Healing governance? Four health NGOs in war-torn Eastern Congo: the most that health organizations can hope for is to contribute indirectly to better governance. But they can continue to save lives.

AuthorDijkzeul, Dennis
PositionStrong and weak states: cases of governance

Disasters visit Eastern Congo on a continual basis: war, volcanic eruptions, ethnic strife, epidemics, refugee inflows and perhaps worst of all, for most people, a lack of hope. Expatriates who initially work there with idealistic goals) end to leave the region seeing it as a place where life only gets worse. The region barely knows a government or governance system, unless one calls warlord politics and a war economy functioning governance systems. The war and absence of a well-functioning state have exacted a terrible toll on the health of the people living in Eastern Congo. Mortality and morbidity are extremely high, probably the highest in the world.

This article studies the current health system in Eastern Congo. Based on field research conducted during the summers of 2001 and 2002, it explains the overall political situation and its relationship to the ailing health system. Four non-governmental organizations (NGOs)--the Association Regionale d'Approvisionnement en Medicaments Essentiels (ASRAMES), International Rescue Committee (IRC), Malteser and Medical Emergency Relief International (MERLIN)--are attempting to improve this system and bring down mortality and morbidity, which in turn has implications for strengthening governance in Eastern Congo.

FROM MOBUTU TO WAR

During his long reign, Mobutu Sese Seko slowly hollowed out the Congolese state. From the 1960s to the late 1980s, Mobutu used the Congo's immense natural wealth, as well as Cold War support, especially from the U.S., France and Belgium, for an extensive patronage network. Government bureaucracies were slowly destroyed by corrupt management and milked for resources for patronage. Agricultural output, an important tax base, went into steep decline with the Zairization process of the 1970s. Many farms were distributed to the regime's cronies, who were frequently unable to run the farms effectively. Mining companies, a central part of the economy, suffered from underinvestment and were gradually stripped of their assets. Ever since the assassination of Patrice Lumumba, the elected leader of Congo's independence, in 1961, democratic movements have been curtailed. When necessary, Mobutu used the army and secret services to crush opposition.

Building on the colonial heritage of exploitation and violent oppression, Mobutu centralized and personalized his control of the Congolese state. Foreign companies and local citizens became dependent on Mobutu and the cronies of the ruling regime to make progress. Mobutu never attempted to build a well functioning state, nor did he want to foster a productive private sector or a vociferous civil society. These would have hampered his patronage system. As a result, the basic elements of good governance were slowly demolished in the Congo.

By the early 1990s, disaster was looming as the resources for Mobutu's patronage system, and hence his ability to buy loyalty, were drying up. The economy had been in decline since the 1980s. The International Monetary Fund (IMF) and World Bank promoted structural reform and, with the end of the Cold War, Mobutu lost the support from his patron states. Only France continued to support him on and off in its increasingly futile attempts to play a major role in the Great Lakes region and support la francophonie. As the 1990s progressed, Mobutu resorted to increasingly desperate measures. He used the Central Bank to print money to pay his expenses, causing hyperinflation. He also used ethnic tension between the Kasai and Katangese to diminish support for his main political opponent, Etienne Tshisekedi, who was an ethnic Kasai. Similarly, he promoted violence against Congolese of Rwandan descent in Eastern Congo. Through this violence, his clients obtained new wealth by stripping the assets of these population groups. Mobutu then asserted his authority because the ethnic groups needed him to mediate and asked for his protection. He also exploited the refugee inflow after the Rwandan genocide to regain international political support. (1) He facilitated the French intervention in Rwanda that helped some of the leaders behind the Rwandan genocide escape. When the Rwandan refugee camps were established around Lake Kivu, Mobutu did not order his army to separate the Hutu extremists--the perpetrators of the genocide-from the other refugees. Indeed, Mobutu and the French mistrusted the Tutsi-dominated Rwandese Patriotic Front (RPF) that had defeated the genocidaires because it originated in English-speaking Uganda.

