Patients waiting for treatment at the the Kamandelena Health Center in the Demba Health Zone. Photo by: Dr. Jean Coco, IMA health advisor

NAIROBI — As a crisis hits a country, the humanitarian sector often rushes in to assist communities with escalating medical needs. Frequently, this means bringing in foreign health workers and setting up makeshift health centers. As the crisis passes, foreign health workers leave and tent clinics are packed up. While intended to sustain communities through disaster, these types of parallel health systems can often damage the existing health infrastructure in the country, as local health worker salaries go unpaid and health clinics are abandoned in favor of free services suddenly available in the communities.

IMA World Health, a Washington, D.C.-based nonprofit, has been experimenting with a different model in the Kasai region of the Democratic Republic of the Congo over the past year, to ensure that its health infrastructure is functional in the wake of the region’s crisis.

The Kasai region, located in the center of DRC, consists of five of the country’s 26 provinces. In 2016, violence broke out between a militia group and the national security services in the region, which at its height, displaced 1.4 million and left 3.2 million people severely food insecure. While the violence has since calmed and is now sporadic, hundreds of thousands of people remain displaced.

The Kasai crisis has been unique to other humanitarian crises, in some ways. People would flee into the forest, stay for several days or weeks, and return to their villages. Because of this, most of the displacement occurred internally within DRC, or even internally within provinces, rather than spilling over national borders. Working in that context, IMA World Health has focused on paying patient fees directly to local health clinics so that the local health systems can continue to function.

From development to humanitarian response

IMA World Health’s presence in the region predates the crisis. Starting in 2014, the organization began implementing its “Access to Primary Health Care Project,” which is a health systems strengthening program in DRC in partnership with the government, with a significant portion of that project implemented in the Kasai region. The project is funded by a five-year £185 million ($243 million) contract from the United Kingdom’s Department for International Development.

In 2017, after the violence hit, the United States Agency for International Development, through its Office of U.S. Foreign Disaster Assistance, came onboard and provided a $1.5 million grant to IMA World Health to fund a transition into a humanitarian response.

Before the crisis, patients paid 50 cents to $1 for a health visit, which covers access to a health care professional, lab testing, and any medicine that is prescribed. These prices were subsidized through the development project, to keep them low. But when violence hit the Kasai region, and people lost their livelihoods, even those rates were too high.

“That’s a significant amount of money, especially during a crisis like this, where people aren’t able to grow their food,” said Scott Shannon, IMA World Health deputy country director for DRC.

Up to 70 percent of the OFDA funds were used to eliminate these fees for the patients. IMA World Health paid the health clinics directly, which meant that health workers still received salaries and facilities were kept functioning. These humanitarian efforts built off a foundation that was already in place from the development project, such as training, equipment, and support to provincial and health zone supervision.

In other humanitarian crises, depending on the length, health workers may have to seek work elsewhere if patients aren’t coming to their clinics, said Shannon. An influx of foreign health workers could also distort the payment structure for health workers in the local economy, making it difficult to sustain in the long run.

“Continuing, as much as possible, the normal way that the system functions was a high priority for us,” he said.

Transparency and transitioning out of the crisis

At the end of the month, clinics report to IMA World Health how many patients they’ve seen. Local partner organization Santé Rurale carry out monitoring visits to verify these patients actually visited the clinic, including random sampling surveys in the community. The money is then transferred through mobile money transfers to the head nurse’s phone. Community leaders and other health officials are also informed of the transfer of funds, so that there is transparency around the payment. A certain percentage of those funds are allocated to salaries, maintenance of the facility, and medicines.

In the cases where local nurses have had to flee, and can’t return because of interethnic tensions, IMA World Health has worked with the provincial or health zones authorities to find a replacement health worker locally.

This type of model also makes it easy for humanitarians to transition out of the crisis, said Shannon. Now that OFDA funding for free care has ended, the existing health systems remain intact.  

“That is different from many emergency response activities wherein an outside humanitarian agency sets up a temporary free care structure and then later leaves the area taking the free care structure with it.  During the time the free care is offered, the established infrastructure falls apart because no patients are using it. However, if the population is able to once again resume paying the small fee in the health facility which they had paid prior to the outbreak of violence, the transition is almost seamless,” he said.

As part of the transition out of the crisis, IMA World Health is proposing a follow-up project, which would expand the number of clinics it works with, and make services free for children, pregnant women, and individuals with disabilities. It will also include some equipment replacement and rehabilitation of health centers that have been destroyed or looted during the violence.

If violence were to break out in the Kasai region again, the organization would ramp up with a funding appeal to support the broader community by eliminating their patient fees.

About the author

  • Sara Jerving

    Sara Jerving is a Global Health Reporter based in Nairobi. Her work has appeared in The Wall Street Journal, The New York Times, the Los Angeles Times, Vice News, and Bloomberg News, among others. Sara holds a master's degree from Columbia University Graduate School of Journalism where she was a Lorana Sullivan fellow. She was a finalist for the Livingston Award for Young Journalists in 2018, part of a Vice News Tonight on HBO team that received an Emmy nomination in 2018 and received the Philip Greer Memorial Award from Columbia University Graduate School of Journalism in 2014. She has reported from over a dozen countries.