World Health Organization s2

WORLD HEALTH ORGANIZATION DR Congo Health Update July 2001

This update offers a snapshot of some of the More hands for emergency action activities of WHO and other partners in WHO hopes soon to recruit a second specialist health in the Democratic Republic of Congo. in emergency and humanitarian action to join its It is by no means comprehensive. Further office in Kinshasa thanks to funding from the information can be obtained from the web Swedish government. Currently the area is sites and contacts noted at the end of the covered by WHO communicable disease expert document. Dr Tshioko Kweteminga, who has begun training local health zone chiefs in Kinshasa in the management of emergency situations. With Emergency response extra hands on deck, the office hopes to extend Clear shift to public health needed this training to both provincial health authorities and WHO’s district medical epidemiologists in Health care in DRC must be redirected from the the near future, and to take a stronger role in current facility-based curative care to a public helping all actors in health strategically co- health approach focused on the main killer ordinate their activities and gain better impact. conditions if humanitarian interventions are to address the unacceptable mortality and morbidity evident in the country. This was the HIV/AIDS key message of a joint WHO-UNICEF mission Interest raised but money slow which spent late July in DRC. Donor interest in the struggle against HIV/AIDS The mission found that, despite good intentions, in DRC has been rising, but a new plan of action up to 70% of the population is now excluded drawn up by the Programme Nationale pour le from accessing basic health services, while all Lutte contra SIDA in collaboration with an forms of preventative public activities are committee of UN organisations and international severely curtailed, not least because salaries of NGOs has yet to garner firm commitments. health service workers are linked to curative care. This observation led to the mission’s DRC was the first country to design and second key recommendation: that “health implement an HIV/AIDS programme with the worker remuneration must be separated from support of the World Bank and UN agencies, but payment by patients…and linked to performance in recent years funding has faltered. of a package which directly targets the main The Government of Norway recently donated killers, both in the health centre and at $400,000 to WHO to improve surveillance and household level.” testing for HIV/AIDS (see below), but proposals The nine-person mission presented their for supporting supplies, health education and findings to a donor contact group meeting palliative care for related conditions such as oral focused on health and food security in Geneva candidiasis at home remain on the starting in early July. They also called for a ‘massive blocks. effort’ on HIV/AIDS and malnutrition which, they Meanwhile, the situation around the country in say, provides an increasingly frightening terms of contraceptive supplies and blood underlay to the situation. security means is dire. In Katanga province, for As follow up, WHO is now working on a plan of example, the availability of safe blood has action to kick start the necessary radical shift to slipped from almost 90% of health districts in the public health care. province in 1989 at the height of a UNAIDS/EU funded programme, to partial coverage in less For mission report, http://www.who.int/eha/disasters, than 10 zones today, according to WHO’s click on DRC sitrep. provincial medical epidemiologist Dr Edmond For further information, please contact: Magazani. WHO DRC: contacts at the end of this update. Dr William Aldis, WHO AFRO, [email protected]; The remaining services are well maintained by Dr Agustino Paganini, UNICEF, [email protected] MSF-Belgium, which also supports one of the few Dr Rayana Buhakah, WHO/HQ, [email protected].