There was always resistance to Mobutu, but for many years, rebel movements did not gain sufficient popular or international support. Laurent Kabila began his rebellion in the 1960s, but it languished for decades. Only in the 1990s did his Alliance des Forces Democratiques pour la Liberation du Congo (AFDL) receive strong support from the Rwandan and Ugandan armies. The Rwandans intervened because they wanted to dismantle the refugee camps: Interahamwe and soldiers from the former Rwandan armed forces used these camps as bases for rearmament and attacks on Rwandan soil. They also terrorized the camp population and prevented many of the refugees from returning. (2) In May 1997, Kabila and his troops took over Kinshasa, and Mobutu fled the country. (3)

By 1998, the alliance between Kabila and the Rwandan Army had fallen apart. In August 1998, the Rassemblement Congolais pour la Democratie (RCD), with support from the Rwandan, Ugandan and Burundian armies, started another war to displace Kabila's regime. This war soon reached a stalemate. Kabila received support from Angola, Zimbabwe, Chad and Namibia, while Uganda and Rwanda grew apart over their different economic interests and supported different rebel groups. As a result, the country was divided into roughly three parts. The Front de Liberation de Congo (FLC) led by Jean Pierre Bemba, and supported by the Ugandans, occupied the northern part of the Congo. Several people close to Bemba used to have close ties to Mobutu. The RCD, supported by the Rwandans, maintained control over the eastern region, while government forces controlled the western and southern region. In the meantime, the Interahamwe continued to destabilize parts of eastern Congo and Rwanda. The Mayi-Mayi were also active in RCD- and FLC- held territory. Originally, they were local self-defense groups or parts of local communities that fought against foreign occupation, but they evolved into armed bandits that raped and looted the local population. Moreover, there were local ethnic conflicts, for example between the Lendu and the Hema in the Oriental province.

The different warring factions and their international supporters were generally more interested in the economic exploitation--for example of diamonds and coltan--than in ending the war, so it increasingly became unclear who was fighting whom. (4) Ugandans and Rwandans fought each other in Kisangani. The Banyamulenge, Congolese Tutsis who had cooperated with the AFDL in 1996 and later sided with the Rwandans, fell out with them in 2002. The RCD began cooperating with some Mayi-Mayi groups it used to fight, while continuing to fight other Mayi-Mayi groups. As a result, the Congolese war broke down into "dozens of overlapping micro-wars in which almost all the victims [were] civilians." (5)

At the national political level, the death of Laurent Kabila in January 2001 and subsequent replacement by his son Joseph Kabila led to renewed diplomatic interventions to achieve peace. An unarmed United Nations (UN) observer force United Nations Organization Mission in the Democratic Republic of the Congo (MONUC) was placed close to the front line, and the warring factions partially withdrew. The Namibian and Chadian forces pulled out completely. The Burundians remained only to fight "their" rebel forces across their border. The Ugandans, Rwandans and Zimbabweans withdrew some of their troops, but many remained, particularly among the Rwandans.

In spring 2002, official talks in South Africa between the three main parties in the conflict broke down, but the Kabila government and the FLC were able to reach an agreement so that some 70 percent of the country's territory was officially under control of the Kinshasa government. No agreement was reached with the Rwandan-controlled RCD in Eastern Congo. The local population generally opposed the RCD and became increasingly restless. (6) Even when Kabila and Rwandan president Paul Kagame reached a peace agreement in August 2002, the spirits of the local population did not lift. When the Rwandans finally pulled out as stipulated by the peace accords, it was not at all certain that the Kabila government would be able to control the territory effectively. In a few cases, large-scale violence occurred. Continued low-key fighting and criminal rackets are common, and corrupt warlord politics continues in one way or another, probably into the near future. Rebuilding state structures and developing sound governance will take time and may fail.

THE STATE OF THE HEALTH SYSTEM

In the 1980s, Mobutu came under increasing pressure from the Bretton Woods institutions to control the national budget deficit. As usual, the Pete de la Nation decided not to limit his personal expenses and patronage politics; instead he cut the budgets for health and education. As a consequence, the health system increasingly had to fend for itself and the Congo became a natural experiment in cost recovery. (7) Congolese health care is based on an "auto-finance system" under which health facilities receive no financial support from the health ministry. Rather, each health facility is expected to generate its own revenues by charging fees for medical consultations and any medicine prescribed. Consultation fees are actually a legal requirement under Congolese law, and the local health authorities do not accept their eradication. The health facility uses its revenues to pay staff incentives, buy...

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