase the capacity ofpreventive programs (distribution of insecticide treated bednets). Prioritising areas with thelongest transmission season• Reduce maternal mortality by increased access to Emergency Obstetric Care• Scaling up HIV prevention programs• Monitor nutritional status in high risk areas and among vulnerable populations, reducechildhood malnutrition rates if above emergency thresholds.• More effective advocacy and interventions for the protection of populations, in particularto prevent SGBV, and ensure access to counselling and treatment of rape victims• In transition areas, building on achievements of the humanitarian programs, strengthenthe capacity of national partners to manage and supervise the health services.• Ensuring that priorities are agreed upon between health partners and improving theframework for health coordination and joint planningSummary of gaps and challenges:• The security situation remains a cause for humanitarian needs and a constraint toimplement programs. There are still many areas to which there is no or only sporadic access.• In these and other areas that do not receive support from international NGOs, access toadequate health services remains very low, mainly as they function as private services,recovering 100% of the costs.• Given the low amount of financial resources available in the MoH, and the fact that fewof these arrive in the periphery of the country, support to the functioning of the public healthsystem will continue to fall on the shoulders of external donors.• Adequate and effective support to secondary level of health services is identified as oneof the important gaps.• The high poverty levels and limited opportunities for economic growth remain aconstraint for humanitarian agencies to withdraw from areas that are in transition.Development agencies are not yet ready to take over programs. 8
  8. 8. Annex 3: Principal agencies providing health assistanceProvince INGOSouth Kivu ACF, AMI, CEBUMAC, ICRC, GTZ, IMC, IRC, Louvain, Malteser, MSF H, CISS, DOCS, ODPI, CARITASNorth Kivu DOCS, Oxfam, MDM, CESVI, IRC, ACTION AID, CARITAS, MSF-H, SODERU, World Vision,Orientale (Ituri) Malteser, COOPI, MSF-Ch, Oxfam, Medair, DOCSManiema CARE, Merlin, CARITAS, Concern, ACF, COOPINorth Katanga Alisei, Solidarité, CARITAS, MSF-E, IRC, MDM-F 9
  9. 9. Annex 4: Context• Since 1998 the Democratic Republic of the Congo (DRC) has been rent by ethnic strifeand civil war. Troops from several countries have intervened in the conflict.• A cease-fire was signed in 1999, but skirmishing has continued. In January 2001President Laurent Kabila was assassinated; he was replaced by his son Joseph who hassince moved to implement the stalled Lusaka Peace Agreement, allowing the deployment ofUN troops, and adopting economic policies in line with WB and IMF prescriptions.• United Nations Military Observer Mission to Congo (MONUC) established in November1999 to monitor the implementation of the Lusaka peace deal signed earlier the same year.Presently, in phase III of their intervention and dealing with the program for Disarmament,Demobilisation, Repatriation, Reintegration and Resettlement (DDRRR).• The economic and political crises in DRC as well as natural disasters, such as recentvolcano eruption, have increased public health risks for the population.• Civil Conflicts have displaced over a 2 M persons in North and South Kivu. More than330,000 people are refugees in DRC due to civil conflicts in neighbour countries (Sudan,Rwanda, Republic of Congo, Burundi and Angola).• DRC is one of the poorest countries of the world (GDP per capita of USD 97) and has aHuman Development Index of 0.43 (ranking it 152nd out of 175 countries). The economy hasbeen declining for years, as well as overseas development assistance has been reduced fromUSD 476 M to USD 168 M between 1991-97.• Languages spoken are: French (official), Lingala, Kingwana , Kikongo, Tshiluba• Main religious groups: Roman Catholic 50%; Protestant 20%; Kimbaguist10%; Muslim10%; others sects and indigenous beliefs 10%.• Main ethnic groups: over 200 African ethnic groups of which the majority are Bantu; inthe North and South Kivu are the Banyarwanda, divided in Hutus (Bantu) and Tutsis (Hamitic)Political and Administrative Division• 11 provinces: Bandundu, Bas-Congo, Equateur, Kasai-Occidental, Kasai-Oriental,Katanga, Kinshasa city, Maniema, Nord-Kivu, Orientale, Sud-Kivu• Each province is sub-divided in districts and each district in administrative areas (zones).Affected Population• Total country population: 58, 317,9307• Internally Displaced Persons: 3.4 million as of August 20038• Despite continued efforts by humanitarian actors to reach the victims, it is estimated thatout of the 4 million inhabitants of Ituri, 500,000 to 1 million were displaced, and out of thismillion displaced, only 110,000 of them who reached Oicha and Beni towns in North Kivureceived assistance.27 UN OCHA 18 Nov 03 10
  10. 10. Distribution of IDPs by province (July 99-end 2003)• Great increase of IDPs in Orientale due to crisis in Ituri (mid-2003)• The majority of displaced persons were found in the eastern provinces of North Kivu,Katanga, Orientale and South Kivu, (Aug 2002)The majority of displaced persons were foundin the eastern provinces of North Kivu, Katanga, Orientale and South Kivu, (Aug 2002)• about 1 million IDPs in the Kivus as of Aug 2002• The number of IDPs in Equateur decreased greatly from Dec 2000 to Sept 2001• The number of IDPs in Orientale increased greatly from Dec 2000 to Sept 2001 and thenincreased again in Feb 2002• The number of IDPs in Katanga increased by 100,000 between Dec 00 and Sept 01November 2003 ORIGIN FIGURESEquateur DRC 168,000Katanga DRC 412,000Maniema DRC 234,000North Kivu DRC 1,209,000Orientale DRC 791,000South Kivu DRC 413,700East and West Kasai DRC 145,000Kinshasa DRC 41,000TOTAL IDPs 3.4 million(Based on numbers provided by UN OCHA, 18 Nov 03, p19)Source: UN OCHA 15 July 1999, 11 July 2000, 31 December 2000 (p.11), 30 September 2001;28 February 2002, p.13; August 2002; 31 July 2002 11
  11. 11. Accessibility and Essentials for Logistics• Rainy season: north of Equator: April to October, south of Equator: November to March• Routes of access. Transport infrastructure has largely collapsed, and insecurity iswidespread. Transport cost for humanitarian assistance goods is extremely high.• Transport by rail/road: out of the 145,000 km of roads, no more than 2,500 are asphalt.Chronology of major natural disasters:Drought 20-Jan-1979; 500,000 affected - Drought 1984; 300,000 affected - Flood 30-Nov-1999; 78,000 affected - Flood 31-Dec-1997; 35,506 affected - Flood 20-May-1990; 27,500affected - Flood Dec-2001; 13,000 affected - Volcano 10-Jan-1977; 8,010 affected -Earthquake 20-Mar-1966; 3,600 affected 12
  12. 12. Annex 5: International stakeholdersSource: OCHA and Humanitarian Partners, June 4, 2004 13