1 July 2001 WORLD HEALTH ORGANIZATION centres for voluntary testing and counselling, but Having spent the past month visiting the their reach is limited. provincial capitals of eastern DRC in a rapid Health education too is also barely taking place analysis of malaria control activities, Dr Ezard with health zones and national NGOs citing lack says the magnitude of the problem is “nearly of simple equipment, like paper and pens, as overwhelming”. morale-sapping obstacles to even voluntary “Malaria is the number one cause of mortality for work. the population of nearly 20 million in the east. There are big problems of security, logistics and Accurate figures overdue infrastructure, low access to health services, no Improving capacity to assess the impact of HIV preventative activities and a real lack of and testing capacities is the goal of a $400,000 standardisation of approach to surveillance and dollar Norwegian donation. Currently five treatment.” sentinel sites are producing HIV/AIDS At the same time however, she says, there is information, in Kinshasa, Karawa (Equateur), “huge enthusiasm” among national and Mikalay (Kasai Occidental), Kabondo (Orientale) international NGOs, local authorities and UN and Sendwe (Katanga). These are the remnants agencies to address the problem. of a 14-site project set up by UNAIDS in 1992. Meanwhile in Kinshasa, the national programme But in-depth investigation of country-wide committee, supported by the USAID-funded prevalence is long overdue, say experts. BASICS (Basic support for Institutionalising National figures collected through the health Child Survival), WHO and other NGO partners, information system cite just under 10,000 new has started working on a new national cases of HIV for 2000. But public health consensus strategy which is likely to insist on authorities estimate the real figures, based on preventative action as well as a re-defined the sentinel site information, are more like treatment protocol, based results of resistance 173,000 new cases a year, with a total of almost studies (see below). 1.3 million adults and children already living with * The Roll Back Malaria Initiative, instigated by HIV. WHO, aims to galvanise partnership between Similarly, prevalence rates are believed to be local authorities, national and international much higher than the quoted average of 5% NGOs, UN agencies and communities to work across the country. Recent investigations among across all sectors and to implement strategies in apparently healthy family blood donors in prevention, education, access to treatment and Kalemie, North Katanga, found over a third were environmental action. HIV positive, while a study of patients in the General Hospital in Bukavu found a prevalence New protocols to fight resistance of 32% among adult males, 54% among adult Five studies into the effectiveness of common females and 26.5% among children. malaria treatments in Western DRC show there Multiple troop movements and displacement in is 25-35% resistance to choloroquine and less recent years to and from neighbouring countries than 5% resistance to sulphadoxine- where prevalence ranges from 12% (Central pyrimethamine (Fansidar). African Republic) to 27% (Rwanda and Zambia) However, studies in the east are essential has made DRC “well prepared for an explosion before the development of new treatment of HIV/AIDS,” says WHO focal point Dr Tshioko protocols so as to ensure new approaches are Kweteminga. “I can hardly think of better vector not quickly over-run by resistance problems, and than tens of 1000s of young men with hard work has started in three sites which already currency roaming around the country,” adds have experience in malaria research another observer. Resistance patterns tends to move from East to West across Africa, says Roll Back Malaria co- Malaria ordinator for the eastern provinces, Dr Nadine Co-ordinated focus is crucial Ezard. In Burundi, for example, 80 to 90% of malaria is resist to chloroquine and a worrying Two experts have been recruited to help drive 30-50% to sulphadoxine-pyrimethamine the Roll Back Malaria Campaign* in DRC which (Fansidar). The latter is currently the official is the latest development in the fight to reduce second line treatment in DRC and one of the few death and illness from malaria. Dr Mantshumba remaining cheap treatment options. Bikete Iyombo takes up the post of RBM “ There is widespread use of choloroquine of coordinator for the west of the country while Dr dubious quality and dubious dosing in eastern Nadine Ezard is RBM coordinator for the east DRC . On top of this people often don’t complete based in WHO Goma.

2 July 2001 WORLD HEALTH ORGANIZATION their courses. There is also likely to be and at present there is no money to continue the significant resistance to sulphadoxine- project,” says Mrs Flora Chirwisa, WHO’s pyrimethamine because of the high rate of national officer for reproductive health. transmission,“ says Dr Ezard. Current calculations suggest 1837 women per Choloroquine is still the first line treatment in the 100,000 die in childbirth in DRC, over three national protocols, but many health workers times the African average and more than 42,000 move straight to quinine, if patients can afford it. a year. Anaemia, malaria, sexually transmitted However, where drug fees make up a significant disease, poor spacing of pregnancy, a high rate part of health worker ‘salaries’, there is also of adolescent pregnancy and late attendance widespread multiple prescribing. are major contributors to the death rate. In the African region, there is an increasing drive towards combination therapies involving Child Health particularly sulphadoxine pyrimethamine, artemesinin derivatives or amodiaquine. But, Training in essential care for children with each combination treatment costing the The first training of trainers based on the newly equivalent of an insecticide impregnated bed adapted protocols for the integrated net, sheer economics is likely to force a shift management of childhood diseases in DRC took towards preventative measures. place last month. The 10 day workshop involved 24 potential Reproductive health trainers, seven international consultants, local ministry child specialists, and WHO national Good start falters for lack of funds officer for child health Dr Brigitte Kini . An 18-month project designed to introduce Health centre level training will be piloted in integrated reproductive health care October 2001 in two health zones in Kinshasa, programming throughout DRC drew to a close in one in Bas Congo, and two in Kasai Orientale. June as funds finished. All will receive basic supplies as part of the Funded through UNFPA and implemented by project, which is funded by UNICEF, WHO and WHO, the programme has involved workshops international NGOs such as ‘Horizon Santé’ in seven provinces for all those involved in Currently under fives in DRC are estimated to improving reproductive health outcomes and suffer five to six episodes of diarrhoea a year, 10 family planning, including health staff, national episodes of malaria-like fever and 14 episodes NGOs, university lecturers, community leaders of acute respiratory tract infection. and traditional health workers. It also included the development of a 10-day practical updating Immunisation up but a long way to go course for nurses which has been piloted in Although average figures for routine vaccination Kinshasa. rose slightly in 1999-2000 according to figures The provincial workshops focused on discussion from WHO’s Expanded Programme on of care for at-risk mothers, strategies for Immunization unit, overall the picture is grim. intervention and the resources needed to take The rise stems largely from intensive efforts in action. They also started the process of defining NGO-supported health zones and improvements a minimum package of reproductive and family in cold chain due to the expansion of the polio planning services, based on the national policy, programme. But still fewer than one third of for all levels of the health system. children routinely receive childhood vaccination “ It’s necessary for people to talk the same and averages for some antigens fall as low as language and work to the same strategy,” says 18% while in Orientale Province, rates run at 0 Dr Mwela, a local gynaecologist and co- to 10%. ordinator of the workshops for WHO. NGO and WHO efforts to improve the cold chain However, lack of funds is delaying the further roll and training of staff are continuing. But as one out of these projects, while severe problems with logistician explains succinctly: “If you have the medical supplies and equipment has limited the fridge, you don’t have the kerosene to run it. impact of the practical course. When you have the kerosene, you don’t have “The training was very good – it reminded me of the vaccine. Then the fridge breaks down many things I learnt at college and it introduced because of poor maintenance, or there are no me to new ideas. But it’s very difficult to put it vaccine cards. There always seems to be into practice because we have so little means,” something. explained one participant. On top of this, NGOs are reporting frequent “People are motivated and enthusiastic but now reluctance among health workers to give they need equipment, supplies and supervision, childhood vaccination, or indeed provide any

3 July 2001 WORLD HEALTH ORGANIZATION preventative care, free of charge because their there are just too many systems attempting to pay is mostly derived from fees for service. gather data. Both short term solutions and long term thinking Currently health workers throughout the country is required according to the key partners in are asked to file information into four separate childhood health, and a five year strategic plan unconnected databases, all of which use for the development of EPI activities has just different criteria to produce figures. These data been completed by local health authorities, streams are linked to the Expanded Programme thanks to the technical and financial support of for Immunization, the ‘Quatrieme Direction” in the US funded group Basic Support for charge of communicable diseases, the WHO-led Institutionalising Child Survival (BASICS) and polio surveillance system, and National Health WHO. Information System or SNIS. The fact that the first two of these, though in the Communicable Diseases same building, produce entirely different measles figures due to the different statistical Antennae to improve epidemic radar criteria they use, is an evidence of the confusion In the past nine months, WHO has set up 11 this situation can cause. provincial ‘antennae’ staffed with medical WHO, a major donor and the ministry are epidemiologists, logisticians and radio currently discussing the possibility of developing communications and recruited 42 one central surveillance centre which would epidemiologists to work at district level. Both work to standardise and streamline all forms of levels are funded by the Global Polio Campaign reporting, which would not only to produce more but are charged in their terms of reference with accurate data but also less arduous reporting addressing the much broader brief of routes for health workers. strengthening surveillance of all epidemic-prone Currently only 30% of health zones submit at diseases as well as polio. least one health report a year, and this report There is a lot to strengthen: two thirds of the does not necessarily involve data from every health zones in the country still file no reports facility in the zone. and the remaining 30% file a minimum of one report a year. Staff motivation is a key issue at Free drugs bode well for tryps teams all administrative levels. DRC’s fight against sleeping sickness is to get a “ By the time you get the information of an significant boost from a $25 million initiative epidemic, it’s often too late to do anything – between WHO, international NGO Médecins people have either recovered or died,” says one Sans Frontières and pharmaceutical MSF head co-ordinator. manufacturers Aventis Pharma and Bayer. In certain areas, where health zones are more The new project assures continued manufacture accessible or are directly supported by of crucial drugs and free supply to countries in epidemiologically-minded NGOs, reporting is need, and will release funds to increase the better. In Kinshasa for example, French NGO number of mobile teams working in the field Epicentre supervises a surveillance system in 12 whose role in seeking out infected people is sentinel sites throughout the city, while out in the crucial element in combating the disease. provinces the Médecins Sans Frontières “ This initiative has changed the situation branches place heavy emphasis on surveillance dramatically,” says Dr Simon Van Nieuwenhove, and rapid response, and are part of the weekly WHO’s African regional adviser for Ministry/WHO monitoring group that meets in trypanosomiasis or sleeping sickness. Kinshasa. “ First it gives us the drugs we thought would WHO tracks epidemic prone-diseases via its disappear. And secondly, since most of the cost provincial and district epidemiologists who have of the sleeping sickness control programme at also been involved in communicable disease present is drugs, and the pharmaceutical training for health workers in 10 provinces. companies are now giving them free, much of According to WHO focal communicable disease the money donated will be able to be reallocated focal point Dr Tshioko, there are also plans to to increase active screening.” extend training to community leaders once new Mobile teams, which have managed to continue WHO African Regional Office case definitions for functioning in many areas despite the war, are community reporting are finalised. co-ordinated by the national Bureau Central de Sorting out the data streams la Trypanosomiase which is supported by WHO and funded by Belgium to tune of $2.5 million a Obtaining accurate medical information in DRC year. The Belgian Government has also given is difficult, not only because of difficult $1.5 million to WHO’s African regional communications but also, ironically, because

4 July 2001 WORLD HEALTH ORGANIZATION programme for trypanosomiasis, currently based expenditure ranging from $0.68 in Goma, $0.29 in Kinshasa, to co-ordinate and develop similar in Butembo, $0.18 in Kayna. programmes in other affected countries over the Adding this to insecurity and lack of external next two years. NGOs such as MSF Belgium support for day-to-day functioning of health strongly support the programme, and manage centres in many zones, it’s now estimated that mobile teams particularly in Equateur, one of the over 70% of the population of Congo does not focal points of the disease. have access to basic primary health care. DRC is one of the largest reservoirs of Both the Belgian Government and a joint WHO- trypanosomiasis. Forty years ago cases were UNICEF health mission recently called on down to just a few thousand but the breakdown donors attending a strategic conference in of health services, withdrawal of bilateral aid Geneva in July to consider other mechanisms and, finally, war halted the active screening of for funding health care, including supporting the vulnerable populations that is the only way to government to pay health care worker salaries, stop transmission. In 1998 reported new cases not only to reduce exclusion, but also to remove reached 26,000 a year, though real figures are the perverse incentive to carry out fee-carrying likely to be more than 100,000 people affected curative care at the expense of preventative and but not yet diagnosed, since the current 35 public health activities. mobile screening teams are reaching less than But one major donor representative in Kinshasa 12% of the population at risk. noted “There is a painful disconnect: we as It is hoped that increasing access to previously donors are willing, for example, to pay refugees a inaccessible areas, the new climate for funding salary to provide health service in refugee camps, activities in DRC, and the advent of the but we are not willing to do the same with those trypanosomiasis initiative will all contribute to who are equally impoverished but have remained increasing this reach. for whatever reason in their own country.” Health care financing Health zone coverage Community participation excludes Initiatives target the unsupported International NGO Merlin has managed to more After 10 years absence, the US Government is than double attendance at their clinics by re-establishing support to health zones in DRC. dropping the consultation fee (which is the only Over the next five years it will put US$25 million source of salary for the centre staff) from 10 into 60 health zones via SANRU III, a project Franc Congolese (approximately 6 US¢) to 5FC which like its predecessors SANRU I and II will including drugs. But they believe they are still target its support at rural areas via health excluding large numbers of people who cannot services run by the churches. afford even that. Likely to be managed by the umbrella NGO “ Cost recovery is a nightmare: people pretend Interchurch Medical Assistance, SANRU aims to they do it so that people don’t become provide global assistance to health zones, from dependent but the reality is that we don’t have drugs, vaccines and medical supplies to training enough money to pay staff to work even though and management support. The 60 health zones we know that cost recovery reduces access,” span east and west DRC but the first to receive says eastern DRC head of mission fir British support are likely to be predominantly in the NGO Merlin, Susan Lillicrap. West. In Kisangani IRC head of misison Sebastian The European Union is also rehabilitating and Fessneau says while the objective is “auto- supporting some 500 health structures in financement, sustainability is very difficult”. roughly 50 health zones through its Programme Most NGOs try to police exemption systems for d’Appui Transitoire au Secteur de santé (PATS) indigents and free essential services such as Focused mainly on Greater Kinshasa and its vaccination, but without the ability to supervise hinterland provinces of Bas-Congo and daily many report difficulties in ensuring the Bandundu, half of the project’s US$38 million most vulnerable have access. goes to supplying health zones via various The scope of family difficulties has been further church and local NGOs with the remainder highlighted by household surveys carried out by destined to support particular programmes in OCHA in Kinshasa province which suggest that areas such as water and sanitation, the majority of the population are living on an trypanosomiasis and HIV/AIDS. average of 20 cents per person per day. Other surveys in North Kivu show daily per-person

5 July 2001 WORLD HEALTH ORGANIZATION Newly accessible areas draw NGOs One exception is North Kivu where ECHO is supporting – to the tune of $100,000 a month – With the agreement of the belligerents to a central drug supply system run by local NGO withdraw last July, previously inaccessible areas ASRAMES which supplies 19 health zones via close to the ‘old’ frontline have begun to open up international NGOs. to those health NGOs with enough logistical flexibility to get there. Drugs are supplied free, and organisations and/or health centres decide whether or not to In the far west of Province Orientale, for example, levy a user fee. Most currently charge a global the International Committee of the Red Cross ‘episode of illness’ fee which is dedicated to recently began shipping drugs and supplies to paying salary and running costs of the health Ikela, a health zone where the majority of the centre. The problem is that charges are town’s 50,000 population continues to be generally calculated on the amount needed to displaced into the forest onto the eastern side of give staff a basic salary rather than the capacity the old frontline. Access to the area, 260 km as of the population to pay. the crow flies from Kisangani, is only by boat, “ What we ask is that NGOs don’t just drop motorbike and bicycle Though the initial drugs, or user charges into the health system exploration team found no major epidemics and but that they have a system of management of no visible deprivation of food, they reported user charges and exemptions to maximise “zero” availability of medication and no routine access,” says an ECHO spokesperson. immunisation for three years. For their part MSF Holland are hoping to open up a new emergency site 300km north west of Rehabilitation Kisangani, in Yahuma health zone where, says More than just a paint job MSF-H Kisangani head of mission Joseph A $3 million rehabilitation project funded by Leberer, “intervention is more or less justified UNDP and implemented by WHO which across the whole area, even on emergency includes an innovative income generation criteria.” component has seen use of the targeted health “It’s not that people are so sick, but that there is facilities more than double in the past year. no recourse for any even small medical The programme focused on six health zones in problem,” he adds. Bandundu, Katanga and Bas Congo, and Further south, British emergency health NGO involved rehabilitating and re-equipping parts of Merlin is extending its programme from the district hospitals, health centres, and the jungle province of Maniema into frontline Lodja provincial health authority offices. in Kasai Oriental. and MSF Spain has reopened WHO and Ministry of Health staff also trained a health centre and three health posts in the doctors, health workers and technicians in battle-scarred health zone of Pweto in North health service management, epidemic Katanga and is exploring the possibility of surveillance and laboratory techniques, and expanding into other areas of opposition- community leaders and local organizations in controlled North Katanga. In the west, MSF setting up health committees, small project Belgium are moving to re-establish activities in management, and social mobilisation for health. Equateur. But the more unusual element of the programme was injections of cash for income generation Drug and medical supply projects. “When we asked why they didn’t use Drug logistics are nightmare the health facility, people said it was because they couldn’t afford it. There’s no point in How to maintain drug and medical supplies in rehabilitating a health centre which can’t survive the face of tortuous terrain, starved economy without minimal fees if people can’t afford to use and no central essential drugs distribution is a it,” says WHO project leader Professor Ngo Bebe. major issue in the health zones of Congo. In the small community of Kisanfu in Katanga, In most areas UN agencies, international NGOs the health committee used their $1500 grant and church organisations work to provide for from the project to buy haricot beans and their supported health zones through individual fertiliser for a two hectare plot which last month suppliers and logistics which not only eliminates produced a harvest of eight times the original the possibility of economies of scale in input. purchasing but also leads to duplication in This has been divided between the health storage, transport and supervision. And even in committee who will use the income to ensure an supported centres, drug ruptures are frequent adequate supply of drugs and materials in the leaving patients self medicating from centre and to subsidise patients, and local small unregulated private pharmacies.

6 July 2001 WORLD HEALTH ORGANIZATION farmers to use part as food and part for income country, which is followed by the provision of a and seed return next year. limited amount of essential supplies. “The “We want to see the impact of the new source of trouble is we can reinforce capacity but it’s income on the use of this health centre and on difficult to maintain supplies so that those trained the public health of this community.” says Dr can carry out the work when they get back to Jean de Dieu Illunga, the health zone’s medical their laboratory,” says Prof. Kandolo. officer. “If it works, we want to spread the idea to Maintaining supplies and motivating workers other health centres by giving them seed beans where salaries are often irregular or non-existent from our harvest to start their own.” is a issue throughout the health service in DRC. According to Professor Ngo Bebe, the increased National Reference Laboratory use of health facilities is due to the combination WHO, together with the Governments of of factors including supplies and confidence Belgium, France, Japan and the US, is also “ The population has more confidence in their putting funds into rehabilitating, equipping and health facility, but it’s more than just the improving the function of the national reference rehabilitation. Even without the war, the situation laboratory, the Institute National de la of the health centres was in crisis. Everyone Recherche Biomedical in Kinshasa. Three staff basically forgot about them because they didn’t from the INRB and one from Lumbumbashi are have any supplies. currently being funded on WHO’s new laboratory “ We’ve done a lot of work to sensitise the training programme in Lyon, France. The aim is population as to why they should use the health to develop the INRB into high level virology lab. centres and to improve their access. It’s too early to know whether projects like the haricot Polio eradication beans are having an effect on people’s actual health, but the dramatic increase in use of the First round down – two to go centres is encouraging.” Over 11.5 million children were reached in the USAID, Cooperazione Italiana and UNICEF first round of the 2001 National polio have all contributed to the rehabilitation projects immunisation days giving a “more than in addition to UNDP and WHO, and the satisfactory” coverage in all the 11 provinces, European Union funded an introductory according to WHO’s polio campaign team leader conference last year. Dr Matthieu Kamwa. Similar income generation projects are being More than 150,000 people are estimated to have piloted with the Association of Young been involved with this year the Red Cross of Handicapped People for Artistic Progress in the Democratic Republic of Congo mobilising all Lumbumbashi and an organisation for orphans its volunteers for the effort. They joined local in Kolwezi. NGOs, church groups, health workers in a massive campaign that saw vaccinators moving Laboratories deep into the country by foot, by bike, by outboard-powered canoe, by punt, and even, Ten new labs needed for basic service DRC’s few roads allowing, by car. Laboratories in DRC have suffered long years of Second and third rounds are due to take place in neglect. Many function barely with old August and September, and in a small number dysfunctional equipment and constant search for of high risk health zones where logistics allow, reagents and supplies. the final round in October will include measles Working with some funds from its African vaccination to test the viability of using the polio Regional Office, its regular budget and Rotary structure as a foundation for campaigns to fight International, and in the hope of attracting new this childhood disease. donor funds, WHO has assessed and planned the creation or rehabilitation of 10 laboratories Negotiations across borders throughout the territory. Only one of these, This year’s NIDs were part of a synchronised Amikivu in Goma, is currently functioning with effort across a large swathe of Central Africa any capacity, thanks to support from UNHCR, including Angola, DRC, Republic of Congo and WHO and the European Union. Five need to be Gabon. While high level negotiations brought created from scratch – Bukavu, Mbuji Mayi, expressions of support from all parties, at local Kikwit, Kindu, Matadi – while Lumbumbashi, level teams worked to make the connections Mbandaka, Kisangani, Kananga labs all need to between warring parties, tribal chiefs and be extensively rehabilitated and equipped. communities in order to reach 127,000 under In the meantime, WHO has started a series of fives living in border or insecure zones. updating seminars for laboratory staff around the

7 July 2001 WORLD HEALTH ORGANIZATION Neither level is simple, as WHO polio team  www.who.int/eha/disasters Emergency leader Dr Matthieu Kamwa notes. “ There are and Humanitarian Action Dept, WHO armed groups that can be identified but there Geneva are also many unidentified armed groups. We  www.reliefweb.int/ OCHA must not be over-optimistic about our ability to  www.intrescom.org/index.cfm: reach all children this year. The big picture of International Rescue Committee peace can be deceptive on the ground.’  www.oxfam.org.uk/policy/papers/drc2.ht Indeed, the effort to reach every under-5-year m: Oxfam International old was sadly marked by the death of a social mobiliser as a result of hostile forces in North  www.msf.org/countries/index.cfm? Kivu, and the arrest and beating of five others indexid=22D106CD-BEC7-11D4- along Equateur and Province Orientale border. 852200902789187E: Médicins sans Frontiéres Security concerns also reach beyond immunisation days, says WHO epidemiologist Mr Yon Fleerackers. “Ensuring health workers have security for surveillance and investigation Contact WHO in DRC of acute flaccid paralysis cases is an ongoing WHO Kinshasa concern because this work doesn’t take place on Phone: 001 321 953 9001 a clearly identified timetable.” Mobile: 00 243 884 0789 Building on the investment WHO Representative The polio programme has substantial economic Dr Leonard Tapsoba implications for health workers and others [email protected] whose monthly salaries are often only just in Communicable Diseases and double dollar figures. Emergency and Humanitarian Action Over the three months of planning and Dr Tshioko Kweteminga implementing 2001 NIDs, some US$15 million of [email protected], the total US$32 million budget raised from international donors is poured into the country in Expanded Programme of Immunisation the form incentives, per diems, and payments Dr Matthieu Kamwa for goods and services. The remainder is spent [email protected] largely on vaccines and investment in Reproductive Health infrastructure like transport, cold chain and Mme Flore Chirwisa communication equipment. [email protected] Getting the best value out of that money is a Health Systems Management headache in such a large and impoverished Professor Ngo Bebe, country, says WHO polio team leader Dr [email protected] Matthieu Kamwa. “We are using supervision and spot checks, controls during and after activities, Regional adviser on Trypanosomiasis but we are not thousands of people.” Dr Simon Van Nieuwenhove An important aspect of the investment, he adds, is [email protected] the logistical resources put in place by the global Laboratories campaign should be used to strengthen and re- Prof Denis Kandolo Kakongo establish basic primary health care services. [email protected] This year the core programme team has grown Health information to 180 people including 15 expatriates, 11 Mme Marie Claire Fwelo: Congolese epidemiologists at provincial level [email protected] and 42 at district levels, supported by logisticians, radio operators and drivers. All staff are employed by the polio programme to ensure WHO Goma working standards are met, but work alongside Phone: 001 871 762 095 141 local health inspectors in polio and integrated surveillance activities. Eastern Co-ordinator Dr Ncharre, [email protected] DRC Health on the web Epidemiologist For further documents on the Democratic Laurence Chabirand, Republic of Congo, please visit: [email protected] 00 250 0858 7551

8 July 2001 WORLD HEALTH ORGANIZATION Roll Back Malaria Dr Nadine Ezard, [email protected] 00 250 084 11 416

This document was researched and written by Hilary Bower, information officer for WHO Emergency and Humanitarian Action Department, Geneva, The content does not necessarily reflect official WHO views or policies. For further information, please email [email protected] or [email protected] or WHO DRC on the following contact addresses.

9 July 2001